Energy and protein intakes of acute stroke patients.

BACKGROUND: Although protein-energy malnutrition has been cited as a frequent complication following stroke, there is very little data describing nutritional intake among hospitalized patients. OBJECTIVE: To report: i) the level of protein and energy intake, ii) the adequacy of intake during the first 21 days of hospitalization and iii) to examine the differences in nutritional intake associated with diet type (regular texture, texture-modified and enteral feeding). DESIGN: Prospective observational study of an inception cohort. The energy and protein intakes of well-nourished patients with recent onset of first time stroke were assessed at admission to hospital and at days 7, 11, 14 and 21. Adequacy of energy intake at each of these intervals was expressed as a percentage (actual intake/energy requirement assessed by indirect calorimetry x 100). Adequacy of protein intake was assessed in a similar manner, with 1 g/kg of actual or adjusted body weight used to estimate requirement. The nutritional intakes of patients receiving regular diets, dysphagia diets and enteral tube feedings were compared using one-way ANOVA. RESULTS: The average energy intakes of the entire study group ranged from 19.4-22.3 Kcals/kg/day over five observation points, representing 80.3-90.9% of measured requirements; protein intake and ranged from 0.81-0.90 g/kg day yielding adequacy of intake of 81-90% of requirement. There were significant differences in energy intakes and/or adequacy of intake of patients receiving different diet types at days 11, 14 and 21 (p < 0.05) and differences in protein intake and/or adequacy of protein intake at all intervals except admission (p < 0.05). Patients receiving enteral tube feedings consumed more calories and protein compared to those patients on regular or dysphagia diets. CONCLUSIONS: On average, newly diagnosed, well-nourished, hospitalized patients consumed 80-91% of their both their energy and protein requirements, in the early post stroke period.

Educational intervention in the management of acute procedure-related wound pain: a pilot study.

OBJECTIVE: This report describes the pilot testing of an educational intervention to manage acute pain associated with wound care in an outpatient clinic. The intervention included essential elements of pain education identified in the acute pain literature: provision of information; pain measurement; establishing expectations; treatment planning; teaching environment. METHOD: The intervention was tested on five patients attending a wound clinic for scheduled treatment. Patients were aged 65 years or older and had a history of experiencing pain during treatment procedures such as dressing changes and debridement. Before the intervention, the study nurse gave the patients information about the procedure, discussed strategies they could use to make it as comfortable as possible, and explained how they could use a rating scale to denote any physical and emotional distress. RESULTS: All patients used the intervention strategies. Three out of five reported reduced pain and/or distress following the intervention. CONCLUSION: The pilot study supported the use of education as a pain control strategy in wound care and illuminated key methodological issues for further research on this topic.

Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies.

OBJECTIVE: To determine whether dysphagic stroke patients receiving oral (thickened-fluid dysphagia) diets or nonoral (enteral feedings supplemented with intravenous fluids) diets met their estimated fluid requirements. DESIGN: Cohort study. SETTING: University-affiliated hospital. PARTICIPANTS: Thirteen dysphagic patients with new strokes were studied for 21 days postadmission to hospital. INTERVENTIONS: Seven patients (group 1) were started on nonoral feeding and later progressed to oral diets and 6 patients (group 2) received oral dysphagia diets only. MAIN OUTCOME MEASURE: Fluid intake. RESULTS: Fluid intake of patients in group 1 significantly declined over the 21 days (mean +/- standard deviation, 3158 +/- 523mL/d vs 984 +/- 486mL/d; p < .0001), representing 134% +/- 26% and 43% +/- 20% of their fluid requirements, respectively. Mean fluid intake of patients in group 2 was 755 +/- 162mL/d, representing 33% +/- 5% of requirements. This volume was significantly lower than the fluid intake of patients who received nonoral feeding (p < .0001). CONCLUSIONS: Dysphagic stroke patients who received thickened-fluid dysphagia diets failed to meet their fluid requirements whereas patients on enteral feeding and intravenous fluid regimens received ample fluid.

Photographic assessment of the appearance of chronic pressure and leg ulcers.

The purpose of this paper was to examine the validity and reliability of using photographs of wounds to accurately assess wound status. The results of assessing wound appearance using wound photographs was compared to results obtained from a bedside assessment using the Pressure Sore Status Tool (PSST). The photographic wound assessment tool (PWAT) used in this comparison represents a modified version of the PSST and includes the six domains that can be determined from wound photographs. The PWAT was used on photographs of both chronic pressure ulcers (n = 56) and leg ulcers due to vascular insufficiency (n = 81). The photographic tool has excellent intrarater (ICC = 0.96) and interrater (ICC = 0.73) reliability and good concurrent validity (r = 0.70) compared with a full bedside assessment PSST. The PWAT has also shown to be sensitive to change in wound appearance of healing ulcers, but not nonhealing ulcers. These results would suggest that in the event that a full bedside assessment is not possible, wound photographs may be used to accurately assess wound appearance of both chronic pressure ulcers located on the trunk and vascular ulcers of the lower extremity. Establishing a valid and reliable assessment of wound healing using photographic images is of great relevance to the advancing fields of computer image analysis and telemedicine.

A clinical evaluation of 3M no sting barrier film.

The maintenance of healthy skin depends on factors such as moisture, the nutritional status of the patient, and mechanical forces. A barrier film can be a valuable adjunct in the prevention and treatment of injury to skin. One hospital evaluated barrier film, a new alcohol-free film-forming liquid skin protectant, in its geriatric and spinal cord rehabilitation units. A total of 33 patients were enrolled in the study. The purpose of the evaluation was to determine if barrier film reduced redness, assisted in the adhesion of dressing and condom catheters, prevented or reduced maceration, prevented or reduced skin stripping, and/or had any adverse effects on patients. Redness was reduced in 96% of patients who were at risk. Maceration was prevented in 94% of subjects, and skin stripping was prevented in 100% of patients. Dressing adhesion improved significantly in 90% of subjects. For all subjects, regardless of method of application, barrier film was easy to apply. No patient experienced any adverse effects during the study. On the basis of this clinical trial, we found barrier film to be an effective liquid skin sealant and protectant.

Comparison of caregivers', residents', and community-dwelling spouses' opinions about expressing sexuality in an institutional setting.

Opinions regarding the appropriateness of elderly residents' sexual behaviors in a chronic care hospital and how to respond to inappropriate behaviors were surveyed. Study participation was open to all staff (N = 1,205), eligible residents (N = 182) and community-dwelling spouses (N = 103). Participation rates were 40% (residents), 42% (spouses), 34% (nursing staff), 50% (allied health staff), and 22% (support staff). Staff completed the questionnaire independently, while residents and spouses were offered self-completion or a structured interview. Almost all selected the interview. Residents and spouses were less tolerant than staff of residents' masturbating, engaging in sexual relationships, viewing sexual materials, and making sexual approaches to staff. Privacy was the primary determinant of appropriateness for behaviors for all groups. Staff and spouses were more likely to endorse counseling when behaviors were perceived as inappropriate than residents. Nurses endorsed counseling less frequently than allied health professionals and support staff. Nurses were more likely to have been approached sexually by a resident. Differences of opinion are interpreted in terms of cohort influences on values and contextual influences on behavior.

Pressure ulcer assessment instruments: a critical appraisal.

Numerous evaluation tools have been developed to document various aspects of wound status or appearance of pressure ulcers. These include the Pressure Sore Status Tool (PSST), Pressure Ulcer Scale for Healing (PUSH Tool), Sussman Wound Healing Tool (SWHT), Sessing scale, and the Wound Healing Scale (WHS). A critical appraisal of the literature was undertaken to examine the purpose and methods for the development of each instrument, the extent to which the instruments have been validated to date, the practicality of their use, and the work that remains to be done to establish their suitability for clinical and/or research purposes. All of these instruments have been developed to describe and evaluate change in pressure ulcer status over time with the exception of the WHS, which was developed as an alternative to reverse staging. More of the validation parameters have been addressed for the PSST and the Sessing scale than for the PUSH Tool, the SWHT, and the WHS. All of the instruments can be completed within approximately 5 minutes except the PSST, which requires 10 to 15 minutes to complete. For all instruments, experience with wounds and training in the use of the instrument are required to improve reliability. For each of the measurement instruments, suggestions are made that would complete necessary validation procedures and thus prepare the instruments for clinical and/or research purposes.

Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example.

Statistical methodology for the concurrent assessment of interrater and intrarater reliability is presented. Application of the methodology is illustrated with an example of one therapist using two goniometers repeatedly to measure knee joint angles. Methods for estimating the coefficients, testing hypotheses, constructing confidence intervals, and computing sample size requirements are provided. In addition, the calculation and clinical interpretation of the standard error of measurement (SEM) are discussed. It is recommended that (1) when both interrater and intrarater reliability are being assessed, a repeated-measures design be used to take advantage of the increased precision gained by using all observations in the statistical analysis, and (2) appropriate statistical tests, confidence intervals, and SEMs always be used in conjunction with the estimated reliability coefficients.

Interrater reliability of pinch and grip strength measurements in patients with cumulative trauma disorders.

The purposes of this study were to examine the interrater reliabilities of grip, lateral pinch, and tripod pinch measurements in patients with cumulative trauma disorders. Thirty-eight patients with unilateral (n = 28) or bilateral (n = 10) cumulative trauma disorders were tested independently by two hand therapists, during a one-hour period. The tests were completed in a normal hand clinic environment using the standard protocol recommended by the American Society of Hand Therapists. Interrater reliability coefficients for the scores obtained using either a single repetition or the mean of three repetitions were very high (intraclass correlation coefficient [ICC] > 0.87) for all strength measurements. As a result, strength determination in this patient group, when performed by different hand therapists, may be considered reliable.

Employment patterns and related opinions: a survey of physical therapists.

Physical therapy educators require specific information about the number of graduates who remain in the profession and about their opinions related to undergraduate training and their postgraduate requirements. A mail questionnaire survey of physical therapists who graduated from an Ontario university's physical therapy program between 1969 and 1978 was conducted to determine: occupational patterns, satisfaction with undergraduate preparation for employment, interest in graduate studies and, if the graduate was unemployed at that time, the need for re-entry preparation for employment. With one follow-up mailing to non-respondents, a response rate of 93.4 per cent was obtained. Of the 141 respondents, 110 were working full-time and 15 were working part-time in physical therapy. Eighty-eight per cent of employed physical therapy graduates agreed that their education had prepared them sufficiently for employment. Fifty-three per cent of the graduates indicated that they would like to pursue an area of clinical specialization through graduate study. It is concluded that the graduates of the program under study believe that they have been well prepared for employment; not only do they maintain a clinical interest in the profession, but they aspire to personal and professional advancement through graduate studies.