COMMON MEDICAL PROBLEMS IN SURGICAL WARDS AND

COMMON SURGICAL PROBLEMS IN MEDICAL WARDS IN HOSPITAL

SELAYANG (WITH SPECIAL ATTENTION TO PRESSURE SORE) IN

MAY 2010

KULLIYYAH OF MEDICINE

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

JUNE 2010

ii

ABSTRACT

Pressure sore is fast becoming endemic in Malaysian public hospitals. A cross-sectional study on the prevalence of pressure sore and its management in the medical and surgical wards at Hospital Selayang was conducted in May 2010. In addition, the prevalence and management of other common surgical problems in medical wards (namely gastritis, deep vein thrombosis, and gastrointestinal bleed) were also studied. Conversely, the prevalence and management of common medical problems (namely diabetes mellitus and hypertension) in surgical wards were studied. The objectives of this study were to estimate the prevalence and to identify the common modes of management of pressure sore as well as other common medical and surgical disorders. The participants must have been admitted to the general medical or surgical wards of Hospital Selayang, and have these disorders during their admission. The data were collected using research record forms (RRF), in which socio-demographic factors like age, race, and gender were recorded. The data was analyzed using SPSS 17 software. The prevalence of pressure sore was 4.05% and 2.05% in the medical and surgical wards, respectively. Management includes nursing care as well as the use of dressing (most of which is normal saline dressing) over the sore. The prevalence of gastritis in the surgical wards is 2.14% (1.71% potential); prevalence of deep vein thrombosis is 1.28% (1.71% potential); the prevalence of gastrointestinal bleed is 2.99%. The prevalence of diabetes mellitus in the surgical wards is 13.33%; the prevalence of hypertension is 17.33%.

iii

DECLARATION

We hereby declare that this dissertation is the result of our own investigations, except where otherwise

stated. We also declare that it has not been previously or concurrently submitted as a whole for any other

degrees at International Islamic University Malaysia (IIUM) or any other institutions.

Date: 20th July 2010

…………………………………………..

Abdul Razak bin Mohamed Ismail

(Matric. No.: 0619747)

…………………………………………..

Ahmad Afifuddin bin Abdullah

(Matric. No.: 0615517)

…………………………………………..

Hamzah bin Sukiman

(Matric. No.: 0611281)

…………………………………………..

Mohd Hafiz bin Johari

(Matric. No.: 0616849)

iv

ACKNOWLEDGEMENTS

Alhamdulillah, praises to Allah for we have finally completed our research. We thank our supervisor, Assoc.

Prof. U Kyaw Tin Hla for all his guidance and assistance in helping us complete this research. We would also

like to extend our gratitude to Dr. Muhammad Taufiq Khalila bin Razali, our external supervisor and pleasant

host at Hospital Selayang. And to all staff members of Hospital Selayang, most notably those assigned to

wards 4A, 4B, 9C and 9D. And finally, to all the patients, without whom our vocation would be rendered

meaningless.

v

TABLE OF CONTENTS

Table of Contents ABSTRACT ............................................................................................................................................................. ii

DECLARATION ...................................................................................................................................................... iii

ACKNOWLEDGEMENTS........................................................................................................................................ iv

LIST OF TABLES ................................................................................................................................................... vii

LIST OF FIGURES ................................................................................................................................................. vii

INTRODUCTION ....................................................................................................................................................1

LITERATURE REVIEW .............................................................................................................................................2

OBJECTIVES ...........................................................................................................................................................5

General Objective .............................................................................................................................................5

Specific Objectives ............................................................................................................................................5

METHODOLOGY ....................................................................................................................................................6

Study Place .......................................................................................................................................................6

Study Period .....................................................................................................................................................6

Study Design .....................................................................................................................................................6

Study Population ..............................................................................................................................................6

Sampling method .............................................................................................................................................6

Inclusion Criteria ...............................................................................................................................................6

Exclusion Criteria ..............................................................................................................................................6

RESULTS ................................................................................................................................................................7

Demographic Data ............................................................................................................................................7

Wards Admission ..........................................................................................................................................7

Sample Population ........................................................................................................................................7

Pressure Sore ................................................................................................................................................. 10

Frequency .................................................................................................................................................. 10

Onset ......................................................................................................................................................... 11

Risk Factors ................................................................................................................................................ 11

Stage .......................................................................................................................................................... 12

Management ............................................................................................................................................. 13

Complications ............................................................................................................................................ 14

Surgical Cases in Medical Wards ................................................................................................................... 15

vi

Frequency .................................................................................................................................................. 15

Gastritis Management ............................................................................................................................... 16

Deep Vein Thrombosis Management ........................................................................................................ 16

Gastrointestinal Bleeding Management .................................................................................................... 17

Medical Cases in Surgical Wards ................................................................................................................... 18

Frequency .................................................................................................................................................. 18

Management of Diabetes Mellitus ............................................................................................................ 19

Management of Hypertension .................................................................................................................. 20

DISCUSSIONS ..................................................................................................................................................... 21

LIMITATIONS ...................................................................................................................................................... 24

CONCLUSION ..................................................................................................................................................... 24

REFERENCES....................................................................................................................................................... 25

APPENDIX I – RESEARCH CONSENT FORM ........................................................................................................ 26

APPENDIX II – RESEARCH RECORD FORM.......................................................................................................... 28

vii

LIST OF TABLES

Table 1 NPUAP Stages of Pressure Sore .............................................................................................................. 2

Table 2 Norton Scale............................................................................................................................................ 3

Table 3 Number of Admissions to Medical and Surgical Wards.......................................................................... 7

Table 4 Demography of Sample Population ........................................................................................................ 7

Table 5 Frequency of Pressure Sore in Medical and Surgical Wards ................................................................ 10

LIST OF FIGURES

Figure 1 Age Distribution of the Sample Population ........................................................................................... 8

Figure 2 Distribution of Gender of Sample Population ....................................................................................... 8

Figure 3 Distribution of Race of Sample Population ........................................................................................... 9

Figure 4 Frequency of Pressure Sore in Medical and Surgical Wards ............................................................... 10

Figure 5 Onset of Pressure Sore ........................................................................................................................ 11

Figure 6 Risk Factors of Pressure Sore Based on Norton Score ........................................................................ 11

Figure 7 Frequency of Pressure Sore Based on Stages ...................................................................................... 12

Figure 8 Type of Dressing Used for Pressure Sore ............................................................................................ 13

Figure 9 Local Complications of Pressure Sore .................................................................................................. 14

Figure 10 : General Complications of Pressure Sore ......................................................................................... 14

Figure 11 Surgical Cases in Medical Wards (9C and 9D) ................................................................................... 15

Figure 12 Gastritis Management in Medical Wards .......................................................................................... 16

Figure 13 Deep Vein Thrombosis in Medical Wards ......................................................................................... 16

Figure 14 Gastrointestinal Bleeding Management in Medical Wards .............................................................. 17

Figure 15 Medical Cases in Surgical Wards ....................................................................................................... 18

Figure 16 Management of Diabetes Mellitus in Surgical Wards ....................................................................... 19

Figure 17 Types of Insulin Management in Surgical Wards .............................................................................. 19

Figure 18 Management of Hypertension in Surgical Wards.............................................................................. 20

INTRODUCTION

It is a sad reflection of today’s standard of healthcare that pressure sores remain prevalent despite

the field of medicine having progressed by leaps and bounds. It is well established that pressure sores are

essentially preventable. It is an avoidable condition, the treatment of which incurs a taxing burden on the

healthcare system, siphoning precious resources from where they are needed most.

Wards of Malaysian public hospitals are no stranger to accommodating patients with pressure sores,

more so if they present with predisposing risk factors. Others may have developed sores prior to admission.

This, coupled with the fact that many patients stay in the wards for protracted durations, exponentially

increase the frequency at which sores are observed in these wards.

This research attempts to capture the state of affairs with regards to pressure sore management in

medical and surgical wards in Hospital Selayang. Though the result of this study will hardly be representative

of other wards, much less other public hospitals, it nonetheless provides a useful glimpse of how pressure

sores are currently being managed. This hopefully will enable healthcare workers to provide better care so

as to effectively reduce its incidence in the future.

Numerous papers regarding pressure sore have been published throughout the academia. Yet their

continuing occurrence signals an imperfection in the implementation of its management. It is hoped that the

undertaking of this study will help contribute towards better sore management in Hospital Selayang.

Judicious patient care has the potential to prevent sores altogether, and having zero pressure sore among

warded patients should be the goal for every healthcare worker to labour towards. Though as of now this

goal remains apparently elusive.

2

LITERATURE REVIEW

The United States National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcer thus: A

localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure,

or pressure in combination with shear and/or friction (Black, 2007). The NPUAP further stages pressure sore

into four, largely retaining the original classification first proposed by Shea in 1975. This definition was

adopted by the NPUAP during its first Consensus Conference in 1989, and has been retained up until the

latest conference in 2007, albeit with minor modifications (Black, 2007). The latest iteration incorporates

two additional stages to the existing four, namely “suspected deep tissue injury” and “unstageable”. The

stages of pressure ulcer are as below (Black, 2007):

STAGE & CRITERIA FURTHER DESCRIPTION

Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk)

Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed

Table 1 NPUAP Stages of Pressure Sore

3

It is difficult to put an estimate on the global prevalence of pressure sore in healthcare institutions

worldwide, since the standard of care inevitably vary between countries and populations with contrasting

socioeconomic levels. Conservative estimates put it at 5.3% (Stausberg, 2005), while other studies suggest

that, even under optimal care, pressure sore develops in as many as 10.2% of patients admitted (Phillips,

2009).

However, one overriding concern that all these studies point towards is the relative constancy of

pressure sore prevalence rates over the years, which sees neither a rise nor a decline. Most authors also

implicate the ‘common’ risk factors for the development of pressure sore, namely old-age, debility, and

incontinence.

There is, sadly, a paucity of published data regarding pressure sore in Malaysian public hospitals. It is

hoped that more of such studies be undertaken in the future so as to facilitate better management of

pressure sore.

The Norton Scale, first published in 1962, remains a relatively reliable predictive indicator for

pressure sore, having a sensitivity of 46·8% and a specificity of 61·8% (Pancorbo-Hidalgo, 2006). However, its

use is far from universal, despite having existed for decades. Its ease-of-use makes it preferable to many

other newer risk assessment methods. Coupled with shrewd clinical assessment, the Norton Scale is a

valuable tool in detecting patients at risk to develop pressure sore (van Marum, 2000).

The table below depicts the Norton Score (Norton, 1989):

CRITERION SCORE

Physical condition 4 = Good

3 = Fair

2 = Poor

1 = Very bad

Mental condition 4 = Alert

3 = Apathetic

2 = Confused

1 = Stupor

Activity 4 = Ambulant

3 = Walk with help

2 = Chair bound

1 = Bed bound

Mobility 4 = Full

3 = Slightly impaired

2 = Very limited

1 = Immobile

Incontinent 4 = Not

3 = Occasionally

2 = Usually/Urine

1 = Doubly

*Calculated as the sum of the scores in all 5 areas. A score < 14 indicates a high risk of pressure

ulcer development.

Table 2 Norton Scale

4

More than 30 different pressure sore assessment scales are in use today, the ones in common

employ include the Braden Scale, the Waterlow Scale, the Cubbin–Jackson Score, and the

Pressure Sore Prediction Score (PSPS) (Pancorbo-Hidalgo, 2006).

5

OBJECTIVES

General Objective

To determine the common surgical cases in medical wards and common medical cases in surgical wards in

Hospital Selayang from 17th May 2010 to 22nd June 2010 with special attention to pressure sore.

Specific Objectives

1. To identify the problems in managing pressure sore as well as common surgical cases in medical

wards and common medical cases in surgical wards in Hospital Selayang.

2. To describe the sociodemographic characteristics of patients admitted to the surgical wards (4A and

4B) and medical wards (9C and 9D) of Hospital Selayang from 17th May 2010 to 22nd June 2010.

3. To measure the burden of pressure sore in medical and surgical wards in Hospital Selayang.

4. To describe the risk factor of pressure sore.

5. To identify the type of dressings used for pressure sore.

6. To measure the prevalence of gastritis, deep vein thrombosis and gastrointestinal bleeding in

medical wards in Hospital Selayang and identify their management respectively.

7. To measure the prevalence of diabetes mellitus and hypertension in surgical wards in Hospital

Selayang and identify their management respectively.

8. To recommend to the respective departments on pressure sore as well as common surgical cases in

medical wards and common medical cases in surgical wards, and the importance in optimal

management of these conditions.

6

METHODOLOGY

Study Place

The study was conducted in the general medical wards (9C and 9D), and the general surgical wards (4A and

4B) of Hospital Selayang, Kuala Lumpur.

Study Period

The study was conducted from 17th May 2010 to 22nd June 2010, totalling 5 weeks.

Study Design

A cross sectional study was conducted among the patients in the wards mentioned above. This study design

was chosen since it best reflects the intent of the study. Its simplicity and rapid execution is also an

advantage given the limited time-frame of the study.

Study Population

Patients admitted to the wards 9C, 9D, 4A, and 4B of Hospital Selayang.

Sampling method

Purposive sampling was employed, in which patients who either presented with an existing pressure sore

during admission, or those who developed pressure sore during their stay are taken as samples.

Inclusion Criteria

All patients admitted to the aforementioned wards.

Exclusion Criteria

Patients for whom no proper documentation was done.

7

RESULTS

Demographic Data

Wards Admission

For the entire duration of the study, a total number of 395 patients were admitted to the medical

wards, 210 of whom are female while the rest are male.

Another 292 patients were admitted to the surgical wards, but there were more males, totaling

169, than there were females.

Wards Female, N Male, N Total, N

Medical 210 185 395

Surgical 123 169 292 Table 3 Number of Admissions to Medical and Surgical Wards

Sample Population

Among those admitted, 27 patients from the medical wards were identified to have surgical

problems, and they were included in the study sample. Conversely, a total of 34 patients in the

surgical ward were found to have medical problems, and thus were included in the study. In total,

61 patients were identified to qualify for the study.

The age of the sample population ranged from 11 to 94 years with a mean of 63.6 years and a

median of 63 years. The age distribution of the sample follows a non-normal distribution.

Based on gender distribution, 57% of the samples are male, while the rest are female. Most of the

sample is ethnic Chinese (47%), followed by the Malays (33%) and Indians (15%). Another 5% are

non-Malaysians.

Variables N %

Ward Medical 27 Surgical 34

Age 61 63.61(17.519)*

Gender Male 35 57.00 Female 26 43.00

Races Malay 20 33.00 Chinese 29 47.00 Indian 9 15.00 Others 3 5.00

*mean (standard deviation) Table 4 Demography of Sample Population

8

35(57%)

26 (43%)

Distribution of Sample Based on Gender

Male

Female

Figure 1 Age Distribution of the Sample Population

Figure 2 Distribution of Gender of Sample Population

N 61

Mean 63.61

Median 63.00

Mode 57

Minimum 11

Maximum 94

9

20(33%)

29 (47%)

9 (15%)

3 (5%)

Distribution of Sample Based on Races

Malay

Chinese

Figure 3 Distribution of Race of Sample Population

10

Pressure Sore

Frequency

Throughout the period of the study, 22 patients were identified to have developed pressure sore

either at home or in the wards.

16 of them from the medical wards, which represents 4.05% of total medical wards admission in 9C

and 9D. On the contrary, 6 patients in surgical wards developed pressure sore, which represents

2.05% of total surgical wards admission in 4A and 4B.

Wards N %

Medical 16 4.05

Surgical 6 2.05

Table 5 Frequency of Pressure Sore in Medical and Surgical Wards

Figure 4 Frequency of Pressure Sore in Medical and Surgical Wards

4.05%

2.05%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Medical (9D & 9C) Surgical (4A & 4B)

Pe

rce

nta

ge (

%)

Ward

Frequency of Pressure Sore in Medical and Surgical Wards

11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Before Admission After Admission

Pe

rce

nta

ge (

%)

Onset of Pressure Sore

Onset

Of the total 22 patients who were identified to have pressure sore, 50% were found to develop it

during ward admission, while another 50% were brought in with pressure sore.

Figure 5 Onset of Pressure Sore

Risk Factors

The Norton score was used to identify the group of patients at high risk to develop pressure sore.

The parameters for Norton score include physical condition, mental condition, activity, mobility and

incontinence.

Based on Norton score, 86% of the 22 patients who developed pressure sore were in the high risk

group.

Figure 6 Risk Factors of Pressure Sore Based on Norton Score

14%

86%

Risk Factors of Pressure Sore Based on Norton Score

Low risk > 14High Risk ≤14

12

Stage

Among those who developed pressure sore, most of them, 45.5% were in stage II, while 31.8% were

in stage I. There was no patient who developed stage IV pressure sore throughout the study period.

Figure 7 Frequency of Pressure Sore Based on Stages

31.8%

45.5%

22.7%

0.0% 0%

10%

20%

30%

40%

50%

Stage I Stage II Stage III Stage IV

Pe

rce

nta

ge (

%)

Axis Title

Frequency of Pressure Sore Based on Stages

13

Management

In the wards, nursing management including periodical repositioning of patients, usage of Ripple’s

mattress, skin care, dressing as well as surgical managements were done.

Focusing on the types of dressings used to manage pressure sore, 36.4% of the total 22 patients had

normal saline dressings, 31.8% had patch-based dressings (the most commonly used being

Duoderm patch), and 13.6% had gel-based dressing (the most common of which is Duoderm gel).

However, there were about 9.1% of the patients had no dressings for the management of their

pressure sores.

Honey dressing was no longer the standard dressing for management of pressure sore in Selayang

Hospital, and none of the patients seen for the study had honey dressing as part of their pressure

sore management.

Figure 8 Type of Dressing Used for Pressure Sore

36.4%

13.6%

31.8%

9.1% 9.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Normal saline Gel-based Patch-based Povidone Nil

Pe

rce

nta

ge (

%)

Types of Dressing Used for Pressure Sore

14

Complications

18.2% of patients with bed sore developed local complications including infected wound and

superficial gangrene.

Figure 9 Local Complications of Pressure Sore

On the other hand, 4.5% from the total patients with pressure a sore developed general

complication which is sepsis.

Figure 10 : General Complications of Pressure Sore

18.2%

81.8%

Local Complications of Pressure Sore

Yes

No

4.5%

95.5%

General Complications of Pressure Sore

Yes

No

15

Surgical Cases in Medical Wards

Frequency

The total number of admissions to the medical wards for the study period was 234 patients.

Of these, 27 (11.5%) were found to have surgical problems.

2.99% of the patients in the medical wards developed gastrointestinal bleeding. Another 2.14% had

gastritis and 1.71% were given prophylactic treatment for gastritis (denoted “potential” gastritis). In

addition, 1.28% of total medical wards admission had deep vein thrombosis with 1.71% given

prophylaxis for deep vein thrombosis (denoted “potential” deep vein thrombosis).

Figure 11 Surgical Cases in Medical Wards (9C and 9D)

2.14%

1.28%

2.99%

1.71%

1.71%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

Gastritis Deep Vein Thrombosis GastrointestinalBleeding

Pe

rce

nta

ge (

%)

Diseases

Surgical Cases in Medical Ward (9C and 9D)

Potential

Yes

16

Gastritis Management

All of the patients who had been treated for gastritis were given single type of medications and no

other intervention was done. Out of that 66.67% were given proton pump inhibitors, while the rest

were given H2 antagonists.

Figure 12 Gastritis Management in Medical Wards

Deep Vein Thrombosis Management

Deep vein thrombosis cases in medical wards were managed using either medical, pharmacological

or surgical management, or a combination thereof.

All of the patients treated for deep vein thrombosis were given mechanical managements such as

TED stockings and ambulation. 28.6% were given pharmacological managements which included

low-molecular weight heparin and warfarin. However, none of them needed surgical intervention.

Figure 13 Deep Vein Thrombosis in Medical Wards

66.67%

33.33%

0%

20%

40%

60%

80%

Proton Pump Inhibitor H2 Antagonist

Per

cen

tage

(%

)

Type of Medication

Management of Gastritis in Medical Wards

100%

28.60%

0% 0%

20%

40%

60%

80%

100%

Mechanical Pharmacological Surgical

Pe

rcen

tage

(%)

Management of Deep Vein Thrombosis in Medical Wards

17

Gastrointestinal Bleeding Management

Most of the patients (57.1%) in the medical wards with gastrointestinal bleeding had undergone

endoscopic intervention. On the other hand, 28.6% were given medications such as proton pump

inhibitors and H2 antagonists. However, a total of 14.3% had no active management.

Figure 14 Gastrointestinal Bleeding Management in Medical Wards

57.1%

28.6%

0.0%

14.3%

0%

10%

20%

30%

40%

50%

60%

Endoscopic Medications Surgical No ActiveManagement

Pe

rce

nta

ge (

%)

Management of Gastrointestinal Bleeding in Medical Wards

18

Medical Cases in Surgical Wards

Frequency

In this study, the frequency of diabetes mellitus and hypertension in surgical wards (4A and 4B) for

the two weeks durations were calculated. The total surgical wards admission for the designated

period was 150 patients, of whom 34 (22.6%) were identified to have medical problems.

A total 13.33% from the total surgical admission had diabetes mellitus while 17.33% had

hypertension.

Figure 15 Medical Cases in Surgical Wards

13.33%

17.33%

0%

5%

10%

15%

20%

Diabetes Mellitus Hypertension

Per

cen

tage

(%

)

Diseases

Medical Cases in Surgical Wards (4A and 4B)

19

Management of Diabetes Mellitus

95% of the diabetic patients in surgical wards received active management. Most of the diabetic

patients in surgical wards were treated with insulin therapy which accounts for 60% of them. Of

those receiving insulin therapies, 42% were put on sliding scale, 33% were on mixed type insulin,

17% were on short-acting insulin while the rest was on long acting insulin.

Figure 16 Management of Diabetes Mellitus in Surgical Wards

Figure 17 Types of Insulin Management in Surgical Wards

0%

10%

20%

30%

40%

50%

60%

70%

Insulin Oral HypoglycaemicAgent

No Active Management

Pe

rce

nta

ge (

%)

Management of Diabetes Mellitus in Surgical Wards

8%

17%

33%

42%

Types of Insulin Management in Surgical Wards

Long Acting Insulin

Short Acting Insulin

Mixed Type Insulin

Sliding Scale

20

Management of Hypertension

96.15% of hypertensive patients in surgical wards received anti-hypertensive agents for the

management of hypertension. Among those, 46.15% received single anti-hypertensive treatment

and 34.62% received double anti-hypertensive therapy.

Figure 18 Management of Hypertension in Surgical Wards

46.15%

34.62%

15.38%

3.85%

0%

10%

20%

30%

40%

50%

1 type 2 types 3 types No Medication

Pe

rce

nta

ge (

%)

Anti-Hypertensive Agent

Management of Hypertension in Surgical Wards

21

DISCUSSIONS

1. Demographic Data

The total number of patients admitted to the medical wards and surgical wards were unequal, which could

possibly lead to bias in the results. Gender distribution was almost equal, with males slightly outnumbering

females. This may be partly explained by the relative prevalence of chronic medical and surgical diseases

among males in the general population, resulting in more males being admitted.

The age of samples does not follow a normal distribution. The results showed that most of the samples were

elderly. There would inevitably be bias in the upcoming results, since it is expected that common medical

and surgical disorders, as well as pressure sore would be more common in the elderly.

Racial distribution was also not equal and not representative of the Malaysian population. This likely reflects

the local demography at Selayang, where the majority of the population is of Chinese ethnicity.

2. Pressure Sore

2.1. Frequency

The result showed that the occurrence of pressure sore in medical wards was higher than in surgical wards.

From our observation, this could possibly be due to the understaffed medical wards which are most of the

time overcrowded with admissions. In addition, far more patients were admitted to the medical wards,

leading to higher patient turnover as well as bed occupancy rate. This situation may result in suboptimal

management of those patients who are at risk of developing bed sore. Since the management of pressure

sore in medical and surgical wards was mostly manpower-dependent, it is wise to increase the number of

staff members in the wards for the better quality of in-ward management.

2.2. Onset

Those patients who came in with pressure sore were found to not be managed adequately by the caretakers,

as a result of poor counseling for proper management of pressure sore at home by medical personnel.

Besides that, they were also not given adequate training to handle such patients. In addition, most of the

patients and their family members have poor to moderate income; they cannot afford to purchase and do

the dressing themselves. In order to minimize the occurrence of pressure sore in community (before

admission), frequent home visits for the patients that are susceptible to develop pressure sore could help in

educating the family members in proper management and prevention of pressure sore.

2.3. Risk Factors

The Norton score was used to identify the susceptibility of a patient to develop pressure sore. The

parameters included in the Norton score include physical condition, mental condition, activity, mobility and

incontinence.

22

Based on the score, 86% of the 22 patients who developed pressure sore were in the high risk group. This

shows that appropriate bed sore prophylaxis is crucial especially for these high risk patients in order for

them to not develop bed sore during their stay in the hospital.

2.4. Stage

Among those who developed pressure sore, the majority of them (45.5%) had stage II pressure sore. This

observation could be postulated to be due to late detection of the sore while it was still in stage I, thus its

progression to stage II.

2.5. Management

In the wards, nursing managements including repositioning of patients, usage of Ripple’s mattress, skin care,

and dressing as well as surgical managements were done.

There were about 9.1% of the patients had no dressings whatsoever for the management of their pressure

sores. This situation arises probably due to lack of referral to the team that manages patients with pressure

sore by the team receiving the patient.

2.6. Complications

Although the majority of patients did not develop complications from pressure sore, complications could still

be prevented in those few who did develop them. The situation arises probably due to late detection of

pressure sore in early stage that further lead to delay in management of pressure sore.

3. Surgical Cases in Medical Wards

3.1. Frequency

The results show that there is a significant number of surgical cases in medical wards. Hence, good

interdepartmental communication between surgery and medical is needed in order to provide a better

management of the patients.

3.2. Gastritis Management

Most patients recovered within days after initiating gastritis management. Hence it showed that proper

management was taken in managing gastritis in medical wards.

3.3. Deep Vein Thrombosis Management

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Most patients in medical wards that had deep vein thrombosis fully recovered due to proper management in

the medical wards. The occurrence of deep vein thrombosis in susceptible patients was also reduced due to

active management from the medical staff in preventing deep vein thrombosis.

3.4. Gastrointestinal Bleeding Management

From the results, a total of 14.3% of patients who developed GI bleeding had no active management. From

our observation in the wards, these patients have succumbed to his primary illness before the management

of gastrointestinal bleeding was initiated.

4. Medical Cases in Surgical Wards

4.1. Frequency

From the results, it showed that there is a significant number of diabetes mellitus and hypertension cases in

the surgical wards. Again, good interdepartmental communication between surgery and medical is

paramount in order to provide a better management of the patients. Referral of the patients that had

uncontrolled hypertension and diabetes mellitus or who had related complication of the illnesses were

practised and should be enhanced for better management of the patients’ conditions.

Besides that, a well-versed knowledge in these conditions management among surgical wards staff members

is helpful in providing proper management in these conditions.

4.2. Management of Diabetes Mellitus

Most diabetic patients in surgical wards were treated using insulin in order to optimize their blood sugar

level before surgical operation since it is easier to control. Infusion of insulin using sliding scale was used for

patients who had uncontrolled blood sugar level who were scheduled for surgery.

Besides that, oral hypoglycemic agents, particularly metformin, could lead to lactic acidosis in post-operative

patients. However, surgical patients who were not indicated for surgical operation were still treated using

oral hypoglycemic agents in surgical wards.

4.3. Management of Hypertension

Management of hypertension was based on previously prescribed antihypertensive medication by medical

practitioners. Most patients simply had their previously prescribed medications continued in the wards.

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LIMITATIONS

Whilst every effort was made to ensure accuracy and reliability of the results, bias inevitably exists

that would affect the results. One obvious shortcoming is the study model itself. A cross-sectional study

means that the exposure and outcome are measured at a single point of time. While easier to execute, it can

only establish association, not causation. A cohort study is needed for causality to be conclusively

established.

In addition, this study model involves only a relatively short duration (5 weeks), which may cause the

results to not be representative of the actual figures. Poor record-keeping may also result in certain patients

with the disorders under study go undetected.

The study was limited to Hospital Selayang, where the majority of patients are of Chinese ethnicity

and live in urban areas. This demography may be true for Selayang, but is hardly representative of the whole

Malaysian population.

CONCLUSION

This study concludes that the prevalence of pressure sore in the medical and surgical wards of

Hospital Selayang in May 2010 is 4.05% and 2.05%, respectively. The majority of patients (86%) were found

to be at high risk to develop sore, and almost half of the samples (45.5%) had stage II pressure sore. It was

found that half of the total patients developed sore in the wrds, while another half developed it prior to

admission. Nursing care was generally satisfactory, and the type of dressing most used is normal saline

(36.4%) and Duoderm patch (31.8%). Only a small minority developed local (18.2%) or general complications

(4.5%).

The most common surgical disorder among patients in the medical wards is gastritis, with 2.1%

having developed gastritis, while another 1.7% are potentially at high risk to develop it. This is followed by

deep vein thrombosis, with 1.3% of patients having developed it, while another 1.7% are at risk. 3.0% of

patient in the ward developed gastrointestinal bleeding during their stay.

Overall, hypertension was found to be more common than diabetes mellitus among the patients in

the surgical wards, with a prevalence of 17.3%. The majority of these patients receive anti-hypertensive

monotherapy in the wards. 13.3 % had diabetes mellitus, the majority of whom required insulin as part of

their diabetes management.

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Norton, D. (1989). Calculating the risk: Reflections on the Norton Scale. Decubitus, 2, 24.

Pancorbo-Hidalgo, P., Garcia-Fernandez, F., Lopez-Medina, I., & Alvarez-Nieto, C. (2006). Risk

assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced

Nursing, 54(1), 94-110.

Phillips, L., & Buttery, J. (2009). Exploring pressure ulcer prevalence and preventative care. Nursing

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Stausberg, J., Kröger, K., Maier, I., Schneider, H., & Niebel, W. (2005). Pressure ulcers in secondary

care: incidence, prevalence, and relevance. Advances in Skin & Wound Care, 18(3), 140.

van Marum, R., Ooms, M., Ribbe, M., & Van Eijk, J. (2000). The Dutch pressure sore assessment

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APPENDIX I – RESEARCH CONSENT FORM

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APPENDIX II – RESEARCH RECORD FORM

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