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
 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%.

ii
 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)

iii
 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.

iv
 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

v
 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

vi
 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

vii
 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.
 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.
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.
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.
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.
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.
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.
Table 1 NPUAP Stages of Pressure Sore
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.
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)
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
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.
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.
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

2
 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

3
 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).

4
 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.

5
 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.

6
 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

7
 N 61
Mean 63.61
Median 63.00
Mode 57
Minimum 11
Maximum 94

Figure 1 Age Distribution of the Sample Population

Distribution of Sample Based on Gender

26 (43%)
Male
Female
35(57%)

Figure 2 Distribution of Gender of Sample Population

8
 Distribution of Sample Based on Races
3 (5%)

9 (15%)

20(33%)

Malay

Chines
e

29 (47%)

Figure 3 Distribution of Race of Sample Population

9
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

Frequency of Pressure Sore in

Medical and Surgical Wards
5.0%
4.05%
4.0%
Percentage (%)

3.0%
2.05%
2.0%

1.0%

0.0%
Medical (9D & 9C) Surgical (4A & 4B)
Ward

Figure 4 Frequency of Pressure Sore in Medical and Surgical Wards

10
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.

Onset of Pressure Sore

100%
90%
80%
70%
Percentage (%)

60%
50%
40%
30%
20%
10%
0%
Before Admission After Admission

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.

Risk Factors of Pressure Sore

Based on Norton Score
14%

Low risk > 14

High Risk ≤14

86%

Figure 6 Risk Factors of Pressure Sore Based on Norton Score

11
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.

Frequency of Pressure Sore

Based on Stages
50% 45.5%
Percentage (%)

40% 31.8%
30% 22.7%
20%
10%
0.0%
0%
Stage I Stage II Stage III Stage IV
Axis Title

Figure 7 Frequency of Pressure Sore Based on Stages

12
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.

Types of Dressing Used for Pressure Sore

40%
36.4%
35%
31.8%

30%

25%
Percentage (%)

20%

15% 13.6%

9.1% 9.1%
10%

5%

0%
Normal saline Gel-based Patch-based Povidone Nil

Figure 8 Type of Dressing Used for Pressure Sore

13
Complications

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

Local Complications of Pressure Sore

18.2%

Yes

No

81.8%

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.

General Complications of Pressure Sore

4.5%

Yes
No

95.5%

Figure 10 : General Complications of Pressure Sore

14
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).

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

4.5%

4.0%

3.5%

3.0% 1.71%
Percentage (%)

2.5%
1.71%
2.0% Potential
1.5% 2.99% Yes

1.0% 2.14%
1.28%
0.5%

0.0%
Gastritis Deep Vein Thrombosis Gastrointestinal
Bleeding
Diseases

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

15
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.

Management of Gastritis in
Medical Wards
80% 66.67%
Percentage (%)

60%
40% 33.33%

20%
0%
Proton Pump Inhibitor H2 Antagonist
Type of Medication

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.

Management of Deep Vein

Thrombosis in Medical Wards
100%
100%
80%
Percentage(%)

60%
40% 28.60%
20%
0%
0%
Mechanical Pharmacological Surgical

Figure 13 Deep Vein Thrombosis in Medical Wards

16
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.

Management of Gastrointestinal
Bleeding in Medical Wards
60% 57.1%

50%
Percentage (%)

40%
28.6%
30%
20% 14.3%
10%
0.0%
0%
Endoscopic Medications Surgical No Active
Management

Figure 14 Gastrointestinal Bleeding Management in Medical Wards

17
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.

Medical Cases in Surgical Wards (4A and

4B)
20%
17.33%
Percentage (%)

15% 13.33%

10%

5%

0%
Diabetes Mellitus Hypertension
Diseases

Figure 15 Medical Cases in Surgical Wards

18
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.

Management of Diabetes Mellitus in

Surgical Wards
70%

60%

50%
Percentage (%)

40%

30%

20%

10%

0%
Insulin Oral Hypoglycaemic No Active Management
Agent

Figure 16 Management of Diabetes Mellitus in Surgical Wards

Types of Insulin Management in

Surgical Wards
8%

17%
Long Acting Insulin
42%
Short Acting Insulin
Mixed Type Insulin
Sliding Scale

33%

Figure 17 Types of Insulin Management in Surgical Wards

19
 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.

Management of Hypertension in Surgical Wards

50% 46.15%

40%
34.62%
Percentage (%)

30%

20% 15.38%

10%
3.85%

0%
1 type 2 types 3 types No Medication
Anti-Hypertensive Agent

Figure 18 Management of Hypertension in Surgical Wards

20
 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.

21
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

22
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.

23
 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.

24
 REFERENCES
Black, J., Baharestani, M., Cuddigan, J., Dorner, B., Edsberg, L., Langemo, D., et al. (2007). National
Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Advances in Skin &
Wound Care, 20(5), 269-274.

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
times, 105(16), 34.

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
score or the Norton scale for identifying at-risk nursing home patients? Age and Ageing,
29(1), 63.

25
APPENDIX I – RESEARCH CONSENT FORM

26
27
APPENDIX II – RESEARCH RECORD FORM

28
29
30
31