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Twin Cities District Dietetic Association Meeting
November 9, 2010
Kim Bihm, RD, LD, CDEMary Murphy, RN, MA, CWOCN
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ObjectivesIdentify anatomy and physiology of skinDescribe prevention strategies to reduce
incidence of pressure ulcersDescribe an interdisciplinary approach to
prevention and treatment of pressure ulcersDefine nutritional treatment modalities for
wound healing.
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Why should we care?Complications to patients
Lead to pressure ulcersPainfulInfectionQuality of Life
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Why should we care?Cost
HospitalizationsHealth care workers Skin Care Products
Reduction in payment from regulatory bodies
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Incidence of Pressure Ulcers (PU)Data from the NPUAP
Volume: 1-3 million people in US develop PU/year
Mortality: 60,000 people die from PU complications/year
Quality of Life: PU reduce quality of life due to pain, treatments, increased length of institutional stay, etc.
Finances: Cost of treating PU ranges from 5-8.5 billion dollars/year
Legal: 87% of verdicts from NH cases goes to PlaintiffAverage award is $13.5 millionHighest award is $312 million in one case!
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Clinical Practice Guidelines by NPUAP/EPUAP:Evidenced-Based Practice
Best scientific research availableSystemic review of literatureProvides tools for best judgmentAllows decision-making on more
than “expert opinion” alone.
DOES NOT dictate practice or replace clinical reasoning or judgment – it ENHANCES these!
These are guidelinesPolicies are absolute
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An interdisciplinary approach to prevention and treatment of pressure ulcers• Hospital skin team
– Registered Dietitian– Wound, Ostomy, Continence nursing– Occupational Therapy/Physical Therapy– Physicians – primary/specialty
• Plastic surgery
– RN staff– Respiratory Therapy– Education staff– Nursing Manager– Pharmacist
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Interdisciplinary Approach
PhysicianC-collar inspection
orders
NursingPressure Ulcer
Protocol
NutritionHigh protein, high
calorie diet with snacks and supplements
Physical TherapyWheelchair cushion
pressure mappingAvoiding shear during
transfers
Occupational TherapyCognitive screeningAssistive Technology
Speech TherapyMemory assessmentCognitionCommunicationAssistive Technology
All disciplines need to assess for risk and put prevention interventions into place:
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Prevention: Risk Assessment
Co-morbiditiesPrevious PUSmoking hx
Long OR timeLong ED staysCritically ill – ICU= 4x moreWheelchairsObese/thin
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Guidelines to Preventing Pressure Ulcers
Combination of Risk Assessment + Skin Inspection + Clinical JudgmentReassess RISK
Upon admissionAt regular frequencyChange in condition
Skin InspectionsHead to toe inspection regularly
Individualized plan of careUse Interdisciplinary Approach
MD, Nutrition, PT/OT, Speech Therapy
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Anatomy and Physiology of SkinLargest organ of the bodyWeight: up to 15% of body weight – about 6
poundsSize: Average adult – 3000 square inchesReceives 1/3 of body’s circulating blood
volumeConstantly exposed to changing
environmentsHas capability to self-regenerate
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Skin Layers: EpidermisOutermost layer made of epidermal cellsThin and avascularRegenerates every 4-6 weeksMelanocytes reside in epidermis
Melanin is pigment responsible for color of skin
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Skin LayersDermis
Thicker layerContains:
blood vesselshair follicleslymphatic vesselssebaceous glandssweat and scent glandsnerve endings
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Skin Layer: Dermis•Collagen:
•Major structural protein•Gives skin strength•Anchors dermis to hypodermis layer
•Elastin:•Responsible for skin recoil and resiliency•Allows skin to stretch
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Skin Layers: HypodermisSubcutaneous Tissue
Composed of adipose and connective tissueFilled with major blood vessels, nerves and
lymphatic vesselsAttaches dermis to underlying structuresProvides insulation and cushioning to bodyActs as a ready reserve of energy
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Functions of SkinBody Image
Maintenance of body formAppearance, attributes and expression
SensationAbundant nerve receptors in skin
TouchHeat/ColdPainPressure Moisture
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Functions of SkinRegulation of body temperature
98.6 F / 37 CThermoregulatory mechanisms:
CirculationBlood vessels dilate to dissipate heatBlood vessels constrict to shunt heat to body organs
Sweating2-5 million sweat glands
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Functions of SkinProtection
Safety against sunburnMelanin in the epidermal cells protects against
ultraviolet light
MetabolismVitamin D formation
Presence of sunlightThis activates the metabolism of calcium and
phosphate and minerals (important in bone formation)
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Functions of SkinProtection
Barrier to germs and poisons Normal floral =
Staph AureusDiphtheroidsGram neg bacilliNOT Candida – That comes from GI tract
Chemical defensesSweat, oils, wax from skin glands contain lactic acid
and fatty acidThese acids make skin pH acidic to kill bacteria and
fungi
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Functions of SkinMaintenance of water balance
Prevents loss of water through evaporation<10% moisture – cells shrink = increase invasion of bacteria
>30-40% moisture level = macerationIncreased permeabilityIncreased risk of injury from friction
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Theory of pHpH refers to management of acid or base
levels Acidic is 0-6Neutral is 7Basic is 8-14
Rain is 5.6Seawater is >7Milk is <7Gastric juices are acidicSaliva and blood are neutral
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Skin pHSkin pH is 4-6.8 with mean of 5.5
Depends on area of body
Urine, stool, soap and frequent cleansing will increase pH to more basic levelsPooled urine changes pH to 7.1 – or alkaline
shift = this contributes to overgrowth of bacteria
Patients with fecal incontinence are 22x more likely to develop pressure ulcers
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Skin Changes
Age-Related changes:Functions declineEpidermal/dermal junction flattens
Decreases skin strengthIncreases risk for tearing
Melanocytes shrink (decrease in volume)Increases sensitivity to sun
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Skin ChangesAge-Related changes:
Decreased sweat production Leads to increased dryness and flaking
Nutrition changesMedications
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Guidelines to Preventing Pressure UlcersSkin Inspections
Checking all bony prominences Check under skin foldsCheck under medical devicesCheck where there is limited sensationEducate professional staff on skin conditions
for early identificationTechnique for blanching responseHow to assess warmth, edema, and induration
Set time frame for on-going inspections
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What are Pressure Ulcers? Pressure ulcer definition:
A pressure ulcer is 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.
Different from:Neuropathic ulcers
Arterial ulcers Venous
ulcers
Trauma injuries
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Stage I Pressure UlcersIntact skin with non-
blanchable redness of a localized area- usually over a bony prominence.
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Stage II Pressure UlcersPartial 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 ruptured serum-filled blister.
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Stage III Pressure UlcersFull thickness tissue
loss. Subcutaneous fat may be visible but not bone, tendon, muscle.
Slough may be present, but does not obscure the depth of tissue loss.
May include undermining and tunneling
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Stage IV Pressure UlcersFull thickness tissue
loss with exposed bone, tendon or muscle.
Slough/eschar may be present.
Often includes undermining/tunneling.
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Unstageable Pressure UlcersFull thickness tissue
loss in which actual depth of ulcer is completely obscured by slough and/or eschar.
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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/ shear.
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Iatrogenic Damage:Pressure Injury from Medical Devices
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Assess for Risk by RNBraden Risk Assessment (by Barbara
Braden)Reliable research based risk assessment tool
SensoryMobilityActivityFriction/ShearNutrition Moisture
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Risk due to Sensory ImpairmentCan they feel?
Prevention:If they can’t feel – someone must look at skin!!Check under devicesCheck for proper fitting shoes and socksNeed redistribution mattress
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Risk due to Mobility ImpairmentCan they move themselves?
Prevention:Must be turned every 2 hoursMust be trained in proper pressure reliefMust have pillows elevated
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Risk due to ActivityCan they walk?Are they bedfast? Chair fast?
Prevention:Do they have a PT/OT consult?Do they have a proper fitting wheelchair
cushion?Must have training in pressure relief
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Risk due to Friction and ShearAre they sliding in bed or wheelchair?
Prevention:Watch transfers from w/c to bed
If concerned, get PT/OT consult
Manage spasticityReport concerns to MD
Keep knee gatch up in bed to prevent sliding in bed
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SKIN INSPECTIONS:Bony Prominences To Check
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Support SurfacesHow to make sense of the confusion????
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What Do We Know- Evidence
Pressure = Force/AreaPressure is caused by perpendicular force =
Treatment = pressure redistributionPressure redistribution = depth of pressure without
bottoming out
Shear is parallel force = Treatment = prevent sliding
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Features of Support SurfacesAir Fluidized
A feature that provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment
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Features of Support SurfacesLow Air Loss
A feature that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin.
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Features of Support SurfacesFoam
Elastic foam or Visco-elastic foam
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Features of Support SurfacesGel
A feature that is a solid, jelly-like material that can have properties ranging from soft and weak to hard and tough. It is a soft molding layer that contours around the shapes and bumps of the human body. Consider
gel products for zone
redistribution
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Features of Support SurfacesAlternating Pressure
A feature that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude and rate of change parameters.
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Repositioning – Evidence ARelieve/redistribute pressure30 degree side lying is importantAlternate positionsAvoid shearAvoid lying on medical devicesAvoid slouching in w/c – use footplatesAvoid HOB elevation: HOB = shear/pressureElevate heels Consider “zone” positioning changesConsider: Every layer on top of surface changes
the surface supportThink of chux/linen/briefs = change in performance of
bed
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Wheelchair cushionsCheck w/cushion –
pressure mapping
Check chair positionBack tilt w/ legs upUpright w/ foot
rests
Limit sitting time
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Risk due to MoistureIs their skin too moist?Prevention:
Avoid plastic diapersAvoid extra pads that retain heat Skin barrier protection is critical
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Moisture Prevention Goals:Promote health of epidermis
Maintain intact epidermal barrier
Eliminate/minimize exposure to irritants
Treat infection if present
Create environment for healing damaged skin
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Prevention StrategiesKeep skin clean, dry and protected
Toileting programStructured bowel program
Gentle cleansing-avoid mechanical irritationBalanced pH cleanser + moisturizer or humectantsSoft cloth vs. wash clothPat dry
Skin protectant/barrierDimethiconePetrolatumZinc
Moisturizer - Emollient
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Products: UnderpadsBriefs/ underpads
Needs to be highly absorptiveNeeds to quickly wick moisture away from patient
Plastic/cloth absorptive products are occlusive Trap perspiration = increase heat/moisture =
increase skin damageTypically made of 3 layers:
Water-permeable cover next to skinAbsorbent core (holds in moisture increasing heat)Water proof backing
Look for product that “wicks” moisture away (polymer)
Adhesive tabs seal and reseal as needed for easy inspection
Durable – resist tearingDifferent sizesBreathable
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ProductsConsider containment products
External cathetersIndwellingSuprapubic cathetersIntermittent CathetersFecal pouchesFecal tubes
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Complex Process of Wound Healing
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Risk due to NutritionAre they eating/drinking enough?Prevention:
Need RD consult for any Braden score of 1 or 2
High protein dietImportance of snacks and supplementsGood hydrationMultivitamins/ mineralsLabs: prealbumin
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NutritionScreen for nutritional deficiencies
Send nutrition consultsMonitor for signs of dehydration – I/OsMonitor weight changesHighlight Braden Subcategory of Nutrition
Prioritize protein intake
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Specific RecommendationsOffer high protein supplements in addition to
usual diet.Plan for supplement 60 minutes between
meals
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Resource for Nutrition
The Role of Nutrition in Pressure Ulcer Prevention and Treatment:National Pressure Ulcer Advisory Panel
White Paper
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Patient/Caregiver Education
Causes/ risk factors for PU developmentWays to minimize risk:
Regular inspectionsPrevent friction/shearRoutinely turn/repositionAvoid use of rings, foam cut outs, donut-type
devicesMaintain adequate nutrition and fluid intakeMonitor for weight loss, poor appetitePromptly report health care changes to providers
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TREATMENT of Pressure Ulcers:GOLD STANDARD of Wound Healing:
Good signs of healing by 2 weeks30% healing at 4 weeksFull closure at 12 weeks
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Guidelines to Treatment of Pressure UlcersPrinciples of wound healing:
Eliminate cause – moisture, pressure, shear , friction
Wound cleansingKeep infection free
Topical treatments Moist wound healingProtect periwoundRefer as necessary for debridementManage nutrition
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Repair of Skin DamageRepair of partial thickness skin damage
RegenerationDamage is confined to epidermal and superficial
dermal layersEpithelial cells will reproduce
Trauma triggers inflammatory responseErythema, Edema, Serous exudate
Epidermal resurfacing beginsDay 7 - new blood vessels sproutDay 9- Collagen fibers are visible
Collagen synthesis continues until about day 10-15
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Repair of Skin DamageRepair of full thickness skin damage
Scar formationDamage is deeper – to deeper dermal structures
(hair follicles, sebaceous glands and sweat glands), subcutaneous tissue, muscle, tendons, ligaments, bone
Damage is permanent.
Healing is done by primary or secondary intentionPrimary intention – surgical closureSecondary intention –scar formation
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Repair of Skin DamageScar formation process is complex with
several phases:Hemostasis phase
Clot formationInflammatory phase
Clean up phaseTakes 3-4 days usually
Proliferation phaseVascular integrity restoredNew connective tissue is growingGranulation tissue growthWound contraction
Maturation / Remodeling phase
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Wound Management StrategiesWound cleansing – Evidence C
Cleanse wound and periwound with each dressing changeProvide enough pressure to remove debris but not
cause trauma (trauma = increase risk of infection)Product: Ok to use water/NS/ wound cleanser
(reduces friction with surfactant)Ok to shower open wound
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Wound Management StrategiesManage wound infections
Contamination Non-replicating organisms
Colonized Bacteria in wound bed Organisms are attached and replicating Not affecting the environment
Common organisms: staph and pseudomonasCritically colonized
Wounds with more than 100,000 organisms will not heal Perpetual inflammatory phase Wound culture recommended at this point- 70% MRSA now
Infection Invasion of the soft tissue Clinically ill Dose x virulence/ host response
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Wound Management Strategies
Topical AgentsDakin’s solution – Sodium hypochiorite – 0.25%
Good for gram - & + - best on staphBleach w/ chlorine active ingredient
Protect periwound skin with petroleum
Acetic Acid – 0.5%Good for gram - & + - Best on pseudomonas
Cadexomer Iodine -Good for gram - & +, and anaerobes
No resistance notedEffective in 48 hoursAbsorptiveLimit to 2 weeks – risk of dermatitis
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Wound Management Strategies
Topical AgentsSilver
Silver Sulfadiazine ointmentGood for gram -, Klebsiella, PseudomonasSeeing increased resistance to silver
Honey-broad antimicrobial coverage Important to consider due to increase in resistance Good for gram -& +, pseudomonas, e-coli Change pH of wound tissue Don’t use if allergy to bee-stings
Hydrophera blue- Broad antimicrobial coverage Polyvinyl alcohol sponge impregnated Methylene Blue and Gentian
Violet Good for broad spectrum coverage- including MRSA and VRE Dressing is highly absorptive so good for highly exudative wounds
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Wound Management StrategiesTopical antimicrobials – for tissue
organismsBactoban is resistant nowNeomycin/Neosporin – NO NEO! = contact
dermatitisGentamycin = nephrotoxicity and resistance
Bacitracin is ok stillGood for gram +Resistance is rare
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Wound Management StrategiesSystemic antibiotics for:
Bacterimia/ sepsisAdvancing cellulitisOsteomyelitis
95% of bone exposed is + for osteo
Caution: MRSA is very virulentCellulitis to pneumonia in 24-48 hours
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Wound Management StrategiesDebride the pressure ulcer of devitalized
tissueDebridement options:
SurgicalConservative sharp
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Wound Management StrategiesDebride the pressure ulcer of devitalized
tissueDebridement options:
High pressure fluid irrigationUltrasonic
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Wound Management StrategiesDebride the pressure ulcer of devitalized
tissueDebridement options:
MechanicalAutolyticEnzymatic
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Wound Management StrategiesDebride the pressure ulcer of devitalized
tissueDebridement options:
Maggot Therapy
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Wound Management StrategiesVAC Therapy
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Wound Management StrategiesElectrical Stimulation
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Wound Management StrategiesHyperbaric Oxygen Therapy
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Wound Management StrategiesLiving Skin Equivalents
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Wound Management StrategiesFlap Surgery –
Umar Choudry, MD
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Interdisciplinary Teamwork !!!!!
SCI Provider:Pre-op medical clearanceAnticoagulant assessment
Transfuse if Hgb < 8Spasticity management
Patient needs to lie straight for 3-4 weeks
WOC Nurse:Prep wound – VAC therapy
Pre-Surgery Preparation
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Nutrition ConsultAssess nutrition needsPre-albumin goal of >20 before surgeryZinc at least in normal range goalSupplemental vitamin C and multivitamin
Speech Therapy Consult (if hx of dysphagia/aspiration)
Assess risk of aspiration post-opMay need to consider non-oral feeding alternative
Pre-Surgery Preparation
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Physical Therapy and Occupational Therapy pre-op consults for baseline assessments
Physical TherapyTransfersSeating/Positioning including pressure mappingROMTone
Occupational TherapyADLsAdaptive Equipment needsFunctional transfersSeating/Positioning
Pre-Surgery Preparation
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Post-op Course3 weeks on Air Fluidized bed
Week 4Switch to low air loss bedBegin stretching
Week 5-6 Sitting program
Discharge week 6-7
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2009 to present:16 flap surgeriesZERO losses of the flap
VAMC -Mpls SCI Unit Outcomes:
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The Registered Dietitian’s
Role in Wound Healing
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Pressure Ulcer Prevention
• Global expert (NPUAP/EPUAP) consensus SUPPORTS nutritional assessment as part of a comprehensive interdisciplinary approach to preventing pressure ulcers!
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Pressure Ulcer PreventionNutritional assessment can identify under
nutrition, protein energy malnutrition, and unintentional weight loss (conditions that can contribute to the development of pressure ulcers or delay healing of pressure ulcers.
NPUAP white paper 2009
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Risk for Pressure Ulcers
Unintentional weight lossUnder nutritionProtein energy malnutritionLow BMIInability to eat independentlyCachexiaHyper metabolism
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Risk for Pressure UlcersDiabetes
Maintenance of proper glycemic control is vital to the healing process.
Blood glucose may be influenced by non-nutritional factors such as illness, stress, infection, wounds, etc
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Risk for Pressure UlcersDiabetes
Calorie needs are increased to promote wound healing.
The major fuel source for collagen synthesis is carbohydrates (~55% of calories should come from carbohydrates)
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Risk for Pressure UlcersDiabetes
Medications may need to be adjusted to accommodate increased carbohydrate intake.IV insulin drip may be used to control
blood sugars post-op
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Under Nutrition
Problems chewing and/or swallowing
Decrease ability to feed selfDecreased appetiteAdvanced ageUnintentional weight loss
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Unintentional Weight Loss
Can lead to:Impaired immune systemDecreased serum albumin &
prealbuminDecreased ambulationWeaknessDevelopment of pressure ulcersNon-healing pressure ulcers
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Loss of Lean Body MassDefined as the mass of the body minus the fat
that is metabolically active and accounts for ~75% of normal body wt.
When <10% of LBM is lost, wound healing has priority for protein substrate
When >10% of LBM is lost, the stimulus to restore LBM competes with the wound for protein
When >20% of LBM is lost, correction of the LBM takes precedence and wound healing stops
Medscape Today The Stress Response to Injury and Infection...:
• The Wound Healing Process and the Stress Response
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Prevention: Risk Assessment
Co-morbiditiesDiabetes
Renal diseaseImmunosuppressi
onMalnutrition
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Consultation of RDWhen to consult the Registered
Dietitian:When patient is identified as:
Being at risk for pressure ulcers Braden Risk Assessment score less than
19Braden Risk Assessment- Nutritional
sub-score of 1 or 2Existing pressure ulcerNewly discovered pressure ulcer within
24 hoursWorsening of a ulcer or with an ulcer not
progressing through the normal stages of healing
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Consultation of RDInadequate oral intake as shown by:
• NPO status or clear liquid diet for >3 days
• Eating <75% of meals for >3 days• Failure to consume nutritional
supplements >3 daysDifficulty chewing and/or swallowingUnable to eat independentlySignificant weight loss >5% in 30 days or
>10% in 180 days
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Example of Nutrition Consult Template
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Braden Risk Assessment Nutrition Subcategory1. Very Poor
Never eats or completes meal2 servings or < of proteinPoor fluid intake1/3 of any food offered or NPO or IV
fluids/clear liquids for > 5 days
NEEDS NUTRITION CONSULT
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Braden Risk Assessment Nutrition Subcategory2. Probably Inadequate
Eats ½ of any food offeredProtein: 3 servings of meat or dairy dailyOccasional intake of supplement or tube
feeding or liquid diet less than requirementsHow often is TF turned off for activities?
NEEDS NUTRITION CONSULT
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Braden Risk Assessment Nutrition Subcategory3. Adequate
Eats > 50% of most meals4 servings of protein dailyOccasionally refuses meal but takes
supplement or tube feeding or TPN meets needs
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Braden Risk Assessment Nutrition Subcategory4. Excellent
Eats most meals and never refuses a mealEats 4 or more servings of meat and dairy
dailyDoesn’t require supplements
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Nutrition Care Process
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Nutritional Assessment Data
Food / Nutrition historyLab data, medical test and proceduresAnthropometric measurements including
weight historyPhysical examination findings (i.e. brittle
nails, thinning hair, fragile & thin skin)Patient History
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Nutritional Assessment DataEstimating calories, protein, fluid, vitamin and
mineralsAdequacy of po intake (past and current)Barriers in meeting optimal nutrition -swallowing difficulties -chewing problemsCognitive deficits-ability to feed selfBraden Risk Assessment scale, BMI, weight
changes Individual goals and wishes of the patient
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Nutrition DiagnosisPES Statement
~60 nutrition diagnoses within 3 domains: 1- Clinical 2- Intake 3- Behavioral- EnvironmentalIdentifies a specific nutritional problem that
the Registered Dietitian is responsible for treating ADA Nutrition Diagnosis and Intervention: Standardized
Language for the NCP
Example: Inadequate energy intake related to decreased appetite and dysphagia as shown by a significant wt loss of 6% in the past month and leaving >25% of meals uneaten for the past 4 days.
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Nutrition InterventionsSpecific to the nutrition diagnosis
Interventions: • Strategies to positively change:• a nutrition-related behavior• environmental condition• health status for the patient
ADA Nutrition Diagnosis and Intervention: Standardized Language for the NCP
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Nutrition Interventions
Develop individualized interventions with the patient and the family
Educate the patient and their familyLiberalize the diet as much as possibleObtain food preferences Allow flexibilityDiscuss high protein/high calorie
snacks/supplements with patients
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Nutrition Monitoring and Evaluation
Monitoring, measuring , and analyzing patient outcomes relevant to the nutrition diagnosis, plan of care and goals
Frequent follow up may be necessary when there is a change in condition or the wound is not healing
Check in with WOC nurse frequently!
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Nutrition Monitoring & EvaluationMonitor po intake of meals, snacks, and supplements
Monitor weight and weight changes
Monitor nutritional labs but keep in mind that they may not always reflect the current nutritional status
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Biochemical AssessmentHepatic Proteins:Serum albuminSerum prealbuminSerum transferrin
Hepatic Proteins and Nutrition Assessment; Journal of the American Dietetic Association 2004
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Nutrition Labs: Albumin and Prealbumin
Helpful Careful of interpretation
Indicators of:Morbidity and mortalitySystemic illness
Help identify patients who may become malnourished
Helpful for trending
Negative acute phase reactanti.e. Increase illness =
Decrease in lab valuesDecrease after surgeryDecrease with infection,
stress and inflammationIncreases with
dehydration
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Nutritional Requirements for Wound Healing
National Pressure Ulcer Advisory Panel White Paper 2009
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Calorie RequirementsUse 30-35 calories/kg body weight as a
guide
Calorie needs may be higher in patients who are underweight or have had a significant weight loss
Calorie needs may be higher in individuals with co-morbid medical conditions such as COPD, cancer, acute spinal cord injury, traumatic brain injury, hemodialysis, etc
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Calorie RequirementsWeight loss should not be a goal in
overweight or obese patients with pressure ulcers
Caloric intake may need to be lowered in patients with chronic SCI who start to have an undesired weight gain.
Weights must be monitored closely
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Protein RequirementsUse 1.25-1.5 gm protein/kg body
weight as a guide
Protein needs may be greater than 1.5 gm/kg body weight if the patient has multiple pressure ulcers, larger stage 3 or 4 pressure ulcers, has pressure ulcers that are draining, or if lower protein levels are not promoting healing
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Protein RequirementsProtein needs should be individualized using
clinical judgment
Ensure that adequate fluids are being provided or consumed and that renal function is preserved
Caution should be exercised when determining protein needs in patient’s with impaired renal function and in the elderly
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Fluid Requirements30-35 ml/kg body weight per day or
1 ml/calorie is usually adequate
Fluid needs will be higher in patients with diarrhea, vomiting, profuse sweating, elevated temperature and/or in those experiencing considerable amounts of wound drainage or on VAC therapy
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Fluid RequirementsPatients receiving higher amounts of
protein may also need higher amounts of fluid . Those using air-fluidized beds may require an additional 10-15 ml per kg of body weight per day
Monitor for signs symptoms of dehydration
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Fluid Requirements
Interventions may need to be considered if fluid intake is inadequate (i.e. initiation of IV fluids, increase water flushes in patients receiving tube feedings)
If fluid restriction is medically necessary, then a minimum of 1500 ml daily is suggested
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Vitamin and Mineral Requirements
Other than a MVI, additional supplements or individual vitamin and minerals should only be recommend IF the patient is known to have a diet deficient in that vitamin or mineral and/or shows signs and symptoms of a clinical deficit
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Vitamin and Minerals
Ascorbic Acid
-enhances collagen production
-increases formation of blood vessels
-supports immune system
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Vitamin and Minerals
Vitamin A
-stimulate collagen production
-enhances cell production
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Vitamin and Minerals
Vitamin E
-stabilizes cellular membranes
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Vitamin and Minerals Zinc
-DNA and protein synthesis
-Cellular production
-Collagen formation
If patient is known to have a diet insufficient in zinc, suggest supplementing with 40 mg of elemental zinc/day in divided doses for a 2-3 week period of time
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Vitamin and Minerals
Arginine
-stimulates protein production
-supports immune function
-stimulates collagen production
At this time, safe maximum doses are not
knownMore research is needed to verify what
effects it has on healing of pressure ulcers
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Vitamin and MineralsGlutamine
-decreases protein breakdown
-supports immune function
-stimulates cell growth and reproduction
At this time supplemental use of arginine
and glutamine is controversial and more research is needed. Supplementation is not recommended at this time (ADA Nutrition Care Manual 2009)
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Feeding PracticesProvide assistance with meal set-up
and feeding as needed
Consult a Speech-Language Therapist and/or Occupational Therapist if a patient is found to have swallowing difficulties or problems self-feeding
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Feeding PracticesEncourage patients to eat in a common patient
dining area to promote socialization and allow for greater supervision of diet tolerance, food preferences, and assistance needs
Provide therapeutic nutritional supplements, food fortifiers, and enhanced foods as appropriate. Supplements may be high calorie, high protein, and/or have some other component known to support or enhance wound healing
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Nutrition SupportConsider alternate method of
nutrition support if oral intake inadequate and if patient/family is agreeable.
Consult Nutrition Support Team or Registered Dietitian (RD) for enteral or parenteral nutrition support recommendations.
If the gut is working, the ideal route for feeding is enteral nutrition support.
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EducationEducating the patient and family on
the role of nutrition in wound healing is essential
Give examples good sources of protein and how to incorporate them into their meals and snacks/supplements
Provide written materials on nutrition and wound healing
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Nutrition is One Aspect of Care
134
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In ConclusionPrevention is the best treatmentProvide consistent, adequate
nutritionProvide individual plan of careLiberalize diet as much as possibleEducate patient, family, and staffProvide frequent follow upWorking as a team is essential
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Questions
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Please feel free to e-mail us if you would like additional information or resources:
[email protected]@va.gov
Follow Up
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References:Institute For Clinical Systems Improvement:
Pressure Ulcer Prevention and Treatment Protocol, 2010 at ICSI.org
Pressure Ulcer Prevention and Treatment Quick Reference Guide, 2009 – Developed by the NPUAP/EPUAP, npuap.org
National Database of Nursing Quality Indicators (NDNQI) at nursingquality.org
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ReferencesGuideline for Prevention and Management of
Pressure Ulcers – WOCN Clinical Practice Guideline Series
American Dietetic Association-Nutrition Care Manual 2009
ADA Nutrition Diagnosis and Intervention: Standardized Language for the NCP
The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper 2009http://www.npuap.org/Nutrition%20White%20Paper
%20Website%20Version.pdf