Transcript Nutrition Guidelines for Pressure Ulcer Management

Nutrition Guidelines
for Pressure Ulcer
Management
1/4/07
Braden > 18
No Pressure Ulcer or
Non-Healing Wound
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Monitor intake and weight
Consult dietitian if:
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Usual criteria on Admission Database
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Intake consistently less than 75%
Nausea, vomiting, diarrhea
Metabolically stressed state - trauma, fever
Significant weight loss (non fluid related):
• 1% in 1 week
• 5% in 1 month
• 7.5% in 3 months
• 10% in 6 months
Recommended RD Actions
Braden > 18
without Pressure Ulcer
with ↓appetite, weight loss,  needs,  loss via V & D
Complete nutrition assessment
Based on findings:
Request pre-albumin
Add oral supplements
Add between meal snacks
Assistance, reminders, encouragement at
mealtime
3 Day Calorie Count
Based on response to above consider:
Tube feeding
Parenteral nutrition
Braden < 18
Without Pressure Ulcer/Non Healing Wound
With adequate nutrition intake
Nutrition Goals:
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Maintain current intake of nutrition
Achieve and maintain desirable weight
Routine Follow Up:
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Visual assessment of skin
• Back of head
• Elbows
• Heals
• Back side
Assessment of:
• Weight
• Intake
• Pre-albumin
• Changes in condition
Braden < 18
Without pressure ulcer or non healing wound;
With inadequate hydration, protein &/or weight loss
Nutrition Goal:
Protein:
1.2g pro/kg/d
Calories: 25 – 30 kcals/kg/d
29 – 33 kcals/kg/d Para
24 – 27 kcals/kg/d Quad
Use ABW subtract 5 – 10 kcals/kg/d for Obesity
Fluid:
• 30 ml/kg; min of 1500 ml/d unless contraindicated
• SCI: 35 ml/kg; min 2500 ml/d unless contraindicated
• Add 10 – 15 ml/kg for air fluidized beds
Recommended RD Actions Continued
Braden < 18
Without pressure ulcer or non healing wound;
With inadequate hydration, protein &/or weight loss
Complete nutrition assessment
 First meet fluid needs
 Supplement with whey protein powder
or use whey based tube feeding
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e.g.Propass 6 gm/pkt
If BMI < 20 change diet to high
cal/high protein
 Add therapeutic multi-vit/min
supplement
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Recommended RD Actions Cont
Braden < 18
Without pressure ulcer or non healing wound;
With inadequate hydration, protein &/or weight loss
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Follow up weekly:
 Visual assessment
 Assessment of wt, intake, pre-albumin, medical condition
 Correct source of poor intake if able
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Food preferences
Constipation
Illness depression
Pain
Medication causing poor appetite
Consider glutamine: 10 g/d
Evaluate need for anabolic agent and/or nutrition support
Stage 1 & 2 Pressure Ulcers
Without: heavy exudate, VAC therapy, poor appetite, diarrhea,
weight loss, Alb < 3.5 or PAB < 15
Nutrition Goal:
Protein: 1.2 – 1.5g pro/kg/d
Calories:
25 – 30 kcal/kg/d
29 - 33 kcals/kg/d Para
24 - 27 kcals/kg/d Quad
Use ABW & subtract 5-10 kcals/kg/d for obese
Fluid:
• 30 ml/kg; min of 1500 ml/d unless contraindicated
• SCI: 35 ml/kg; min 2500 ml/d unless contraindicated
• Add 10 – 15 ml/kg for air fluidized beds
(Matrix Matress Replacement or Kinair)
Recommended RD Actions:
Stage 1 & 2 Pressure Ulcers: Without: Heavy exudate, VAC
therapy, poor appetite, diarrhea, wt loss, Alb < 3.5 or PAB < 15
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Complete nutrition assessment
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First meet fluid needs
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10 – 15 gm/d whey protein
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7 – 15 gm/d arginine
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Therapeutic multi vitamin min supplement
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25 mg zinc along with 2 mg of Cu for 2 weeks or less
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Follow up weekly
Stage 1 & 2 Pressure Ulcers
With: heavy exudate, VAC therapy, poor appetite, diarrhea,
weight loss, Alb < 3.5 and/or PAB < 15
Nutrition Goal:
Protein:
1.5 – 2.5 gm pro/kg/d
Calories:
30 – 35 kcal/kg/d
33 - 35 kcals/kg/d Para
27 - 30 kcals/kg/d Quad
Use ABW & subtract 5-10 kcals/kg/d for obese
Fluid:
35 ml/kg; min of 2000 ml/d unless contraindicated
SCI: 35 ml/kg; min 2500 ml/d unless contraindicated
Add 10 – 15 ml/kg for air fluidized beds
(Matrix Mattress or Kinair bed)
Recommended RD Actions:
Stage 1 & 2 Pressure Ulcers
With: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss,
Alb < 3.5 and/or PAB < 15
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Complete Nutrition Assessment
First meet fluid needs
10 – 15 gm/d whey protein
10 – 20 gm/d arginine
Therapeutic multi vitamin min supplement
25 mg zinc along with 2 mg of Cu daily for 4-6
weeks or less
Check Oxandrolone guidelines for appropriateness if
weight loss and skin breakdown present (See
Oxandrolone guidelines)
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If Tube Fed, use peptide based formula; avoid
formulas high in simple CHO
Follow up at moderate to high risk (1-2 times/wk)
Stage 3 & 4 Pressure Ulcer
Non Healing Wound
Nutrition Goal
Protein:
Calories:
1.5 – 2.0 gm/pro/kg/d
30 - 35 kcals/kg/d
(35 – 40 if heavy exudate)
33-35 kcals/kg/d para
27 – 30 kcals/kg/d quad
Fluid:
35 ml/kg; min of 2000 ml/day unless contraindicated
SCI: 35-40 ml/kg;min 2500-3000 ml/d unless contraindicated
Add 10 – 15 ml/kg for air fluidized beds
(Matrix Mattress or Kinair bed apply)
Recommended RD Actions:
Stage 3 & 4 Pressure Ulcer/Non Healing Wound
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Complete Nutrition Assessment
First meet fluid needs
10 – 15 gm/d whey protein
10 – 20 gm/d arginine
Therapeutic multi vitamin min supplement
25 mg zinc along with 2 mg of Cu daily for 4-6 weeks
Check Oxandrolone guidelines for appropriateness if weight loss
and skin breakdown present (See Oxandrolone guidelines)
If Tube Fed, use peptide based formula; with MCTs; avoid
formulas high in simple CHO
RD follow at moderate to high risk (1- 3 times/wk)
Oxandrolone
Action: amino acids driven into protein synthesis pathway;
catabolic activity is decreased
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Actions/Benefits
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Relative low cost
Anti catabolic
Increased protein
synthesis
Marked return of lean
mass in conjunction with
optimum nutrition vs
nutrition alone
Wt gain approximately
75% lean body tissue
Acts on cell androgenic
receptors
Cleared by kidneys,
avoiding hepatotoxicity
Anabolic effect is dose
dependent
Well tolerated for longterm use
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Contraindications/Side Effects
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Stimulation of androgensensitive tumors, mainly
prostate CA
Known liver disease or
LFTs greater than twice the
upper limit of normal
Oral anticoagulation
therapy e.g. warfarin
Pregnancy
Breast Cancer (male or
female; hypercalcemic
type)
Prostate CA
Nephrosis
Hypocalcemia
Uncontrolled diabetes
Dosing of Oxandrolone
Usual Dose: 10 mg twice daily
 Renal insufficiency: 5 mg twice daily
 Strive for adequate protein intake first
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Conditionally Essential Amino Acids
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Arginine:
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Wound Healing (via IGF 1)
Required for collagen
synthesis (precursor to
polyamines)
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Increased in collagen
deposition in wound bed
with 15g of arg/d
Average dietary intake 7.5g
arg/day
Increased blood flow
• Nitric Oxide Pathway
• NO levels decreased in
DM
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Glutamine:
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Nitrogen Shuttle
• Regulates protein turnover
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Stores depleted at 10 – 15%
loss of lean body mass
Immunity
• Preferred fuel source for
lymphocytes & enterocytes
• N-Acetyl Cysteine + Glutamine
= Glutathione which leads to
decreased oxidative stress
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GI Function & Immunity
• Restores gut integrity & brush
boarder which improves
absorption & appetite (20 g
gln/d)
• Precursor for nucleotides
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Helps maintain
• Acid base balance
• Ammonia production
Conclusions:
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These recommendations are from best
practice organizations and the dietetics
profession.
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Several have not been tried here at HCMC
and are worthy of trial.
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Our challenge is to implement these
guidelines and evaluate effectiveness in the
population at HCMC.