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Twin Cities District Dietetic
Association Meeting
November 9, 2010
Kim Bihm, RD, LD, CDE
Mary Murphy, RN, MA, CWOCN
Objectives
Identify anatomy and physiology of skin
Describe prevention strategies to reduce incidence of
pressure ulcers
Describe an interdisciplinary approach to prevention
and treatment of pressure ulcers
Define nutritional treatment modalities for wound
healing.
Why should we care?
Complications to patients
Lead to pressure ulcers
Painful
Infection
Quality of Life
Why should we care?
Cost
Hospitalizations
Health care workers
Skin Care Products
Reduction in payment from regulatory bodies
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 Plaintiff
Average award is $13.5 million
Highest award is $312 million in one case!
Clinical Practice Guidelines by
NPUAP/EPUAP:
Evidenced-Based Practice
Best scientific research available
Systemic review of literature
Provides tools for best judgment
Allows decision-making on more
than “expert opinion” alone.
DOES NOT dictate practice or replace
clinical reasoning or judgment
– it ENHANCES these!
These are guidelines
Policies are absolute
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
Interdisciplinary Approach
All disciplines need to assess for risk and put prevention
interventions into place:
Occupational Therapy
Pressure Ulcer Protocol
Nutrition
C-collar inspection orders
Nursing
Physician
High protein, high calorie
diet with snacks and
supplements
Physical Therapy
Wheelchair cushion
pressure mapping
Avoiding shear during
transfers
Cognitive screening
Assistive Technology
Speech Therapy
Memory assessment
Cognition
Communication
Assistive Technology
Prevention: Risk Assessment
Co-morbidities
Previous PU
Smoking hx
Long OR time
Long ED stays
Critically ill –
ICU= 4x more
Wheelchairs
Obese/thin
Guidelines to Preventing Pressure Ulcers
Combination of Risk Assessment + Skin
Inspection + Clinical Judgment
Reassess RISK
Upon admission
At regular frequency
Change in condition
Skin Inspections
Head to toe inspection regularly
Individualized plan of care
Use Interdisciplinary Approach
MD, Nutrition, PT/OT, Speech Therapy
Skin Inspection
Interdisciplinary
Approach
Risk Assessment
Development
of Prevention
Strategies
Anatomy and Physiology of Skin
Largest organ of the body
Weight: up to 15% of body weight – about 6 pounds
Size: Average adult – 3000 square inches
Receives 1/3 of body’s circulating blood volume
Constantly exposed to changing environments
Has capability to self-regenerate
Skin Layers: Epidermis
Outermost layer made of epidermal cells
Thin and avascular
Regenerates every 4-6 weeks
Melanocytes reside in epidermis
Melanin is pigment responsible for color of skin
Skin Layers
Dermis
Thicker layer
Contains:
blood vessels
hair follicles
lymphatic vessels
sebaceous glands
sweat and scent glands
nerve endings
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
Skin Layers: Hypodermis
Subcutaneous Tissue
Composed of adipose and connective tissue
Filled with major blood vessels, nerves and lymphatic
vessels
Attaches dermis to underlying structures
Provides insulation and cushioning to body
Acts as a ready reserve of energy
Functions of Skin
Body Image
Maintenance of body form
Appearance, attributes and expression
Sensation
Abundant nerve receptors in skin
Touch
Heat/Cold
Pain
Pressure
Moisture
Functions of Skin
Regulation of body temperature
98.6 F / 37 C
Thermoregulatory mechanisms:
Circulation
Blood vessels dilate to dissipate heat
Blood vessels constrict to shunt heat to body organs
Sweating
2-5 million sweat glands
Functions of Skin
Protection
Safety against sunburn
Melanin in the epidermal cells protects against ultraviolet light
Metabolism
Vitamin D formation
Presence of sunlight
This activates the metabolism of calcium and phosphate and
minerals (important in bone formation)
Functions of Skin
Protection
Barrier to germs and poisons
Normal floral =
Staph Aureus
Diphtheroids
Gram neg bacilli
NOT Candida – That comes from GI tract
Chemical defenses
Sweat, oils, wax from skin glands contain lactic acid and fatty
acid
These acids make skin pH acidic to kill bacteria and fungi
Functions of Skin
Maintenance of water balance
Prevents loss of water through evaporation
<10% moisture – cells shrink = increase
invasion of bacteria
>30-40% moisture level = maceration
Increased permeability
Increased risk of injury from friction
Theory of pH
pH refers to management of acid or base levels
Acidic is 0-6
Neutral is 7
Basic is 8-14
Rain is 5.6
Seawater is >7
Milk is <7
Gastric juices are acidic
Saliva and blood are neutral
Skin pH
Skin 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 levels
Pooled 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
Skin Changes
Age-Related changes:
Functions decline
Epidermal/dermal junction flattens
Decreases skin strength
Increases risk for tearing
Melanocytes shrink (decrease in volume)
Increases sensitivity to sun
Skin Changes
Age-Related changes:
Decreased sweat production
Leads to increased dryness and flaking
Nutrition changes
Medications
Guidelines to Preventing Pressure Ulcers
Skin Inspections
Checking all bony prominences
Check under skin folds
Check under medical devices
Check where there is limited sensation
Educate professional staff on skin conditions for early
identification
Technique for blanching response
How to assess warmth, edema, and induration
Set time frame for on-going inspections
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
Trauma
injuries
Arterial
ulcers
Venous
ulcers
Stage I Pressure Ulcers
Intact skin with non-
blanchable redness of a
localized area- usually over
a bony prominence.
Stage II Pressure Ulcers
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 ruptured
serum-filled blister.
Stage III Pressure Ulcers
Full 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
Stage IV Pressure Ulcers
Full thickness tissue loss
with exposed bone,
tendon or muscle.
Slough/eschar may be
present.
Often includes
undermining/tunneling.
Unstageable Pressure Ulcers
Full thickness tissue loss
in which actual depth of
ulcer is completely
obscured by slough
and/or eschar.
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.
Iatrogenic Damage:
Pressure Injury from Medical Devices
Assess for Risk by RN
Braden Risk Assessment (by Barbara Braden)
Reliable research based risk assessment tool
Sensory
Mobility
Activity
Friction/Shear
Nutrition
Moisture
Risk due to Sensory Impairment
Can they feel?
Prevention:
If they can’t feel – someone must look at skin!!
Check under devices
Check for proper fitting shoes and socks
Need redistribution mattress
Risk due to Mobility Impairment
Can they move themselves?
Prevention:
Must be turned every 2 hours
Must be trained in proper pressure relief
Must have pillows elevated
Risk due to Activity
Can 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
Risk due to Friction and Shear
Are they sliding in bed or wheelchair?
Prevention:
Watch transfers from w/c to bed
If concerned, get PT/OT consult
Manage spasticity
Report concerns to MD
Keep knee gatch up in bed to
prevent sliding in bed
SKIN
INSPECTIONS:
Bony
Prominences
To Check
Support Surfaces
How to make sense of the confusion????
What Do We Know- Evidence
Pressure = Force/Area
Pressure is caused by perpendicular force =
Treatment = pressure redistribution
Pressure redistribution = depth of pressure without
bottoming out
Shear is parallel force =
Treatment = prevent sliding
Features of Support Surfaces
Air Fluidized
A feature that provides pressure redistribution via a
fluid-like medium created by forcing air through beads
as characterized by immersion and envelopment
Features of Support Surfaces
Low Air Loss
A feature that provides a flow of air to assist in
managing the heat and humidity (microclimate) of the
skin.
Features of Support Surfaces
Foam
Elastic foam or Visco-elastic foam
Features of Support Surfaces
Gel
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
Features of Support Surfaces
Alternating 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.
Repositioning – Evidence A
Relieve/redistribute pressure
30 degree side lying is important
Alternate positions
Avoid shear
Avoid lying on medical devices
Avoid slouching in w/c – use footplates
Avoid HOB elevation: HOB = shear/pressure
Elevate heels
Consider “zone” positioning changes
Consider: Every layer on top of surface changes the surface
support
Think of chux/linen/briefs = change in performance of bed
Wheelchair
cushions
Check w/cushion –
pressure mapping
Check chair position
Back tilt w/ legs up
Upright w/ foot rests
Limit sitting time
Risk due to Moisture
Is their skin too moist?
Prevention:
Avoid plastic diapers
Avoid extra pads that retain heat
Skin barrier protection is critical
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
Prevention Strategies
Keep skin clean, dry and protected
Toileting program
Structured bowel program
Gentle cleansing-avoid mechanical irritation
Balanced pH cleanser + moisturizer or humectants
Soft cloth vs. wash cloth
Pat dry
Skin protectant/barrier
Dimethicone
Petrolatum
Zinc
Moisturizer - Emollient
Products: Underpads
Briefs/ underpads
Needs to be highly absorptive
Needs to quickly wick moisture away from patient
Plastic/cloth absorptive products are occlusive
Trap perspiration = increase heat/moisture = increase skin
damage
Typically made of 3 layers:
Water-permeable cover next to skin
Absorbent 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 tearing
Different sizes
Breathable
Products
Consider containment products
External catheters
Indwelling
Suprapubic catheters
Intermittent Catheters
Fecal pouches
Fecal tubes
Complex Process of Wound Healing
Risk due to Nutrition
Are they eating/drinking enough?
Prevention:
Need RD consult for any Braden score of 1 or 2
High protein diet
Importance of snacks and supplements
Good hydration
Multivitamins/ minerals
Labs: prealbumin
Nutrition
Screen for nutritional deficiencies
Send nutrition consults
Monitor for signs of dehydration – I/Os
Monitor weight changes
Highlight Braden Subcategory of Nutrition
Prioritize protein intake
Specific Recommendations
Offer high protein supplements in addition to usual
diet.
Plan for supplement 60 minutes between meals
Resource for Nutrition
The Role of Nutrition in Pressure Ulcer
Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
Patient/Caregiver Education
Causes/ risk factors for PU development
Ways to minimize risk:
Regular inspections
Prevent friction/shear
Routinely turn/reposition
Avoid use of rings, foam cut outs, donut-type devices
Maintain adequate nutrition and fluid intake
Monitor for weight loss, poor appetite
Promptly report health care changes to providers
TREATMENT of Pressure Ulcers:
GOLD STANDARD of Wound Healing:
Good signs of healing by 2 weeks
30% healing at 4 weeks
Full closure at 12 weeks
Guidelines to Treatment of Pressure Ulcers
Principles of wound healing:
Eliminate cause – moisture, pressure, shear , friction
Wound cleansing
Keep infection free
Topical treatments
Moist wound healing
Protect periwound
Refer as necessary for debridement
Manage nutrition
Repair of Skin Damage
Repair of partial thickness skin damage
Regeneration
Damage is confined to epidermal and superficial dermal
layers
Epithelial cells will reproduce
Trauma triggers inflammatory response
Erythema, Edema, Serous exudate
Epidermal resurfacing begins
Day 7 - new blood vessels sprout
Day 9- Collagen fibers are visible
Collagen synthesis continues until about day 10-15
Repair of Skin Damage
Repair of full thickness skin damage
Scar formation
Damage 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 intention
Primary intention – surgical closure
Secondary intention –scar formation
Repair of Skin Damage
Scar formation process is complex with several phases:
Hemostasis phase
Clot formation
Inflammatory phase
Clean up phase
Takes 3-4 days usually
Proliferation phase
Vascular integrity restored
New connective tissue is growing
Granulation tissue growth
Wound contraction
Maturation / Remodeling phase
Wound Management Strategies
Wound cleansing – Evidence C
Cleanse wound and periwound with each dressing
change
Provide 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
Wound Management Strategies
Manage wound infections
Contamination
Non-replicating organisms
Colonized
Bacteria in wound bed
Organisms are attached and replicating
Not affecting the environment
Common organisms: staph and pseudomonas
Critically 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
Wound Management Strategies
Topical Agents
Dakin’s solution – Sodium hypochiorite – 0.25%
Good for gram - & + - best on staph
Bleach 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 noted
Effective in 48 hours
Absorptive
Limit to 2 weeks – risk of dermatitis
Wound Management Strategies
Topical Agents
Silver
Silver Sulfadiazine ointment
Good for gram -, Klebsiella, Pseudomonas
Seeing 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
Wound Management Strategies
Topical antimicrobials – for tissue organisms
Bactoban is resistant now
Neomycin/Neosporin – NO NEO! = contact dermatitis
Gentamycin = nephrotoxicity and resistance
Bacitracin is ok still
Good for gram +
Resistance is rare
Wound Management Strategies
Systemic antibiotics for:
Bacterimia/ sepsis
Advancing cellulitis
Osteomyelitis
95% of bone exposed is + for osteo
Caution: MRSA is very virulent
Cellulitis to pneumonia in 24-48 hours
Wound Management Strategies
Debride the pressure ulcer of devitalized tissue
Debridement options:
Surgical
Conservative sharp
Wound Management Strategies
Debride the pressure ulcer of devitalized tissue
Debridement options:
High pressure fluid irrigation
Ultrasonic
Wound Management Strategies
Debride the pressure ulcer of devitalized tissue
Debridement options:
Mechanical
Autolytic
Enzymatic
Wound Management Strategies
Debride the pressure ulcer of devitalized tissue
Debridement options:
Maggot Therapy
Wound Management Strategies
VAC Therapy
Wound Management Strategies
Electrical Stimulation
Wound Management Strategies
Hyperbaric Oxygen Therapy
Wound Management Strategies
Living Skin Equivalents
Wound Management Strategies
Flap Surgery –
Umar Choudry, MD
Pre-Surgery Preparation
Interdisciplinary Teamwork !!!!!
SCI Provider:
Pre-op medical clearance
Anticoagulant assessment
Transfuse if Hgb < 8
Spasticity management
Patient needs to lie straight for 3-4 weeks
WOC Nurse:
Prep wound – VAC therapy
Pre-Surgery Preparation
Nutrition Consult
Assess nutrition needs
Pre-albumin goal of >20 before surgery
Zinc at least in normal range goal
Supplemental vitamin C and multivitamin
Speech Therapy Consult (if hx of dysphagia/aspiration)
Assess risk of aspiration post-op
May need to consider non-oral feeding alternative
Pre-Surgery Preparation
Physical Therapy and Occupational Therapy pre-op
consults for baseline assessments
Physical Therapy
Transfers
Seating/Positioning including pressure mapping
ROM
Tone
Occupational Therapy
ADLs
Adaptive Equipment needs
Functional transfers
Seating/Positioning
Post-op Course
3 weeks on Air Fluidized bed
Week 4
Switch to low air loss bed
Begin stretching
Week 5-6
Sitting program
Discharge week 6-7
VAMC -Mpls SCI Unit Outcomes:
2009 to present:
16 flap surgeries
ZERO losses of the flap
The Registered
Dietitian’s Role
in Wound
Healing
Pressure Ulcer Prevention
• Global expert (NPUAP/EPUAP) consensus
SUPPORTS nutritional assessment as part of a
comprehensive interdisciplinary approach to
preventing pressure ulcers!
Pressure Ulcer Prevention
Nutritional 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
Risk for Pressure Ulcers
Unintentional weight loss
Under nutrition
Protein energy malnutrition
Low BMI
Inability to eat independently
Cachexia
Hyper metabolism
Risk for Pressure Ulcers
Diabetes
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
Risk for Pressure Ulcers
Diabetes
Calorie needs are increased to promote wound
healing.
The major fuel source for collagen synthesis is
carbohydrates (~55% of calories should come from
carbohydrates)
Risk for Pressure Ulcers
Diabetes
Medications may need to be adjusted to
accommodate increased carbohydrate intake.
IV insulin drip may be used to control blood
sugars post-op
Under Nutrition
Problems chewing and/or swallowing
Decrease ability to feed self
Decreased appetite
Advanced age
Unintentional weight loss
Unintentional Weight Loss
Can lead to:
Impaired immune system
Decreased serum albumin & prealbumin
Decreased ambulation
Weakness
Development of pressure ulcers
Non-healing pressure ulcers
Loss of Lean Body Mass
Defined 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
Prevention: Risk Assessment
Co-morbidities
Diabetes
Renal disease
Immunosuppression
Malnutrition
Consultation of RD
When to consult the Registered Dietitian:
When patient is identified as:
Being at risk for pressure ulcers
Braden Risk Assessment score less than 19
Braden Risk Assessment- Nutritional sub-score
of 1 or 2
Existing pressure ulcer
Newly discovered pressure ulcer within 24 hours
Worsening of a ulcer or with an ulcer not
progressing through the normal stages of healing
Consultation of RD
Inadequate 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
days
Difficulty chewing and/or swallowing
Unable to eat independently
Significant weight loss >5% in 30 days or >10%
in 180 days
Example of Nutrition Consult Template
Braden Risk Assessment
Nutrition Subcategory
1. Very Poor
Never eats or completes meal
2 servings or < of protein
Poor fluid intake
1/3 of any food offered or NPO or IV fluids/clear liquids
for > 5 days
NEEDS NUTRITION CONSULT
Braden Risk Assessment
Nutrition Subcategory
2. Probably Inadequate
Eats ½ of any food offered
Protein: 3 servings of meat or dairy daily
Occasional intake of supplement or tube feeding or
liquid diet less than requirements
How often is TF turned off for activities?
NEEDS NUTRITION CONSULT
Braden Risk Assessment
Nutrition Subcategory
3. Adequate
Eats > 50% of most meals
4 servings of protein daily
Occasionally refuses meal but takes supplement or tube
feeding or TPN meets needs
Braden Risk Assessment
Nutrition Subcategory
4. Excellent
Eats most meals and never refuses a meal
Eats 4 or more servings of meat and dairy daily
Doesn’t require supplements
Nutrition Care Process
Nutritional Assessment Data
Food / Nutrition history
Lab data, medical test and procedures
Anthropometric measurements including weight
history
Physical examination findings (i.e. brittle nails,
thinning hair, fragile & thin skin)
Patient History
Nutritional Assessment Data
Estimating calories, protein, fluid, vitamin and
minerals
Adequacy of po intake (past and current)
Barriers in meeting optimal nutrition
-swallowing difficulties
-chewing problems
Cognitive deficits-ability to feed self
Braden Risk Assessment scale, BMI, weight changes
Individual goals and wishes of the patient
Nutrition Diagnosis
PES Statement
~60 nutrition diagnoses within 3 domains:
1- Clinical
2- Intake
3- Behavioral- Environmental
Identifies 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.
Nutrition Interventions
Specific 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
Nutrition Interventions
Develop individualized interventions with the patient
and the family
Educate the patient and their family
Liberalize the diet as much as possible
Obtain food preferences
Allow flexibility
Discuss high protein/high calorie snacks/supplements
with patients
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!
Nutrition Monitoring & Evaluation
Monitor 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
Biochemical Assessment
Hepatic Proteins:
Serum albumin
Serum prealbumin
Serum transferrin
Hepatic Proteins and Nutrition Assessment;
Journal of the American Dietetic Association 2004
Nutrition Labs:
Albumin and Prealbumin
Helpful
Indicators of:
Morbidity and mortality
Systemic illness
Help identify patients who
may become malnourished
Helpful for trending
Careful of interpretation
Negative acute phase reactant
i.e. Increase illness =
Decrease in lab values
Decrease after surgery
Decrease with infection,
stress and inflammation
Increases with dehydration
Nutritional
Requirements for
Wound Healing
National Pressure Ulcer Advisory Panel White Paper 2009
Calorie Requirements
Use 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
Calorie Requirements
Weight 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
Protein Requirements
Use 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
Protein Requirements
Protein 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
Fluid Requirements
30-35 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
Fluid Requirements
Patients 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
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
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
Vitamin and Minerals
Ascorbic Acid
-enhances collagen production
-increases formation of blood vessels
-supports immune system
Vitamin and Minerals
Vitamin A
-stimulate collagen production
-enhances cell production
Vitamin and Minerals
Vitamin E
-stabilizes cellular membranes
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
Vitamin and Minerals
Arginine
-stimulates protein production
-supports immune function
-stimulates collagen production
At this time, safe maximum doses are not known
More research is needed to verify what effects it
has on healing of pressure ulcers
Vitamin and Minerals
Glutamine
-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)
Feeding Practices
Provide 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
Feeding Practices
Encourage 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
Nutrition Support
Consider 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.
Education
Educating 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
Nutrition is One Aspect of Care
134
In Conclusion
Prevention is the best treatment
Provide consistent, adequate nutrition
Provide individual plan of care
Liberalize diet as much as possible
Educate patient, family, and staff
Provide frequent follow up
Working as a team is essential
Questions
Follow Up
Please feel free to e-mail us if you would like additional
information or resources:
[email protected]
[email protected]
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
References
Guideline 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
2009
http://www.npuap.org/Nutrition%20White%20Paper%20Website%
20Version.pdf