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Advance Concepts in Pressure Ulcer Care Rachel Hudes, Dietetic Intern Benedictine University 5/20/2011.

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Presentation on theme: "Advance Concepts in Pressure Ulcer Care Rachel Hudes, Dietetic Intern Benedictine University 5/20/2011."— Presentation transcript:

1 Advance Concepts in Pressure Ulcer Care Rachel Hudes, Dietetic Intern Benedictine University 5/20/2011

2 Statistics 1-3 million people develop pressure ulcers each year. In 2006, costs for a pressure ulcer pt ranged from $16,700 to $20,400 compared to $10,000 for non pressure ulcer patients. In acute care facilities it is estimated that 60,000 people die each year from pressure ulcer complications. Incidence of pressure ulcers ranges from: – 2.3% to 23.9% in long-term care – 0.4% to 38% in acute care – 0% to 17% in home care – 0% to 6% in rehabilitative care Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.

3 Pressure ulcers are areas of damage to the skin and underlying tissue, due to the lack of blood flow to these areas. Usually occur over bony protrusions such as over the sacrum, ischial tuberosities, trochanters, malleoli, and heels. Population most at risk are those who have limited mobility and may be confined to a bed or wheelchair for prolonged periods of time. – Commonly occur in the elderly, those residing in nursing homes, pt’s with spinal cord injuries, those with nerve damage, and the immobile acutely ill. Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24: Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper

4 The Braden Scale Used for predicting pressure ulcer risk and should be completed at admission to healthcare institutions. Helps in the assessment process for determining the needs of the patient, along with identifying triggers. The lower the score, the higher the risk. – Those with an 18 or lower are considered high risk. People with low Braden scores should be checked for pressure ulcers. Individuals should be reassessed following a change in condition. Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper

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6 Stage 1 Stage 2 University of Washington. Taking Care of Pressure Sores.

7 Stage 3 Stage 4 University of Washington. Taking Care of Pressure Sores.

8 Risk Factors for Pressure Ulcers Extrinsic factors are primary causes of pressure ulcers and effort should be taken to avoid these. Intrinsic factors vary between people and should be assessed for and identified. They influence the skin’s supporting structure and lymphatic system. Medical nutrition therapy should focus on improving or preventing PU increase caused by these. Victorian Government Health Information. (2008) Pressure Ulcer Basics.

9 Extrinsic Factors Moisture: – causes skin vulnerability alters the resistance of the epidermis to extend forces by softening the skin’s surface and reducing the tensile strength. Friction: – Resistance to movement between the patient’s skin and the external support surface. – Acts in a direction that is opposite to patient movement. Victorian Government Health Information. (2008) Pressure Ulcer Basics.

10 Sheering Forces: Shearing forces are exerted parallel to the skin and is generated by forces (friction) acting against it and moving in the opposite direction. Victorian Government Health Information. (2008) Pressure Ulcer Basics.

11 Intrinsic Factors Nutritional status: – Poor nutrition has a significant role in PU development. – Research indicates that the following factors increase the risk of developing a PU: malnutrition low levels of protein/albumin recent weight loss or morbid obesity specific micronutrient deficiencies such as Vitamin C, iron, and zinc. Victorian Government Health Information. (2008) Pressure Ulcer Basics. American Dietetic Association. ADA Evidence Analysis Library. Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:

12 Individual characteristics – > 65 years of age Risk for depletion of lean body mass, since this naturally occurs with age (Sarcopenia). Older age also results in natural changes to the skin and body. – Generally more fragile, thinner, less elastic, and drier then the skin of young adults, so more vulnerable to damage. – Also new skin cells are usually generated more slowly. – Dehydration risk increases. – Immobility – Inability to eat independently Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:

13 – Multiple co-morbidities that may result in poor blood flow, immobility, and neurological disorders. Diabetes, Hypertension, Dementia – Oxygen delivery system: Decreased supply of oxygen to the area under stress leads to increased risk. – Respiratory disorders, reduced cardiac output, chronic infections, smoking, autonomic dysfunction (as seen in spinal cord injury) In a hypoxic environment, fibroblasts cannot replicate, production of collagen is reduced, and risk of infection increases. Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:

14 – Medications: Drugs that increase the risk of developing pressure ulcers include those that decrease sensation May result in less movement, decrease inflammatory response, and decrease peripheral blood pressure. – Corticosteroids – Nonsteroidal anti-inflammatory drugs Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.

15 Pathophysiology of Pressure Ulcers Due to multiple factors, pressure ulcers are formed when on-going pressure over a certain area of the body results in the squeezing of tiny blood vessels. Blood that normally carries oxygen and nutrients to these cells are blocked, resulting in tissue death/skin break-down.

16 Pressure Distribution on Skin Layers Victorian Government Health Information. (2008) Pressure Ulcer Basics.

17 Case Study

18 Patient (pt) Profile 75 y/o Caucasian male Came from a Nursing home, inability to communicate well, and is single. Was admitted to Saint Anthony Hospital for dehydration, constipation, UTI, sepsis, and pressure ulcers (Stage 1, 2, and 4). Past Medical History (PMH) – Cerebrovascular accident w/ Hemiplegia – Hypertension – Hypoxia – Leukocytosis

19 Anthropometrics Height: 66 inches Weight: lbs/76.3 kg Body Mass Index: 27.4 (Overweight) Ideal Body Weight (IBW): 142 lbs % IBW: 118.2%

20 Food & Nutrition History Difficulty swallowing and chewing Currently constipated and dehydrated Currently getting enteral nutrition support – Jevity 80mL/hr X 18hrs – Water flushes at 300 mL every 6hrs Past diet orders: enteral nutrition support

21 Physical Assessment Patient is bedridden/immobile Lies with his elbows against the bed with head back Braden score of 6/23 Eyes were closed and patient was not in a state to communicate Appeared to be resting comfortably Pt was wearing heal protectors

22 Abnormal Labs Lab Test Normal ValueValueIndication BUN (mg/dL) H Reflects dehydration status Kidney function appears to be normal because electrolytes and creatinine were all at normal levels. BUN/creatinine (mg/dL) H Reflects dehydration status and elevated BUN level. CRP<19.6 H Indicates that the pt is in a state of active inflammation/has infection due to pressure ulcers, sepsis, and UTI. ESR (mm/hr)2052 H Marker of inflammation. May be related to the multiple contractures in his left extremities.

23 ESR A marker of inflammation within the body and is commonly used to screen for severe arthritis. The constant tightness and lack of mobility, due to paralysis, resulted in his joints stiffening up and contractures. Because this pt is experiencing similar joint damage as to someone who has severe arthritis, it is likely that this elevated lab is a marker of this pt’s multiple contractures. American Association for Clinical Chemistry. ( ) ESR. Lab Tests Online.

24 Additional Important Labs Albumin/Prealbumin/Total serum protein Hemoglobin/Hematocrit Total lymphocyte count Serum nutrient levels if deficiencies suspected American Dietetic Association. ADA Evidence Analysis Library.

25 CVA Contractures Urinary Tract Infection Paralysis Pressure Ulcers Disease Inter-relationships

26 Pressure Ulcers DehydrationSepsis

27 Contributing Factors to Pressure Ulcers Paralysis – Lack of mobility – Bedridden – Contracture formation – Incontinent – Nerve damage CVA/Hypoxia/HTN – Poor circulation – Vasoconstriction and loss of vessel elasticity resulting in damage and weakness.

28 Older Age – Sarcopenia: natural decline in lean body mass. – Decrease in skin integrity – Decrease in immunity and more prone to infections – Dependent on Nursing Home care Sepsis – Compromised immune system. – Hypermetabolic state Dehydration – Decrease in blood volume which can result in compromised delivery of oxygen, nutrients, and immune cells to damaged area. Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12 th Edition. Saunders Elsevier. St. Louis, MO

29 Assessment of Nutrition Needs Calories kcals (30-35 kcals/kg) Protein gms (1.5-2 gms/kg) Fluid mL/day (30-35 mL/kg) Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25: American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.

30 Nutrient Dosing Information and Recommendations Glutamine UL:.57 g/kg/day (d) Arginine Maximum safe level not established Zinc 40 mg/d in deficient pts until corrected. UL: 40 mg/d Vitamin C mg/day considered protective mg/d for wound healing UL: 2 g Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25: American Dietetic Association. Pressure Ulcers. Nutrition Care Manual. Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12 th Edition. Saunders Elsevier. St. Louis, MO

31 Glutamine This amino acid serves as an energy source and for proliferation by inflammatory cells within the wound. Glutamine was found to increase wound healing rates of burned patient’s, who are commonly deficient. It has been shown to maintain mucosal integrity and reduce infection rates. More research is needed to determine its effectiveness specifically on pressure ulcer healing. The NPUAP and EPUAP do not recommend routine glutamine supplementation for pressure ulcers pts. Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper

32 Arginine The use of arginine supplemented formulations should be considered in pt’s with pressure ulcers who are critically ill or undergoing major surgery, as immune enhancing formulas. Results showing an increase in collagen synthesis and wound breaking strength in pts with incisional wounds has yet to be displayed in pressure ulcer pts. One study showed improvement in pressure ulcer healing when 2 high pro, high energy nutrition supplements containing arginine, vitamin C and zinc, were given over a 4 week period compared to a group given a only a standard diet and another group given 2 high-calorie/high protein supp/day. Additional research is also needed to recommend its use alone or with other nutrients for pressure ulcer healing.

33 Zinc Important to maintain adequate levels and correct deficiency in order to promote wound healing and immunity function. – No more then 40 mg/d is recommended and only until deficiency is corrected. No evidence that supplementation improves healing of vascular or pressure ulcers in pts without deficiency. – High serum Zinc levels may inhibit the healing process because it competes with copper in binding to albumin. Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.

34 Vitamin C It is important to identify and correct deficiencies through supplementation as it plays a role in collagen synthesis and immune responsiveness. The is no evidence that giving higher doses of vitamin C alone in pressure ulcer pts is beneficial in relation to healing. One study showed that giving an oral nutrition supplement made up of a combination of 500 mg Vitamin C, arginine, and zinc, significantly improved the rate of pressure ulcer healing 2.5 fold in PU pts. Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24: Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.

35 Beta-hydroxy-beta-methylbutyrate (HMB) A metabolite of Leucine In recent research, it has been included in nutrient mixtures, also containing glutamine and arginine. (14 gm glutamine, 14 gm arginine, 2 gm HMB) – One study’s results noted a significant rise in collagen deposition compared to control group. No clear conclusion and more research is needed in the administration of nutrient mixtures. American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.

36 Product Advertised Wound Healing ComponentsDiet Indications Juven Glutamine, Arginine, HMB (Revigor) Oral or TF Enlive High quality protein, vitamin, and mineral drink Clear liquid Perative High protein, Arginine TF ProMod Liquid protein, Collagen protein hydrolysate Oral or TF Resource Araginaid Extra L-Arginine, Zinc, Vitamin C Oral Nutren Replete High Protein, vitamin, and mineral formula TF

37 Conclusion Close follow-up is needed as maintaining adequate nutrition is crucial in the pressure ulcer healing process. More has not been shown to always be better regarding the supplementation of individual nutrients, but there is promising data showing the benefits of certain nutrient mixtures. More research is needed in the form of multi centered clinical trials, observing larger populations: – to further define nutrient needs for pressure ulcer healing – To observe the relationship between oral nutrition supplements and pressure ulcer healing.

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39 References Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper Doley J. (2010) Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice, (25), Desneves KJ, Todorovic BE, Cassar A, Crowe TC. (2005) Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition, (24), University of Washington. Taking Care of Pressure Sores. Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12 th Edition. Saunders Elsevier. St. Louis, MO Victorian Government Health Information. (2008) Pressure Ulcer Basics. American Dietetic Association. ADA Evidence Analysis Library. American Association for Clinical Chemistry. ( ) ESR. Lab Tests Online. Version.pdfhttp://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious- disease/sepsis/#s0020http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious- disease/sepsis/#s0020 American Dietetic Association. Pressure Ulcers. Nutrition Care Manual. Lizaka S, Sanada H, Nakagami G, Sekine R, Koyanagi H, Konya C, Sugama J. (2010) Estimation of protein loss from wound fluid in older patients with severe pressure ulcers. J. Nutrition, (26),


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