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:
Kimberly.Bihm@va.gov
Mary.Murphy5@va.gov
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