Advance Concepts in
Pressure Ulcer Care
Rachel Hudes, Dietetic Intern
Benedictine University
5/20/2011
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. 1-15.
Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.
• 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;24:979-987.
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. 1-15.
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. 1-15.
Stage 1
Stage 2
University of Washington. Taking Care of Pressure Sores. http://www.sci.washington.edu/info/pamphlets/pressure_sores.asp
Stage 3
Stage 4
University of Washington. Taking Care of Pressure Sores. http://www.sci.washington.edu/info/pamphlets/pressure_sores.asp
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.
http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm
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.
http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm
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.
http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm
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.
http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm
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;24:979-987.
• 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. 1-15.
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;24:979-987.
– 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. 1-15.
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;24:979-987.
– 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. 1-15.
Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.
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.
Pressure Distribution on Skin Layers
Victorian Government Health Information. (2008) Pressure Ulcer Basics.
http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm
Case Study
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
Anthropometrics
• Height: 66 inches
• Weight: 167.8 lbs/76.3 kg
• Body Mass Index: 27.4 (Overweight)
• Ideal Body Weight (IBW): 142 lbs
• % IBW: 118.2%
Food & Nutrition History
• Difficulty swallowing and chewing
• Currently constipated and dehydrated
• Currently getting enteral nutrition support
– Jevity 1.2 @ 80mL/hr X 18hrs
– Water flushes at 300 mL every 6hrs
• Past diet orders: enteral nutrition support
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
Abnormal Labs
Lab Test
Normal
Value
Value
Indication
Reflects dehydration status
Kidney function appears to be normal
because electrolytes and creatinine were
all at normal levels.
BUN (mg/dL) 6-20
BUN/creatinine 0.60(mg/dL)
20.00
34 H
Reflects dehydration status and elevated
47.89 H BUN level.
Indicates that the pt is in a state of active
inflammation/has infection due to pressure
ulcers, sepsis, and UTI.
CRP
ESR (mm/hr)
<1
9.6 H
20
Marker of inflammation. May be related to
the multiple contractures in his left
52 H extremities.
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. (2001-2011) ESR. Lab Tests Online. http://www.labtestsonline.org
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.
Disease Inter-relationships
Contractures
Pressure
Ulcers
CVA
Paralysis
Urinary Tract
Infection
Dehydration
Pressure
Ulcers
Sepsis
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.
• 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: 12th Edition. Saunders Elsevier. St. Louis, MO. 287-295.
Assessment of Nutrition Needs
Calories
2300 - 2670 kcals (30-35 kcals/kg)
Protein
115-150 gms (1.5-2 gms/kg)
Fluid
2300 - 2670 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. 1-15.
Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.
American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.
Nutrient
Dosing Information and
Recommendations
Glutamine
UL: .57 g/kg/day (d)
Arginine
Maximum safe level not established
40 mg/d in deficient pts until corrected.
UL: 40 mg/d
Zinc
Vitamin C
70-150 mg/day considered protective
500-1000 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. 1-15.
Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.
American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.
Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12th Edition. Saunders Elsevier. St. Louis, MO. 287-295.
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. 1-15.
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.
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. 1-15.
American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.
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. 1-15.
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;24:979-987.
Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.
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.
Product
Advertised Wound
Healing Components Diet 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
L-Arginine, Zinc, Vitamin
Resource Araginaid Extra C
Oral
Nutren Replete
High Protein, vitamin,
and mineral formula
TF
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.
References
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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. 1-15.
Doley J. (2010) Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice, (25), 50-60.
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), 979-987.
University of Washington. Taking Care of Pressure Sores.
http://www.sci.washington.edu/info/pamphlets/pressure_sores.asp.
Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12th Edition. Saunders Elsevier. St. Louis, MO.
287-295.
Victorian Government Health Information. (2008) Pressure Ulcer Basics.
http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm
American Dietetic Association. ADA Evidence Analysis Library.
American Association for Clinical Chemistry. (2001-2011) ESR. Lab Tests Online. http://www.labtestsonline.org
Version.pdfhttp://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectiousdisease/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), 890-895.