Right to Avoid Pressure Ulcers PEGGY KLOSTER YEN

M alnutrition sets the stage for development of pressure ulcers, retarded wound heal-

ing, and prolonged hospital stays. As many as 40 percent of all elders in hos- pitals and nursing homes have some degree of malnutrition.

How can you ensure that elders in your care are not among those at greater risk of skin breakdown and other problems due to malnutrition?

First, begin your nutrition screening right at admission. A "yes" answer to even one of the basic screening ques- tions should trigger a more complete assessment of the person's nutritional state (see "What You Need to Know, "" at righO.

Protein, calories, vitamins C, A, and K, and the mineral zinc are the nu- trients most important to preventing and healing pressure ulcers. Provide vitamins and minerals in amounts no greater than 100 to 150 percent of the Recommended Dietary Allowances, however. (See "'Latest RDAs for Adults 51+, "" on the next page.) Larger doses will not speed wound healing.

Second, gather objective measures of nutritional status such as weight in relationship to height, skinfold thick- ness, serum albumin, hematocrit, and hemoglobin. Check a height-weight chart to determine whether the patient is underweight. Skinfold thickness charts are also available to help deter- mine whether an individual is under- or overweight.*

The normal adult level for serum al- bumin is 3.5-5.0 g/100 ml; for hemo- tocrit is 37-48 percent for women, 45- 52 percent for men; and for hemoglo- bin is 10-17 g/100 ml.

Low levels in these parameters can

Peggy Kloster Yen, RN, MPH, is a nutrition consultant, Chronic Disease Nutrition Services ofthe Family Health Administration, Maryland Department of Health and Mental Hygiene, in Baltimore.

signal nutritional problems, and aid in monitoring progress.

Encourage health care staffto think of weight measurement as they do

WHAT YOU NEED TO KNOW

Asking a patient these questions at ad- mission can help you spot the elder at risk for malnutrition and pressure ulcer formation:

• Have you recently lost weigh~ • What is your weight?. (Compare this to a body-weight chart to see if weight is 10 percent or more below the desirable weight.) • Do you have difficulty chewing? • Can you always swallow without any trouble? • Are you able to feed yourself? • Have you had any change in appetite or food tolerance? • Do you have any food allergies or foods you won't eat?. • Do you ever have constipation? What about diarrhea? • Are you ever confused? Disoriented? • Do you ever use enteral or parenteral feedings? • How much alcohol and/or drugs to you use? • Do you live alone? • Do you have any trouble going out to shop? Getting around to cook? • What is your monthly income? what are your monthly expenses?

blood pressure or pulse--as a vital sign. If a nutritious diet is consumed by a malnourished patient with pres- sure ulcers, and the patient is gaining weight, that is the best sign that nutri- tional "recovery" is taking place.

Fortify the Diet

Elders who "just can't eat enough" need a diet high "in concentrated sources of nutrients, like fortified milk, and low in nutrient-sparse foods, like tea, broth, and gelatin.

Food supplements are the best solu-

*Manual of Clinical Dietetics. The American Dieietic Association, Chicago, 1988, p. 55).

tion for many elders. Time supple- ments so that they do not interefere with regular meals. It's usually best to give the supplements in the afternoon and before bedtime, since these are the longest between-meal periods.

Some good supplement choices are Enrich (Ross Laboratories) and Susta- cal with Fiber (Mead Johnson). Both are lactose free, contain 10 to 11 grams of protein in 8 ounces, and have fiber to aid bowel regularity.

Ensure Plus (Ross Laboratories), Sustacal HC (Mead Johnson), and Comply (Sherwood Medical) are high- er in protein (about 15 grams in 8 ounces) but do not contain fiber. The most protein per ounce is found in Iso- cal HCN (17 grams per 8 ounces; Mead Johnson), Magnacal (16 grams per 8 ounces; Sherwood Medical), and Two- Cal HN (almost 21 grams per 8 ounces; Ross Laboratories).

Fortified milk contains almost as much protein as the commercial sup- plements--19 grams in 8 ounces-- and costs less. You can make your own fortified milk by adding one cup of nonfat'dry milk powder to a quart of regular or iowfat milk. With twice as much protein per cup as regular milk, it packs a nutritional punch for older adults whose volume of intake is very limited.

Mixing fortified milk can be a prob- lem in institutions, though. Measured, individual servings of enteral formu- las are usually the easiest form of sup- plement since they can be stored un- opened without refrigeration. The commercial supplements do cost more, as much as a dollar a can.

And remember, it's not enough just to order supplements for elderly pa- tients. Make sure they are actually de- livered to the patient and document how much of each can the elder drinks. If adequate nutrients cannot be con- sumed orally, other feeding routes (gastrostomy, nasogastric tube) must be considered.

Geriatric Nursial_Seatcmber/October 1990 255

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NEWS WATCH Continued from page 218

Nurse on the Move in Long-Term Care

ALBANY, NY--Beverly M. Westa- colt, RN, MBA, has been appointed vice president of member services for the New York Association of Homes and Services for the Aging. In the new- ly created position, Ms. Westacott will be responsible for developing and maintaining new member services and recruiting new members. Pre- viously, Ms. Westacott was deputy county executive for Health and Hu- man Services in Broome County, New York, and before that director of the Broome County Office for Aging.

WE'RE IN A RUSH TO BETTER THE WORLD

Would you like to practice in the expanding field of gerontological 4 nursing at one of the most progressive academic health centers in the country? We invite ou to consider pining our professional nuts ng staff at the Johnston P,. Bowman C/~nter for the E derly (JRB) a 175-bed hospital at Rush-Presbyterian-St. Luke's Medical Center. JRI3 has tour specialized clinical units: Geriatric Medicine, Ger attic Rehabilitation, Sk ed Nursing and Geriatric Psychiatry. What makes nursing specia at Rush is a commitment to professionalism. Nurses at Rush have set the practice standards for quality of nursing care. Moreover, our nurses enjoy excellent benefits including:

Sa ares up to $51,177 • Generous tuition reimbursement : Full and part-time positions with including a weekender option

flexible scheduling : Shared governance program • Progressive clinical ladder Individualized preceptorship orientation

Primary nursing pr0~ram Continuing education opportunities • In-house registry

Rush University oilers a clinical maj0r in Gerontological and Rehabilitation Nursing for the M.S., N.D. and D.N.Sc. degrees.

We're interested in your career satisfact on and your future, Please write or ca : Nurse Recruitment, (312) 942-3456 (collect in Illinois) or 1-800-621-4626 ~toll-free outside Illinois). Rush-Presbyt¢,I an-St. Luke s Medical Center , 729 S. Paulina St., Chicago, IL 60612. Equal 0pportun ty Employer.

~ Rush-Presbyterian-St. Luke's Medical Center " ~

Circle No. 10 o n R e a d e r Inquiry Card

256 Geriatric Nursing September/October 1990

NUTRITION

Latest RDAs for Adults 51+

Males Females

Protein 63g 50g

Fat-soluble viilamins A 1,000 (ug) 800 (ug) D 5 (ug) 5 (ug) E 10 (rag) 8 (rag) K 10 (ug) 8 (ug)

Water-soluble vitamins C 60 (rag) 60 (mg) Thiamin 1.2 (mg) 1.0 (mg) Riboflavin 1.4 (mg) 1.2 (mg) Niacin 15 (mg) 13 (rag) % 2 (r~) 2 (rag) Folate 200 (ug) 180 (ug) B12 2 (ug) 2 (ug)

Minerals

Calcium 800 (mg) 800 (rag) Phosphorous 800 (mg) 800 (mg)

Magnesium 350 (mg) 280 (rag) Iron 10 (mg) 10 (mg) zinc 15 (mg) t2 (rag) Iodine 150 (rag) 150 (rag) Selenium 70 (ug) 55 (ug)

The recommended daily allowances (RDAs) ex- pressed are average intakes over 24 hours. Diets should include a variety of common foods in order to provide trace nutrients for which human require- merits are less well defined.

Screening for Health

Recognizing the important role that nutrition plays in the health of older Americans, the American Academy of Family Physicians, the American Di- etetic Association, and the National Council on the Aging have joined to- gether to launch a five-year effort to promote routine nutrition screenings and better nutritional care.

Called the Nutrition Screening Ini- tiative, the project will promote pro- fessional development, education of the elderly about nutrition, and activi- ties in support of reimbursement for improved nutrition services. Such an effort may begin to make nutrition less a cause and more a preventive solu- tion for pressure ulcer care in elders.