The One With the Pressure Ulcer

Aimee Takamura

Sodexo Mid-Atlantic Dietetic Intern

January 2014

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Executive Summary

Introduction of patient

Objective data

Medical history

Nutrition history

Discussion of disease

Pathophysiology Role of nutrition Wound care

Treatment and hospital course

Learning Objectives

After attending this presentation, participants should be able to:

Explain the differences between acute and chronic woundsIdentify key nutrients needed in wound healing and explain their significance Estimate nutritional needs for individuals with pressure ulcersAppreciate the impact adequate nutrition has on wound healing

About Pressure Ulcers (PUs)

Definition: 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 and/or friction (NPUAP) ~1-3 million Americans develop PUs annuallyMortality rate: ~60,000 people/yearPhysical, emotional, and financial burdens

Before I get into details about the patient, I want to give you all a little background about PUs

Definition

The National Pressure Ulcer Advisory Panel (NPUAP) defines PUs as: a 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 and/or friction.

Physical, emotional, and financial burdens

Patients suffering from PUs often have a decreased quality of life, as they experience physical, emotional, and financial burdens. PUs are a source of pain and discomfort, can lead to increased length of hospital stay and risk for infection, decreased mobility and independence, and social isolation.

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About PUs - Financial

Agency for Healthcare Research and Quality (AHRQ) estimated that development of PUs increased the average length of stay from 5 days ($10,000/day) to 13-14 days ($16,755 $20,430/day) Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for PUs that develop during a patients length of stay

In terms of finance, PUs are associated with huge medical costs for both the care facility and the patient.

CMS

As of 2008, the Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for PUs that develop during a patients length of stay

As financial burdens rise and regulations become increasingly stricter, prevention and treatment of PUs is becoming more and more critical.

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Introduction

AB is an 83 y.o. Caucasian female admitted with a stage IV midline sacral decubitus ulcer (pressure ulcer)Lives with 24 hour nursing support, is followed by a wound care nurse, and has help from her husband, who lives independently Bed-bound with limited mobility, needs assistance with all ADLsLOS = 16 days: November 10th 26th

AB is an 83 y.o. Caucasian female admitted from a wound care center with a stage IV midline sacral decubitus ulcer (pressure ulcer).

She lives with 24 hour nursing support and help from her husband, who lives independently. She is bed-bound with limited mobility and needs assistance with activities of daily living, including eating. Her total length of stay at Howard County General Hospital was 17 days: November 10th 24th.

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Objective Data

Height: 56 Weight 110#s BMI = 18 + Fever and chills, skin woundsCachectic appearance, +4 bilateral lower extremity (BLE) edema, left leg osteomyelitis, pressure ulcer on left heel, stage IV sacral decubitus ulcer

BMI = 18: lower end of the normal range.

Upon arrival, a review of her systems revealed she was positive for fever and chills, and positive for skin wounds; all other systems were negative. Significant findings from a physical assessment revealed a cachectic appearance, bilateral lower extremity (BLE) edema +4, left leg osteomyelitis, pressure ulcer on left heel, and a stage IV sacral decubitus ulcer.

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Lab Values

DateReference Range11/10Hb11.5-16 g/dL13.4Hct35-47%39.3Na135-146 mmol/L133 (L)K3.5-5.3 mmol/L3.7Cl98-110 mmol/L95.7 (L)BG60-99 mg/dL178 (H)BUN7-25 mg/dL19Creatinine0.5-1.4 mg/dL0.7Ca8.5-10.4 mg/dL7.2 (L)Albumin3.2-4.6 g/dL2.3 (L)

Serum sodium and chloride were low upon arrival, likely due to ABs +4 edema, as fluid retention can cause hyponatremia and hypochloremia.

ABs blood glucose was elevated. However, this is a common finding in an acute care setting, as infection, illness, and stress all contribute to increased levels.

As for calcium, many things affect serum levels, including dietary intake, which was likely insufficient given her reported poor PO intake.

ABs low serum albumin levels were likely influenced by her hydration status. A prealbumin test would have been more reflective of her nutritional status.

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Current Hospital Medications

Medicine Indications Nutrient interactions Lasix K wasting diuretic used to treat ABs edemaDiarrhea w/ high doses (sorbitol)FragminAnticoagulant used in DVT treatmentNot for those with pork allergiesOndansetron Antiemetic used to treat nausea d/t surgery, chemotherapyUsually, no dietary changes are neededOxycodoneUsed to treat severe pain for long periods of timeDo not crushCaution with grapefruit and citrus; avoid alcoholDilantin Used to treat seizures and irregular heartbeatsFolate drug metabolism; drug folate levels. metabolism of vit D and K Take Ca, Mg, antacids separately by 2 hrsVancomycin Used to treat gram + organisms (staph, C. diff colitis, eg)Little GI absorption Oral vancomycin has a bitter tasteCalcium carbonateUsed to increase ABs low calcium statusTake 1-3 hrs after meal Take Zn, Fe, Mg suppl separately by 1-2 hrsVitamin D3Taken to enhance ABs calcium status in conjunction with calcium carbonate Ca absorptionMaintain vit D status

Fragmin: pork allergies - derived from pig intestines

Oxycodone: AB was experiencing severe pain d/t the PU

Vanco - IV administration is needed for the drug to work in areas other than the intestine

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Medical History

Surgical History

AB has a history of atrial fibrillation, seizure, pneumonia, gallbladder cancer, bilateral leg edema, left food osteomyelitis, trigger finger, bedbound/unable to walk, and ex-smoker.

Her surgical history includes appendectomy, surgery for a neck and hip fracture, colonoscopy in 2014 with no abnormal findings, right hand surgery, cholecystectomy in 2004, resection of extrahepatic biliary tree in 2004, partial hepatectomy in 2004, excision of portal lymph node in 2004, and Roux-en-Y reconstruction in 2004

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Nutrition History

Diet prescription: Regular dietMinimal PO intake due to increased pain, altered mental status, and medicationsABs husband reported she was not a big eater to begin with; always on the thinner sideWorsening nutrition status ABs appetite fluctuated day to day; she did not eat consistent mealsOn a typical day, she ate a few bites of food here and there and drank up to one Ensure a day

Minimal PO intake

AB had not eaten much since her admission due to increased pain, altered mental status due to her UTI, and side effects from her medications.

A 24-hour diet analysis could not be completed due to incomplete documentation and minimal reported PO intake.

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Discussion of Disease

NPUAP-EUPAP Nutrition Guidelines approved by the EAL for evidence-based guidelines regarding pressure ulcersThe Academy acknowledges the limited evidence available on this topicRecommended RDs rely on clinical judgment, best practice resources, and communication with other professionals to best support patients with woundsPathophysiology, role of nutrition, wound care

The EAL Wound Care Workgroup approved the NPUAP-EUPAP Nutrition Guidelines for evidence-based guidelines regarding pressure ulcers, since they met the Academy criteria for use in the EAL.

The Academy acknowledges the limited evidence available on this topic, and recommends that dietitians rely on appropriate clinical judgment, best practice resources, and communicate with other professionals to best support patients with wounds.

In this section, I will discuss the pathophysiology of wound healing, the role of nutrition, proper wound care

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Pathophysiology

Normal wound healing occurs in three phases: inflammation, proliferation, and remodeling

Inflammatory phase

Blood clot cytokines and growth factors neutrophils inflammatory response Monocytes macrophages

Normal wound healing occurs in three phases: inflammation, proliferation, and remodeling. As soon as a wound is inflicted, the inflammatory phase is initiated. Vasoconstriction occurs first, followed by a clotting cascade, which ultimately form a blood clot. The clot attracts cytokines and growth factors, which in turn attract neutrophils. These neutrophils initiate the inflammatory response and help to clear the wound of debris and bacteria for the first 48 hours. In the meantime, monocytes are recruited to the wound, where they transform to macrophages. Macrophages mediate angiogenesis, form fibrous tissue, synthesize nitric oxide, and continue to clear debris from the wound site.

In the image, you can see the clot forming and attracting the the neutrophils; macrophages are missing from this diagram

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Pathophysiology

Proliferation phase

4 days after infliction includes 4 steps: angiogenesis, epithelialization, granulation, and tissue formation/collagen deposition Dependent on fibroblasts and growth factors that work to ensure these processes occur

The proliferative phase usually begins four days after infliction of the wound and includes four steps: angiogenesis, epithelialization, granulation, and tissue formation/collagen deposition. This process is largely dependent on fibroblaststhe main cells involved in granulation tissue formationand various growth factors that work to ensure these processes occur.

Image

In the image, you can see the fibroblasts working to form a new extracellular matrix; also, there are keratinocytes working to replace the epidermis or superficial layer of the skin.

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Pathophysiology

Remodeling phase

Begins ~1 week after infliction and can continue for months to years Preliminary fibrous network forms and functions as a site for collagen deposition and cellular growthWound tensile strength = 70-80% of normal skin

The remodeling, or maturation, phase typically begins a week after infliction of the wound and can continue for years. During remodeling, a preliminary fibrous network forms from fibronectina component of the extracellular matrix. This network functions as a base for collagen deposition and cellular growth and migration, contributing to increased wound tensile strength of up to 70-80% of normal skin. As the wound matures, vascularization decreases and the differentiation of fibroblasts into myofibroblasts increase.

In the image, scar tissue is the fibrous tissue that replaces normal skin after healing has occurred

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Pathophysiology

Chronic Wounds

Non-healing wounds exist in a chronic state of inflammationIschemia and bacterial overgrowth are 2 main reasons Elevated levels of collagenases and proteases work to clear debris from the woundResults in extracellular matrix destruction and protein loss Risk factors: diabetes, age, malnutrition, corticosteroid use, and hypothyroidism

Ive just explained the wound healing process characteristic of acute wounds.

The non-healing wound, however, exists in chronic state of inflammation.

Ischemia (lack of O2) and bacterial overgrowth are two main reasons for wounds to remain in this inflammatory state.

Continual recruitment of neutrophils leads to elevated levels of collagenases and proteases in efforts to clear debris from the wound. This ultimately results in extracellular matrix destruction and protein loss, which impedes the healing process.

A variety of factors can lead to these states, such as diabetes, age, malnutrition, corticosteroid use, and hypothyroidism.

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Staging Wounds

The NPUAP recommends using a validated pressure ulcer classification system to assess wounds. At HCGH, a staging system from I-IV is used:Stage I: Non-blanchable erythemaColor change, intact skin Stage II: Partial thickness loss of dermisShallow open ulcer with red/pink wound bed; no sloughStage III: Full thickness skin lossBone, tendon, muscle not exposedStage IV: Full thickness tissue lossExposed bone, tendon, or muscleUnstageable: Full thickness tissue loss depth unknown Depth not detectable due to slough or eschar

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Role of Nutrition

Malnutrition is directly associated with PU development, increasing patients risk twofold Results from chronic inadequate intakeInsufficient energy and protein inhibits ones ability to fight infection and negatively impacts the healing process Indicated with PU development, and associated with poor prognosis in patients with existing onesMalnutrition is a reversible condition It is important to identify at-risk patients and begin appropriate nutrition intervention as soon as possible

Malnutrition is directly associated with PU development, increasing patients risk twofold.

Other risk factors include anorexia of aging (characterized by decreased appetite accompanied by weight loss and a decreased metabolic rate), dehydration, unintentional weight loss, low BMI, hypermetabolism, and functional issues like altered mental status, inability to feed oneself, difficulty chewing and/or swallowing, limited mobility, and altered GI function.

Malnutrition results from chronic inadequate provision of nutrients. Insufficient energy and protein intake inhibits ones ability to fight infection and negatively impacts the healing process in those with existing PUs. Malnutrition is indicated with PU development, and associated with poor prognosis in patients with existing ones

However, it is a reversible condition only fixed by adequate nutrient administration. Therefore, it is important to identify at-risk patients and begin appropriate nutrition intervention as soon as possible.

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Role of Nutrition

Nutritional needs:Calories: 30-35 kcals/kg of body weightProtein: 1.25-1.5 grams/kg body weightEnsure adequate fluid intake for hydrationMVI or supplementation to prevent vitamin and mineral deficiencies, especially with inadequate intake Vitamins A and C, zinc, magnesium, copper, and amino acids glutamine and arginine are nutrients of particular interestLacking evidence to substantiate specific recommendations for supplementation

Nutritional Needs:

PUs require increased energy and protein intake in order to heal.

Based on the latest guidelines developed by the NPUAP-EPUAP, it is recommended that one provide 30-35 calories/kg of body weight, 1.25-1.5 grams of protein/kg body weight, encourage daily fluid intake for adequate hydration, and offer a multivitamin or supplementation to prevent vitamin and mineral deficiencies, especially with inadequate intake.

Additionally, the Academy recommends tight blood glucose control for reducing infectious complications in critically ill patients

In terms of micronutrients, vitamins A and C, zinc, magnesium, copper, and amino acids glutamine and arginine are of particular interest. However, lack of strong evidence and scientific research prevents specific recommendations from being substantiated. Most of these recommendations are based on expert opinion and preliminary research findings.

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Role of Nutrition

Vitamin A

Increases the number of monocytes and macrophages, thereby stimulating epithelialization and collagen depositionDRI = 700ug/d (F); 900ug/d (M) Wound healing: 3,000-4,500 ug/d (10,000-50,000 IU/d) for 10 days Caution with corticosteroidsSupplementation is indicated in those who do not meet the DRI for vitamin A Monitor administration in patients with renal and liver failureLimited RBP catabolism and hepatic vitamin A storage

Vitamin A contributes to the wound healing process, especially during the inflammatory phase.

Vitamin A helps to increase the number of monocytes and macrophages in the wound, thereby stimulating epithelialization and collagen deposition, which ultimately enhances wound healing.

The DRI for vitamin A is 700ug/d for females and 900ug/d for males. However, to support wound healing, 3,000-4,500 ug/d (10,000-50,000 IU/d) for 10 days is recommended. This dose may have to be adjusted for those receiving corticosteroids, as vitamin A can interfere with the anti-inflammatory effects.

Monitoring serum vitamin A levels is useful in individuals with PUs; supplementation is indicated in those who do not meet the DRI for vitamin A to boost the healing process.

Since vitamin A is a fat soluble vitamin, it is important not to over-supplement (toxicity a concern).

Administration needs to be carefully monitored in patients with renal and liver failure, as RBP catabolism and hepatic vitamin A storage is limited

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Role of Nutrition

Vitamin C

Aids in collagen synthesis via capillary formation, production and activity of fibroblasts, and neutrophil proliferationSupplementation shown to enhance wound healing, especially if deficiency noted100-200 mg/d for stage I II PUs1,000-2,000 mg/d for stage III IV PUsEating citrus fruits is an easy way to increase vitamin C intake.

Vitamin C plays a critical role in collagen synthesis via capillary formation, production and activity of fibroblasts, and neutrophil proliferation. Vitamin C supplementation has been shown to enhance wound healing, especially if the individual is vitamin C deficient. Supplementation is especially important for those who drink alcohol or smoke, as these behaviors can increase vitamin C excretion from the body. Since vit C is water-soluble, toxicity is rare.

Studies have demonstrated that supplementation of 100-200 mg/d is beneficial for those with stage I II PUs, and 1,000-2,000 mg/d is beneficial for those with stage III IV PUs. Citrus fruits are a simple way to increase daily vitamin C intake. However, if food intake is compromised, other forms may need to be considered.

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Role of Nutrition

Zinc

Plays a role in collagen and protein synthesis, cellular proliferation, and wound healingSupplementation only with zinc deficiencyExcess zinc interferes with copper and iron absorption; can lead to deficiencies RDA = 8 mg/d (F), 11 mg/d (M)Supplementation to support wound healing: up to 40 mg/d (176 mg zinc sulfate) x 10 days

Zinc plays a role in collagen and protein synthesis, cellular proliferation, and wound healing.

Supplementation is recommended only when zinc deficiency is present. Excess zinc interferes with copper and iron absorption, and can lead to deficiencies of these two micronutrients.

The RDA for zinc is 8 mg/d for women and 11 mg/d for men.

Supplementation to support wound healing is generally up to 40 mg/d, or 176 mg zinc sulfate, for 10 days.

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Role of Nutrition

Magnesium

Acts as a cofactor for certain enzymes and combines with ATP to power many processes needed for wound healingRDA = 320 mg/d (F), and 420 mg/d (M)

Copper

Involved in the formation of certain enzymes (cytochrome oxidase, lysyl oxidase, cytosolic antioxidant SOD) necessary for cross-linking of connective tissuesRDA = 900 ug/dayCaution with zinc supplementation, toxicity Recommended supplementation dose: up to 10 mg/d (tolerable upper limit)

Magnesium is a trace element necessary for protein and collagen formation. It acts as a cofactor for certain enzymes and combines with ATP to power many processes needed for wound healing.

The RDA for magnesium is 320 mg/d for women and 420 mg/d for men.

Copper is a critical nutrient involved in the formation of certain enzymes (cytochrome oxidase, lysyl oxidase, cytosolic antioxidant superoxide dismutase) necessary for cross-linking of connective tissues, and thus would healing.

The RDA for copper is 900 ug/day.

Zinc deficiency has been linked to impaired wound healing. However, it is important to note that zinc toxicity or over-supplementation may cause copper deficiency.

The recommended dose of supplementation is up to 10 mg/d, which set as the tolerable upper limit.

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Role of Nutrition

Glutamine

Conditionally essential amino acid involved in stimulation of the inflammatory response. No studies have examined the effect of supplementation on wound healing

Arginine

Conditionally essential amino acid shown to increase the production of nitric oxide, enhance immune function, and act as substrates for protein and collagen synthesis Possible cause of hemodynamic instability due to increased nitric oxide production (Desneves, et. Al, 2015)No conclusive evidence to support supplementation for wound healing

Glutamine is a conditionally essential amino acid involved in many physiological processes like amino acid and nucleotide synthesis, gluconeogenesis, supporting immune function, and would healing via stimulation of inflammatory responses.

Supplementation has been shown to improve immune function and nitrogen balance post surgery, but no studies have examined its effect on wound healing. Therefore, there are no evidence-based guidelines for glutamine supplementation in regards to PUs.

Arginine is another conditionally essential amino acid that has been indicated in wound healing. Arginine has been shown to increase the production of nitric oxide, enhance immune function, and act as substrates for protein and collagen synthesis thereby promoting wound healing. In a recent study, the authors discovered that, compared to a standard hospital diet, supplemental arginine, vitamin C, and zinc improved PU healing. However, other studies have found that arginine supplementation may lead to hemodynamic instability due to increased nitric oxide production.

Similar to glutamine, there is no conclusive evidence that supports supplementation for wound healing.

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Role of Nutrition

Supplementation

Has not been shown to improve outcomes in certain patient populationsInsufficient evidence exists to recommend use beyond overcoming deficienciesMore important to identify those who are malnourished or at risk of malnutrition, and provide and encourage intake of a balanced diet

While supplementation of certain vitamins, minerals, and amino acids have shown to improve outcomes in certain patient populations, there is insufficient evidence to recommend their use beyond overcoming deficiencies. It is important to identify those who are malnourished or at risk of malnutrition, and provide and encourage intake of a balanced diet.

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Wound Care

PUs should be assessed upon admission and weekly thereafter; healing should begin within two weeks following wound care Tools for assessment: Pressure Ulcer Scale for Healing (PUSH) Bates-Jensen Wound Assessment Tool Clinical judgmentDocument physical findings: Length and width Depth Tunneling or underminingThe wound care nurse assessed and cleaned ABs wound every 3-5 days. Documentation included pictures.

According to NPUAP, PUs should be assessed upon admission and weekly thereafter; healing should begin within two weeks following wound care. Progress should be assessed using a tool like the Pressure Ulcer Scale for Healing (PUSH):

An assessment tool used to objectively monitor pressure ulcer healing; lower the score = better

looks at length and width

exudate amount: none, light, moderate, heavy

tissue type: eschar, slough, granulation tissue, epithelial tissue, or closed/resurfaced

Bates-Jensen Wound Assessment Tool

Another assessment tool used to monitor PU healing; it is a little more comprehensive than the PUSH tool, and consists of 15 items:

size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, skin color, edema, induration, granulation, and epithelialization

each item is scored from a scale of 1-5, 5 being the worst outcome

Or clinical judgment.

The use of photographs or data collection devices may be helpful. If no improvement is shown in 2 weeks, re-evaluation is necessary. HCGH does not use tools like those mentioned above; instead, clinical judgment, evaluation, and the staging system is implemented.

Documented physical findings include length and width of wound, depth, and presence of tunneling or undermining:

Tunneling: wounds that extend below the surface and may connect 2+ ulcers over a specific area

Undermining: subcutaneous pockets that form at the edge of ulcers due to necrosis of fat or muscle tissue

The wound care nurse assessed and cleaned ABs wound every 3-5 days. The wound care nurse always used pictures in her documentations. In her first note, she included an initial picture (baseline) after the wound was cleaned.

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Wound Care

Proper PU care includes routine wound cleaning, proper dressings, debridement, and possible surgery Topical and/or systemic treatments are useful Wound vacuum assisted closure (VAC) devicePositioning devices like foam pillows, cushions, heel coversDebridement when there is presence of necrotic tissueSurgical procedures, like operative debridement, for advanced PUsRequires a multidisciplinary approach involving a medical team comprised of a physician, dietitian, nurses, and wound care specialists

Proper treatments of advanced PUs include routine wound cleaning, proper dressings, debridement, and surgery if indicated.

The use of topical treatments, like antiseptics and antimicrobial silver dressings, are useful to control bacterial growth, prevent further contamination, and reduce inflammation. Systemic antibiotics should be used in patients with systemic infections like cellulitis, osteomyelitis, SIRS, or sepsis.A wound vacuum assisted closure (VAC) device may be useful when treating a chronic, non-healing PU. This device uses vacuum suction to close a wound while allowing drainage to occur through a connected tube. (cite, wound vac)Additionally, positioning devices like foam pillows, cushions, heel covers, should be used to relieve and redistribute pressure away from the PU site. (cite, tempest)For stage III-IV PUs, debridement is almost always indicated when there is presence of necrotic tissue. Dead tissue provides a medium for infection and inflammation, which ultimately impairs wound healing. After debridement, wounds may appear larger than before, but this does not mean that the wound has worsened. It is important that all professionals involved in the patients care are aware of the course of treatment to prevent false assessment and documentation. Surgical procedures, like operative debridement, may be beneficial in some patients.

Wound care involves a multidisciplinary approach involving a medical team comprised of a physician, dietitian, nurses, and wound care specialists. It is evident that optimal nutrition, among other factors, plays a role in the healing process; RDs should be aware of this and understand their critical role in delivering effectual nutrition interventions to support healing. Ongoing collaboration between the medical team and the patient is necessary in order to provide quality care.

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Wound VAC

Treatment & Hospital Course

Visit #1 initial

LOS 2 daysMD consult for poor nutrition status and stage IV decubitus ulcerAB sleeping upon arrival, husband present and able to provide relevant informationAB has had a decreased appetite for a while; unable to recall exact time framesNoted +4 BLE edemaWound RN assessed AB, cleaned and dressed the woundDiscussed supplementsagreed to send 1 Ensure and 1 Pro-stat per day

Visit #1 initial

LOS: 2 days

The dietitian was consulted by ABs attending MD for poor nutritional status related to her decubitus ulcer.

During this visit, AB was sleeping, but her husband was able to provide me with information.

He confirmed her poor nutritional status and reported she has had a decreased appetite for quite some time.

However, she has always been a small eater and, in his opinion, did not eat enough even when she was well.

He was not able to recall exact time frames.

ABs lunch tray was barely touched upon arrival.

We discussed supplements and agreed to send one Ensure and one Pro-stat per day to aid in wound healing.

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Visit #1 initial

Nutrition diagnosis:

Inadequate protein intake R/T wound healing AEB stage IV pressure ulcer on heel and midline sacrum

Goals: PO intake of 50-100% To drink 1 Ensure and 1 Pro-stat per day, as toleratedAssigned a high level of careEstimated energy needs:

Calories: 1500-1750 kcals (30-35 kcals/kg)

Protein: 50-70g (1.0-1.4g/kg)

Fluids: 1mL/kcal or per medical team recommendations

Treatment & Hospital Course

Nutrition diagnosis:

Inadequate protein intake R/T wound healing AEB pressure ulcer on heel and midline sacrum

The goal for AB was to eat 50-100% of her meals and to drink 1 Ensure and 1 Pro-state per day, as tolerated. She was assigned a high level of care due to her nutritional status and poor PO intake.

Energy needs were calculated as follows:

Calories: 1500-1750 kcals (30-35 kcals/kg)

Protein: 50-70g (1.0-1.4g/kg)

Fluids: 1mL/kg or per medical team recommendations

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Visit #2 follow up

LOS 4 days

AB sleepings/p debridement x 1 dayPer RN report, she had a good appetite with PO intake of ~50% Drinking the Ensure but has not tried Pro-statAssigned a moderate level of care

Treatment & Hospital Course

LOS: 4 days

The wound was debrided bedside yesterday by ABs attending physician. She tolerated the procedure well and had minimal blood losses. Pain medication was administered as ordered.

During this follow up visit, AB was sleeping. Per her nurse, she had a good appetite and was eating about 50% of her meals. She was drinking the Ensure but had not yet tried the Pro-stat. Overall, some improvement was shown but the nutrition diagnosis was not yet resolved. She was assigned a moderate level of care as her appetite was better and she was drinking the Ensure.

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Visit #3 follow up

LOS 8 days Debridement done today againAB in immense pain, confused due to high doses of medications Husband reported ABs appetite fluctuated from day to dayPO intake of 0-50% Drinking up to 1 Ensure a day, still has not tried Pro-stat Assigned a high level of nutrition care due to her worsening PO intake and non-healing wound

Treatment & Hospital Course

Visit #3 follow up

LOS: 8 days

AB was in immense pain and confused due to the amount of pain medications administered, so she was not able to provide any useful information.

Luckily, her husband was present at the time of the visit. He reported that ABs appetite fluctuated from day to daysome days she ate well (about 50%), and others she barely ate anything.

She continued to drink up to Ensure a day, but had not yet tried the Pro-stat. Her nutrition diagnosis remained unresolved.

She was assigned a high level of nutrition care due to her worsening PO intake and non-healing wound.

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Visit #4 follow up

LOS 11 daysABs PU not showing signs of healing, a wound VAC was added 2 days agoRemained drowsy and confused due to her pain medications Her husband reported drastically decreased PO intake for the past two days. Drinking up to one Ensure a day, still had not tried Pro-stat Discontinued Pro-stat until the surplus ran out. Assigned a high level of care

Treatment & Hospital Course

Visit #4 follow up

LOS: 11 days

ABs PU was not showing signs of healing. She was still drowsy and confused due to her pain medications. Her husband reported her appetite had been drastically decreased for the past two days; she was barely eating but still drinking up to one Ensure a day. She still had not tried the Pro-stat. According her ABs husband, she was not willing to try it at this time. Pro-stat was discontinued at this time until the surplus ran out. No improvement was shown and her nutrition diagnosis remained unresolved. She was assigned a high level of care due to worsening of her wound and continued poor PO intake.

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Visit #5 follow up

LOS: 14 days Palliative/comfort careFluid restriction of 1000mL/day was prescribed due to a 5L positive fluid balance and pulmonary edema ABs husband reported her intake was slightly improved since the last visitDrinking up to one Ensure a day but refusing the Pro-statPlans being made for discharge back to a wound care centerAssigned a high level of care

*On LOS day #16, AB was discharged to a rehab wound care center for continued care

Treatment & Hospital Course

Visit #5 follow up

LOS: 14 days

A fluid restriction of 1000mL/day was prescribed due to a 5L positive fluid balance and pulmonary edema. ABs husband reported her intake fluctuated throughout the day but was slightly improved since the last visit; AB continued to drink one Ensure a day and still refused the Pro-stat. No improvement was shown and her nutrition diagnosis remained unresolved. Again, she was assigned a high level of care.

LOS day #17: ABs condition stabilized and plans were made for discharge to a wound care center, where continued intensive care could be provided.

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Lab Values

Overview of ABs lab values over the course of her hospital stay

ABs hematocrit levels decreased over her length of stay, indicating her hydration status may have declined. By the end, she had minimal PO intake; these findings reflect that. Serum sodium was low upon arrival, but likely returned to normal after initiation of Lasix. Low serum chloride levels may have been due to ABs +4 edema, as fluid retention can cause hypochloremia. Blood glucose was elevated upon arrival, likely due to infection, illness, and stress. Serum calcium levels can be influenced by many factors, including dietary intake; ABs poor PO intake may have contributed to decreased levels. ABs albumin levels were likely influenced by her hydration status. A prealbumin test would have been more reflective of her nutritional status.

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Date

Reference Range

11/10

11/14

11/17

11/24

WBC

3.9-11.3 K/mm3

14.88 (H)

7.31

6.01

5.97

Hb

11.5-16 g/dL

13.4

12.3

11.7

11.7

Hct

35-47%

39.3

35.4

34.1 (L)

34.6 (L)

Na

135-146 mmol/L

133 (L)

135

139

140

K

3.5-5.3 mmol/L

3.7

4.3

4.4

3.9

Cl

98-110 mmol/L

95.7 (L)

101

104.2

98.9

BG

60-99 mg/dL

178 (H)

90

82

96

BUN

7-25 mg/dL

19

11

10

8

Creatinine

0.5-1.4 mg/dL

0.7

0.7

0.7

0.7

Ca

8.5-10.4 mg/dL

7.2 (L)

7.9 (L)

8 (L)

7.8 (L)

Albumin

3.2-4.6 g/dL

2.3 (L)

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2.5 (L)

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In the Future

Request prealbumin tests Request routine tests for vitamin A and C, magnesium, zinc, and copper status Suggest a daily MVI to help AB meet the RDIs for critical nutrientJuven as a supplement alternative to Pro-statPossible calorie count, consideration of nutrition support

In the future, if I encounter this patient again or anyone with a similar diagnoses, there are a few things I would do that I did not get to address this time. First, I would recommend getting a prealbumin test done to more accurately assess nutritional status. ABs albumin level likely was influenced by her hydration status and edema and not reflective of the adequacy of her diet. In addition to ordering a prealbumin test, I would recommend getting routine vitamin and mineral tests for vitamin A and C, magnesium, zinc, and copper. After doing extensive research about the impact of nutrition on PU healing, I realize the importance of monitoring levels of certain nutrients. Even though there is no evidence to support supplementation, it is important that deficiencies do not develop or are reversed. I would also suggest a daily multivitamin to help AB meet the RDIs for critical nutrients since her PO intake was so poor.

I would have offered AB a different protein supplement since she did not want Pro-stat. At HCGH, Juven is another supplement intended for wound healing that may have been better received. Unlike Pro-stat, which is 1oz, of thick, syrupy, and sweet, Juven is a powder mix that tastes just like an orange flavored drink (orange Tang). However, Juven needs to be mixed with 8-12 oz water and may pose problems for those on fluid restrictions.

Lastly, if PO intake continued to decline, I would have considered the initiation of nutrition support (PN).

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Role of the RD

Ideal PU treatment requires collaboration and communication between a multidisciplinary team: physician, RNs, wound specialist, and dietitiansWith an established link between nutrition and wound healing, dietitians play a critical role in the treatment of PUsMonitoring nutritional status and the provision of supplementsTheir contributions as part of a larger team can have considerable impact and should not go unrecognized

PUs will continue to be of great concern in acute care settings, as the incidence and mortality rate is alarmingly high. Ideal PU treatment requires collaboration and communication between a multidisciplinary team. The physician may be responsible for any surgeries and debridements; the RN nurses roles may include wound assessment, cleaning, dressing and repositioning; the nursing team handles the day-to-day care of the patient; and the dietitians are likely responsible for monitoring nutritional status and the provision of supplements.

It is known that nutrition plays a significant role in prevention and healing. While the exact range of kilocalories and grams of protein per kilogram of body weight are debated, it is important to encourage energy and protein intake, as they are necessary to promote healing. While supplementation beyond overcoming deficiencies is not supported by clinical evidence, meeting the RDIs for certain nutrients is beneficial.

With an established link between nutrition and wound healing, dietitians play a critical role in the treatment of PUs. Their contributions as part of a larger team can have considerable impact and should not go unrecognized.

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References

"NPUAP Pressure Ulcer Stages/Categories | The National Pressure Ulcer Advisory Panel - NPUAP." The National Pressure Ulcer Advisory Panel NPUAP. Web. 05 Jan. 2015

Hall, Katherine. "Pressure Ulcers: Identification, Treatment, and Prevention." Support Line 36.4 (2014): 3-9. Web. 21 Dec. 2014.

"Pressure Ulcer Treatment Recommendations." Agency for Healthcare Research and Quality. 2009. Web. 18 Dec. 2014

Stechmiller, J. K. "Understanding the Role of Nutrition and Wound Healing." Nutrition in Clinical Practice 25.1 (2010): 61-68. Web. 28 Dec. 2014.

Roberts, Shelley, Wendy Chaboyer, Michael Leveritt, Merrilyn Banks, and Ben Desbrow. "Nutritional Intakes of Patients at Risk of Pressure Ulcers in the Clinical Setting." Nutrition (2013). 5 Jan. 2015.

"Pressure Ulcers." Nutrition Care Manual. Eat Right. Web. 28 Dec. 2014.

Lizaka, S., T. Kaitani, G. Nakagami, J. Sugama, and H. Sanada. "Clinical Validity of the Estimated Energy Requirement and the Average Protein Requirement for Nutritional Status Change and Wound Healing in Older Patients with Pressure Ulcers: A Multicenter Prospective Cohort Study." Geriatrics and Gerontology International (2014). Web. 28 Dec. 2014.

Doley, J. "Nutrition Management of Pressure Ulcers." Nutrition in Clinical Practice 25.1 (2010): 50-60. Web. 5 Jan. 2015.

Dorner, Becky, Mary Posthauer, and David Thomas. "The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper." National Pressure Ulcer Advisory Panel (2009). Web.

Desneves, K., B. Todorovic, A. Cassar, and T. Crowe. "Treatment with Supplementary Arginine, Vitamin C and Zinc in Patients with Pressure Ulcers: A Randomised Controlled Trial." Clinical Nutrition 24.6 (2005): 979-87. Web. 5 Jan. 2015.

Sergi, G., A. Coin, S. Mulone, E. Castegnaro, V. Giantin, E. Manzato, L. Busetto, E. M. Inelmen, S. Marin, and G. Enzi. "Resting Energy Expenditure and Body Composition in Bedridden Institutionalized Elderly Women With Advanced-Stage Pressure Sores." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62.3 (2007): 317-22. Web. 28 Dec. 2014.

Cereda, Emanuele, Catherine Klersy, Mariangela Rondanelli, and Riccardo Caccialanza. "Energy Balance in Patients with Pressure Ulcers: A Systematic Review and Meta-Analysis of Observational Studies." Journal of the American Dietetic Association 111.12 (2011): 1868-876. Web. 5 Jan. 2015.

Tempest, Megan, Erika Siesennop, Kristin Howard, and Katherine Hartoin. "Nutrition, Physical Assessment, and Wound Healing." Support Line (2010): 22-27. Web. 5 Jan. 2015.

"Wound Care." Evidence Analysis Library. Eat Right. Web. 18 Dec. 2014.

Schiffman, Jessica, Michael S. Golinko, Alan Yan, Anna Flattau, Marjana Tomic-Canic, and Harold Brem. "Operative Debridement of Pressure Ulcers." World Journal of Surgery 33.7 (2009): 1396-402. Web. 15 Jan. 2015.

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Questions??

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Thank you!

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