the role of nutrition in pressure ulcer treatment: a case

The Role of Nutrition in Pressure Ulcer Treatment:A Case Study

Katherine TomainoJune 11, 2012

Pressure Ulcers

Also known as decubitus ulcers Localized injury to skin or underlying tissue,

usually occur over bony prominences − Sacrum− Heels− Ischium

Bluestein & Jahaveri, 2008.

Pressure Ulcers

Occur secondary to unrelieved pressure− which causes reduction in blood flow to

capillary network causing reduction in available oxygen and

nutrients and thus damage to tissues

Staged according to severity: I-IV

Bluestein & Jahaveri, 2008.

Pressure Ulcers

http://www.lhsc.on.ca/Health_Professionals/Wound_Care/images/pressure.gif http://www.acphospitalist.org/archives/2007/07/pressure_ulcer.jpg

Pressure Ulcers: Risk Factors

Limited mobility Vascular disease Advanced age Extrinsic pressure or friction

Moisture Compromised nutrition

− Anorexia, dehydration, weight loss, low BMI, impaired ability to eat independently

Bluestein & Jahaveri, 2008. NPUAP, 2009.

http://thelaughingstork.com/wp-content/uploads/2009/06/Advanced-Maternal-Age-150x150.jpg

Pressure Ulcers Severe protein-calorie malnutrition alters

several physiological processes that promote skin status:

− Tissue regeneration− Immune function− Inflammatory response

Malnutrition / underweight status also leads to − Reduced skin fold thickness− Reduced fat mass

Thomas, 2001

Pressure Ulcers Adequate energy intake promotes anabolism, collagen

synthesis, and healing.

Protein is responsible for synthesis of enzymes, cell multiplication, tissue synthesis.

Adequate intake of fluids, vitamins, and minerals supports immune function, amongst other essential physiological processes.

NPUAP, 2009

Limited evidence exists related to MNT for prevention of PU

Current nutrition recommendations primarily based on:

− expert opinion− best practice

guidelines− small research

studies

Pressure Ulcers

NPUAP, 2009

NPUAP Recommendations1. Energy – Provide sufficient calories 30-35 kcal/kg body weight for individuals with PU

− Liberalize diet restrictions that may decrease intake.

− Provide supplements if appropriate when intake is inadequate.

2. Protein – Provide adequate protein for positive nitrogen balance

1.25-1.5 gm/kg body weight− Assess renal function to ensure high levels of

protein are appropriate and tolerated. NPUAP, 2009

NPUAP Recommendations3. Provide and encourage adequate fluid intake for

hydration− Fluids should be calculated based on

individual fluid needs, taking into account hydration status, kidney function, and increased losses.

− Patients consuming increased levels of protein may require additional fluid.

4. Provide adequate vitamins and minerals− Encourage a balanced diet to achieve

adequate intake of essential micronutrients− Provide supplements when necessary to meet

DRI

Protein - Amino Acids

Arginine and glutamine become conditionally essential during conditions of severe stress.

However, no definitive research exists to support arginine or glutamine's effect on wound healing, and no maximum safe dosage of arginine supplementation has been established.

NPUAP, 2009http://images-en.busytrade.com/103257000/L-arginine--L-citrulline-L-histidine-L-glutamine.jpg

Micronutrients

Previously, Vitamin C and Zinc have been hypothesized to be related to pressure ulcer healing

Available studies have shown that mega dose supplementation of Vitamin C and Zinc have not been shown to accelerate wound healing.

NPUAP, 2009http://www.thedailygreen.com/cm/thedailygreen/images/oranges-vitamin-c-lg.jpg

Micronutrients are recommended at DRI levels.

Post NPUAC

Brewer et al (2010) compared 18 spinal cord injury patients supplemented with 9g / day arginine containing nutritional supplement with a control group.

− Found that mean ulcer healing times were 10.5 weeks vs. 21 + weeks for the intervention group and controls respectively

− “Promising” benefit of arginine supplementation for wound healing in individuals with spinal cord injury

Brewer et al, 2010.

Post NPUAC Theilla et al (2012) assessed use of fish oil supplements vs

control micronutrient supplement on healing of PU and immune function for 40 critically ill ICU patients admitted with PU.

− Severity/ stage of PU increased significantly for control group after 4 weeks, but was maintained at baseline levels for fish oil intervention groups

− Suggests that fish oil supplemented formula may prevent worsening of pressure ulcers and this may be mediated by adhesion molecule expression in the immune response.

Theilla et al, 2012

Case study: John Cash*

90 y.o male nursing home resident Height: 72'' / Weight: 57 kg / BMI: 17 Past medical history: fracture of C1 & C2

cervical spine s/p MVA, hypertension, CHF, hypercholesterolemia, CVA, MI, PPM, A-fib, prostate cancer (s/p TURP, 1995)

Admitted to RBMC PAD Intensive Care Unit for hypotension / jaw cellulitis / acute on chronic kidney disease

*Not his real name.

Case Study: John Cash

Awake / alert / confused Complete functional dependence Braden scale: 9 (very high risk) NKA, NKFA PO intake: fair DNR – no lab for dx purposes Social services

Case study: John Cash

Skin status:− Left mandible pressure ulcer, stage IV – bone

exposed− R / L heel pressure ulcer, stage I

S/P MVA (6 months prior) → fracture CI & C2 cervical spine → declined Halo & surgery → wearing cervical collar


Philadelphia Cervical Collar (http://image.made-in-china.com/2f0j00iZftCQhRFEbT/Philadelphia-Cervical-Collar.jpg


Stage IV pressure ulcer (http://www.millerandzois.com/images/BedsoreStage4.jpg)


Medications− Heparin− Cefepime HCl− Protonix− Atropine sulfate, Simvastatin, Coreg, Enalrapril,

Spironolactone− Aspirin− MVI− Vitamin C− IVF: D5NS at 100ml/hr (TV: 2.4L/day, kcal: 408)


Labs (4/17/2012)− Glucose: 107 − Na: 138− K: 4.8− Albumin: 2.6 ↓− BUN: 105 ↑− Creatine: 3.4 ↑

ProBNP: 14086 ↑ GFR: 18 ↓

I/O: 2375/700


Diet history at nursing home: − NAS, chopped − Ensure TID (per 8oz: 350 kcal, 13 gm protein)− ProStat TID (per 1oz, 60 kcal, 15 gm protein)

Current diet order:− 1800 ADA 2gm Na, low cholesterol diet− Ensure pudding TID (per *

Case study: John Cash Previous poor PO intake per NH records Patient appears malnourished, BMI: 17 Stage IV PU Per RN, patient with very slow intake, needs total

assistance. No N/V/D/C.

Estimated needs− Calories: 30-35 kcal / kg− Protein: 1.2-1.3 gm / kg− Water: 30-35 ml / kg

Case Study: John CashNutrition Diagnosis: Increased nutrient needs

Related to: Wound healing, underweight status

As evidenced by: L mandible stage IV PU, BMI: 17, previous poor PO intake

Nutrition interventions

1. Recommend NAS diet + Ensure TID (per 8oz: 350kcal, 13gm protein) + ProStat BID (per 1oz: 60kcal, 15gm protein) Goal: meet nutrition kcal and protein needs

2. Encourage PO intake, feeding assistance at all meals

Goal: increase oral energy intake

Monitoring & Evaluation

1. PO intake / 50-75% meals and supplements

2. ↑ BUN, ↑ Creat. – monitor renal status for safety with current protein recommendations

3. ↓ Album / 3.0 g/dL or greater

4. Skin Status / ↓ breakdown with adequate kcal, protein intake & wound care

Case study: John CashOutcome

After just two days, Mr. Cash was transferred from the RMBC PAD ICU to JFK Medical Center where he was to be seen by a neuro-surgeon with the authority to discontinue his cervical collar.

During his stay at RMBC he was treated with antibiotics and attended by the wound care nurse team.

Consults included infectious disease, cardiology, and clinical nutrition. No further labs or diagnostic tests were pursued per request of the family.

Questions?

the role of nutrition in pressure ulcer treatment: a case

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