twin cities district dietetic association meeting november 9, 2010 kim bihm, rd, ld, cde

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Twin Cities District Dietetic Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE Mary Murphy, RN, MA, CWOCN

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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 - PowerPoint PPT Presentation

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Page 1: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Twin Cities District Dietetic Association Meeting

November 9, 2010

Kim Bihm, RD, LD, CDEMary Murphy, RN, MA, CWOCN

Page 2: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

ObjectivesIdentify anatomy and physiology of skinDescribe prevention strategies to reduce

incidence of pressure ulcersDescribe an interdisciplinary approach to

prevention and treatment of pressure ulcersDefine nutritional treatment modalities for

wound healing.

Page 3: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Why should we care?Complications to patients

Lead to pressure ulcersPainfulInfectionQuality of Life

Page 4: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Why should we care?Cost

HospitalizationsHealth care workers Skin Care Products

Reduction in payment from regulatory bodies

Page 5: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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 PlaintiffAverage award is $13.5 millionHighest award is $312 million in one case!

Page 6: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Clinical Practice Guidelines by NPUAP/EPUAP:Evidenced-Based Practice

Best scientific research availableSystemic review of literatureProvides tools for best judgmentAllows decision-making on more

than “expert opinion” alone.

DOES NOT dictate practice or replace clinical reasoning or judgment – it ENHANCES these!

These are guidelinesPolicies are absolute

Page 7: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 8: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Interdisciplinary Approach

PhysicianC-collar inspection

orders

NursingPressure Ulcer

Protocol

NutritionHigh protein, high

calorie diet with snacks and supplements

Physical TherapyWheelchair cushion

pressure mappingAvoiding shear during

transfers

Occupational TherapyCognitive screeningAssistive Technology

Speech TherapyMemory assessmentCognitionCommunicationAssistive Technology

All disciplines need to assess for risk and put prevention interventions into place:

Page 9: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Prevention: Risk Assessment

Co-morbiditiesPrevious PUSmoking hx

Long OR timeLong ED staysCritically ill – ICU= 4x moreWheelchairsObese/thin

Page 10: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Guidelines to Preventing Pressure Ulcers

Combination of Risk Assessment + Skin Inspection + Clinical JudgmentReassess RISK

Upon admissionAt regular frequencyChange in condition

Skin InspectionsHead to toe inspection regularly

Individualized plan of careUse Interdisciplinary Approach

MD, Nutrition, PT/OT, Speech Therapy

Page 11: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE
Page 12: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Anatomy and Physiology of SkinLargest organ of the bodyWeight: up to 15% of body weight – about 6

poundsSize: Average adult – 3000 square inchesReceives 1/3 of body’s circulating blood

volumeConstantly exposed to changing

environmentsHas capability to self-regenerate

Page 13: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Skin Layers: EpidermisOutermost layer made of epidermal cellsThin and avascularRegenerates every 4-6 weeksMelanocytes reside in epidermis

Melanin is pigment responsible for color of skin

Page 14: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Skin LayersDermis

Thicker layerContains:

blood vesselshair follicleslymphatic vesselssebaceous glandssweat and scent glandsnerve endings

Page 15: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 16: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Skin Layers: HypodermisSubcutaneous Tissue

Composed of adipose and connective tissueFilled with major blood vessels, nerves and

lymphatic vesselsAttaches dermis to underlying structuresProvides insulation and cushioning to bodyActs as a ready reserve of energy

Page 17: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Functions of SkinBody Image

Maintenance of body formAppearance, attributes and expression

SensationAbundant nerve receptors in skin

TouchHeat/ColdPainPressure Moisture

Page 18: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Functions of SkinRegulation of body temperature

98.6 F / 37 CThermoregulatory mechanisms:

CirculationBlood vessels dilate to dissipate heatBlood vessels constrict to shunt heat to body organs

Sweating2-5 million sweat glands

Page 19: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Functions of SkinProtection

Safety against sunburnMelanin in the epidermal cells protects against

ultraviolet light

MetabolismVitamin D formation

Presence of sunlightThis activates the metabolism of calcium and

phosphate and minerals (important in bone formation)

Page 20: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Functions of SkinProtection

Barrier to germs and poisons Normal floral =

Staph AureusDiphtheroidsGram neg bacilliNOT Candida – That comes from GI tract

Chemical defensesSweat, oils, wax from skin glands contain lactic acid

and fatty acidThese acids make skin pH acidic to kill bacteria and

fungi

Page 21: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Functions of SkinMaintenance of water balance

Prevents loss of water through evaporation<10% moisture – cells shrink = increase invasion of bacteria

>30-40% moisture level = macerationIncreased permeabilityIncreased risk of injury from friction

Page 22: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Theory of pHpH refers to management of acid or base

levels Acidic is 0-6Neutral is 7Basic is 8-14

Rain is 5.6Seawater is >7Milk is <7Gastric juices are acidicSaliva and blood are neutral

Page 23: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Skin pHSkin 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 levelsPooled 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

Page 24: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Skin Changes

Age-Related changes:Functions declineEpidermal/dermal junction flattens

Decreases skin strengthIncreases risk for tearing

Melanocytes shrink (decrease in volume)Increases sensitivity to sun

Page 25: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Skin ChangesAge-Related changes:

Decreased sweat production Leads to increased dryness and flaking

Nutrition changesMedications

Page 26: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Guidelines to Preventing Pressure UlcersSkin Inspections

Checking all bony prominences Check under skin foldsCheck under medical devicesCheck where there is limited sensationEducate professional staff on skin conditions

for early identificationTechnique for blanching responseHow to assess warmth, edema, and induration

Set time frame for on-going inspections

Page 27: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Arterial ulcers Venous

ulcers

Trauma injuries

Page 28: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Stage I Pressure UlcersIntact skin with non-

blanchable redness of a localized area- usually over a bony prominence.

Page 29: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Stage II Pressure UlcersPartial 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.

Page 30: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Stage III Pressure UlcersFull 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

Page 31: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Stage IV Pressure UlcersFull thickness tissue

loss with exposed bone, tendon or muscle.

Slough/eschar may be present.

Often includes undermining/tunneling.

Page 32: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Unstageable Pressure UlcersFull thickness tissue

loss in which actual depth of ulcer is completely obscured by slough and/or eschar.

Page 33: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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.

Page 34: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Iatrogenic Damage:Pressure Injury from Medical Devices

Page 35: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Assess for Risk by RNBraden Risk Assessment (by Barbara

Braden)Reliable research based risk assessment tool

SensoryMobilityActivityFriction/ShearNutrition Moisture

Page 36: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk due to Sensory ImpairmentCan they feel?

Prevention:If they can’t feel – someone must look at skin!!Check under devicesCheck for proper fitting shoes and socksNeed redistribution mattress

Page 37: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk due to Mobility ImpairmentCan they move themselves?

Prevention:Must be turned every 2 hoursMust be trained in proper pressure reliefMust have pillows elevated

Page 38: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk due to ActivityCan 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

Page 39: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk due to Friction and ShearAre they sliding in bed or wheelchair?

Prevention:Watch transfers from w/c to bed

If concerned, get PT/OT consult

Manage spasticityReport concerns to MD

Keep knee gatch up in bed to prevent sliding in bed

Page 40: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

SKIN INSPECTIONS:Bony Prominences To Check

Page 41: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Support SurfacesHow to make sense of the confusion????

Page 42: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

What Do We Know- EvidencePressure = Force/Area

Pressure is caused by perpendicular force = Treatment = pressure redistributionPressure redistribution = depth of pressure without

bottoming out

Shear is parallel force = Treatment = prevent sliding

Page 43: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Features of Support SurfacesAir Fluidized

A feature that provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment

Page 44: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Features of Support SurfacesLow Air Loss

A feature that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin.

Page 45: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Features of Support SurfacesFoam

Elastic foam or Visco-elastic foam

Page 46: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Features of Support SurfacesGel

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

Page 47: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Features of Support SurfacesAlternating 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.

Page 48: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Repositioning – Evidence ARelieve/redistribute pressure30 degree side lying is importantAlternate positionsAvoid shearAvoid lying on medical devicesAvoid slouching in w/c – use footplatesAvoid HOB elevation: HOB = shear/pressureElevate heels Consider “zone” positioning changesConsider: Every layer on top of surface changes

the surface supportThink of chux/linen/briefs = change in performance of

bed

Page 49: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wheelchair cushionsCheck w/cushion –

pressure mapping

Check chair positionBack tilt w/ legs upUpright w/ foot

rests

Limit sitting time

Page 50: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk due to MoistureIs their skin too moist?Prevention:

Avoid plastic diapersAvoid extra pads that retain heat Skin barrier protection is critical

Page 51: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 52: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Prevention StrategiesKeep skin clean, dry and protected

Toileting programStructured bowel program

Gentle cleansing-avoid mechanical irritationBalanced pH cleanser + moisturizer or humectantsSoft cloth vs. wash clothPat dry

Skin protectant/barrierDimethiconePetrolatumZinc

Moisturizer - Emollient

Page 53: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Products: UnderpadsBriefs/ underpads

Needs to be highly absorptiveNeeds to quickly wick moisture away from patient

Plastic/cloth absorptive products are occlusive Trap perspiration = increase heat/moisture =

increase skin damageTypically made of 3 layers:

Water-permeable cover next to skinAbsorbent 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 tearingDifferent sizesBreathable

Page 54: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

ProductsConsider containment products

External cathetersIndwellingSuprapubic cathetersIntermittent CathetersFecal pouchesFecal tubes

Page 55: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Complex Process of Wound Healing

Page 56: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk due to NutritionAre they eating/drinking enough?Prevention:

Need RD consult for any Braden score of 1 or 2

High protein dietImportance of snacks and supplementsGood hydrationMultivitamins/ mineralsLabs: prealbumin

Page 57: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

NutritionScreen for nutritional deficiencies

Send nutrition consultsMonitor for signs of dehydration – I/OsMonitor weight changesHighlight Braden Subcategory of Nutrition

Prioritize protein intake

Page 58: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Specific RecommendationsOffer high protein supplements in addition to

usual diet.Plan for supplement 60 minutes between

meals

Page 59: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Resource for Nutrition

The Role of Nutrition in Pressure Ulcer Prevention and Treatment:National Pressure Ulcer Advisory Panel

White Paper

Page 60: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Patient/Caregiver Education

Causes/ risk factors for PU developmentWays to minimize risk:

Regular inspectionsPrevent friction/shearRoutinely turn/repositionAvoid use of rings, foam cut outs, donut-type

devicesMaintain adequate nutrition and fluid intakeMonitor for weight loss, poor appetitePromptly report health care changes to providers

Page 61: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

TREATMENT of Pressure Ulcers:GOLD STANDARD of Wound Healing:

Good signs of healing by 2 weeks30% healing at 4 weeksFull closure at 12 weeks

Page 62: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Guidelines to Treatment of Pressure UlcersPrinciples of wound healing:

Eliminate cause – moisture, pressure, shear , friction

Wound cleansingKeep infection free

Topical treatments Moist wound healingProtect periwoundRefer as necessary for debridementManage nutrition

Page 63: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Repair of Skin DamageRepair of partial thickness skin damage

RegenerationDamage is confined to epidermal and superficial

dermal layersEpithelial cells will reproduce

Trauma triggers inflammatory responseErythema, Edema, Serous exudate

Epidermal resurfacing beginsDay 7 - new blood vessels sproutDay 9- Collagen fibers are visible

Collagen synthesis continues until about day 10-15

Page 64: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Repair of Skin DamageRepair of full thickness skin damage

Scar formationDamage 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 intentionPrimary intention – surgical closureSecondary intention –scar formation

Page 65: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Repair of Skin DamageScar formation process is complex with

several phases:Hemostasis phase

Clot formationInflammatory phase

Clean up phaseTakes 3-4 days usually

Proliferation phaseVascular integrity restoredNew connective tissue is growingGranulation tissue growthWound contraction

Maturation / Remodeling phase

Page 66: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesWound cleansing – Evidence C

Cleanse wound and periwound with each dressing changeProvide 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

Page 67: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesManage wound infections

Contamination Non-replicating organisms

Colonized Bacteria in wound bed Organisms are attached and replicating Not affecting the environment

Common organisms: staph and pseudomonasCritically 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

Page 68: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management Strategies

Topical AgentsDakin’s solution – Sodium hypochiorite – 0.25%

Good for gram - & + - best on staphBleach 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 notedEffective in 48 hoursAbsorptiveLimit to 2 weeks – risk of dermatitis

Page 69: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesTopical Agents

Silver Silver Sulfadiazine ointment

Good for gram -, Klebsiella, PseudomonasSeeing 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

Page 70: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesTopical antimicrobials – for tissue

organismsBactoban is resistant nowNeomycin/Neosporin – NO NEO! = contact

dermatitisGentamycin = nephrotoxicity and resistance

Bacitracin is ok stillGood for gram +Resistance is rare

Page 71: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesSystemic antibiotics for:

Bacterimia/ sepsisAdvancing cellulitisOsteomyelitis

95% of bone exposed is + for osteo

Caution: MRSA is very virulentCellulitis to pneumonia in 24-48 hours

Page 72: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesDebride the pressure ulcer of devitalized

tissueDebridement options:

SurgicalConservative sharp

Page 73: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesDebride the pressure ulcer of devitalized

tissueDebridement options:

High pressure fluid irrigationUltrasonic

Page 74: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesDebride the pressure ulcer of devitalized

tissueDebridement options:

MechanicalAutolyticEnzymatic

Page 75: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesDebride the pressure ulcer of devitalized

tissueDebridement options:

Maggot Therapy

Page 76: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesVAC Therapy

Page 77: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesElectrical Stimulation

Page 78: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesHyperbaric Oxygen Therapy

Page 79: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesLiving Skin Equivalents

Page 80: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Wound Management StrategiesFlap Surgery –

Umar Choudry, MD

Page 81: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Interdisciplinary Teamwork !!!!!

SCI Provider:Pre-op medical clearanceAnticoagulant assessment

Transfuse if Hgb < 8Spasticity management

Patient needs to lie straight for 3-4 weeks

WOC Nurse:Prep wound – VAC therapy

Pre-Surgery Preparation

Page 82: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition ConsultAssess nutrition needsPre-albumin goal of >20 before surgeryZinc at least in normal range goalSupplemental 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

Page 83: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Physical Therapy and Occupational Therapy pre-op consults for baseline assessments

Physical TherapyTransfersSeating/Positioning including pressure mappingROMTone

Occupational TherapyADLsAdaptive Equipment needsFunctional transfersSeating/Positioning

Pre-Surgery Preparation

Page 84: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Post-op Course3 weeks on Air Fluidized bed

Week 4Switch to low air loss bedBegin stretching

Week 5-6 Sitting program

Discharge week 6-7

Page 85: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

2009 to present:16 flap surgeriesZERO losses of the flap

VAMC -Mpls SCI Unit Outcomes:

Page 86: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

The Registered Dietitian’s

Role in Wound Healing

Page 87: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE
Page 88: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Pressure Ulcer Prevention• Global expert (NPUAP/EPUAP) consensus

SUPPORTS nutritional assessment as part of a comprehensive interdisciplinary approach to preventing pressure ulcers!

Page 89: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Pressure Ulcer PreventionNutritional 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

Page 90: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk for Pressure Ulcers

Unintentional weight lossUnder nutritionProtein energy malnutritionLow BMIInability to eat independentlyCachexiaHyper metabolism

Page 91: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk for Pressure UlcersDiabetes

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

Page 92: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk for Pressure UlcersDiabetes

Calorie needs are increased to promote wound healing.

The major fuel source for collagen synthesis is carbohydrates (~55% of calories should come from carbohydrates)

Page 93: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Risk for Pressure UlcersDiabetes

Medications may need to be adjusted to accommodate increased carbohydrate intake.IV insulin drip may be used to control

blood sugars post-op

Page 94: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Under NutritionProblems chewing and/or swallowing

Decrease ability to feed selfDecreased appetiteAdvanced ageUnintentional weight loss

Page 95: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Unintentional Weight Loss Can lead to:Impaired immune systemDecreased serum albumin &

prealbuminDecreased ambulationWeaknessDevelopment of pressure ulcersNon-healing pressure ulcers

Page 96: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Loss of Lean Body MassDefined 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

Page 97: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Prevention: Risk Assessment

Co-morbiditiesDiabetes

Renal diseaseImmunosuppressi

onMalnutrition

Page 98: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Consultation of RDWhen to consult the Registered

Dietitian:When patient is identified as:

Being at risk for pressure ulcers Braden Risk Assessment score less than

19Braden Risk Assessment- Nutritional

sub-score of 1 or 2Existing pressure ulcerNewly discovered pressure ulcer within

24 hoursWorsening of a ulcer or with an ulcer not

progressing through the normal stages of healing

Page 99: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Consultation of RDInadequate 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 daysDifficulty chewing and/or swallowingUnable to eat independentlySignificant weight loss >5% in 30 days or

>10% in 180 days

Page 100: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Example of Nutrition Consult Template

Page 101: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Braden Risk Assessment Nutrition Subcategory1. Very Poor

Never eats or completes meal2 servings or < of proteinPoor fluid intake1/3 of any food offered or NPO or IV

fluids/clear liquids for > 5 days

NEEDS NUTRITION CONSULT

Page 102: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Braden Risk Assessment Nutrition Subcategory2. Probably Inadequate

Eats ½ of any food offeredProtein: 3 servings of meat or dairy dailyOccasional intake of supplement or tube

feeding or liquid diet less than requirementsHow often is TF turned off for activities?

NEEDS NUTRITION CONSULT

Page 103: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Braden Risk Assessment Nutrition Subcategory3. Adequate

Eats > 50% of most meals4 servings of protein dailyOccasionally refuses meal but takes

supplement or tube feeding or TPN meets needs

Page 104: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Braden Risk Assessment Nutrition Subcategory4. Excellent

Eats most meals and never refuses a mealEats 4 or more servings of meat and dairy

dailyDoesn’t require supplements

Page 105: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition Care Process

Page 106: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutritional Assessment DataFood / Nutrition historyLab data, medical test and proceduresAnthropometric measurements including

weight historyPhysical examination findings (i.e. brittle

nails, thinning hair, fragile & thin skin)Patient History

Page 107: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutritional Assessment DataEstimating calories, protein, fluid, vitamin and

mineralsAdequacy of po intake (past and current)Barriers in meeting optimal nutrition -swallowing difficulties -chewing problemsCognitive deficits-ability to feed selfBraden Risk Assessment scale, BMI, weight

changes Individual goals and wishes of the patient

Page 108: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition DiagnosisPES Statement~60 nutrition diagnoses within 3 domains: 1- Clinical 2- Intake 3- Behavioral- EnvironmentalIdentifies 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.

Page 109: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition InterventionsSpecific 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

Page 110: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition Interventions

Develop individualized interventions with the patient and the family

Educate the patient and their familyLiberalize the diet as much as possibleObtain food preferences Allow flexibilityDiscuss high protein/high calorie

snacks/supplements with patients

Page 111: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition Monitoring and EvaluationMonitoring, 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!

Page 112: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition Monitoring & EvaluationMonitor 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

Page 113: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Biochemical AssessmentHepatic Proteins:Serum albuminSerum prealbuminSerum transferrin

Hepatic Proteins and Nutrition Assessment; Journal of the American Dietetic Association 2004

Page 114: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition Labs: Albumin and Prealbumin

Helpful Careful of interpretation

Indicators of:Morbidity and mortalitySystemic illness

Help identify patients who may become malnourished

Helpful for trending

Negative acute phase reactanti.e. Increase illness =

Decrease in lab valuesDecrease after surgeryDecrease with infection,

stress and inflammationIncreases with

dehydration

Page 115: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutritional Requirements for Wound Healing

National Pressure Ulcer Advisory Panel White Paper 2009

Page 116: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Calorie RequirementsUse 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

Page 117: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Calorie RequirementsWeight 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

Page 118: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Protein RequirementsUse 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

Page 119: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Protein RequirementsProtein 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

Page 120: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Fluid Requirements30-35 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

Page 121: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Fluid RequirementsPatients 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

Page 122: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 123: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 124: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Vitamin and Minerals

Ascorbic Acid -enhances collagen production -increases formation of blood vessels -supports immune system

Page 125: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Vitamin and Minerals

Vitamin A -stimulate collagen production -enhances cell production

Page 126: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Vitamin and Minerals

Vitamin E -stabilizes cellular membranes

Page 127: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 128: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Vitamin and Minerals

Arginine -stimulates protein production -supports immune function -stimulates collagen production At this time, safe maximum doses are not

knownMore research is needed to verify what

effects it has on healing of pressure ulcers

Page 129: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Vitamin and MineralsGlutamine -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)

Page 130: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Feeding PracticesProvide 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

Page 131: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Feeding PracticesEncourage 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

Page 132: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition SupportConsider 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.

Page 133: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

EducationEducating 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

Page 134: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Nutrition is One Aspect of Care

134

Page 135: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

In ConclusionPrevention is the best treatmentProvide consistent, adequate

nutritionProvide individual plan of careLiberalize diet as much as possibleEducate patient, family, and staffProvide frequent follow upWorking as a team is essential

Page 136: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Questions

Page 137: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Please feel free to e-mail us if you would like additional information or resources:

[email protected]@va.gov

Follow Up

Page 138: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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

Page 139: Twin Cities District Dietetic  Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

ReferencesGuideline 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 2009http://www.npuap.org/Nutrition%20White%20Paper

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