Advance Concepts in Pressure Ulcer Care

Rachel Hudes, Dietetic InternBenedictine University

5/20/2011

Statistics• 1-3 million people develop pressure ulcers each year.

• In 2006, costs for a pressure ulcer pt ranged from $16,700 to $20,400 compared to $10,000 for non pressure ulcer patients.

• In acute care facilities it is estimated that 60,000 people die each year from pressure ulcer complications.

• Incidence of pressure ulcers ranges from:– 2.3% to 23.9% in long-term care– 0.4% to 38% in acute care– 0% to 17% in home care – 0% to 6% in rehabilitative care

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.

• Pressure ulcers are areas of damage to the skin and underlying tissue, due to the lack of blood flow to these areas.

• Usually occur over bony protrusions such as over the sacrum, ischial tuberosities, trochanters, malleoli, and heels.

• Population most at risk are those who have limited mobility and may be confined to a bed or wheelchair for prolonged periods of time.– Commonly occur in the elderly, those residing in nursing

homes, pt’s with spinal cord injuries, those with nerve damage, and the immobile acutely ill.

Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:979-987. Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.

The Braden Scale• Used for predicting pressure ulcer risk and should be

completed at admission to healthcare institutions.

• Helps in the assessment process for determining the needs of the patient, along with identifying triggers.

• The lower the score, the higher the risk. – Those with an 18 or lower are considered high risk.

• People with low Braden scores should be checked for pressure ulcers.

• Individuals should be reassessed following a change in condition.

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.

Stage 1

Stage 2

University of Washington. Taking Care of Pressure Sores. http://www.sci.washington.edu/info/pamphlets/pressure_sores.asp

Stage 3

Stage 4

University of Washington. Taking Care of Pressure Sores. http://www.sci.washington.edu/info/pamphlets/pressure_sores.asp

Risk Factors for Pressure Ulcers

•Extrinsic factors are primary causes of pressure ulcers and effort should be taken to avoid these.

•Intrinsic factors vary between people and should be assessed for and identified. They influence the skin’s supporting structure and lymphatic system. Medical nutrition therapy should focus on improving or preventing PU increase caused by these.

Victorian Government Health Information. (2008) Pressure Ulcer Basics. http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm

Extrinsic Factors• Moisture: – causes skin vulnerability• alters the resistance of the epidermis to extend forces

by softening the skin’s surface and reducing the tensile strength.

• Friction: – Resistance to movement between the patient’s

skin and the external support surface.– Acts in a direction that is opposite to patient

movement. Victorian Government Health Information. (2008) Pressure Ulcer Basics. http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm

Sheering Forces:

• Shearing forces are exerted parallel to the skin and is generated by forces (friction) acting against it and moving in the opposite direction.

Victorian Government Health Information. (2008) Pressure Ulcer Basics. http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm

Intrinsic Factors• Nutritional status:– Poor nutrition has a significant role in PU

development. – Research indicates that the following factors

increase the risk of developing a PU:• malnutrition• low levels of protein/albumin• recent weight loss or morbid obesity• specific micronutrient deficiencies such as Vitamin C,

iron, and zinc.

Victorian Government Health Information. (2008) Pressure Ulcer Basics. http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htmAmerican Dietetic Association. ADA Evidence Analysis Library.Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:979-987.

• Individual characteristics – > 65 years of age

• Risk for depletion of lean body mass, since this naturally occurs with age (Sarcopenia).

• Older age also results in natural changes to the skin and body. – Generally more fragile, thinner, less elastic, and drier then

the skin of young adults, so more vulnerable to damage.– Also new skin cells are usually generated more slowly. – Dehydration risk increases.

– Immobility

– Inability to eat independently

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:979-987.

– Multiple co-morbidities that may result in poor blood flow, immobility, and neurological disorders.• Diabetes, Hypertension, Dementia

– Oxygen delivery system:• Decreased supply of oxygen to the area under stress leads

to increased risk.– Respiratory disorders, reduced cardiac output, chronic infections,

smoking, autonomic dysfunction (as seen in spinal cord injury)• In a hypoxic environment, fibroblasts cannot replicate,

production of collagen is reduced, and risk of infection increases.

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:979-987.

–Medications:• Drugs that increase the risk of

developing pressure ulcers include those that decrease sensation• May result in less movement,

decrease inflammatory response, and decrease peripheral blood pressure. – Corticosteroids–Nonsteroidal anti-inflammatory

drugs

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.

Pathophysiology of Pressure Ulcers• Due to multiple factors, pressure ulcers are

formed when on-going pressure over a certain area of the body results in the squeezing of tiny blood vessels.

• Blood that normally carries oxygen and nutrients to these cells are blocked, resulting in tissue death/skin break-down.

Pressure Distribution on Skin Layers

Victorian Government Health Information. (2008) Pressure Ulcer Basics. http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm

Case Study

Patient (pt) Profile• 75 y/o Caucasian male

• Came from a Nursing home, inability to communicate well, and is single.

• Was admitted to Saint Anthony Hospital for dehydration, constipation, UTI, sepsis, and pressure ulcers (Stage 1, 2, and 4).

• Past Medical History (PMH)– Cerebrovascular accident w/ Hemiplegia– Hypertension– Hypoxia– Leukocytosis

Anthropometrics• Height: 66 inches

• Weight: 167.8 lbs/76.3 kg

• Body Mass Index: 27.4 (Overweight)

• Ideal Body Weight (IBW): 142 lbs

• % IBW: 118.2%

Food & Nutrition History• Difficulty swallowing and chewing

• Currently constipated and dehydrated

• Currently getting enteral nutrition support– Jevity 1.2 @ 80mL/hr X 18hrs– Water flushes at 300 mL every 6hrs

• Past diet orders: enteral nutrition support

Physical Assessment• Patient is bedridden/immobile

• Lies with his elbows against the bed with head back

• Braden score of 6/23

• Eyes were closed and patient was not in a state to communicate

• Appeared to be resting comfortably • Pt was wearing heal protectors

Abnormal Labs

Lab TestNormal Value Value Indication

BUN (mg/dL) 6-20 34 H

Reflects dehydration statusKidney function appears to be normal because electrolytes and creatinine were all at normal levels.

BUN/creatinine (mg/dL)

0.60-20.00 47.89 H

Reflects dehydration status and elevated BUN level.

CRP <1 9.6 H

Indicates that the pt is in a state of active inflammation/has infection due to pressure ulcers, sepsis, and UTI.

ESR (mm/hr) 20 52 H

Marker of inflammation. May be related to the multiple contractures in his left extremities.

ESR• A marker of inflammation within the body and

is commonly used to screen for severe arthritis.

• The constant tightness and lack of mobility, due to paralysis, resulted in his joints stiffening up and contractures.

• Because this pt is experiencing similar joint damage as to someone who has severe arthritis, it is likely that this elevated lab is a marker of this pt’s multiple contractures.

American Association for Clinical Chemistry. (2001-2011) ESR. Lab Tests Online. http://www.labtestsonline.org

Additional Important Labs

• Albumin/Prealbumin/Total serum protein

• Hemoglobin/Hematocrit

• Total lymphocyte count

• Serum nutrient levels if deficiencies suspected

American Dietetic Association. ADA Evidence Analysis Library.

CVA

Contractures

Urinary Tract Infection

Paralysis

Pressure Ulcers

Disease Inter-relationships

Pressure Ulcers

Dehydration

Sepsis

Contributing Factors to Pressure Ulcers

• Paralysis– Lack of mobility – Bedridden– Contracture formation– Incontinent – Nerve damage

• CVA/Hypoxia/HTN– Poor circulation– Vasoconstriction and loss of vessel elasticity

resulting in damage and weakness.

• Older Age– Sarcopenia: natural decline in lean body mass.– Decrease in skin integrity– Decrease in immunity and more prone to

infections– Dependent on Nursing Home care

• Sepsis– Compromised immune system.– Hypermetabolic state

• Dehydration– Decrease in blood volume which can result in

compromised delivery of oxygen, nutrients, and immune cells to damaged area.

Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12 th Edition. Saunders Elsevier. St. Louis, MO. 287-295.

Assessment of Nutrition Needs

Calories 2300 - 2670 kcals (30-35 kcals/kg)

Protein 115-150 gms (1.5-2 gms/kg)

Fluid 2300 - 2670 mL/day (30-35 mL/kg)

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.

NutrientDosing Information and

Recommendations

Glutamine UL: .57 g/kg/day (d)

Arginine Maximum safe level not established

Zinc

40 mg/d in deficient pts until corrected.UL: 40 mg/d

Vitamin C

70-150 mg/day considered protective500-1000 mg/d for wound healingUL: 2 g

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.American Dietetic Association. Pressure Ulcers. Nutrition Care Manual. Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12 th Edition. Saunders Elsevier. St. Louis, MO. 287-295.

Glutamine• This amino acid serves as an energy source and for proliferation

by inflammatory cells within the wound.

• Glutamine was found to increase wound healing rates of burned patient’s, who are commonly deficient.

• It has been shown to maintain mucosal integrity and reduce infection rates.

• More research is needed to determine its effectiveness specifically on pressure ulcer healing.

• The NPUAP and EPUAP do not recommend routine glutamine supplementation for pressure ulcers pts.

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.

Arginine• The use of arginine supplemented formulations should be

considered in pt’s with pressure ulcers who are critically ill or undergoing major surgery, as immune enhancing formulas.

• Results showing an increase in collagen synthesis and wound breaking strength in pts with incisional wounds has yet to be displayed in pressure ulcer pts.

• One study showed improvement in pressure ulcer healing when 2 high pro, high energy nutrition supplements containing arginine, vitamin C and zinc, were given over a 4 week period compared to a group given a only a standard diet and another group given 2 high-calorie/high protein supp/day.

• Additional research is also needed to recommend its use alone or with other nutrients for pressure ulcer healing.

Zinc

• Important to maintain adequate levels and correct deficiency in order to promote wound healing and immunity function. – No more then 40 mg/d is recommended and

only until deficiency is corrected.

• No evidence that supplementation improves healing of vascular or pressure ulcers in pts without deficiency. – High serum Zinc levels may inhibit the healing

process because it competes with copper in binding to albumin.

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.

Vitamin C• It is important to identify and correct deficiencies

through supplementation as it plays a role in collagen synthesis and immune responsiveness.

• The is no evidence that giving higher doses of vitamin C alone in pressure ulcer pts is beneficial in relation to healing.

• One study showed that giving an oral nutrition supplement made up of a combination of 500 mg Vitamin C, arginine, and zinc, significantly improved the rate of pressure ulcer healing 2.5 fold in PU pts.

Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition. 2005;24:979-987.Doley J. Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice. 2010;25:50-60.

Beta-hydroxy-beta-methylbutyrate (HMB)• A metabolite of Leucine

• In recent research, it has been included in nutrient mixtures, also containing glutamine and arginine. (14 gm glutamine, 14 gm arginine, 2 gm HMB)– One study’s results noted a significant rise in collagen

deposition compared to control group.

• No clear conclusion and more research is needed in the administration of nutrient mixtures.

American Dietetic Association. Pressure Ulcers. Nutrition Care Manual.

ProductAdvertised Wound

Healing Components Diet Indications

Juven Glutamine, Arginine, HMB (Revigor) Oral or TF

Enlive

High quality protein, vitamin, and mineral drink Clear liquid

Perative High protein, Arginine TF

ProMod

Liquid protein,Collagen protein hydrolysate Oral or TF

Resource Araginaid Extra L-Arginine, Zinc, Vitamin C Oral

Nutren Replete High Protein, vitamin, and mineral formula TF

Conclusion• Close follow-up is needed as maintaining adequate

nutrition is crucial in the pressure ulcer healing process.

• More has not been shown to always be better regarding the supplementation of individual nutrients, but there is promising data showing the benefits of certain nutrient mixtures.

• More research is needed in the form of multi centered clinical trials, observing larger populations: – to further define nutrient needs for pressure ulcer healing– To observe the relationship between oral nutrition

supplements and pressure ulcer healing.

References• Dorner B, Posthauer ME, Thomas D.(2009)The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National

Pressure Ulcer Advisory Panel White Paper. Nutrition White Paper. 1-15.• Doley J. (2010) Nutrition Management of Pressure Ulcers. Nutrition in Clinical Practice, (25), 50-60.• Desneves KJ, Todorovic BE, Cassar A, Crowe TC. (2005) Treatment with supplementary arginine, vitamin C, and zinc in

patients with pressure ulcers: A randomized controlled trial. Clinical Nutrition, (24), 979-987.• University of Washington. Taking Care of Pressure Sores.

http://www.sci.washington.edu/info/pamphlets/pressure_sores.asp. • Mahan KL, Escott-Stump K. (2008) Krause’s Food & Nutrition Therapy: 12th Edition. Saunders Elsevier. St. Louis, MO.

287-295.• Victorian Government Health Information. (2008) Pressure Ulcer Basics.

http://www.health.vic.gov.au/pressureulcers/pu_basics/module1/topic2/page9.htm• American Dietetic Association. ADA Evidence Analysis Library.• American Association for Clinical Chemistry. (2001-2011) ESR. Lab Tests Online. http://www.labtestsonline.org• Version.pdfhttp://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement

/infectious-disease/sepsis/#s0020• American Dietetic Association. Pressure Ulcers. Nutrition Care Manual. • Lizaka S, Sanada H, Nakagami G, Sekine R, Koyanagi H, Konya C, Sugama J. (2010) Estimation of protein loss from wound

fluid in older patients with severe pressure ulcers. J. Nutrition, (26), 890-895.