mnt for the ckd patient complicated by a pressure ulcer
DESCRIPTION
MNT for the CKD Patient Complicated by a Pressure Ulcer. Stephanie Ruel Sodexo/St. Joseph’s Medical Center. Abstract. Controversy of recommendations Studies: Inconclusive or inadequate. Introduction. Anatomy and Physiology Etiology and pathology Medical management - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/1.jpg)
Stephanie Ruel
Sodexo/St. Joseph’s Medical Center
MNT for the CKD Patient Complicated by a Pressure
Ulcer
![Page 2: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/2.jpg)
Controversy of recommendations
Studies: Inconclusive or inadequate
Abstract
![Page 3: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/3.jpg)
Anatomy and PhysiologyEtiology and pathologyMedical managementMedical Nutrition TherapyThe PatientConclusionFuture studiesRecommendations
Introduction
![Page 4: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/4.jpg)
Chronic Kidney Disease
![Page 5: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/5.jpg)
FunctionsMetabolic waste removalElectrolyte balanceFluid balanceBlood pressure controlpH regulationPlasma volume and osmolalityGlucose homeostasisHormone secretion (erythropoietin)Carnitine synthesis
Anatomy & Physiology of the Kidneys
![Page 6: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/6.jpg)
Anatomy
![Page 7: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/7.jpg)
Anatomy
Afferent arterioleGlomerulusBowmans’s capsuleProximal tubuleEfferent arteriolePeritubular
capillariesRenal vein
Proximal tubule
![Page 8: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/8.jpg)
Glomerulus: Selective permeability
UltrafiltrateSelective resportion and excretion
Physiology: Electrolyte Balance
![Page 9: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/9.jpg)
Tubule Efferent arteriole
= fluid homeostasis
Physiology: Electrolyte Balance
Electrolytes
![Page 10: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/10.jpg)
Two main systems:VasopressinRenin-angiotensin aldosterone
system (RAAS)
Physiology: Fluid Balance
![Page 11: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/11.jpg)
↑Blood osmolality or ↓blood pressure
HypothalamusPituitary gland
Kidney ↑blood pressure ↓blood osmolality
Vasopressin
Vasopressin
![Page 12: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/12.jpg)
↓blood pressureAngiotensinogen
KidneyAngiotensin I
Angiotensin II
Adrenal Aldosterone
↑blood pressure
Renin-Angiotensin Aldosterone System
Renin
Lungs
RAAS
![Page 13: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/13.jpg)
Etiology & Pathology
![Page 14: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/14.jpg)
Diabetes Hypertension Family historyEthnicityAutoimmune diseaseInfectionSevere dehydrationAcute renal failure (ARF)
Etiology & Pathology
![Page 15: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/15.jpg)
44%
of new CKD diagnoses caused by diabetes
Diabetic Nephropathy
![Page 16: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/16.jpg)
Diabetic NephropathyGlomerular Anatomy
mesangium
![Page 17: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/17.jpg)
↑blood glucose afferent arteriole dilationaltered hemodynamic regulation↑blood flow to glomerulus
Hypertrophy damage to podocytes Hyperfiltration and mesangial cellsHyperperfusion
altered permeabilityof glomerulus= PROTEINURIA
Hyperglycemia
![Page 18: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/18.jpg)
Inflammatory mediatorsProinflammatory cytokines
Oxidative stressInflammation
FibrosisGlomerulosclerosis
Kimmelstiel-Wilson lesions
Proteinuria
![Page 19: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/19.jpg)
DefinitionHypertension:
Systolic >140mm Hgor
Diastolic >90mm HgPrehypertension:
121/81mm Hg – 139/89mm HgNormal blood pressure:
<120/80mm Hg
Hypertension
![Page 20: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/20.jpg)
Cause and effectBlood vessel remodelingInflammationOxidative stressArteriosclerosis
Hypertension
![Page 21: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/21.jpg)
Endothelial lesions in blood vessels caused by buildup of hyaline
Decreased action of smooth muscle cells
Inhibited autoregulationIschemic tubulointerstitial injury
Hyaline Arteriosclerosis
![Page 22: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/22.jpg)
Studies – Impact of protein restriction and blood pressure control on progression of CKD:
Modification of Diet in Renal Disease (MDRD) study
Northern Italian Cooperative Study Group
Multiple studies with smaller sample size; data from mid-1980’s to mid-1990’s
INCONCLUSIVE, INSIGNIFICANT
Dietary Protein
![Page 23: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/23.jpg)
Medical Management
![Page 24: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/24.jpg)
Irreversible loss of kidney function with decreased glomerular filtration rate (GFR) and/or evidence of kidney damage that persists >3 months, progressive in nature.
Diagnosis
Stage
eGFR (mL/min/1.73m2)
Description
1 >90 Kidney damage with normal or increased GFR
2 60-89 Kidney damage with mildly decreased GFR
3 30-59 Moderately decreased GFR
4 15-29 Severely decreased GFR
5 <15 or dialysis Kidney failure
![Page 25: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/25.jpg)
Item Normal ValueIn CKD, may
be:
Potassium 3.5-5.3meq/L Elevated
Phosphorus 3.4-5.9mg/dL Elevated
Blood urea nitrogen (BUN)
9-20mg/dL Elevated
Creatinine 0.5-1.3mg/dL Elevated
Albumin 3.5-5g/dL Decreased
Sodium 135-150meq/L Elevated
Urine protein Negative Positive
Blood pressure <120/80mm Hg Elevated
Laboratory Values
![Page 26: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/26.jpg)
Hypertension: 80-85% Angiotensin Receptor Blockers (ARBs)
Angiotensin Converting Enzyme (ACE) Inhibitors
Diuretics
Antihypertensive Therapy
![Page 27: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/27.jpg)
Albuminuria >300mg and all diabetic CKD (without hypertension)ARBsACE Inhibitors
Albuminuria <30mg and BP >140/90mm HgTarget BP <140/90mm Hg
Albuminuria >30mg, BP >130/80mm HgTarget BP <130/80mm Hg
Blood Pressure Control/RAAS
![Page 28: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/28.jpg)
Highest risk category for development of cardiovascular disease (CVD)
CVD as cause of death before end-stage renal disease (ESRD) and dialysis
Statins
Improving Cardiovascular Health
![Page 29: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/29.jpg)
Target HbA1C ~7.0%Hypoglycemia risk
Medication and lifestyle modification
Glycemic Control
![Page 30: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/30.jpg)
Metabolic Bone DiseaseParathyroid hormone (PTH)CalciumPhosphorus
PotassiumMetabolic acidosisAnemia
Overview of Additional Complications
![Page 31: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/31.jpg)
Smoking cessationPhysical activity
Weight managementFunctional capacity
Non-pharmacological Interventions
![Page 32: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/32.jpg)
AllopurinolAvosentanMesenchymal stem cells
New Medication and Treatment
![Page 33: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/33.jpg)
GFR <10ml/min/1.73m2
Symptoms:Electrolyte abnormalitiesAcid-base disturbanceUncontrolled BP and fluid balanceUremiaCognitive impairmentDecline in nutritional status
Dialysis
Renal Replacement Therapy
![Page 34: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/34.jpg)
Treatment of choiceEarlier decision:
GFR <20ml/min/1.73m2
Irreversible progression for 6-12 months
Impact:Reduction of dietary restrictionsDelays or eliminates need for
dialysisMedications to prevent rejection =
↓immunity
Renal Transplant
![Page 35: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/35.jpg)
Pressure Ulcers
![Page 36: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/36.jpg)
Functions:Conduct sensory data to the brain via nerve
endings located in the skinProtect the bodyRegulate body temperatureSynthesize vitamin DStore energy and water
Anatomy & Physiology of the Integumentary System
![Page 37: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/37.jpg)
Etiology & Pathology
![Page 38: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/38.jpg)
Injury to the skin and/or underlying tissue as a result of pressure, friction, shear, or ischemiaRisk factors:ImmobilityPoor perfusion of blood supplyMoistureAnemiaAgeNutrition status
Development of Pressure Ulcers
10-18%
![Page 39: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/39.jpg)
Inflammasomes in kertinocytesActivation of inflammatory cytokines
Danger signals and wound healing
Youth vs. Aging
Inflammasome Activity
![Page 40: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/40.jpg)
Stage Description
ISkin intact but with non-blanchable redness for >1 hour after relief of pressure
IIBlister or other break in the dermis with partial thickness loss of dermis
III
Full thickness tissue loss. Subcutaneous fat may be visible, destruction extends into muscle; undermining or tunneling may occur
IV
Full thickness skin loss with involvement of bone, tendon, or joint; often includes undermining and tunneling
UnstageableFull thickness tissue loss in which base of ulcer is covered by slough and/or eschar in the wound bed
Suspected Deep Tissue
Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying tissue from pressure and/or shear
Stages of Pressure Ulcers
![Page 41: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/41.jpg)
A: Stage IB: Stage IIC: Stage IIID: Stage IV
Stages of Pressure Ulcers
![Page 42: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/42.jpg)
Medical Management
![Page 43: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/43.jpg)
Risk assessment (Braden Scale score)Proper positioning and rotationSupport surfacesPain managementInfection managementWound cleansingDebridementDressingsBiophysical agents
Prevention & Care
![Page 44: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/44.jpg)
Medical Nutrition Therapy(MNT)
![Page 45: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/45.jpg)
AssessmentDiagnosisInterventionMonitoringEvaluation
Nutrition Care Process
![Page 46: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/46.jpg)
MultidisciplinaryAnthropometricsMedical and social historiesMedicationsAnalysis of laboratory values
Assessment
![Page 47: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/47.jpg)
Diet and diet historyNutrition statusComorbid conditionsLab values of BUN, potassium,
phosphorus, albumin, urinalysisAssess for education needs
Nutrition Assessment for CKD
![Page 48: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/48.jpg)
Nutrient Dietary Recommendation
Energy 23-35kcal/kg/dayProtein (without
DN)0.6-0.8g/kg body weight
Protein (presence of DN)
0.8-0.9g/kg body weight
Sodium <2.4g/day
Potassium(stages 3-4)
<2.4g/day
Phosphorus 800-1000mg/day
Calcium(stages 3-4)
2g/day
Vitamin DSupplementation if 25-hydroxyvitamin D
<30ng/ml
IronSupplementation if:
Serum ferritin <100ng/ml andTransferrin saturation <20%
Fluid Varies with medical status
Nutrition Prescription for CKD
![Page 49: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/49.jpg)
MNT for Hypertension and DiabetesDiabetes: glycemic control through consistent-carbohydrate diabetes meal planning
Hypertension:
![Page 50: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/50.jpg)
Dietary protein restriction did not significantly slow progression
Dietary restrictions and nutrition status
BP control was more effective in reducing proteinuria than modifications in dietary protein intake
The Role of Dietary Protein
![Page 51: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/51.jpg)
Comprehension of and adherence to dietary recommendations
Maintenance of ideal body weightBlood glucose controlBlood pressure controlNormalization/improvement of
nutrition-related laboratory values
Monitoring & Evaluation
![Page 52: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/52.jpg)
Dietary intake as related to needsStaging of pressure ulcer and changes
in stage/healingUsefulness of laboratory valuesUnintentional weight changesMobility assessmentAssess for education needsAdditional risk factors/comorbid
conditions
Nutrition Assessment for Pressure Ulcers
![Page 53: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/53.jpg)
Based on limited, small studies and expert opinion:
Nutrition Prescription for Pressure Ulcers
Nutrient Recommendation
Energy30-35kcal/kg IBW (up to 40kcal/kg for repletion)
Protein 1.25-2g/kg
ZincIf deficiency is suspected,
220mg ZnSO4 bid for <3 weeks
Arginine/Glutamine
Inconclusive support, but may be supplemented if not
contraindicated
Fluid30-35mL/kg, minimum 1500mL
unless contraindicated
![Page 54: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/54.jpg)
Necessity of protein in tissue-building
Ability of body to utilize protein in wound-healing
Nitrogen loss in wound exudateAttaining a positive nitrogen balanceProtein as energy in catabolism
The Role of Dietary Protein
![Page 55: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/55.jpg)
Achievement of ideal body weight/weight maintenance
BMIEvidence of wound healingAdequate nutrient intakeAdequate hydrationComprehension/knowledge of
nutrition recommendations
Monitoring & Evaluation
![Page 56: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/56.jpg)
The Patient
![Page 57: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/57.jpg)
88 year old Caucasian femaleAdmitted for altered mental status and
dehydrationPMH: CKD stage 3-4, HTN, diverticular
disease, dementiaBraden Scale score: 9 (high risk)Upper and lower coccyx stage III pressure
ulcersPoor oral intake and deteriorating mobility
x 3 months
Patient Summary
![Page 58: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/58.jpg)
170# (140% IBW 99-121# upper end of range)Unable to obtain weight history
Height: 5’2”BMI 31.2kg/m2 Stage I obesityDysphagia evaluation: severe oropharyngeal
dysphagia with purees and thickened liquids; high risk for airway obstructionRecommendation: NPO, aggressive oral
care for secretions
Patient Summary
![Page 59: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/59.jpg)
Basic/Comprehensive Metabolic Panel and GFR Normal 1/13/14 1/8/14
Sodium 135-150mEq/L 140 155H
Potassium
3.5-5.3mEq/L 2.7LL 4.8
Chloride 96-107mEq/L 109H 112H
BUN 9-20mg/dL 50H 114HH
Creatinine
0.5-1.3mg/dL 1.4H 3.1H
Glucose 70-110mg/dL 100 85
Calcium 8.5-10.5mg/dL 8.5 9.3
Albumin 3.5-5g/dL 2.1L 2.9L
eGFR >60ml/min/m2 38L 15L
Laboratory Values
![Page 60: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/60.jpg)
Diagnosis: sepsis of urinary source, acute on chronic renal failure secondary to dehydration, likely aspiration pneumonia
Patient confused and lethargic+bowel sounds, no edemaChest x-ray: bibasilar infiltrates, left
pleural effusion+Urine culture: E.coli+Blood culture: S.capitus
Medical Management
![Page 61: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/61.jpg)
IV fluids for rehydration (D5 ½ NS @100ml/hr)
IV fluids modified for potassium repletion:KCl20mEq/L, D5 ½ NS @50ml/hr
IV antibiotics Zosyn and Vancomycin
Dressing changes for pressure ulcers
Medical Management
![Page 62: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/62.jpg)
Feeding withheld until rehydration and electrolyte balance achieved
Poor venous accessOral secretions, congestion, high
aspiration risk – no nasogastric tube inserted for feeding or medication administration
Care for pressure ulcer poorly documented
Medical Management
![Page 63: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/63.jpg)
High nutritional riskEnergy needs: 30-35kcal/kg adjusted
body weight (BW) = 1800-2100kcal/dayProtein needs: until ARF resolved:
0.8g/kg adjusted BW = 48g/day protein (Once ARF resolved, increase protein to 1.4-1.5g/kg adjusted BW = 85-97g/day protein)
Fluid needs: 1ml/kcal = 1800-2100ml/day
Nutrition Assessment
![Page 64: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/64.jpg)
Inadequate protein-energy intake related to SLP recommendation, poor venous access, no NGT insertion as evidenced by NPO status, no PN/EN support order.
Nutrition Diagnosis
![Page 65: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/65.jpg)
1. Patient will meet >75% energy needs via appropriate route within 3 days.
2. Patient will receive restricted dietary protein until ARF resolved (protein to be increased to promote wound healing once ARF resolved)
Nutrition Goals
![Page 66: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/66.jpg)
1. If patient to remain NPO >3 days, recommend TF via NGT with Suplena goal rate at 42ml/hr continuous; provides 1008ml total volume, 1814kcal, 743ml free H2O, 45g protein. Initiate feed at 20ml/hr increase 10ml/hr q4H to goal.
2. Free H2O autoflush 30ml/hr (total free H2O 1463ml); adjust IVF prn, additional fluids per MD
3. Will follow for updated TF recommendations once ARF resolved
4. Maintain head of bed at least 30-45 degrees during feed, monitor GI signs and symptoms for intolerance and hold feeds if intolerance or residuals >250ml.
Nutrition Interventions
![Page 67: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/67.jpg)
Initiation of TFAdvancement of TF to goal rateTolerance of TFNutrition-related labsWound/skin status
Nutrition Monitoring & Evaluation
![Page 68: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/68.jpg)
Patient received no nutrition support during hospital stay (7 days); patient was made DNR/DNI on last day of admission and discharged into hospice care
Pressure ulcer protocol was poorly documented
Plan of care was poorly communicatedNo attempts were made to place NGT
COMMUNICATION!
Critical Comments
![Page 69: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/69.jpg)
Evidence supporting dietary protein restriction for CKD is stronger than evidence supporting the role of increased dietary protein in wound healing of pressure ulcers
Antihypertensive therapy is more impactful than dietary protein on proteinuria
Non-dietary factors are of greater importance in prevention and treatment of pressure ulcers
Conclusions
![Page 70: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/70.jpg)
Level of dietary protein necessary to preserve lean body mass (positive nitrogen balance)
Temporary increase in dietary protein for wound healing and progression of CKD
Dietary protein increases in a patient with a pressure ulcer and the impact on level of proteinuria
Additional long term study on impact of dietary protein restriction in patients with proteinuria
Additional studies with larger sample size to examine role of dietary protein in wound healing
Future Study
![Page 71: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/71.jpg)
Increased overall energy intake of 30-35kcal/kg
Dietary protein restriction of 0.6-0.8g/kg as a lifestyle
Transient increase of protein to 1.25-2g/kg for up to 8 weeks in presence of a pressure ulcer while monitoring renal function
Liberalization of diet as necessary to achieve recommended energy intake
Consideration of patient’s wishes
Recommendations
![Page 72: MNT for the CKD Patient Complicated by a Pressure Ulcer](https://reader038.vdocuments.net/reader038/viewer/2022110103/56814c09550346895db90a0a/html5/thumbnails/72.jpg)
References available upon request.