The Role of Nutrition in Pressure Ulcer Treatment: A Case Study Katherine Tomaino June 11, 2012

Transcription

1 The Role of Nutrition in Pressure Ulcer Treatment: A Case Study Katherine Tomaino June 11, 2012

2 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.

3 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.

4 Pressure Ulcers

5 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, NPUAP, 2009.

6 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

7 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

8 Pressure Ulcers Limited evidence exists related to MNT for prevention of PU Current nutrition recommendations primarily based on: expert opinion best practice guidelines small research studies NPUAP, 2009

9 NPUAP Recommendations 1. Energy Provide sufficient calories 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 gm/kg body weight Assess renal function to ensure high levels of protein are appropriate and tolerated. NPUAP, 2009

10 NPUAP Recommendations 3. 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

11 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,

12 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. Micronutrients are recommended at DRI levels. NPUAP,

13 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 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.

14 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

15 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.

16 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

17 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

18 Case study: John Cash Philadelphia Cervical Collar (

19 Case study: John Cash Stage IV pressure ulcer (

20 Case study: John Cash 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)

21 Case study: John Cash Labs (4/17/2012) Glucose: 107 Na: 138 K: 4.8 ProBNP: GFR: 18 Albumin: 2.6 BUN: 105 I/O: 2375/700 Creatine: 3.4

22 Case study: John Cash 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 *

23 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: kcal / kg Protein: gm / kg Water: ml / kg

24 Case Study: John Cash Nutrition Diagnosis: Related to: Increased nutrient needs 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

25 Case study: John Cash Outcome 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.

26 Questions?