Nutrition Care For Pressure Ulcer Prevention & Treatment

Transcription

1 Nutrition Care For Pressure Ulcer Prevention & Treatment Becky Dorner & Associates, Inc.

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3 Nutrition Care for Pressure Ulcer Treatment and Prevention Inservice Instructions: This Nutrition Care for Pressure Ulcer Treatment and Prevention Inservice provides many of the tools you need to educate staff on the role of adequate nutrition in the prevention and treatment of pressure in your facility: Slides for the Inservice: The slides can be shown on computer or projected on a screen using a data projector. You can show the slides directly from the Acrobat file by simply clicking on the icon that looks like a computer screen. Or you can go to the tool bar and click on View and Full Screen to show the slides on your screen. Then click the down arrow button or the page down button on your keyboard. Presenter s Notes for the Inservice: Review the presenter s notes prior to presenting the slides. The presenter s notes offer additional information not included on the slides, suggestions for how to present some of the information, and activities you may want to incorporate. Handouts for the Inservice: Simply copy the handouts and the pre- post-tests for participants. Do not provide the answer key for the pre-post tests. You can choose to give the test before and after the training, or just after the training to determine the effectiveness of your inservice and whether or not additional training is needed.

4 Slides 1

5 Objectives 1. Describe the importance of adequate nutrition (calories, protein, fluids) in the prevention and treatment of pressure ulcers 2. Identify at least 3 nutrition-related risk factors for pressure ulcers 3. Identify at least 3 reasons to refer to the RDN/NDTR for pressure ulcer prevention and/or treatment 2

6 Anatomy of Skin The skin is a vital organ Made up of layers: -Epidermis -Dermis -Subcutaneous tissue Aging causes changes in the skin that can increase risk for pressure ulcers 3

7 What is a Pressure Ulcer? Skin break down due to unrelieved pressure to a bony area - Can develop in as little as 2 hours -Skin may appear as a reddened area, but there may be damage to the underlying tissues and muscle Can decrease quality of life because of discomfort and need for care 4

8 Common Pressure Points Pressure is greatest over bony prominences -Sacrum, coccyx, hips, heels -Important to avoid pressure to these areas 5

9 Common Pressure Points Different types of tissues have different tolerance levels to pressure Friction, shear and excess moisture at pressure points combine to increase risk 6

10 Risk Factors Impaired mobility or functional ability Medical problems like end stage kidney disease, thyroid disease, or diabetes Drugs that may affect wound healing Impaired blood flow Refusal of care and treatment Cognitive impairment 7

11 Risk Factors (continued) Skin exposure to urine or feces A healed ulcer that could re-open Under nutrition, malnutrition and poor hydration Obesity Other risk factors: diabetic neuropathy, frailty 8

12 Staging Pressure Ulcers Pressure ulcers can be minor (Stage I) or severe (Stage IV) Initially, skin may be reddened But there may be additional damage to the underlying tissues and muscle Damage can include muscle or bone If infected, more treatment will be needed 9

13 Staging Pressure Ulcers Staging is important because: It identifies how severe the pressure ulcer is It describes the extent of tissue damage It helps determine what type of treatment to use The National Pressure Ulcer Advisory Panel defines pressure ulcers and their stages For more information, visit 10

14 Avoidable or Unavoidable Avoidable The resident developed a pressure ulcer and that the facility did not do one or more of the following: Evaluate the resident's clinical condition and pressure ulcer risk factors Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice Monitor and evaluate the impact of the interventions Revise the interventions as appropriate Unavoidable The resident developed a pressure ulcer even though the facility had: Evaluated the resident s clinical condition and pressure ulcer risk factors Defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice Monitored and evaluated the impact of the interventions Revised the approaches as appropriate 11

15 Nutrition Care Nutrition is an important part of a patient s comprehensive care plan Nutrition care should be provided for those who are at risk, or already have a pressure ulcer Goals Prevent the pressure ulcer from occurring; or Promote healing and improve nutritional status if possible 12

16 Protein-Energy Malnutrition Protein is used for energy if other energy sources (carbohydrates and fats) are not available in the diet If not enough protein/energy are consumed over time, health declines and pressure ulcers can result 13

17 Risk Factors for Altered Nutritional Status Poor food/fluid intake Inability to consume meals Lack of available food or fluid Environmental factors affecting food intake or appetite GI disorders Adverse consequences of medications Malabsorption of nutrients Age-related loss of muscle mass or wasting Advanced or end stage diseases and conditions Hypermetabolic state (increases needs for energy and protein) 14

18 Early Identification of Risk Nutrition screening tools can identify potential nutrition problems early on During routine care, monitor for: Poor food or fluid intake Difficulty eating Unintended weight loss Changes in cognitive function or skin turgor Refer to nursing or the RDN/NDTR to allow for early interventions 15

19 Physical Signs & Symptoms: Protein-energy Malnutrition Pale Skin Red, swollen lips Swollen and/or dry tongue with scarlet or magenta hue Poor skin turgor Thin appearance Bilateral edema Muscle Wasting Calf tenderness Reduced urinary output 16

20 Refer to the RDN or NDTR Altered nutritional status can have an impact on the development and healing of pressure ulcers Nutrition intervention is vital for preventative care and treatment You can help determine which individuals are at risk and make referrals to your supervisor or the RDN or NDTR 17

21 Higher Calorie/Protein Needs Those with pressure ulcers need extra calories and protein for healing Example: Male 120#, 5 4 tall and 85 years old Normal With a Pressure Ulcer Calories Protein, gm Fluid, ml

22 Dining Nutrition Interventions Encourage/assist to eat, add adaptive feeding devices Snacks between meals Address social and psychological issues Alter medications to avoid anorexia or treat pain, anxiety, or depression; try appetite stimulants 19

23 Nutrition Interventions Focus on food first! Least restrictive diet Correct diet consistency Encourage to eat meals and snacks Offer substitutions for foods not eaten Use nutrient dense foods/fluids Pack each bite of food with nutrients Enhanced/fortified foods and fluids High calorie/protein supplements if needed 20

24 Hydration Fluid needs must be met 1 ml per calorie consumed or 30 ml/kg body weight per day Or minimum of 1500 ml fluid per day Offer beverages throughout the day Offer preferred beverages Keep accurate fluid intake records 21

25 Hydration Monitor signs and symptoms of dehydration Poor skin turgor Flushed, dry skin Coated tongue Concentrated urine Irritability Confusion 22

26 Team Communications Communicate what you know to the team 1. Identify warning signed and refer high risk To your supervisor or RDN/NDTR 2. Participate in team meetings Communicate information: weights, weigh changes, pressure ulcers, food/fluid intake, etc. 3. Continually monitor for concerns Document food/fluid intake and acceptance of supplements 23

27 Nutrition Care Alerts Warning Signs: Incontinence, moisture Needs help moving, turning in bed or when sitting Purple or maroon colored skin over bony areas, skin tears Action Steps: Report signs to nurse Check/change linens Handle/move individual with care Reposition frequently and properly Report your findings to your supervisor 24

28 Nutrition Care Alerts Warning Signs Unintended weight loss Eats < 50% meals Dehydration Action Steps Encourage food and fluid intake Observe and record food and fluid intake Report weight loss to your supervisor 25

29 Nutrition Care Alerts Team Action Steps Initiate wound management protocol Refer to RDN/NDTR Encourage food and fluid intake Consider nutrition supplements 26

30 Your Role is Critical Identify risk Refer concerns to nursing and RDN/NDTR Assist with nutrition/hydration interventions Monitor for concerns Communicate concerns about nutrition to nursing and RDN/NDTR 27

31 We Hope You Have Enjoyed Becky Dorner & Associates Slide Presentation We also offer many publications that may be of help to you. Please visit or us at for more information 28

32 Presenter s Notes 1

33 Our objectives today are for you to be able to 1. Describe the importance of adequate nutrition (calories, protein, fluids) in the prevention and treatment of pressure ulcers 2. Identify at least 3 nutrition-related risk factors for pressure ulcers 3. Identify at least 3 reasons to refer to the RDN/NDTR for pressure ulcer prevention and/or treatment 2

34 Anatomy of Skin The skin is a vital organ helps to regulate the body s temperature, prevents excessive loss of body fluids, and transmits sensations such as pleasure, pressure and pain. Skin is made up of layers: Epidermis or outer layer of skin, which consists of five layers and regenerates itself every 28 days in a normal, healthy person Dermis which consists of two layers (the papillary dermis and reticular dermis) containing nerve endings, blood vessels, lymphatics, and capillaries Subcutaneous tissue which is composed of adipose and connective tissue, major blood vessels and nerves. Aging causes changes in the skin that can lead to increased risk of pressure ulcers. Aging skin is thinner, subcutaneous layers are reduced (reducing protection of bony prominences), collagen fibers are decreased, circulation slows down, and regeneration time is reduced. This all results in slower healing rates. 3

35 A pressure ulcer is unrelieved pressure to a bony area in which the skin breaks down due to reduced circulation. Pressure Ulcers Can develop in as little as 2 hours. Skin may appear as a reddened area, but there may be additional damage to the underlying tissues and muscle. Between 1 and 3 million people in the US develop pressure ulcers every year. Prevalence (proportion of people with a pressure ulcer at a specific point in time) ranges from 2.3 to 28% in long term care (LTC) facilities, 10 to 18% in acute care facilities, and 0 to 29% in home care. Incidence may be higher in individuals who are of increased age, frail, have a severe illness, have a history of pressure ulcers or those who have experienced eating difficulties and/or significant weight loss. Pressure ulcers can diminish a person s quality of life by causing pain and suffering, and increasing risk of mortality. They increase cost of care due to additional nursing time needed for care, complications (i.e. infection, pain, support surfaces, increased independence, increase hospital length of stay and add other health care costs). Aggressive interventions for prevention and treatment of pressure ulcers can reduce the incidence of pressure ulcers, improve quality of life, and reduce the costs of treatment. 4

36 Common Sites for Pressure Ulcers Pressure ulcers can occur anywhere there is prolonged pressure to soft tissue which reduces availability of nutrients and oxygen and ultimately results in tissue death. Pressure is greatest over bony prominences. Most pressure ulcers occur in the lower part of the body over bony prominences such as the: Sacrum Coccyx ischial tuberosities greater trochanters Heels iliac crests, and lateral and medial malleoli. 5

37 Different types of tissues have different tolerance levels to pressure; muscle has less tolerance than skin. Deep tissue injury to the muscle can occur as a result of prolonged pressure, before the overlying skin shows any damage. Friction, shear and excess moisture all combine to increase risk of pressure ulcer development. 6

38 Nursing uses a validated tool to assess risk of developing pressure ulcers. The Braden Scale: Predicting Pressure Ulcer Risk is a commonly used risk identification tool that identifies level of risk for developing a pressure ulcer. (It includes a nutrition subscale.) Risk factors for pressure ulcer development include: Impaired/decreased mobility and decreased functional ability Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus Drugs such as steroids that may affect wound healing Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency Refusal of some aspects of care and treatment. Examples include refusal to be bathed, repositioned, or refusing assistance with feeding Cognitive impairment 7

39 Risk Factors (continued): Exposure of skin to urine and feces, usually due to incontinence A healed ulcer: areas on the skin with a healed Stage III or IV pressure ulcers may break down again Under nutrition, malnutrition and poor hydration Obesity (increases risk due to decreased mobility, increased incidence of diabetes, cardiovascular and pulmonary problems, increased pressure on pressure points, and decreased mobility). Other risk factors: diabetic neuropathy, frailty Bolded items are areas that can be addressed with nutrition interventions. However, in most obese patients with wounds, wound healing should take precedence over weight loss. If calories and/or protein are cut too significantly it could result in impaired wound healing. 8

40 Pressure ulcers can be minor or severe depending on the amount of damage to the skin and the individual s overall condition. Initially, the skin may appear as a reddened area, but there may be additional damage to the underlying tissues and muscle. Damage may even spread to the bone. The area may become infected resulting in additional need for treatment. Stage 1 is the most minor pressure ulcer, with stage 4 being the most severe. If you notice a reddened area on a patient s body, make sure to report it; it could be a very early pressure ulcer that will worsen if not treated. 9

41 A basic staging system is utilized to determine severity of pressure ulcers, including extent of tissue damage and to monitor healing progress. In 2007 and 2009, the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers. For more information on the revised staging system and definitions, visit Staging is usually done by a treatment nurse and/or nurse practitioner or doctor. 10

42 Avoidable or Unavoidable Pressure Ulcers In nursing homes. surveyors determine if a pressure ulcer was avoidable or unavoidable, and assess the adequacy of the facility s response in preventing and/or treating pressure ulcers. If a pressure ulcer is considered avoidable, the facility can get cited at their annual survey. CMS tag F314 of the nursing home guidance to surveyors defines the following: Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: Evaluate the resident s clinical condition and pressure ulcer risk factors Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice Monitor and evaluate the impact of the interventions Revise the interventions as appropriate Unavoidable means that the resident developed a pressure ulcer even though the facility had: Evaluated the resident s clinical condition and pressure ulcer risk factors Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice Monitored and evaluated the impact of the interventions Revised the approaches as appropriate 11

43 Investigators look for facility or staff failure in: assessment/problem recognition, diagnosis or cause identification, treatment or problem management and pressure ulcer monitoring. Note: At the end of life, some pressure ulcers are unavoidable. 11

44 Pressure redistribution, caring for incontinence needs, appropriate dressings, treatments, and proper nutrition and hydration are all necessary to properly treat and heal pressure ulcers. Nutrition is a vital component of a comprehensive care plan and nutrition care should be provided for those who are at risk, or already have a pressure ulcer. The goal is to prevent the pressure ulcer from occurring in the first place; or if the individual already has a pressure ulcer, to promote healing of the wound and restore the individual to optimal nutritional status if possible. 12

45 Adequate calories, protein and fluids are required for maintenance of tissue integrity and prevention of tissue breakdown. If protein intake and calorie intake is inadequate, protein energy malnutrition (PEM) is a result. The body will only utilize proteins efficiently if enough carbohydrate and fat are consumed to meet energy needs. If used for energy, proteins supply 4 calories per gram (just as carbohydrates do). And proteins can easily be used for energy if there are not enough other energy sources available. If a person goes for a long period of time (weeks or more) without adequate protein, the body will do its best to conserve the protein it needs. Eventually the body will come to a point where it is breaking down protein faster than it can make it. At this point, health will decline as various essential bodily functions slow down because protein is not available for vital roles. (For example, immune functions may slow down, increasing risk of infection). 13

46 Altered Nutritional Status is an unintended and unexpected change in weight that is likely to indicate an undesired alteration in intake or utilization of nutrients. Risk Factors for Altered Nutritional Status Poor food/fluid intake; changes in the ability to taste food Inability to consume meals provided (due to therapeutic or mechanically altered diet, decreased ability to eat independently, poor oral health or hygiene, cognitive or functional decline, pain, etc.) Insufficient availability of food and fluid (e.g., inadequate amount of food or fluid or inadequate tube feedings) Environmental factors affecting food intake or appetite (e.g., comfort and level of disruption in the dining environment) GI disorders (pancreatitis, gastritis, motility disorders, small bowel dysfunction, gall bladder disease, liver dysfunction, prolonged diarrhea, vomiting, constipation or fecal impaction ) Adverse consequences of medications Malabsorption or ineffective utilization of nutrients Age-related loss of muscle mass (sarcopenia) or wasting (cachexia) Diseases and conditions (cancer, diabetes mellitus, advanced or uncontrolled heart or lung disease, infection, fever, liver disease, hyperthyroidism, mood disorders, and repetitive movement 14

47 disorders (e.g., wandering, pacing, or rocking) Hypermetabolism (increased demand for energy and protein due to trauma, stress, pressure ulcers, pneumonia, infection, cancer, hyperthyroidism, fever). Hypermetablolism means a person will need more calories (ie, more food) to maintain their weight. 14

48 Early identification of nutrition/hydration risk is essential. Unintended weight loss contributes to undernutrition and protein energy malnutrition (PEM). Individuals who are old and/or chronically ill may also be more at risk for a dangerous stress response which results in hypermetabolism which can result in unintended weight loss, and loss of lean body tissue. This in turn can lead to PEM, which contributes to increased risk of pressure ulcer development. Nutrition screening can help identify risk factors early on so that nutrition interventions can be implemented to resolve problems and prevent complications. You may be asked to help gather information that is used in nutrition screening tools which can help identify potential nutrition problems early on. Monitor for the following and refer to nursing or the RDN/NDTR to allow for early interventions: Poor food or fluid intake Difficulty eating Unintended weight loss Changes in cognitive function or skin turgor 15

49 Nursing assistants and nurses may be the first to identify protein-energy malnutrition. Physical signs and symptoms of protein energy malnutrition may include: Pale skin Red, swollen lips Swollen and/or dry tongue with scarlet or magenta hue Poor skin turgor Thin appearance (cachexia) Bilateral edema Muscle wasting Calf tenderness Reduced urinary output Report changes in appearance if you notice them. 16

50 Weight loss, malnutrition, and dehydration all have an impact on the development and healing of pressure ulcers. Nutrition intervention is vital for preventative care and treatment, so early referral to a RDN or NDTR is important. Often you notice what is going on with a patient before others do! So you can help determine which residents are at risk, and refer to your supervisor or the RDN or NDTR so they can determine the individual s needs to prevent and/or treat pressure ulcers. 17

51 Older adults in a stressed state need additional calories in order to be able to utilize protein. Individuals with pressure ulcers more calories and protein for healing. Adequate hydration is also very important. General guidelines are : Calories: kcal/kg body weight Protein: weight in kg x grams protein/kg of body weight Fluid: 1 ml per calorie consumed Example: A 120# person normally needs approximately 1146 calories, 55 grams protein, and 1635 ml fluids. But a person of the same gender, weight, height, and age with a pressure ulcer may need more like 1635 to 1900 calories, 68 to 82 grams protein and 1635 ml fluids. (Even more fluids are needed for people who have fluid losses such as vomiting, diarrhea, draining wounds, fever, etc.) For people who are already eating poorly, it is difficult to consume enough food and fluids for healing so nutrition interventions are very important. The increased nutritional needs of those with pressure ulcers are one reason why many patients are on large portions, fortified foods, or nutrition supplements. 18

52 Providing adequate calories, protein and fluid is the most important intervention for pressure ulcers. Implementing individualized interventions that each individual will accept is the first step. Interventions may include recommendations for: Dining needs (encouragement and/or assistance to eat, adaptive feeding devices, small portions, frequent feedings, alternate meal times, dining location, favorite foods, etc.) Social and psychological issues. For example, is depression affecting meal intake? Altering medications to avoid those that may cause anorexia or negative GI effects, or trying medications that may stimulate the appetite or ease pain, depression, or anxiety that might be affecting meal intake. 19

53 The RDN and/or NDTR will determine the appropriate interventions for each individual to meet their nutritional requirements. Based on the individualized nutritional assessment, food intake and interview, calories and protein can be increased through additional food items on the tray, substitutions for foods not eaten and/or between meal supplements. Focus on food first! Encourage individuals to eat their meals, snacks and supplements. If the individual seems to have trouble with the texture of food or consistency of fluids, report this to your supervisor. Nutrient Dense Foods: Increased calories and protein for residents who do not eat well. For some individuals, volume is an issue, and fortified foods and/or concentrated supplements are needed. Foods can be fortified to enhance calories and protein, or supplements may be used as accepted and tolerated by individuals. The idea is to pack each bite of food with as many calories and protein and other nutrients as possible to meet nutritional needs through the food that is already being served at mealtime. Nutrition interventions may include, but are not limited to: Enhanced/fortified foods, calorie dense foods, high protein foods Substitutions/alternates for foods not eaten High calorie/high protein supplement if needed Or Medication pass programs: typically 2 ounces of supplement given three to four times a day, providing 360 to 480 calories a day. 20

54 In some cases, enteral or parenteral feedings must be issued to achieve the nutritional needs of stressed individuals. 20

55 Hydration needs must be met: Provide no less than 1500 ml of fluid per day (6 ¼ cups) A minimum of 1 ml per calorie consumed or 30 ml fluids/kg/day (Some people will need more) Offer beverages throughout the day, and be sure to meet each person s beverage preferences Keep accurate records of fluid intake 21

56 Monitor signs/symptoms of dehydration as appropriate: Poor skin turgor Flushed dry skin Coated tongue Concentrated urine Irritability Confusion 22

57 Communicate what you know to the team 1. Identify warning signs, and refer high risk individuals to your supervisor or RD/DTR. 2. Participate in team meetings and put communications in writing whenever possible. Communicate essential information (weights, weight changes, evidence of new pressure ulcers, food intake records, referral forms, recommendation sheets, etc.) 3. Continually monitor for concerns, and document food and fluid intake, acceptance of supplements and other nutrition interventions. 23

58 These areas are warning signs that there may be an issue with high risk. (Review slides and possible action steps they can take). Refer individuals with these issues to your supervisor and/or RDN/NDTR. 24

59 Continued: These areas are warning signs that there may be an issue with high risk. (Review slides and possible action steps they can take). Refer individuals with these issues to your supervisor and/or RDN/NDTR. 25

60 These areas are warning signs that there may be an issue with high risk. (Review slides and possible action steps they can take). Refer individuals with these issues to your supervisor and/or RDN/NDTR. 26

61 Your role is of critical importance in the care of our residents/patients. Identify risk Refer concerns to nursing and RDN/NDTR Assist with nutrition/hydration interventions Monitor for concerns Communicate concerns about nutrition to nursing and RDN/NDTR 27

62 28

63 Handouts 1

64 Nutrition Care for Pressure Ulcer Treatment and Prevention Nutrition Care For Pressure Ulcer Prevention & Treatment Becky Dorner & Associates, Inc. Objectives 1. Describe the importance of adequate nutrition (calories, protein, fluids) in the prevention and treatment of pressure ulcers 2. Identify at least 3 nutrition-related risk factors for pressure ulcers 3. Identify at least 3 reasons to refer to the RDN/NDTR for pressure ulcer prevention and/or treatment Anatomy of Skin The skin is a vital organ Made up of layers: -Epidermis -Dermis -Subcutaneous tissue Aging causes changes in the skin that can increase risk for pressure ulcers What is a Pressure Ulcer? Skin break down due to unrelieved pressure to a bony area - Can develop in as little as 2 hours -Skin may appear as a reddened area, but there may be damage to the underlying tissues and muscle Can decrease quality of life because of discomfort and need for care Common Pressure Points Pressure is greatest over bony prominences -Sacrum, coccyx, hips, heels -Important to avoid pressure to these areas Common Pressure Points Different types of tissues have different tolerance levels to pressure Friction, shear and excess moisture at pressure points combine to increase risk 1

65 Nutrition Care for Pressure Ulcer Treatment and Prevention Risk Factors Impaired mobility or functional ability Medical problems like end stage kidney disease, thyroid disease, or diabetes Drugs that may affect wound healing Impaired blood flow Refusal of care and treatment Cognitive impairment Risk Factors (continued) Skin exposure to urine or feces A healed ulcer that could re-open Under nutrition, malnutrition and poor hydration Obesity Other risk factors: diabetic neuropathy, frailty Staging Pressure Ulcers Pressure ulcers can be minor (Stage I) or severe (Stage IV) Initially, skin may be reddened But there may be additional damage to the underlying tissues and muscle Damage can include muscle or bone If infected, more treatment will be needed Staging Pressure Ulcers Staging is important because: It identifies how severe the pressure ulcer is It describes the extent of tissue damage It helps determine what type of treatment to use The National Pressure Ulcer Advisory Panel defines pressure ulcers and their stages For more information, visit Avoidable or Unavoidable Avoidable The resident developed a pressure ulcer and that the facility did not do one or more of the following: Evaluate the resident's clinical condition and pressure ulcer risk factors Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice Monitor and evaluate the impact of the interventions Revise the interventions as appropriate Unavoidable The resident developed a pressure ulcer even though the facility had: Evaluated the resident s clinical condition and pressure ulcer risk factors Defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice Monitored and evaluated the impact of the interventions Revised the approaches as appropriate Nutrition Care Nutrition is an important part of a patient s comprehensive care plan Nutrition care should be provided for those who are at risk, or already have a pressure ulcer Goals Prevent the pressure ulcer from occurring; or Promote healing and improve nutritional status if possible 2

66 Nutrition Care for Pressure Ulcer Treatment and Prevention Protein-Energy Malnutrition Protein is used for energy if other energy sources (carbohydrates and fats) are not available in the diet If not enough protein/energy are consumed over time, health declines and pressure ulcers can result Risk Factors for Altered Nutritional Status Poor food/fluid intake Inability to consume meals Lack of available food or fluid Environmental factors affecting food intake or appetite GI disorders Adverse consequences of medications Malabsorption of nutrients Age-related loss of muscle mass or wasting Advanced or end stage diseases and conditions Hypermetabolic state (increases needs for energy and protein) Early Identification of Risk Nutrition screening tools can identify potential nutrition problems early on During routine care, monitor for: Poor food or fluid intake Difficulty eating Unintended weight loss Changes in cognitive function or skin turgor Refer to nursing or the RDN/NDTR to allow for early interventions Physical Signs & Symptoms: Protein-energy Malnutrition Pale Skin Red, swollen lips Swollen and/or dry tongue with scarlet or magenta hue Poor skin turgor Thin appearance Bilateral edema Muscle Wasting Calf tenderness Reduced urinary output Refer to the RDN or NDTR Altered nutritional status can have an impact on the development and healing of pressure ulcers Nutrition intervention is vital for preventative care and treatment You can help determine which individuals are at risk and make referrals to your supervisor or the RDN or NDTR Higher Calorie/Protein Needs Those with pressure ulcers need extra calories and protein for healing Example: Male 120#, 5 4 tall and 85 years old Normal With a Pressure Ulcer Calories Protein, gm Fluid, ml

67 Nutrition Care for Pressure Ulcer Treatment and Prevention Dining Nutrition Interventions Encourage/assist to eat, add adaptive feeding devices Snacks between meals Address social and psychological issues Alter medications to avoid anorexia or treat pain, anxiety, or depression; try appetite stimulants Nutrition Interventions Focus on food first! Least restrictive diet Correct diet consistency Encourage to eat meals and snacks Offer substitutions for foods not eaten Use nutrient dense foods/fluids Pack each bite of food with nutrients Enhanced/fortified foods and fluids High calorie/protein supplements if needed Hydration Fluid needs must be met 1 ml per calorie consumed or 30 ml/kg body weight per day Or minimum of 1500 ml fluid per day Offer beverages throughout the day Offer preferred beverages Keep accurate fluid intake records Hydration Monitor signs and symptoms of dehydration Poor skin turgor Flushed, dry skin Coated tongue Concentrated urine Irritability Confusion Team Communications Communicate what you know to the team 1. Identify warning signed and refer high risk To your supervisor or RDN/NDTR 2. Participate in team meetings Communicate information: weights, weigh changes, pressure ulcers, food/fluid intake, etc. 3. Continually monitor for concerns Document food/fluid intake and acceptance of supplements Nutrition Care Alerts Warning Signs: Incontinence, moisture Needs help moving, turning in bed or when sitting Purple or maroon colored skin over bony areas, skin tears Action Steps: Report signs to nurse Check/change linens Handle/move individual with care Reposition frequently and properly Report your findings to your supervisor 4

68 Nutrition Care for Pressure Ulcer Treatment and Prevention Nutrition Care Alerts Nutrition Care Alerts Warning Signs Unintended weight loss Eats < 50% meals Dehydration Action Steps Encourage food and fluid intake Observe and record food and fluid intake Report weight loss to your supervisor Team Action Steps Initiate wound management protocol Refer to RDN/NDTR Encourage food and fluid intake Consider nutrition supplements Your Role is Critical Identify risk Refer concerns to nursing and RDN/NDTR Assist with nutrition/hydration interventions Monitor for concerns Communicate concerns about nutrition to nursing and RDN/NDTR We Hope You Have Enjoyed Becky Dorner & Associates Slide Presentation We also offer many publications that may be of help to you. Please visit or us at for more information 5

69 Nutrition Care for Pressure Ulcer Treatment and Prevention Inservice Pre/Post Test 1. A pressure ulcer can develop within as little as 2 to 6 hours. True False 2. Pressure ulcers do not include damage to the muscle and bone. True False 3. A basic staging system is utilized to determine severity of pressure ulcers including extent of tissue damage and to monitor healing progress. True False 4. Poor food/fluid intake is not a risk factor for pressure ulcers. True False 5. Weight loss, malnutrition, and dehydration all have an impact on the development and healing of pressure ulcers. True False 6. Individuals with pressure ulcers need additional calories and protein for healing. True False 7. Nutrition is a vital component of a comprehensive care plan for prevention/treatment of pressure ulcers. True False 8. You should always encourage individuals to drink their supplements first before eating the meal. True False 9. If a person has an advanced directive such as DNR, no further nutritional interventions are needed or required. True False 10. You should tell your RDN or NDTR when a person isn t eating well, is losing weight, or is not drinking enough fluids. True False

70 Nutrition Care for Pressure Ulcer Treatment and Prevention Inservice Pre/Post Test Answer Key 1. True 2. False 3. True 4. False 5. True 6. True 7. True 8. False 9. False 10. True