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January 17, 2005

Adult Wound Care — Management of Pressure Ulcers
By Amy Fleishman, MS, RD, CDN
For The Record
Vol. 17 No. 1 Page 42

Increased incidence of pressure ulcers leads to lengthened hospital stays and greater costs.

When people heard of the circumstance surrounding the death of Christopher Reeve, most were shocked to learn of the deadly turn taken by such a benign-sounding ailment. But pressure ulcers and the resulting infections can be common occurrences for people who suffer from health problems such as spinal cord and brain injuries, neuromuscular diseases, and Alzheimer’s.

Pressure ulcers, which are also referred to as decubitus ulcers, pressure sores, and bedsores, are a significant and costly healthcare problem for patients and providers. They are defined by the National Pressure Ulcer Advisory Panel as “…localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.”1 Therefore, pressure ulcers are most likely to occur on the sacrum, hipbone, and heels.

Staging System
Pressure ulcers vary in severity and can be staged as 1, 2, 3, or 4. A stage 1 ulcer is a nonblanchable, reddened area of intact skin. In darker skin tones, the ulcer may appear with red, blue, or purple hues. A stage 2 ulcer is partial thickness skin loss involving the epidermis, dermis, or both. A stage 3 ulcer is full thickness skin loss involving damage to or necrosis of subcutaneous tissue. A stage 4 ulcer is full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle or bone.2

Prevalence and Cost
The fourth national pressure ulcer prevalence survey found an overall 10.1% prevalence rate in 39,874 patients in acute care hospitals.3 Langemo et al found a 23% prevalence rate in a skilled care facility.4 An increased incidence of pressure ulcers leads to lengthened hospital stays and increased costs. Complications of pressure ulcers lead to an annual death rate of approximately 60,000.5 The total national cost of pressure ulcer treatment is at least $5 billion to $8.5 billion annually.6

Risk Factors
The following are several factors that put a patient at risk for developing a pressure ulcer7:

• restricted physical activity, such as being bedridden, wheelchair-bound, paralyzed, or in a coma;

• sensory impairment, such as having difficulty communicating or being unresponsive;

• damp skin, such as being bowel- and bladder-incontinent or perspiring often;

• poor circulation and reduced oxygen supply, as seen with diabetes and peripheral vascular disease; and

• malnutrition.

Braden Scale
The Braden Scale is one of the tools recommended to assess the risk of developing a pressure ulcer. A nurse usually documents the score, which is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction, and sheer. Each category is scored on a scale of 1 to 4, except friction and sheer, which use a 3-point scale. The scores range from 6 to 23, with 23 being the highest, indicating the least risk for a pressure ulcer. Preventive measures should be initiated with a score of 18 or less. See www.bradenscale.com/braden.pdf for a copy of the Braden Scale chart.8

Malnutrition
There is a strong correlation between malnutrition and the risk of developing a pressure ulcer.9 In a prospective study, patients who were malnourished on admission to the hospital were twice as likely to develop pressure ulcers as nonmalnourished patients.10

Malnutrition may increase the risk for a pressure ulcer for several reasons. Weight loss and less subcutaneous fat make the bones more prominent, which causes a steeper pressure gradient, thereby putting the patient at increased risk. Malnutrition can also lead to edema and reduced blood flow in the skin, causing ischemic damage, which is a risk factor for developing a pressure ulcer. Lastly, malnutrition causes muscle loss and the inability to shift position, which leads the patient to spend a longer time in one position and puts him or her at increased risk for a pressure ulcer.

Nutrition Assessment
When a patient is identified as being at risk for developing a pressure ulcer, or if a patient already has a pressure ulcer, a dietitian must assess the patient and determine the necessary nutritional intervention. There are many factors to consider that could put a patient at increased risk for malnutrition, such as age. One study looked at adults over the age of 70 and found that 11.6% experienced pressure ulcers as compared with only 6% of younger people.11

The diet order also plays a crucial role because if the patient is on a restricted diet, it may lead to decreased intake. The patient’s diagnosis, medical history, swallow function, ability to feed oneself, and skin integrity must also be taken into account. The dietitian must also assess psychosocial factors, such as who pays for the food, who cooks, what the cooking facilities are like, and whether there are any food or cultural food preferences.

A main part of the nutrition assessment is looking at food intake, anthropometrics, and labs. Asking patients about their appetite and food intake are two different questions. Patients may have a good appetite, but due to the aforementioned factors, they may be eating less than 50% of the meal. If patients weigh less than 80% of their ideal body weight, they are at increased risk for developing a pressure ulcer. In addition, if patients experience a 5% weight loss in one month or a 10% weight loss in six months, they are at increased risk. The relationship between low albumin and decreased wound healing has been well-documented.12 See Table 1 for albumin and prealbumin values that put patients at risk.

Nutrition Intervention
After assessing whether patients are at risk for developing a pressure ulcer or if they already have one, the dietitian must determine the appropriate intervention. The following recommendations are not evidenced-based practice guidelines, but they will provide a review of the literature, which will help when working with patients with pressure ulcers. Keep in mind that every patient is an individual with different needs. Nutrient requirements will vary depending on several factors, such as the severity of the pressure ulcer, comorbidities, age, and weight. See Table 2 for a summary of recommendations.

Calories are needed to spare the protein and allow for increased needs due to infection. Recommendations for treating pressure ulcers are usually 30 to 35 calories per kilogram. There is no known benefit of overfeeding on wound healing.9 Remember to use adjusted body weight when determining the needs for an obese patient.

Inadequate protein delays wound healing and prolongs the inflammatory phase. Therefore, protein recommendations for treating pressure ulcers are usually 1.2 to 1.5 grams per kilogram. Expressed as a percentage of calories, other recommendations have been 20% to 24% of calories from protein. The maximum recommendation is 2 grams per kilogram because excess protein may strain the liver and kidneys.9

In a prospective, randomized, controlled study of 672 critically ill patients aged 65 and older treated with high-protein nutrition supplements for 15 days, there was a reduction of pressure ulcer risk when compared with controls.13 A study by Chernoff et al looked at the effects of high-protein tube feeding on pressure ulcers. Two study groups, each with six patients on tube feedings, were monitored for eight weeks to assess pressure ulcer healing. One group received a tube feeding that was 16% protein (1.2 grams of protein per kilogram), while the other group received a tube feeding that was 25% protein (1.8 grams of protein per kilogram). Both groups experienced healing of their pressure ulcers; however, the group that received 25% protein showed more healing in the same time frame (70% improvement as opposed to 40% improvement).14

Fluid is needed to maintain good skin turgor and blood flow to wounded tissues, which is essential for the prevention of skin breakdown. Dehydration is a risk factor for pressure ulcers. Recommendations for treating pressure ulcers are usually 30 to 35 milliliters per kilogram or 1 milliliter per calorie. More fluid may be needed if the patient has a fever or fluid loss from an open wound.9 Less fluid may be warranted if a patient is on a fluid restriction.

In addition to calories, protein, and fluid, specific micronutrients have received primary attention in the prevention and treatment of pressure ulcers. If a patient’s diet does not meet 100% of the Recommended Dietary Allowance, a multivitamin/mineral supplement is recommended in addition to the following nutrients:

• Vitamin C aids in collagen synthesis and expedites wound healing. However, in patients who are not vitamin C-deficient, no evidence has been found for wound healing with vitamin C supplementation.15 Recommendations for treating pressure ulcers are usually 1,000 to 2,000 milligrams per day in divided doses if deficiency is suspected.9

• Vitamin A also enhances collagen formation, and a deficiency results in delayed wound healing and increased vulnerability to infection.16 Vitamin A supplementation is warranted for wound healing that has been delayed by vitamin A deficiency, steroid use, excessive vitamin E supplementation, radiation, chemotherapy, or diabetes. Recommendations for treating pressure ulcers are usually 20,000 to 25,000 international units per day orally if deficiency is suspected. Vitamin A can become toxic and cause liver abnormalities if taken in large doses for a long period of time, so vitamin A should be taken for 10 days and then the wound should be reassessed.9

• Zinc is required for collagen formation and protein synthesis. Low serum zinc levels have been associated with impaired healing. Recommendations for treating pressure ulcers are usually 15 to 25 milligrams elemental zinc per day, which is 66 to 110 milligrams zinc sulfate.9 Improvement in wound healing with zinc supplementation has not been shown in patients who were not zinc-deficient. In addition, long-term excessive use of zinc supplementation can induce a copper deficiency, so zinc should be taken for 10 days and then the wound should be reassessed.17,18,19

• Arginine and glutamine are helpful in healing pressure ulcers. They support muscle synthesis and help maintain a healthy immune system.20,21 Arginine supplementation appears to benefit wound healing even if the patient is not deficient. Oral supplementation of 17 to 24.8 grams free arginine per day has been shown to affect wound healing. The safe maximum supplementation for glutamine is 0.57 grams per kilogram.9

Follow-Up Care
After the initial nutrition intervention is completed, patients must be monitored to assess whether their plan of care is being followed and to see whether the pressure ulcer is healing. Communication between all members of the medical team can provide invaluable information. Since the dietitian can’t be with the patient at all meals, meal rounds and calorie counts are essential. A red flag is raised if patients eat less than 50% of their food over three days when compared with their usual eating patterns. Weekly weights and prealbumin should be checked to monitor the patient’s nutritional status. Albumin has a longer half-life than prealbumin and therefore won’t be as good an indicator of the patient’s current nutritional status.

If it is observed through meal rounds, calorie counts, or team meetings that the patient has poor intake, he or she should eat small, frequent meals to consume an adequate amount of calories. The doctor may also want to prescribe an appetite stimulant.

Nutrition supplements help increase the patient’s caloric, protein, and fluid intake. There are a variety of supplements to choose from, ranging from 240 to 360 calories and 8 to 14 grams of protein per 8-ounce serving. The supplements are available in clear liquid, full liquid, pudding, and powder form, as well as being disease-specific, such as for patients with diabetes or kidney disease. Some formulas also contain arginine and glutamine. Therefore, a supplement can be chosen based on the patient’s specific medical condition.

Tube feeding and/or total parenteral nutrition may be necessary if the patient is not consuming enough food and/or supplements. There are tube-feeding formulas available that provide 20% to 25% of protein calories, the recommended amount of protein for healing pressure ulcers. Some of these formulas are also rich in vitamin C and zinc, as well as fortified with arginine. Semielemental feeds are recommended in patients with albumin <2.5 grams per deciliter.22

Nutrition plays a critical role in the prevention and management of pressure ulcers. The older population (aged 65 or older) comprised approximately 13% of the U.S. population in 2003 and is expected to more than double in number to 71.5 million, or 20% of the population, by 2030.23

Older adults experience an increased incidence of pressure ulcers. Since this population is growing, the medical team must take an active role in assessing patients at risk for developing a pressure ulcer. The sooner the intervention, the better the outcome.

— Amy Fleishman, MS, RD, CDN, is the clinical nutrition coordinator for the program for surgical weight loss at Mount Sinai in New York City. She recently served on the New York University Skin Care Committee and lectured to several hospitals on wound care.

References
1. National Pressure Ulcer Advisory Panel. Pressure ulcer prevalence, cost and risk assessment: Consensus Development Conference statement. Decubitus. 1989;2:24-28.

2. National Pressure Ulcer Advisory Staging Report. 2003. Available at: http://www.npuap.org/positn6.html. Accessed September 5, 2004.

3. Barczak CA, Barnett RI, Childs EJ, Bosley LM. Fourth national pressure ulcer prevalence survey. Adv Wound Care. 1997;10:18-26.

4. Langemo DK, Olson B, Hunter S, et al. The incidence of pressure sores in acute care, rehabilitation, extended care home health, and hospice in one locale. Decubitus. 1989;2:42.

5. Allman RM. Pressure ulcers among the elderly. N Engl J Med. 1989;320:850-853.

6. Beckrich K, Aronovitch SA. Hospital-aquired pressure ulcers: A comparison of costs in medical vs. surgical patients. Nursing Economics. 1999;17:263-271.

7. Thomas DR. Improving outcome of pressure ulcers with nutritional interventions: A review of the evidence. Nutrition. 2001;17:121-125.

8. Braden Scale for Predicting Pressure Ulcer Risk. 2001. Available at: http://www.bradenscale.com. Accessed September 6, 2004.

9. Thompson CW. Nutrition and adult wound healing. 2003. Available at: http://www.nutritioncare.org/listserv/wound%20healing.pdf. Accessed September 26, 2004.

10. Thomas DR, Goode PS, Tarquine PH, Allman R. Hospital acquired pressure ulcers and risk of death. J Am Geriatr Soc. 1996;44:1435-1440.

11. Position of the American Dietetic Association: Liberalized diets for older adults in long-term care. J Am Diet Assoc. 2002;102:1316-1323.

12. Anderson CF, Wochos DN. The utility of serum albumin values in the nutritional assessment of hospitalized patients. Mayo Clin Proc. 1982;57:181-184.

13. Bourdel-Marchasson I, Barateau M, Rondeau V, et al. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. Nutrition. 2000;16:1-5.

14. Chernoff RS, Milton KY, Lipschitz DA. The effect of a very high-protein liquid formula on decubitus ulcer healing in long-term tube-fed institutionalized patients. J Am Diet Assoc. 1990;90:A130-A139.

15. Rackett SC, Rothe MJ, Grant-Kels JM. Diet and dermatology. The role of dietary manipulation in the prevention and treatment of cutaneous disorders. J Am Acad Dermatol. 1993;29:447-461.

16. Hunt TK. Vitamin A and wound healing. J Am Acad Dermatol. 1986;15:817-821.

17. Sandstead HH, Henriksen LK, Greger JL, et al. Zinc nutriture in the elderly in relation to taste acuity, immune response, and wound healing. Am J Clin Nutr. 1982;36:1046-1059.

18. Kohn S, Kohn D, Schiller D. Effect of zinc supplementation on epidermal Langerhans’ cells of elderly patients with decubital ulcers. J Dermatol. 2000;27:258-263.

19. Cario E, Jung S, Harder D’Heureuse J, et al. Effects of exogenous zinc supplementation on intestinal epithelial repair in vitro. Eur J Clin Invest. 2000;30:419-428.

20. Kirk SJ, Hurson M, Regan MC, et al. Arginine stimulates wound healing and immune function in elderly human beings. Surgery. 1993;114:155-160.

21. Barbul A, Lazarou SA, Efron DDT, et al. Arginine enhances wound healing and lymphocyte immune responses in humans. Surgery. 1990;108:331-337.

22. Borlase BC, Bell SJ, Lewis EJ, et al. Tolerance to enteral tube feeding diets in hypoalbuminemic critically ill, geriatric patients. Surg Gynecol Obstet. 1992;174:181-188.

23. A Profile of Older Americans: 2003. Washington, D.C.: Administration on Aging. 2003. Available at: http://www.aoa.gov/prof/Statistics/profile/2003/2003profile.pdf. Accessed September 18, 2004.

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