Adult
Wound Care
Management of Pressure Ulcers
Today’s Dietitian
By Amy Fleishman, MS, RD, CDN
Vol. 7, No. 1, p. 38
Actor Christopher Reeve died from a heart attack
brought on by an infection originating from a pressure ulcer. Know
how to manage this risk found frequently in long-term care patients.
When people heard of the circumstance surrounding
the death of Christopher Reeve, most were shocked to learn of the
deadly turn such a benign-sounding ailment can take. But pressure
ulcers and infections from them can be common occurrences for people
with spinal cord injuries, brain injuries, neuromuscular diseases,
and Alzheimer’s, just to name a few.
Pressure ulcers are a significant and costly healthcare
problem for patients and providers. Dietitians must understand the
role nutrition plays in their prevention and management.
Pressure ulcers are also referred to as decubitus
ulcers, pressure sores, and bedsores. 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, and
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, the 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. Age is one of these
factors. 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 above factors may be eating
less than 50% of the meal. Calculate the patient’s ideal body
weight (IBW). If patients are less than 80% of their IBW, 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 the 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 values of albumin and prealbumin that put patients
at risk for pressure ulcers.9
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 the
following 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 the 25% protein showed more healing in the
same time frame (70% improvement as opposed to 40% improvement).14
If your patient requires more protein in his or
her diet, the following are rich sources of protein. Seven grams
of protein are found in 1 ounce of meat, poultry, fish, and cheese,
1 egg, 1/2 cup of beans, peas, and lentils, 1/2 cup of tofu, and
1 tablespoon of peanut butter. Eight grams of protein is found in
1 cup of milk or yogurt.
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
Nutrition Follow-Up
After the initial nutrition intervention is completed, the dietitian
must closely follow these patients to assess whether their plan
of care is being followed and see whether the pressure ulcer is
healing. Do not assume that the patient is receiving the nutrition
therapy you recommended. Communicating with the other 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 during meal rounds, calorie counts,
or team meetings that the patient has poor intake, suggest that
the patient eat small frequent meals for him or her 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 have arginine and glutamine in them.
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, dietitians and all of 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 will be.
— 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.
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11. Position of the American Dietetic Association:
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Diet Assoc. 2002;102:1316-1323.
12. Anderson CF, Wochos DN. The utility of serum
albumin values in the nutritional assessment of hospitalized patients.
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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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