Mariana Covarrubias 1935127 March 2014 Issue Vol. 15 No.

The Role of Vitamin C and Zinc In Pressure Ulcer Prevention and Treatment
By Mariana Covarrubias
Each year in the United States, 1 to 3 million people develop pressure ulcers.1 The Agency for Healthcare Research and Quality indicates that hospitalizations related to pressure ulcers increased 80 percent from 1993 to 2006.2,3 In healthcare facilities pressure ulcers are seen as indicators of inadequate care or low quality service. Attention to this issue is of great importance since complications related to pressure ulcers can result in sepsis, shock, or death.4 More than 2.5 million patients in United States health care facilities suffer from pressure ulcers, and 60,000 die from complications related to pressure ulcers each year.5 In the elderly pressure ulcers increase length of hospital visits and also increase risk of death by up to 400%.6 Dietitians play a vital role in combating malnutrition, usually a big cofactor associated with pressure ulcer development. Pressure Ulcer Scale for Healing (PUSH) Pressure ulcers are areas of damaged tissue and skin that most commonly affect the elderly population.7 Usually seen in hospitals, long term care facilities, and nursing homes, they are generally caused by friction, pressure, or moisture on the skin combined with underlying issues like low immune system, decreased lean body mass, low mobility, and malnutrition.4 In 2009, the National Pressure Ulcer Advisory Panel (NPUAP) provided a new classification

system and guidelines for pressure ulcer treatment. The severity of pressure ulcers is determined by their placement on the Pressure Ulcer Scale for Healing, the scale ranges from 0-17, seventeen being the most severe.1 The PUSH scale is used as a way to assess the healing of pressure ulcers and therefore the effectiveness of oral supplements. In a study in The Journal of Nutrition, pressure ulcers were treated with an oral supplement containing both vitamin C and zinc, the supplementation increased healing rate in comparison to the control group as evidenced by the ratings on the PUSH scale.

The Role of Vitamin C and Zinc Malnutrition can delay healing and increase the risk of chronic pressure ulcers, nutrition strategies like food fortification and oral nutritional supplements are often recommended. 8 Vitamin C helps rebuild collagen, it is important for tissue regeneration and repair.9 When a patient develops a pressure ulcer, usually they are malnourished and have low immunity.10 Malnutrition is a big cofactor in the development of pressure ulcers, and usually also includes deficiencies in certain macro and micro nutrients. A vitamin C deficiency is decreases collagen function, which causes delayed healing and impaired immunity.10 Although vitamin C by itself has not increased healing time in pressure ulcers, when combined with zinc and other micronutrients it has proven beneficial.3 Zinc is a mineral associated with protein synthesis, collagen formation, and cell generation.11 Zinc deficiency may be the result of malnutrition and can cause impaired healing and immune function.11 Research indicates that the rate of pressure ulcer healing accelerates when a wound healing supplement containing zinc, arginine, and vitamin C is administered, making it more preferable than a regular supplement.1

Prevention and Treatment Strategies For the prevention and treatment of pressure ulcers, nutrition is an important part of a complete care plan.1,12,13 Adequate calories, protein, fluids, vitamins and minerals, should be provided because they are required by the body for maintaining tissue regeneration and preventing breakdown. Known risk factors for pressure ulcer development include undernutrition, unintended weight loss, impaired ability to eat independently, low BMI, and dehydration.7,15 Elderly patients who are malnourished are at a higher risk of developing pressure ulcers, dietitians play a critical role in correcting any nutrient deficiencies associated with malnutrition. The treatment of pressure ulcers with an oral supplement containing vitamin C and zinc provided successful results in comparison to just increasing calories or providing oral supplements not specific to wound healing.4 Nutrition screening helps identify individual with compromised nutritional status. According to the American Dietetic Association initial screening is completed upon admission and based on the results of the nutrition screening, a referral is made for a formal assessment by an RD. The RD then conducts a nutritional assessment and makes recommendations for management and interventions. Since most of these patients are malnourished it is recommended that patients receive oral supplementation containing vitamin C and zinc with continued followups upon the smallest change. Where Dietitians Fit In As mentioned, dietitians play an integral role in helping prevent and treat pressure ulcers. To change statistics, RDs must take on a more active role in this issue by staying on top of the latest research, so that they can help patients prevent pressure ulcers. In addition to educating themselves, RDs can educate nurses and doctors and counsel patients on the role nutrition has in

preventing and treating pressure ulcers. According to Becky Dorner, RD, LD all individuals should have a nutritional assessment upon admission and at the slightest condition change. The following medical nutrition therapy recommendations for pressure ulcers are provided by the NPUAP:

At admission each patient with a pressure ulcer should be screened and assessed for nutritional status and follow-up should occur at the slightest condition change or until completely healed.

All patients should be referred to a dietitian immediately for assessment and nutrition intervention.

Assess patients weight loss and weight history. Assess the patients ability to eat independently. Evaluate total food and fluid intake and provide adequate calories(30-35 kcals/kg body weight), make sure to adjust according to stress factors, weight loss, weight gain, and obesity level.

Liberalize diet restrictions when not enough calories consumed because of restrictions. Provide supplement or enhanced foods between meals, if needed. If necessary, consider enteral or parenteral nutrition when inadequate oral intake. Adequate protein (1.25-1.5 g/kg) should be provided to promote pressure ulcer healing. Constantly asses changes in condition and re-assess nutrition intervention according to goals. Make sure to evaluate renal function if high protein levels are recommended.

Encourage appropriate hydration and monitor constantly for signs of dehydration. Additional fluids should be provided for patients with dehydration, elevated temperature, vomiting, or diarrhea.

Encourage a balanced diet including good sources of vitamins and minerals. Make sure to offer vitamin and mineral supplements when malnourished or when deficiencies are confirmed.

It Takes More Than An RD Strong evidence points out that pressure ulcers have become a great concern, creating a significant health risk for patients. As part of the strategy to find a solution to this issue, RDs are essential in helping manage and treat pressure ulcers through supplementation and adequate nutrition. As the primary nutrition professional, dietitians must continue to work with the medical community to help prevent further complications and deaths from pressure ulcers. Mariana Covarrubias, Dietetics and Nutrition Student at Florida International University

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