The One With the

Pressure Ulcer
Aimee Takamura
Sodexo Mid-Atlantic Dietetic Intern
January 2014

Executive Summary
Introduction of patient
Objective data
Medical history
Nutrition history
Discussion of disease
Pathophysiology
Role of nutrition
Wound care

Treatment and hospital course

Learning Objectives
After attending this presentation, participants should be
able to:
Explain the differences between acute and chronic wounds
Identify key nutrients needed in wound healing and explain
their significance
Estimate nutritional needs for individuals with pressure ulcers
Appreciate the impact adequate nutrition has on wound
healing

About Pressure Ulcers (PUs)

Definition: localized injury to the skin
and/or underlying tissue, usually over a bony
prominence, as a result of pressure, or
pressure in combination with shear and/or
friction (NPUAP)
~1-3 million Americans develop PUs
annually
Mortality rate: ~60,000 people/year
Physical, emotional, and financial burdens

About PUs - Financial

Agency for Healthcare Research and Quality
(AHRQ) estimated that development of PUs
increased the average length of stay from 5
days ($10,000/day) to 13-14 days ($16,755
$20,430/day)
Center for Medicare and Medicaid Services
(CMS) no longer reimburses hospitals for PUs
that develop during a patients length of stay

Introduction
AB is an 83 y.o. Caucasian female admitted
with a stage IV midline sacral decubitus ulcer
(pressure ulcer)
Lives with 24 hour nursing support, is
followed by a wound care nurse, and has help
from her husband, who lives independently
Bed-bound with limited mobility, needs
assistance with all ADLs
LOS = 16 days: November 10th 26th

Objective Data
Height: 56
Weight 110#s
BMI = 18
+ Fever and chills, skin wounds
Cachectic appearance, +4 bilateral lower
extremity (BLE) edema, left leg osteomyelitis,
pressure ulcer on left heel, stage IV sacral
decubitus ulcer

Lab Values
Date

Reference
Range

11/10

Hb
Hct
Na
K
Cl
BG
BUN
Creatinine
Ca
Albumin

11.5-16 g/dL

13.4
39.3
133 (L)
3.7
95.7 (L)
178 (H)
19
0.7
7.2 (L)
2.3 (L)

35-47%
135-146 mmol/L
3.5-5.3 mmol/L
98-110 mmol/L
60-99 mg/dL
7-25 mg/dL
0.5-1.4 mg/dL
8.5-10.4 mg/dL
3.2-4.6 g/dL

Current Hospital Medications

Medicine
Lasix

Indications
K wasting diuretic used to treat
ABs edema
Fragmin
Anticoagulant used in DVT
treatment
Ondansetro Antiemetic used to treat nausea
n
d/t surgery, chemotherapy
Oxycodone Used to treat severe pain for long
periods of time
Dilantin

Used to treat seizures and

irregular heartbeats

Vancomycin Used to treat gram + organisms

(staph, C. diff colitis, eg)
Calcium
carbonate

Used to increase ABs low calcium

status

Vitamin D3

Taken to enhance ABs calcium

status in conjunction with calcium
carbonate

Nutrient interactions
Diarrhea w/ high doses (sorbitol)

Not for those with pork allergies

Usually, no dietary changes are
needed
Do not crush
Caution with grapefruit and
citrus; avoid alcohol
Folate drug metabolism; drug
folate levels.
metabolism of vit D and K
Take Ca, Mg, antacids
separately by 2 hrs
Little GI absorption
Oral vancomycin has a bitter
taste
Take 1-3 hrs after meal
Take Zn, Fe, Mg suppl
separately by 1-2 hrs
Ca absorption
Maintain vit D status

Medical History

Surgical History

Nutrition History
Diet prescription: Regular diet
Minimal PO intake due to increased pain, altered
mental status, and medications
ABs husband reported she was not a big eater to
begin with; always on the thinner side
Worsening nutrition status
ABs appetite fluctuated day to day; she did not eat
consistent meals
On a typical day, she ate a few bites of food here
and there and drank up to one Ensure a day

Discussion of Disease
NPUAP-EUPAP Nutrition Guidelines approved
by the EAL for evidence-based guidelines
regarding pressure ulcers
The Academy acknowledges the limited
evidence available on this topic
Recommended RDs rely on clinical
judgment, best practice resources, and
communication with other professionals to
best support patients with wounds
Pathophysiology, role of nutrition, wound care

Pathophysiology
Normal wound healing
occurs in three
phases: inflammation,
proliferation, and
remodeling
Inflammatory phase
Blood clot
cytokines and
growth factors
neutrophils
inflammatory
response
Monocytes
macrophages

Pathophysiology
Proliferation phase
4 days after infliction
includes 4 steps: angiogenesis, epithelialization,
granulation, and tissue formation/collagen deposition
Dependent on fibroblasts and growth factors that
work to ensure these processes occur

Pathophysiology
Remodeling phase
Begins ~1 week after infliction and can continue
for months to years
Preliminary fibrous network forms and functions
as a site for collagen deposition and cellular
growth
Wound tensile strength = 70-80% of normal skin

Pathophysiology
Chronic Wounds
Non-healing wounds exist in a chronic state of
inflammation
Ischemia and bacterial overgrowth are 2 main
reasons
Elevated levels of collagenases and proteases work to
clear debris from the wound
Results in extracellular matrix destruction and
protein loss
Risk factors: diabetes, age, malnutrition, corticosteroid
use, and hypothyroidism

Staging Wounds
The NPUAP recommends using a validated pressure ulcer
classification system to assess wounds. At HCGH, a staging
system from I-IV is used:

Stage I: Non-blanchable erythema

Stage II: Partial thickness loss of dermis

Bone, tendon, muscle not exposed

Stage IV: Full thickness tissue loss

Shallow open ulcer with red/pink wound bed; no slough

Stage III: Full thickness skin loss

Color change, intact skin

Exposed bone, tendon, or muscle

Unstageable: Full thickness tissue loss depth unknown

Depth not detectable due to slough or eschar

Role of Nutrition
Malnutrition is directly associated with PU
development, increasing patients risk twofold
Results from chronic inadequate intake
Insufficient energy and protein inhibits ones
ability to fight infection and negatively impacts
the healing process
Indicated with PU development, and associated
with poor prognosis in patients with existing ones
Malnutrition is a reversible condition
It is important to identify at-risk patients and begin
appropriate nutrition intervention as soon as
possible

Role of Nutrition
Nutritional needs:

Calories: 30-35 kcals/kg of body weight

Protein: 1.25-1.5 grams/kg body weight
Ensure adequate fluid intake for hydration
MVI or supplementation to prevent vitamin and
mineral deficiencies, especially with inadequate
intake

Vitamins A and C, zinc, magnesium, copper, and

amino acids glutamine and arginine are nutrients
of particular interest
Lacking evidence to substantiate specific
recommendations for supplementation

Role of Nutrition
Vitamin A
Increases the number of monocytes and macrophages,
thereby stimulating epithelialization and collagen
deposition
DRI = 700ug/d (F); 900ug/d (M)
Wound healing: 3,000-4,500 ug/d (10,000-50,000 IU/d) for
10 days
Caution with corticosteroids
Supplementation is indicated in those who do not meet the
DRI for vitamin A
Monitor administration in patients with renal and liver
failure
Limited RBP catabolism and hepatic vitamin A storage

Role of Nutrition
Vitamin C
Aids in collagen synthesis via capillary formation,
production and activity of fibroblasts, and
neutrophil proliferation
Supplementation shown to enhance wound
healing, especially if deficiency noted
100-200 mg/d for stage I II PUs
1,000-2,000 mg/d for stage III IV PUs
Eating citrus fruits is an easy way to increase
vitamin C intake.

Role of Nutrition
Zinc
Plays a role in collagen and protein synthesis,
cellular proliferation, and wound healing
Supplementation only with zinc deficiency
Excess zinc interferes with copper and iron
absorption; can lead to deficiencies
RDA = 8 mg/d (F), 11 mg/d (M)
Supplementation to support wound healing: up
to 40 mg/d (176 mg zinc sulfate) x 10 days

Role of Nutrition
Magnesium
Acts as a cofactor for certain enzymes and combines with
ATP to power many processes needed for wound healing
RDA = 320 mg/d (F), and 420 mg/d (M)
Copper
Involved in the formation of certain enzymes (cytochrome
oxidase, lysyl oxidase, cytosolic antioxidant SOD) necessary
for cross-linking of connective tissues
RDA = 900 ug/day
Caution with zinc supplementation, toxicity
Recommended supplementation dose: up to 10 mg/d
(tolerable upper limit)

Role of Nutrition
Glutamine
Conditionally essential amino acid involved in stimulation of
the inflammatory response.
No studies have examined the effect of supplementation on
wound healing
Arginine
Conditionally essential amino acid shown to increase the
production of nitric oxide, enhance immune function, and act
as substrates for protein and collagen synthesis
Possible cause of hemodynamic instability due to increased
nitric oxide production (Desneves, et. Al, 2015)
No conclusive evidence to support supplementation for
wound healing

Role of Nutrition
Supplementation
Has not been shown to improve outcomes in
certain patient populations
Insufficient evidence exists to recommend use
beyond overcoming deficiencies
More important to identify those who are
malnourished or at risk of malnutrition, and
provide and encourage intake of a balanced diet

Wound Care
PUs should be assessed upon admission and weekly
thereafter; healing should begin within two weeks
following wound care
Tools for assessment:
Pressure Ulcer Scale for Healing (PUSH)
Bates-Jensen Wound Assessment Tool

Clinical judgment
Document physical findings:
Length and width
Depth
Tunneling or undermining
The wound care nurse assessed and cleaned ABs
wound every 3-5 days. Documentation included
pictures.

Wound Care
Proper PU care includes routine wound cleaning,
proper dressings, debridement, and possible surgery
Topical and/or systemic treatments are useful
Wound vacuum assisted closure (VAC) device
Positioning devices like foam pillows, cushions,
heel covers
Debridement when there is presence of necrotic
tissue
Surgical procedures, like operative debridement,
for advanced PUs
Requires a multidisciplinary approach involving a
medical team comprised of a physician, dietitian,
nurses, and wound care specialists

Wound VAC

Treatment & Hospital Course

Visit #1 initial
LOS 2 days
MD consult for poor nutrition status and stage IV decubitus ulcer
AB sleeping upon arrival, husband present and able to provide relevant
information
AB has had a decreased appetite for a while; unable to recall exact
time frames
Noted +4 BLE edema
Wound RN assessed AB, cleaned and dressed the wound
Discussed supplementsagreed to send 1 Ensure and 1 Pro-stat per day

Treatment & Hospital Course

Visit #1 initial
Nutrition diagnosis:
Inadequate protein intake R/T wound healing AEB
stage IV pressure ulcer on heel and midline sacrum
Goals:
PO intake of 50-100%
To drink 1 Ensure and 1 Pro-stat per day, as tolerated
Assigned a high level of care
Estimated energy needs:
Calories: 1500-1750 kcals (30-35 kcals/kg)
Protein: 50-70g (1.0-1.4g/kg)
Fluids: 1mL/kcal or per medical team recommendations

Treatment & Hospital Course

Visit #2 follow up
LOS 4 days
AB sleeping
s/p debridement x 1 day
Per RN report, she had a good appetite with PO
intake of ~50%
Drinking the Ensure but has not tried Pro-stat
Assigned a moderate level of care

Treatment & Hospital Course

Visit #3 follow up
LOS 8 days
Debridement done today again
AB in immense pain, confused due to high doses of
medications
Husband reported ABs appetite fluctuated from day
to dayPO intake of 0-50%
Drinking up to 1 Ensure a day, still has not tried Prostat
Assigned a high level of nutrition care due to her
worsening PO intake and non-healing wound

Treatment & Hospital Course

Visit #4 follow up
LOS 11 days
ABs PU not showing signs of healing, a wound VAC was
added 2 days ago
Remained drowsy and confused due to her pain
medications
Her husband reported drastically decreased PO intake
the past two days.
forDrinking
up to one Ensure a day, still had not tried Prostat
- Discontinued Pro-stat until the surplus ran out.

Assigned a high level of care

Treatment & Hospital Course

Visit #5 follow up
LOS: 14 days
Palliative/comfort care
Fluid restriction of 1000mL/day was prescribed due to a
5L positive fluid balance and pulmonary edema
ABs husband reported her intake was slightly improved
since the last visit
Drinking up to one Ensure a day but refusing the Pro-stat
Plans being made for discharge back to a wound care
center
Assigned a high level of care

*On LOS day #16, AB was discharged to a rehab wound

care center for continued care

Lab Values

In the Future
Request prealbumin tests
Request routine tests for vitamin A and C,
magnesium, zinc, and copper status
Suggest a daily MVI to help AB meet the RDIs
for critical nutrient
Juven as a supplement alternative to Pro-stat
Possible calorie count, consideration of
nutrition support

Role of the RD
Ideal PU treatment requires collaboration and
communication between a multidisciplinary team:
physician, RNs, wound specialist, and dietitians
With an established link between nutrition and
wound healing, dietitians play a critical role in the
treatment of PUs
Monitoring nutritional status and the provision
of supplements
Their contributions as part of a larger team can
have considerable impact and should not go
unrecognized

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Debridement

Questions??

Thank you!