Importance of Nutritional Support in Pressure Ulcer Control and Prevention - Literature review Example

Title of the paper Your name Class name Date of submission Introduction Recently the knowledge on the process of wound healing has increased drastically resulting in an immense range of therapeutic options. The selection of these options may become a challenge to medical personnel and physicians. There is substantial knowledge on difficulty in selecting the appropriate therapy for a special type of pressure ulcer. Physicians and medical personnel have identified two types of wounds; chronic and acute wounds, both have specific, typical and unique features since each wound needs nursing care. Pressure ulcers are among the most costly and serious problems among the aged and in the hospital setting (Stechmiller, 2008). The main objective of this paper is to give an explanation on pressure ulcers and the importance of nutrition on pressure ulcer healing. Crowe &Broockbank (2009) says that pressure ulcers is a wound caused by constant pressure, friction, moisture and shear forces, that prevent capillary blood from flowing to the underlying tissues and skin resulting to their damage. Pressure ulcers are inflamed patches that form when a person’s weight rests against a hard surface exerting pressure on the soft tissues and the skin. Its prevalence in both the acute and chronic stage is common among the aged, neurologically impaired and the frail, causing an increase in morbidity, mortality and time spent in hospital. Some of the risk factors for pressure ulcers are prolonged immobility which is common among the aged, uncontrolled diabetes, above 70 years of age, poor circulation, fractures and poor nutritional status. In adults it commonly occur on the heel and the sacrum and develop anywhere in the body tissues (Crowe &Broockbank , 2009). According to the Australian and New Zealand Society for Geriatric Medicine findings in 2007, pressure ulcers develop when the blood vessels supplying nutrients and oxygen to the body and the skin are subjected to pressure failing its functions. According to WA current hospital records, 70.3% of these injuries are caused by poor movement and lifting techniques, shears, poor sensation, poor nutrition, limited movements and poor blood circulation. Since they occur rapidly, it is important to prevent them from occurring, they can start by reddening the skin surface and hide the rest under the skin. They are painful and can be infected causing bone infection or blood poisoning in some adverse conditions. They spread deeply under the skin and destroy the underlying bones and muscles. Pressure ulcers are found anywhere in the body depending on individuals posture; When sitting they may develop at the elbow, buttocks and shoulder blades, when lying on your back they develop at the toes, heel tail bone and the back of your head. Lastly is that they develop when lying on your back at the pelvis, hip, ear and ankle bone (Grey & Harding, 2006). Takehiko, Toshio, Kenji & Kayoko (2011) says that pressure ulcers are classified according to the depth of tissue damage and the classification system used should be authorized by the Australian Wound Management Association (AWMA).This association says that it is not possible to stage pressure ulcer until necrotic tissue has degraded hence any ulcer that was found before the removal of necrotic tissues is said to be un-stageable. (AWMA) in association with NPUAP- EPUAP pressure ulcer association system identified four stages, the first is Non-bleachable erythema of the skin, second is partial thickness of skin loss involving the dermis and the epidermis, third; full thickness skin loss involving the damage of the subcutaneous tissues that may extend to the underlying fascia, fourthly is extensive damage of tissues, muscles and other supporting structures (Takehiko, Toshio, Kenji & Kayoko 2011). According to 2008 state- wide survey conducted in WA hospital 9% of 272 patients had hospital- acquired pressure ulcers giving an estimate of 67.6%. This survey also shows an estimate of PU prevalence in sub- acute and acute health care facilities ranged from 5.6% to 48.4%. The Australian long term care facilities was estimated to be 26% in 2004.Despite being a preventable health problem, it remains an international patient safety risk that needs special attention due to its prevalence rate. Pressure ulcers can be prevented by identifying patients at risk, and implementing prevention strategies for the identified patients (NHMRC 2005). The Australian Wound Management Association’s (AWMA) identified some of the clinical practices for prediction and prevention of pressure ulcers. These elements of prevention include; Inspection of the patients skin daily, conducting a pressure ulcer risk admission assessment on every patient, reassessment of risk for patients daily, keep the patients dry and moisturize the skin, minimize pressure, optimize nutrition and hydration among others. Its aim is to minimize hospital acquired pressure ulcer incidences in WA, to attain this all admitted patients in WA hospital must have a pressure ulcer assessment and those at high prevalence should receive proven and appropriate prevention strategies. The prevention teams (SQuIRe) identified some of pressure ulcer improvement processes that need to be implemented by the hospital executives in WA hospitals, among these is clinicians with experience in wound care and prevention, a team member familiar with quality improvement methods and a senior nursing staff (Lee &Maloney, 2006) As the population ages and individual activities increases pressure ulcer prevalence is expected to rise making it more cost effective in terms of lost wages, productivity, health care costs and human suffering. In South Western Australian hospital (SWA) there is an estimate of 95,695 new pressure Ulcer cases that incurred a mean cost of $315 million per year by 2008, keeping in mind that these costs are underestimates since they do not consider community based physician and nursing cost costs, additional hospital nursing time, and productivity loss for the family and patient. With changes in illness patterns and aging population, pressure ulcer prevalence will continue to escalate until the right prevention and treatment techniques are implemented in both WA and SWA hospitals, hence the objective of pressure ulcer prevention and management programs is to reduce the number of patients with pressure ulcers (Stratton &Elia 2003). Crowe, & Brockbank ( 2009) says that out of these pressure ulcer conditions, nutrition plays a big role in vascular-catheter- associated infections and pressure ulcers. On average stage 2 pressure ulcer treatment costs more than A$ 1,100 on hospital stay and stage 3 and 4 costs nine times more. These costs do not account on the diminished quality of life, discomfort and pains incurred by the patient, hence it is important for the health care providers to carefully monitor and assess each patient’s risks for skin and tissue damages. As a result good nutrition is essential for patients at nutritional risks, maintaining skin integrity and the malnourished who are vulnerable to pressure ulcers. Screening tools like Nestlệ s Mini Nutritional Assessment should be used to identify those at nutritional risk and at what stage. Identifying and knowing who is at higher risk and treating at an early stage will prevent its occurrence and progress to the most complicated stage of pressure ulcers. Nutrients role in pressure ulcer treatment Good nutrition is important for prevention and treatment of pressure ulcers. Studies show that poor nutrition which is caused by poor energy intake, inadequate proteins, weight loss, low vitamin and argenen intake significantly contribute to pressure ulcer development. Nutritional therapy has been identified to be more cost effecting thus posing need fore other nutritional interventions such as tube feeding and oral nutritional supplements for early management of wounds. These guidelines suggest external feeding rather then parental nutrition to eliminate vascular- catheter-associated diseases and maintain immunity and gut integrity. Grey & Harding (2006) says that to enhance the healing process of pressure ulcers it is important to tackle nutrition at every stage by giving special nutrients to patients at different stages of pressure ulcers. Patients with stage 3 and 4 pressure ulcers improved their immune when given energy in the Basal Energy Expenditure range(BEE), where the intervention group (BEE) received about 1.62 g/Kg/day of proteins and 37.9 Kcal/kg in a day energy. After 8 weeks a significant reduction in pressure ulcer prevalence among the control groups and the intervention experienced a reduced number of patients. In this intervention patients with greater pressure ulcers (>25.5cm²) statistically had great benefits of healing faster. According to Grey and Harding (2006) vitamins, minerals and the (BEE) should be advocated to attain maximum healing processes of the wounds. Adequate energy is required to increase and maintain weight for tissue repair and prevent protein metabolism. People with pressure ulcers have increased energy requirement from 10- 60% .Pressure ulcer patients require 25-88% of proteins, studies at malnourished nursing home with pressure ulcers found an improvement when patients consumed 24% protein supplements. In addition 245 patients received an oral nutritional supplement of 46.5 g of protein, 575mg vitamins, 575Kcal, 6.9g arginene. 2- 4 L of fluid a day and for those patients under air- fluided beds will require an addition of 10- 15ml/kg of fluid, 21mg of zinc and 87mg vitamin E daily to their diet,within 12 weeks the pressure ulcer prevalence reduced by 53%. Argenine, zinc, vitamin C, and E also play an important role in wound healing. Arenine promotes the transportation of amino acids into tissue cells and stimulates the secretion of insulin, vitamin C aids in hydroxylation of lysine in production of collagen helps in protein synthesis and collagen formation and vitamin E prevents cells from oxidation (Benati & Pedone, 2001). Argenene Research Show that argenine has greater wound healing process and can prevent the development of pressure ulcers. It is an essential amino acid that has unique and useful pharmacologic effects, it is important in cell proliferation, a substrate for protein synthesis, collagen deposition, nitrogen balance and acts as a precursor for nitric oxide. Argenine depend on habitual argenene intake and normal protein intake at an average intake of 5- 6g/day (Stechmiller 2008).Individuals supplemented with argenine for two weeks at 17g and 24.8g/day showed an improved collagen production rate compared to patients without any adverse event report. Argenen enhances cell proliferation, substrate for protein synthesis, collagen deposition, promotes positive nitrogen balance and T- lymphocyte function, it also has angiogenic and anti-bacterial properties which are important for wound healing processes. It is not required for normal growth and development, it is considered important during poor oral intake and metabolic stress (Stechmiller 2008). Micronutrients Zinc ad vitamin C and E play an important role in modulating pressure ulcer healing and development. Zinc is required for cellular proliferation, immune function and protein synthesis its deficiency can occur due to wound drainage, prolonged dietary deficiency and GI losses, the recommended intake is 8- 14mg/day. Vitamin E is involved in immune enhancing effect and anti- inflammatory responses and 7-10% should be taken to allow total healing. Although results from supplementation are similar to the baseline line vitamin C status may be an important in ascribing a clinical benefit to vitamin C supplementation. Measurements of zinc serum levels are not helpful while poor oral intake may describe a low zinc level and inflammation can give rise to low zinc readings from the plasma to the liver. As zinc is transported by albumin low levels of albumin may interfere with the serum zinc levels, unless over deficiency exists there is less evidence for zinc supplementation to patients with pressure ulcers (Cuddigan & Ayello, 2001). Special nutrition support Crowe & Brockbank (2009) says that in the intervention group 51% of pressure ulcers healed and 46% improved as compared to 30 and 41% of those patients receiving routine program. Although non reached the expected statistical significance, the study shows a suggestive importance for special nutritional support for pressure ulcer. A controlled random trial of 39 patients with stage 3 and 4 pressure ulcer, where an oral supplementation containing zinc, argenene and vitamin C for3 weeks found 29% healed wounds and a decrease in necrotic tissue. Crowe & Brockbank (2009) also argues that a deficiency in these trials was the absence of a control group and the healing rates compared against the historical controls. While the results appeared to show a greater benefit in wound healing when compared to the rate of wound healing from different historical groups, it wasn’t possible to attribute a defined benefit to the supplement because there was no randomization and appropriate comparable control group. Two studies of similar provide real evidence for specialized nutritional support in pressure ulcer healing processes. (NHMRC, 2005) evaluates a distinct vitamin C, zinc and argenene containing nutritional supplement against traditional nutritional support (routine care). Pressure sore status tool was used during this evaluation to trace pressure ulcer changes and healing of patients with server cognitive disabilities randomized to control diet for 2 weeks. Later on a high trend of wound healing was experienced. The final study shows the specialized nutritional support role in the healing process of pressure ulcers. It examines the role of oral supplement containing vitamin C, zinc and argenene against routine care supplements provided for 3 weeks. Thompson & Fuhrman (2005) says that the current nutritional interventions vary depending on the stages of the pressure ulcer. For stage 1 the recommended nutritional diet should be ≥25Kcal, 1.0- 1.2gm/kg proteins, 1 multivitamin, 250mg vitamin C and ≥ 30ml/kg fluid. Stage require 1.5- 1.8gm/kg proteins, 30- 35ml/kg fluid, 30- 35kcal/kg, 220 mg ZnSO4 x 10 days, 1 multivitamin, 500mg (BID) twice daily, 14grams of argenene, 10000 IU vitamin A x 10 days and 14 grams glutamine. Recommendation for stage 2; ≥30 ml/kg fluid, 500 mg vitamin C, 1.25-1.50 gm/kg protein, 30-35 kcal/kg, 220 mg zinc sulfate (ZnSO4) x 10 days, 10,000 International Units (IU) vitamin A x 10 days and 1 multivitamin. The fourth stage recommendations include: 30-35 ml/kg fluid, 30-35 kcal/kg, 500 mg vitamin C BID,1.5-2.0 gm/kg protein, 14 grams glutamine, 220 mg ZnSO4 x 10 days, 2.4 grams HMB is needed, 1 multivitamin and 2.4 grams HMB is needed (Thompson &Fuhurman, 2005). Nutritional interventions with increased protein and calories for pressure ulcers healing was experienced in a 75 year old woman who had stayed in a long term care facility for about 6- 7 years and she was readmitted to the facility on 10/03/ 2012 after a long stay at the hospital (Stratton& Elia 2003). At her arrival, she presented a stage 2 pressure ulcer at the coccyx that was red in color. When the physicians followed her medical history they discovered she had type 2 diabetes mellitus, obstructive sleep apnea, hypertension, morbid obesity, dyslipidemia, chronic gastroesophageal reflux, iron-deficiency anemia, congestive heart failure, chronic pulmonary disease and vascular dementia. In addition this an oral motor dysphagia that needed diet enriched with nectar thickened liquid was realized in her. She was observed to have good appetite. By 10/12/2012 her laboratory taste showed low red blood cells of 2.93, low albumin of 1.9, and low hemoglobin of8.6 (Stratton& Elia 2003). Since may 2012, the patient had been receiving 500mg of vitamin C, where she was discovered to increase her weight from 61kg to 66.4kg, this results shows the positive impact of nutrition supplements among pressure ulcer patients, when given per the recommended measures according to the stage of the illness, for example for her case at stage 2 she was given; 30-35 kcal/kg, 30 ml/kg fluid and 1.25-1.50 g/kg protein. Later she was given a statement stating the increased need for nutrients to promote the wound healing, according to this statement she needed enough protein, fluid and enough calories and since she had low red blood cells, iron deficiency and low hemoglobin, it was also important to be given iron supplements and Niserex to ensure maximum wound healing (Crowe &Brockbank 2009). According to the patient’s case, pressure ulcer may have been caused by various underlying conditions. It is assumed that she may have received while recovering from pyelonephritis disease which she was previously treated from, due to this her immune system was under- stressed and weakened subjecting her to a hyper- metabolic condition that she could require more calories. Here weight records showed a loss of 8.2% within 62 days, this suggested a queuing requirement and adequate consumption of calories during hospital stay, her condition paced her at a high risk of pressure ulcer development since she was underweight, aged, bedfast and immobile As a result her pressure ulcer improved with the help of the increased proteins, vitamins and calories, Up to date here case represents the current research on the need added nutritional treatment to address pressure ulcers. Vitamins A, C and zinc are beneficial to wound healing but basing on the patients case was necessary because she was not given until a week before healing, however her case fully support the nutritional intervention program (Stechmiller 2008). Conclusion In pressure ulcer control and prevention, nutritional support is important and it is related to addressing both the macro and micro- nutrient deficiencies arising from increased nutrient intake or poor oral intake for wound healing. This is evidence for nutrition especially by high- protein supplements is effective for patients at pressure ulcer risk. The pressure ulcer interventions support a trend of increasing pressure ulcer disease- specific formula. Proper treatment that will reduce pressure ulcer incidence should be used regularly on patient as per the recommended measures to attain maximum treatment and total mitigation of the disease.Additionally a nutritional solution that is safe, cheap and efficient be provided in all current nursing and medical approaches to allow the existing classes access them during pressure ulcer treatment. References Benati, G, Delvecchio, S, Cilla, D & Pedone, V 2001, ‘Impact on pressure ulcer healing of an arginine-enriched nutritional solution in patients with severe cognitive impairment’, Arch Gerontol Geriatr, suppl 7, pp. 43-7. Cassar A, Todrovic B, Banks M, Bauer J 2005, ‘Nutrition and Pressure Ulcers,’ The Pathway to Optimal Healing. Dietitians Association of Australia Conference. Perth. Crowe, T & Brockbank, C 2009, ’Nutrition therapy in the prevention and treatment of pressure ulcers’, Wound practice and research, vol. 17, no. 2 , pp. 90-98. Cuddigan, J, Berlowitz, D, Ayello, E 2001, ‘Pressure ulcers in America: prevalence, incidence, and implications for the future: An executive summary of the National Pressure Ulcer Advisory Panel Monograph’, Adv Skin Wound Care, vol.14, pp. 208-15. Graves, N, Birrell, FA, Whitby, M 2005, Modeling the economic losses from pressure ulcers among hospitalized patients in Australia. Vol.13:462-467. Grey, JE, Enoch, S & Harding, KG 2006, ’ABC of wound healing: pressure ulcers’, BMJ, pp. 472-5. Lee, SK, Posthauer, ME, Dorner, B, Redovian, V & Maloney MJ 2006, ’Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial’, Adv Skin Wound Care. National Health and Medical Research Council (NHMRC), 2005, Nutrient References Values for Australiaand New Zealand. Canberra. Prentice, J & Stacey, M 2002, ‘Evaluating Australian clinical practice guidelines for pressure ulcer prevention’, EWMA Journal, vol.2, no. 2, pp. 11-15. Scholes, JMGA & de Jager-v.d. Ende MA, 2004, ‘Nutrition intervention in pressure ulcer guidelines: an inventory’, Nutrition, vol. 20, pp. 548-53. Stechmiller, JK, et al 2008, ‘Wound Healing Society.’ Guidelines for The Prevention of Pressure Ulcers. Vol. 16:151-168. Stratton, R, Green, CJ & Elia, M 2003, ‘Consequences of Diseases related Malnutrition‘, Disease-Related Malnutrition: An Evidence-Based Approach to Treatment, Wallingford, Oxford, CABI, pp. 113-155. Takehiko O., Toshio N., Shingo O., Kenji O., Kayoko A.2011, ‘Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states,’ Wound Repair and Regeneration. Vol. 19: 330- 336. Thompson, C & Fuhrman, MP 2005, ‘Nutrients and wound healing: still searching for the magic bullet’, Nutrition in Clinical Practice, vol. 20, no.3, pp. 331-347. Read More