id=114164 Originally posted August 2004

How to help wounds heal
SUE LEININGER HOGAN is an advanced practice nurse at Allegheny General Hospital in Pittsburgh.

Successful wound healing depends upon proper nutrition. Here's how to make the most of that connection and optimize your patient's recovery. Jump to:

If a wound is not healing as it should, it could be that the patient is malnourished. In the United States, approximately 40% of hospitalized patients—and 85% of patients in nursing homes—suffer from malnutrition.1 Malnutrition might not be detected until obvious signs appear, in some cases because clinicians were not aware that their patient was at risk. One study, for example, found that nurses overestimated patients' dietary intake by 20%.2 Whether a patient's wound is the result of an injury or surgery, proper healing requires optimal nutrition. Wound healing sets off a complex chain of events that involves increased cellular activity and an intensified metabolic demand for nutrients.3 Patients who don't have enough nutrients to meet this increased demand are at risk for delayed healing, infection, longer hospital stays, and even death.1 Although a dietitian will ultimately determine your patient's nutritional needs, you will be the first person to assess the patient's nutritional status and the condition of his wound. To promote optimal wound healing, you'll need to understand the link between nutrition and tissue repair, recognize when a patient is malnourished, and inform the rest of the healthcare team of any changes in the patient's nutritional status.

The three phases of wound healing
Before we can explore the relationship between nutrition and wound healing, it's important to briefly touch upon some wound-healing fundamentals. As you know, wound healing occurs in three overlapping stages: the inflammatory phase, the proliferative phase, and the remodeling phase. The inflammatory phase begins at the onset of the injury and lasts up to six days.4 During this phase, blood vessels constrict and coagulation factors are activated, preventing additional blood loss. The coagulation cascade causes the release of leukocytes, which attack the bacteria in the wound, and monocytes, which remove

dead tissue, blood clots, and bacteria from the site. Protein and clotting factors also permeate the wound. The proliferative phase begins within seven days of the injury and lasts for two to three weeks.4 During this phase, new blood vessels develop, which promote the growth of granulation tissue. New tissue forms a protective covering over the wound. Collagen, which is responsible for tissue repair, is produced by fibroblasts during the proliferative phase. The collagen and the granulation tissue grow and cross-link to form a scar. The remodeling phase begins three weeks after the injury and is characterized by the buildup and breakdown of collagen.4 The wound edges are pulled inward by myofibroblasts, and scar tissue becomes softer and flattens out. Scar tissue continues to strengthen throughout this phase, which can last for up to two years.4 Over time, the scar will change from red to white and reach its full tensile strength of 60% – 70% of the original tissue. Essential to all phases of wound healing are adequate blood flow, tissue perfusion, and oxygenation.5 Adequate blood flow and tissue perfusion help ensure that oxygen and nutrients are delivered to the wound. The production of collagen, for example, depends upon the availability of oxygen and protein at the wound site.5 As collagen develops, other components of the healing process—including white blood cell mobility, granulation tissue formation, and blood vessel development—improve as well.

Take a careful look at nutritional status
Because wound healing is so dependent upon nutrition, a comprehensive nutritional screening is critical. Begin with a diet history.6 Ask about the patient's daily intake, food preferences, and eating environment, including when and how he eats. A change in appetite may be the first indication of a nutrition problem. Find out if there are functional or psychological factors, such as constipation or pain, that might affect your patient's ability to eat. Ask him if he uses nutritional supplements or herbs and if so, which ones. Also ask about drug and alcohol use. A patient who abuses alcohol, for example, is likely to have vitamin, protein, and calorie deficiencies. Alcohol abuse is just one predictor of nutritional deficiencies. Others include a decreased serum albumin level (<3.5 gm/dL); long-term medication use; impaired immune system functioning; acute and chronic diseases, including diabetes mellitus and liver and kidney disease; and weighing less than 80% or more than 120% of the ideal body weight.4 Follow up the diet history with a physical assessment. Patients who are malnourished may have hair that is dull, dry, thin, or easy to pull out.7 They may say that their hair

because the half-life of albumin is 20 days. 16 – 17.6 mg/dL).8 A BMI of 17 – 18. and <16.has lost its natural curl or changed color. a more sensitive indicator of protein deficiency than albumin.9 Prealbumin has a half-life of two to three days. Ask him what he usually weighs to determine if he has recently lost or gained weight. Prealbumin levels will decrease rapidly when a patient is underfed for even a brief period. and hyperpigmentation. Divide the weight (in kilograms) by the height (in meters squared).5 and 25. and retinol-binding protein (2. purplish. your patient may have a nutritional problem. or smooth with papillae.7 A patient who has nutritional deficiencies may have lips that are red or inflamed and cracking (cheilosis). such as a protein or vitamin C deficiency. and they will increase rapidly with dietary support. Remember to record his height. Even with a caloric intake that's excessive. You may observe yellowish lumps around a patient's eyes. Look for paleness.6 Obese patients (BMI >30) should also prompt a second look. redness and fissures of the eyelid corners. or inflamed (gingivitis) or may bleed easily.7 You'll also want to assess the thyroid gland for enlargement.5 – 5. transferrin (200 – 360 mg/dL). severe malnutrition. Teeth may have gray-brown spots. Signs of a nutritional deficiency may also be evident in the patient's face.5 may indicate mild malnutrition. swollen. moderate malnutrition. so it's a very sensitive indicator of a patient's protein status. The most accurate way to determine height is to measure the patient while he's standing up. spongy. Levels below 200 mg/dL indicate that protein stores are becoming depleted. His tongue may be swollen.9 The four serum proteins you should look at are albumin (normal level is 3. a patient may become malnourished before a decrease in serum albumin is noted. and some may be missing.7 Gums may be red.9 Low albumin levels are associated with protein deficiency. and acute metabolic stress. and he might complain of a diminished sense of taste. Weigh him on the same scale at the same time each day.6. Completing the picture with lab work Your nutritional screening should also include a review of the patient's lab results. inflamed (glossitis). A healthy BMI for an adult generally falls between 18. prealbumin (16 – 40 mg/dL). Serum transferrin has a half-life of eight to 10 days and its levels respond quickly to changes in protein intake. Record your patient's weight on admission and frequently throughout his hospital stay. scaling of the skin around the nostrils. protein-losing gastrointestinal disease. that can impair wound healing. or white rings around both eyes. Pay particular attention to serum protein levels.0 gm/dL).9 However. It is. . Use your patient's height and weight to determine his body mass index (BMI).6 – 7. therefore.

10 Feeding your patient to help him heal To avoid malnutrition and wound complications.4 A general rule of thumb is that oral feeding is better than enteral feeding. the patient may have a moderate protein deficiency. The first is the total lymphocyte count. the medications he's receiving. patients need adequate calories. The inability to respond to the antigens—in the form of a rash—may be related to a nutritional deficiency.Levels of <16 mg/dL are associated with malnutrition. Dehydration occurs when a patient doesn't receive enough fluid. fat. in which the patient is given antigens subcutaneously.9 To help ensure that a patient is properly hydrated. The results of two less commonly performed immune system function tests can also identify nutritional roadblocks.000 cells/mm3.5 Water is essential for cells to function normally.6 mg/dL reflect a protein deficiency. levels of <2. As a general rule. vitamins. including the patient's current feeding route.9 Serum protein levels. a dietitian will determine the amounts of carbohydrates.5 – 3 gm/kg per day. see the "Nutrients provide fuel for healing" box. 30 – 35 ml of fluid per kg of body weight per day may be adequate unless contraindicated. The second test is the skin antigen test. protein.10 Other factors to consider include:10 • Is the patient unconscious. or otherwise unable to eat safely? . Patients who are unable to consume at least half of their required calories and protein on their own may need enteral or parenteral nutritional support.) Dehydration reduces blood volume. are just one indicator that the patient's nutritional status is not optimal for wound healing. Water balance.4 Patients with wounds also need adequate protein—1. Based on input from your history and physical assessment. and the procedures he'll undergo. depending upon the severity of the wound and other factors. or hydration. which further decreases circulation and reduces oxygen and nutrient delivery to the tissues. or anergy panel.6 Retinol-binding protein has a half-life of approximately 12 hours.) Calories are needed to supply the energy necessary for wound healing. protein. an adult critical care patient needs 25 – 30 calories per kilogram of body weight per day. which is better than parenteral feeding. (For more information on how these nutrients promote healing. however. and minerals that your patient will need for wound healing. and fluid. If it is lower than 15. or when fluid loss exceeds intake. if necessary. is present when a patient's fluid intake equals his output. (Wound drainage can be a source of fluid loss.11 Clinicians consider many factors when determining which feeding route is best for a patient.9 Your patient may require tube feeding A patient can meet his nutritional requirements orally by eating a balanced diet and. taking supplements. mechanically ventilated.

ones that contain fiber. vomiting. flatus. patients with a wound who also have other conditions such as diabetes. Crucial. more than 100 enteral formulas are available. pulmonary disease. However. warmth. residuals. These formulas provide higher levels of protein. If your patient is receiving enteral feeding. or diarrhea. a gastrostomy or jejunostomy tube can be inserted surgically. and sometimes arginine. Isosource. or pressure sores? Enteral tube feeding is indicated when a patient with a functioning GI tract can't consume the amount or type of nutrients needed by mouth. Irrigating the tube frequently according to your facility's guidelines helps maintain its patency. and how long will nutritional support be required? • Is the patient's skin otherwise intact? Are there draining wounds.• Does the patient have a hard abdomen or an absence of bowel sounds. or nasojejunal route should be considered. and drainage. For example. One benefit of enteral feeding is that it promotes blood flow to the gut and helps maintain mucosal integrity. and discomfort from distention. Conditions such as facial fractures or CNS trauma may also dictate the route used. swelling.2. including Boost HP. a patient may require enteral feeding because he's mechanically ventilated or at risk for aspiration because of altered consciousness. or he has a diminished gag or cough reflex.10 Currently. check tube placement regularly. a nasogastric. formulas designed to strengthen a patient's immune system. fistulas. skin breakdown. Determine how well your patient is tolerating the feeding by assessing for bowel sounds. stools. they would receive a formula designed specifically for their particular condition. which could indicate an obstruction or other problem that might preclude enteral feeding? • Does the patient have bed restrictions that might increase his likelihood of aspiration? • Does the patient have injuries to specific tissues or organs that would affect his ability to consume and digest food? • What are the future medical or surgical plans for the patient. If long-term feeding is necessary. and Promote. . zinc. vitamins (usually A and C). nasoduodenal. nausea. Also assess the tube's exit site for redness. There are "standard" formulas that provide the recommended daily intake of vitamins and minerals. and specialty formulas for patients with a specific disease or condition. Several formulas are promoted as enhancing wound healing.11 If a patient will need enteral feeding for less than four weeks. or impaired liver or kidney function wouldn't receive one of these wound-healing formulas. Instead.

B. L. and watch for hyperglycemia. Nutritional support for wound healing.. Nutritional support and the surgical patient. Heart Lung. & Heitkemper. and electrolytes. amino acids. Saunders.nih. Crit Care Nurse. 10. (2002). J Wound Care. Home Healthc Nurse. Ayello. 4. A patient who'll be receiving TPN should have blood tests to establish baseline levels of phosphorus. which requires a central line. McQuillan. The role of nutrition in wound healing. National Institutes of Health. M. . Leininger.S. Modifying perfusion. trace elements. 2. M.10 Whether your patient's nutritional needs are complex or relatively straightforward. Altern Med Rev. D.. D. is indicated when parenteral feeding will be needed for longer than a week. so check the patient for signs and symptoms of catheter-related infection.When parenteral feeding is necessary Patients who can't tolerate enteral feeding will need parenteral nutrition. A. H. Nutrition in wound healing: A bio-psychosocial perspective.. REFERENCES 1. Williams L. After that. Whitney. 7. Medsurg Nurs. 163. Nurs Clin North Am. MacKay. Pressure ulcer management: The importance of nutrition. (1997). M. Huckleberry. 61(7). www. Am J Health Syst Pharm. 9. Thomas. 3. (2002). 359.. Early enteral feeding of patients with multiple traumas. A patient who shows signs of infection should have a fever workup. K. Philadelphia: W. (1999). M. 11. which may include blood cultures. J. R. et al. (Ed). A. 8. Trauma nursing: From resuscitation through rehabilitation (3rd ed. A.). the line should be replaced. (2003).nlm. 32(4). A. electrolytes. (1999). National Library of Medicine. 123. 719. Crit Care Nurs Q. Total parenteral nutrition (TPN).. nutrition and stress to promote wound healing in patients with acute wounds. vitamins. 6. "Body mass index. Nutritional aspects of wound healing. 9(4).htm (25 May 2004). and complications such as infection or sepsis. Cook. Lipids are sometimes infused separately and are especially useful for patients who have fluid restrictions. and insulin as needed. 11(6). Y. 849. a histamine blocker. delayed healing. Kiy. 25(1). 17(11). & Litchford. S. 8(4). Assessing patients' nutritional needs in the wound-healing process. (2002). A. 40. The central line used to administer TPN raises a patient's risk of infection. 13. Each bag of TPN contains glucose. & Miller. that will help improve his chances of a successful recovery. U." 2003. (1999). K. And in the end. If you suspect that your patient has central line sepsis. 5. your attention to the details will serve him well. (2000). Peripheral parenteral nutrition (PPN) is used for short-term therapy—up to seven days. Cheever. magnesium. Appropriate nutritional support can help patients avoid malnutrition. 28(2). Ferguson. triglycerides. E. 19(6). 671. M. monitor the patient's glucose levels regularly. 225. (2004).

Fat should account for approximately 20% of calorie intake. patients need adequate amounts of nutrients.8 gm/kg of body weight per day. The recommended daily allowance of protein is 0. Insufficient protein intake inhibits collagen and fibroblast production. Fat is a concentrated source of energy. A deficiency decreases collagen and granulation tissue development and increases the likelihood of wound infection. less than that may lead to the breakdown of protein stores. a patient with a wound will need 1. impairing wound healing. Vitamin A can prevent the delay in wound healing that steroids often cause. including carbohydrates. which is necessary for cellular growth. However. taking in too much protein increases protein synthesis. protein. depending upon the severity of the wound and other factors. Carbohydrates are needed for energy. and E). and leukocyte activity.Click here to view full-size graphic Nutrients provide fuel for healing For a wound to heal successfully. Vitamins A and C are also essential for wound healing. A dietitian will determine how much of each nutrient your patient needs. It is necessary for the early inflammatory phase of wound healing. vitamins. and for scar tissue strengthening. Those who don't meet their nutritional needs are at risk for delayed wound healing and other wound-related complications. fat. and minerals. fibroblastic mobility. absorption. An adult's carbohydrate intake should account for 45% 60% of total consumed calories. . High doses of vitamin A. can be toxic. The main carbohydrate is glucose. however. for wound debridement. which puts a burden on the kidneys and liver and can lead to dehydration.5 3 gm/kg per day. Protein is necessary for tissue repair and maintenance. and transport of the fat-soluble vitamins (A. Vitamin A is lipid-soluble and stored in the liver. It is essential for digestion. D.

the dosage should be 100 300 mg a day. 3. M. 13.. When supplementation is necessary. D. It supports collagen development. Other minerals&#151. The role of nutrition in wound healing. can impair wound healing and cause GI distress. 8(4). S. Nutrition in wound healing: A bio-psychosocial perspective. 25(1). copper. There's no evidence that vitamin C accelerates wound healing in patients who don't have a deficiency.namely. (1997). A patient who's deficient in vitamin C may have bleeding gums or small red spots (petechiae) around the hair follicles. MacKay. the body can't store it. A deficiency can lead to abnormalities in white blood cell function.reportedly help with tissue regeneration. 2. and manganese&#151. iron.Vitamin C supports collagen synthesis. 359. 849. 32(4). Leininger. http://findarticles. Ed Library CBS MoneyWatch CBS News Find Articles in: All Business Reference Technology Lifestyle Newspaper Collection . A. Nurs Clin North Am. Too much zinc. It's water-soluble. & Miller. cell division. increasing the risk of wound infection. Altern Med Rev. A. and may bruise easily and heal slowly. Crit Care Nurs Q. Supplementation typically consists of 15 30 mg a day. Kiy. Log In | Join þÿ Search • • • • • • • • • • • • All of BNET Publications Library Home Commentary Leadership Life at Work Business Owners Exec. Nutritional support for wound healing. however. Another requirement for wound healing is zinc. (2002). but deficiencies of these minerals have not been linked to impaired wound healing. (2003). Sources: 1. and protein synthesis.

Health Publications • • Print Share Email Digg Facebook Twitter Google Delicious StumbleUpon Newsvine LinkedIn My Yahoo Technorati Reddit Recommend3 o o o o o o o o o o o o • 0 Comments difference between albumin and prealbumin.1. For wound healing to occur. Knowing the protein status lab values allows the practitioner to determine the degree of protein malnutrition and to initiate early nutritional intervention. and improve wound healing. decrease mortality. practitioners need to understand the underlying reason for measuring them. lower the risk of complications. any protein deficiency must first be corrected. Wound Care. Albumin and prealbumin levels are indicators of visceral protein status. This is important because early nutritional intervention has been shown to decrease the length of stay. Nancy • • • • 1 2 3 Next Nutrition Q&A Q: What is the difference between albumin and prealbumin? When should they be measured for patients with wounds? How are the results interpreted? A: Before examining the specifics of albumin and prealbumin. Sep/Oct 2001 by Collins. if necessary. The Advances in Skin &amp.2 .

Because zinc is associated with improved wound healing. protein-losing nephropathies. albumin is considered a late indicator of malnutrition-an important consideration now that the value of early nutritional intervention is known. any condition that results in a decrease in plasma volume will cause falsely elevated albumin levels. and diseases with increased capillary permeability. Second. such as lupus and other collagen vascular diseases. albumin is a negative acute-phase reactant. such as patients with heart failure or renal disease. zinc's main transport vehicle in the blood is albumin. the albumin concentration reflects the protein status of the blood and internal organs.5 Reliable changes in albumin require at least 2 to 3 weeks of nutritional intervention. albumin has a relatively long half-life of approximately 20 days and a very large serum pool. The reverse is also true: Patients with an expanded plasma volume. may appear to have falsely depleted albumin levels.7 Simply put. hydration status is an important factor to consider when evaluating albumin levels. Because albumin is formed in the liver. In other words. a sizeable amount of the serum pool has been lost. Evaluating albumin There are several considerations to be aware of when evaluating albumin levels. liver function should be considered when evaluating albumin levels. This means that albumin concentrations rise slowly during nutritional therapy (refeeding) and in patients recovering from stress. Generally. By the time albumin values are below normal levels. accounting for more than 50% of total serum proteins. it is important . it is a measure of hepatocyte function. Other disease states that may interfere with the reliability of albumin as a protein status marker are protein-losing enteropathies. Third. low serum albumin concentrations may decrease zinc absorption.More Articles of Interest • • • • • Improving your patient's nutritional status Protein and wound healing Vitamin C and pressure sores Closing the Gap: How to Provide Protein without Increasing Total Calories The role of nutrition in wound healing Albumin Albumin is one of the most abundant proteins found in blood. The blood's concentration of albumin has been suggested as a major determinant of zinc absorption. or pulmonary edema. which keeps fluid within the vascular space.3 The main purpose of albumin within blood is to maintain colloidal osmotic pressure.6 Hence.4 This is why patients with very depleted albumin levels may develop edema. Diseases of the liver cause the hepatocytes to lose the ability to synthesize albumin.4 Fourth. earlier changes are likely due to hemoconcentration issues. Table 1 shows the interpretation of serum albumin levels. First. ascites. The liver manufactures albumin.

Prealbumin is a tryptophan-rich of prealbumin is approximately 2 days. This name was chosen by the Joint Commission on Biochemical Nomenclature to indicate that it is a serum transport protein for thyroxin and retinol-binding protein. the national average reimbursement using CPT code 84134 is $17. This technique has been replaced by more cost-effective immunoturbidimetric technology. The more accurate name for prealbumin is transthyretin. This assay is not as easily affected by comorbities or hydration status as albumin. it has a much shorter half-life and smaller serum pool than albumin. making prealbumin a more timely and sensitive indicator of protein status. Prealbumin Prealbumin is another protein status indicator. The half-. Albumin is readily available in most patient records and routinely ordered in hospitals and long-term-care facilities. it is synthesized in the hepatocytes of the liver. Prealbumin's main function is to serve as a binding and transport protein.9 Table 1 shows the interpretation of serum prealbumin levels. The albumin level has a place in nutrition assessment.6 Rather than a diagnostic tool. prealbumin is a negative acute-phase reactant.5 The term prealbumin is actually a misnomer-the prefix pre implies that it is a precursor for albumin.8 Evaluating prealbumin Like albumin. In the past.(10) More Articles of Interest * Improving your patient's nutritional status . Prealbumin levels can be drawn once or twice per week and used as a sensitive monitor of nutritional progress. The cost of the test using this technology is approximately $3. Monitoring albumin levels over the course of several months can provide a long-term picture of a patient's protein status. most labs analyzed prealbumin levels using a process called closely monitor protein status and correct any deficiencies with early. which it is not. prealbumin should be used as an indicator of nutritional improvement and as a measure of how well nutritional interventions are working. and like albumin. The very short half-life and small serum pool allows small changes in nutritional status to be identified in a short time frame.00.18. it has been noted that elevated prealbumin levels may be seen in patients taking corticosteroids and in patients with Hodgkin disease. aggressive nutritional interventions. This limits its use as a screening tool for malnutrition because low levels could result from either inadequate nutrition or inflammatory stress. New laboratory techniques have made prealbumin a readily available and costeffective assay. Prealbumin should be part of the nutrition assessment for all patients with wounds because it provides the best monitor of current protein status. however.

Prealbumin is the gold standard for monitoring nutritional progress because it provides a quantitative way to document whether the nutrition care plan is working or whether interventions need to be modified. Mahan LK. S. 2nd ed. Bernstein L. p 384-5. . Sun S. Nutrition and Diet Therapy. Philadelphia. 4. Pagana TJ. Brugler L. Whitney ER. DiPrinzio MJ. 2000. p 338. Protein-energy undernutrition among elderly hospitalized patients. Paul: West Publishing Co. The five-year evolution of a malnutrition treatment program in a community hospital.* Protein and wound healing * Vitamin C and pressure sores * Closing the Gap: How to Provide Protein without Increasing Total Calories * The role of nutrition in wound healing Albumin and prealbumin are both indictors of protein nutrition status. Walls RC. Minneapolis/St. Mosby's Diagnostic and Laboratory Test Reference. PA:WB Saunders Co. Cataldo CB. and probably months). MO: Mosby-Yearbook. Nutrition & Diet Therapy.281:2013-9. 2. Pagana. Krause's Food. Jt Comm J Qual Improv 1999. p 657-9. Inc. 3. 4th ed. Louis. Prealbumin is much more sensitive and provides more current information. 1 Oth ed. 1995. KD. Escott-Stump. DeBruyne LK. When evaluating albumin results. New technology makes prealbumin a costeffective and valuable part of the nutrition assessment for every patient with a wound.4:191-206. Sullivan DH. 5. the practitioner should keep in mind that low levels likely reflect a longstanding nutritional deficiency (at least several weeks. References 1. 1995. St.JAMA 1999.

1999. Understanding 1981. p 403-S.them.2nd 1261-3. Prealbumin becomes transthyretin? IUPAC-IUBMB Joint Commission on Biochemical Nomenclature and Nomenclature Committee of IUBMB. 6th ed. Polymedco. Veldee MS. All rights Reserved * Previous *1 *2 *3 * Next .qmw.2001. 9. is a registered and licensed dietitian in private practice in Pembroke Pines. For the past decade she has served as a consultant to health care institutions on issues regarding regulatory compliance. LD/N. 10. Gaithersburg. In: Burtis CA. MD: Aspen Publishers. 8.polymedco. Inc. Last accessed April 4.6. Last accessed April 4. Nutrition. Available at: http://www. Cortlandt Manor. Chernoff prealb. Polymedco brochure. PhD. Rolfes SR. 2001. 7. p 420. Paul: West Publishing Co. Available at: http://www. Questions for future columns may be E-mailed to Dr Collins at Minneapolis/St. and food service management and as a medical-legal expert to law firms involved in health care litigation. 2nd ed. Ashwood ER. Inc. NY. Geriatric Nutrition. RD. Whitney ER.2001. PA:WB Saunders Co. 1993. Copyright Springhouse Corporation Sep/Oct 2001 Provided by ProQuest Information and Learning Company. Nancy Collins. FL. eds. 1994. Philadelphia. clinical nutrition.html. Tietz Textbook of Clinical Chemistry.

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FindArticles. reddened area of intact skin. RD.2 Prevalence and Cost The fourth national pressure ulcer prevalence survey found an overall 10. Pressure ulcers. 17 No. and bedsores. pressure ulcers are most likely to occur on the sacrum. which are also referred to as decubitus ulcers. most were shocked to learn of the deadly turn taken by such a benign-sounding ailment.”1 Therefore. Advances in Skin & Wound Care. All rights reserved.Popular on CBS sites: US Open | PGA Championship | iPad | Video Game Reviews | Cell Phones © 2010 CBS Interactive. or 4. blue. pressure sores. 3. 2005 Adult Wound Care — Management of Pressure Ulcers By Amy Fleishman. 2010. 1 Page 42 Increased incidence of pressure ulcers leads to lengthened hospital stays and greater costs. A stage 4 ulcer is full thickness skin loss with extensive destruction. When people heard of the circumstance surrounding the death of Christopher Reeve. The".874 . 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. or both. Nancy "difference between albumin and prealbumin. the ulcer may appear with red.1% prevalence rate in 39. are a significant and costly healthcare problem for patients and providers. and heels. hipbone. MS. A stage 1 ulcer is a nonblanchable. and Alzheimer’ Copyright Springhouse Corporation Sep/Oct 2001 Provided by ProQuest Information and Learning 26 Oct. Staging System Pressure ulcers vary in severity and can be staged as 1. tissue necrosis. neuromuscular diseases. dermis. A stage 3 ulcer is full thickness skin loss involving damage to or necrosis of subcutaneous tissue. or damage to muscle or bone. A stage 2 ulcer is partial thickness skin loss involving the epidermis. In darker skin tones. 2. All rights Res • • • • 1 2 3 Next January 17. http://findarticles. Privacy Policy | Terms of Use | Advertise | Jobs Visit other CBS Interactive Sites: Collins. 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. or purple hues. CDN For The Record Vol.

and labs.bradenscale. The dietitian must also assess psychosocial factors. thereby putting the patient at increased risk. The patient’s diagnosis. such as age. • sensory impairment. mobility. which is a risk factor for developing a pressure ulcer. and sheer. it may lead to decreased intake.patients in acute care hospitals. Patients may have a good appetite. wheelchair-bound.and bladder-incontinent or perspiring often. Asking patients about their appetite and food intake are two different questions. The scores range from 6 to 23. activity. Malnutrition can also lead to edema and reduced blood flow in the skin. Weight loss and less subcutaneous fat make the bones more prominent.4 An increased incidence of pressure ulcers leads to lengthened hospital stays and increased costs. as seen with diabetes and peripheral vascular disease. they are at increased risk for developing a pressure ulcer. except friction and sheer. • damp skin. Preventive measures should be initiated with a score of 18 or less. or in a coma. and • malnutrition. causing ischemic damage. anthropometrics. they may be eating less than 50% of the meal. such as being bowel. patients who were malnourished on admission to the hospital were twice as likely to develop pressure ulcers as nonmalnourished patients. but due to the aforementioned factors. • poor circulation and reduced oxygen supply. Lastly. A main part of the nutrition assessment is looking at food intake. If patients weigh less than 80% of their ideal body weight. Nutrition Assessment When a patient is identified as being at risk for developing a pressure ulcer. paralyzed. which leads the patient to spend a longer time in one position and puts him or her at increased risk for a pressure ulcer.000.6 Risk Factors The following are several factors that put a patient at risk for developing a pressure ulcer7: • restricted physical activity. moisture. indicating the least risk for a pressure ulcer.8 Malnutrition There is a strong correlation between malnutrition and the risk of developing a pressure ulcer. ability to feed oneself. or if a patient already has a pressure ulcer. There are many factors to consider that could put a patient at increased risk for malnutrition. Complications of pressure ulcers lead to an annual death rate of approximately 60. One study looked at adults over the age of 70 and found that such as being bedridden.11 The diet order also plays a crucial role because if the patient is on a restricted diet.3 Langemo et al found a 23% prevalence rate in a skilled care facility. and whether there are any food or cultural food preferences. Each category is scored on a scale of 1 to 4. nutrition. if patients experience a 5% weight loss in one month or a 10% weight loss .9 In a prospective study. See www. what the cooking facilities are like. a dietitian must assess the patient and determine the necessary nutritional intervention. In addition. which causes a steeper pressure gradient. medical history.pdf for a copy of the Braden Scale chart. who cooks. with 23 being the highest. A nurse usually documents the score. malnutrition causes muscle loss and the inability to shift position. such as who pays for the food. swallow function. such as having difficulty communicating or being unresponsive. which use a 3-point scale. which is composed of six subscales: sensory perception.10 Malnutrition may increase the risk for a pressure ulcer for several reasons. friction. and skin integrity must also be taken into account.5 billion annually.5 The total national cost of pressure ulcer treatment is at least $5 billion to $8. Braden Scale The Braden Scale is one of the tools recommended to assess the risk of developing a pressure ulcer.6% experienced pressure ulcers as compared with only 6% of younger people.

comorbidities.9 . no evidence has been found for wound healing with vitamin C supplementation. and a deficiency results in delayed wound healing and increased vulnerability to infection. Nutrient requirements will vary depending on several factors. The maximum recommendation is 2 grams per kilogram because excess protein may strain the liver and kidneys. Two study six months. the dietitian must determine the appropriate intervention. age.000 to 25. There is no known benefit of overfeeding on wound healing. steroid use.2 grams of protein per kilogram).14 Fluid is needed to maintain good skin turgor and blood flow to wounded tissues. so vitamin A should be taken for 10 days and then the wound should be reassessed. but they will provide a review of the literature. Vitamin A can become toxic and cause liver abnormalities if taken in large doses for a long period of time.8 grams of protein per kilogram). Expressed as a percentage of calories. 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.13 A study by Chernoff et al looked at the effects of high-protein tube feeding on pressure ulcers. were monitored for eight weeks to assess pressure ulcer healing. If a patient’s diet does not meet 100% of the Recommended Dietary Allowance.5 grams per kilogram. randomized. In addition to calories. Both groups experienced healing of their pressure ulcers. Recommendations for treating pressure ulcers are usually 20. the group that received 25% protein showed more healing in the same time frame (70% improvement as opposed to 40% improvement). The following recommendations are not evidenced-based practice guidelines.000 to 2.000 milligrams per day in divided doses if deficiency is suspected. or diabetes. specific micronutrients have received primary attention in the prevention and treatment of pressure ulcers. and fluid. Dehydration is a risk factor for pressure ulcers. The relationship between low albumin and decreased wound healing has been well-documented. in patients who are not vitamin C-deficient. radiation. protein recommendations for treating pressure ulcers are usually 1. other recommendations have been 20% to 24% of calories from protein. Therefore. each with six patients on tube feedings. such as the severity of the pressure ulcer.9 Less fluid may be warranted if a patient is on a fluid restriction. Keep in mind that every patient is an individual with different needs.000 international units per day orally if deficiency is suspected. Inadequate protein delays wound healing and prolongs the inflammatory phase. a multivitamin/mineral supplement is recommended in addition to the following nutrients: • Vitamin C aids in collagen synthesis and expedites wound healing. chemotherapy. which is essential for the prevention of skin breakdown.9 In a prospective.12 See Table 1 for albumin and prealbumin values that put patients at risk. which will help when working with patients with pressure ulcers.2 to 1. however.15 Recommendations for treating pressure ulcers are usually 1. while the other group received a tube feeding that was 25% protein (1. controlled study of 672 critically ill patients aged 65 and older treated with high-protein nutrition supplements for 15 days. excessive vitamin E supplementation. One group received a tube feeding that was 16% protein (1. protein. Recommendations for treating pressure ulcers are usually 30 to 35 milliliters per kilogram or 1 milliliter per calorie.9 Remember to use adjusted body weight when determining the needs for an obese patient.9 • Vitamin A also enhances collagen formation. they are at increased risk. there was a reduction of pressure ulcer risk when compared with controls. More fluid may be needed if the patient has a fever or fluid loss from an open wound. Nutrition Intervention After assessing whether patients are at risk for developing a pressure ulcer or if they already have one. However. See Table 2 for a summary of recommendations. and weight.16 Vitamin A supplementation is warranted for wound healing that has been delayed by vitamin A deficiency.

Albumin has a longer half-life than prealbumin and therefore won’t be as good an indicator of the patient’s current nutritional status. Since this population is growing. or team meetings that the patient has poor intake. such as for patients with diabetes or kidney disease. the recommended amount of protein for healing pressure ulcers. Oral supplementation of 17 to 24.• Zinc is required for collagen formation and protein synthesis. There are a variety of supplements to choose from.5 grams per deciliter. They support muscle synthesis and help maintain a healthy immune RD. The sooner the intervention. ranging from 240 to 360 calories and 8 to 14 grams of protein per 8ounce serving. Nutrition supplements help increase the patient’s caloric. National Pressure Ulcer Advisory Panel. 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.2:24-28. 1989. National Pressure Ulcer Advisory Staging Report. Pressure ulcer prevalence. Therefore.5 million. Since the dietitian can’t be with the patient at all meals. Accessed September 5.8 grams free arginine per day has been shown to affect wound healing. . Decubitus.19 • Arginine and glutamine are helpful in healing pressure ulcers. a supplement can be chosen based on the patient’s specific medical condition. Some of these formulas are also rich in vitamin C and zinc. She recently served on the New York University Skin Care Committee and lectured to several hospitals on wound care. the medical team must take an active role in assessing patients at risk for developing a pressure ulcer. Semielemental feeds are recommended in patients with albumin <2. In addition. he or she should eat small. 2003. full liquid. calorie counts.9 Improvement in wound healing with zinc supplementation has not been shown in patients who were not zinc-deficient. The older population (aged 65 or older) comprised approximately 13% of the U. or 20% of the population. which is 66 to 110 milligrams zinc sulfate. 2. The doctor may also want to prescribe an appetite stimulant. the better the outcome. Available at: http://www. If it is observed through meal rounds. MS.S. Some formulas also contain arginine and glutamine. as well as fortified with arginine. patients must be monitored to assess whether their plan of care is being followed and to see whether the pressure ulcer is healing. so zinc should be taken for 10 days and then the wound should be reassessed.22 Nutrition plays a critical role in the prevention and management of pressure ulcers.npuap. There are tube-feeding formulas available that provide 20% to 25% of protein calories.9 Follow-Up Care After the initial nutrition intervention is completed.html.57 grams per kilogram. References 1.23 Older adults experience an increased incidence of pressure ulcers. 2004. is the clinical nutrition coordinator for the program for surgical weight loss at Mount Sinai in New York City. protein.18.17. — Amy Fleishman. and fluid intake. The supplements are available in clear liquid. cost and risk assessment: Consensus Development Conference statement. as well as being disease-specific. The safe maximum supplementation for glutamine is 0. A red flag is raised if patients eat less than 50% of their food over three days when compared with their usual eating patterns. Communication between all members of the medical team can provide invaluable information. long-term excessive use of zinc supplementation can induce a copper deficiency. frequent meals to consume an adequate amount of calories. pudding.21 Arginine supplementation appears to benefit wound healing even if the patient is not deficient. meal rounds and calorie counts are essential. by 2030. population in 2003 and is expected to more than double in number to 71. Tube feeding and/or total parenteral nutrition may be necessary if the patient is not consuming enough food and/or supplements. CDN. Weekly weights and prealbumin should be checked to monitor the patient’s nutritional status. and powder form.20.

Fourth national pressure ulcer prevalence survey. Available at: http://www. Olson B. Wochos DN. Rothe MJ. Rackett SC. Position of the American Dietetic Association: Liberalized diets for older adults in long-term care. Regan MC. 1990. N Engl J Med. Schiller D.44:1435-1440. Eur J Clin Invest.320:850-853. 1993. Accessed September 26. Efron DDT. 10. extended care home health. J Am Geriatr Soc. 13. 19. The role of dietary manipulation in the prevention and treatment of cutaneous disorders.10:18-26. rehabilitation. Effects of exogenous zinc supplementation on intestinal epithelial repair in vitro.36:1046-1059. Kohn S. Allman RM. Arginine stimulates wound healing and immune function in elderly human beings. J Am Acad Dermatol. surgical patients. 1989. Beckrich K.pdf. Sandstead HH. Anderson CF. The utility of serum albumin values in the nutritional assessment of hospitalized patients. J Am Diet Assoc. Jung S. Zinc nutriture in the elderly in relation to taste acuity. 1999. Cario E. 18. Barnett RI. Tarquine PH. 1986. . Allman R.15:817-821. Diet and dermatology.114:155-160. Lipschitz DA. 15. Childs EJ.16:1-5. J Dermatol. Bourdel-Marchasson I. Bosley LM. 14. Improving outcome of pressure ulcers with nutritional interventions: A review of the evidence. 2004.2:42. 1990. Grant-Kels JM. 17. Nutrition and adult wound healing. Hunt TK. Available at: http://www. Lazarou SA.57:181-184. 1982. 4. Decubitus. Pressure ulcers among the elderly. 2002. Henriksen LK. Braden Scale for Predicting Pressure Ulcer Risk. Thomas DR.17:263-271. Thomas DR. 2000.bradenscale. Hunter S. 7. J Am Diet Assoc. 2001. Barbul A. Mayo Clin Proc. Kohn D. Nursing Economics. Barczak CA. Rondeau V. 2000. The effect of a very high-protein liquid formula on decubitus ulcer healing in long-term tube-fed institutionalized patients. 11. Effect of zinc supplementation on epidermal Langerhans’ cells of elderly patients with decubital ulcers.27:258-263.102:1316-1323.3. 2000. 6. Hurson M. et al. et al. Nutrition.108:331-337. 1982. Surgery. Accessed September 6. Hospital-aquired pressure ulcers: A comparison of costs in medical vs. J Am Acad Dermatol. 16. Langemo DK. Thompson CW. 2001. Barateau M. 2004. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. Vitamin A and wound healing. 1993. et al. Hospital acquired pressure ulcers and risk of death. 2003. and hospice in one locale. Am J Clin Nutr. Nutrition. Greger JL. 1989. Chernoff RS. Milton KY. 1997. Kirk SJ. 12. 8. et al. Harder D’Heureuse J. 21. 1996. Goode PS. Arginine enhances wound healing and lymphocyte immune responses in humans. Aronovitch SA. et al.nutritioncare.90:A130-A139. The incidence of pressure sores in acute et al. 9. Adv Wound Care. immune response.29:447-461. and wound healing. 20. 5.

.: Administration on Aging. D. geriatric patients. Bell SJ. 1992.C. Washington.174:181-188. A Profile of Older Americans: 2003. Borlase BC. et al. Lewis EJ. 2003. Accessed September 18. Available at: http://www. Surg Gynecol Obstet. 2004.pdf. Tolerance to enteral tube feeding diets in hypoalbuminemic critically ill.aoa.