Nutrition Guidelines for Pressure Ulcer Management

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Nutrition Guidelines for Pressure Ulcer Management

  1. 1. Nutrition Guidelines for Pressure Ulcer Management 1/4/07
  2. 2. Braden > 18 No Pressure Ulcer or Non-Healing Wound <ul><li>Monitor intake and weight </li></ul><ul><li>Consult dietitian if: </li></ul><ul><ul><li>Usual criteria on Admission Database </li></ul></ul><ul><ul><ul><li>Intake consistently less than 75% </li></ul></ul></ul><ul><ul><ul><li>Nausea, vomiting, diarrhea </li></ul></ul></ul><ul><ul><ul><li>Metabolically stressed state - trauma, fever </li></ul></ul></ul><ul><ul><ul><li>Significant weight loss (non fluid related): </li></ul></ul></ul><ul><ul><ul><ul><li>1% in 1 week </li></ul></ul></ul></ul><ul><ul><ul><ul><li>5% in 1 month </li></ul></ul></ul></ul><ul><ul><ul><ul><li>7.5% in 3 months </li></ul></ul></ul></ul><ul><ul><ul><ul><li>10% in 6 months </li></ul></ul></ul></ul>
  3. 3. Recommended RD Actions Braden > 18 without Pressure Ulcer with ↓ appetite, weight loss,  n eeds,  loss via V & D <ul><li>Complete nutrition assessment </li></ul><ul><li>Based on findings: </li></ul><ul><ul><ul><li>Request pre-albumin </li></ul></ul></ul><ul><ul><ul><li>Add oral supplements </li></ul></ul></ul><ul><ul><ul><li>Add between meal snacks </li></ul></ul></ul><ul><ul><ul><li>Assistance, reminders, encouragement at mealtime </li></ul></ul></ul><ul><ul><ul><li>3 Day Calorie Count </li></ul></ul></ul><ul><ul><ul><li>Based on response to above consider: </li></ul></ul></ul><ul><ul><ul><li>Tube feeding </li></ul></ul></ul><ul><ul><ul><li>Parenteral nutrition </li></ul></ul></ul>
  4. 4. Braden < 18 Without Pressure Ulcer/Non Healing Wound With adequate nutrition intake <ul><li>Nutrition Goals: </li></ul><ul><li>Maintain current intake of nutrition </li></ul><ul><li>Achieve and maintain desirable weight </li></ul><ul><li>Routine Follow Up: </li></ul><ul><ul><li>Visual assessment of skin </li></ul></ul><ul><ul><ul><li>Back of head </li></ul></ul></ul><ul><ul><ul><li>Elbows </li></ul></ul></ul><ul><ul><ul><li>Heals </li></ul></ul></ul><ul><ul><ul><li>Back side </li></ul></ul></ul><ul><ul><li>Assessment of: </li></ul></ul><ul><ul><ul><li>Weight </li></ul></ul></ul><ul><ul><ul><li>Intake </li></ul></ul></ul><ul><ul><ul><li>Pre-albumin </li></ul></ul></ul><ul><ul><ul><li>Changes in condition </li></ul></ul></ul>
  5. 5. Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss <ul><li>Nutrition Goal: </li></ul><ul><ul><li>Protein: 1.2g pro/kg/d </li></ul></ul><ul><ul><li>Calories: 25 – 30 kcals/kg/d </li></ul></ul><ul><ul><li>29 – 33 kcals/kg/d Para </li></ul></ul><ul><ul><li>24 – 27 kcals/kg/d Quad </li></ul></ul><ul><ul><li>Use ABW subtract 5 – 10 kcals/kg/d for Obesity </li></ul></ul><ul><ul><li>Fluid: </li></ul></ul><ul><ul><ul><li>30 ml/kg; min of 1500 ml/d unless contraindicated </li></ul></ul></ul><ul><ul><ul><li>SCI: 35 ml/kg; min 2500 ml/d unless contraindicated </li></ul></ul></ul><ul><ul><ul><li>Add 10 – 15 ml/kg for air fluidized beds </li></ul></ul></ul>
  6. 6. Recommended RD Actions Continued Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss <ul><li>Complete nutrition assessment </li></ul><ul><li>First meet fluid needs </li></ul><ul><li>Supplement with whey protein powder or use whey based tube feeding </li></ul><ul><ul><li>e.g.Propass 6 gm/pkt </li></ul></ul><ul><li>If BMI < 20 change diet to high cal/high protein </li></ul><ul><li>Add therapeutic multi-vit/min supplement </li></ul>
  7. 7. Recommended RD Actions Cont Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss <ul><li>Follow up weekly: </li></ul><ul><ul><li>Visual assessment </li></ul></ul><ul><ul><li>Assessment of wt, intake, pre-albumin, medical condition </li></ul></ul><ul><ul><li>Correct source of poor intake if able </li></ul></ul><ul><ul><ul><li>Food preferences </li></ul></ul></ul><ul><ul><ul><li>Constipation </li></ul></ul></ul><ul><ul><ul><li>Illness depression </li></ul></ul></ul><ul><ul><ul><li>Pain </li></ul></ul></ul><ul><ul><ul><li>Medication causing poor appetite </li></ul></ul></ul><ul><ul><li>Consider glutamine: 10 g/d </li></ul></ul><ul><ul><li>Evaluate need for anabolic agent and/or nutrition support </li></ul></ul>
  8. 8. Stage 1 & 2 Pressure Ulcers Without: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 or PAB < 15 <ul><li>Nutrition Goal: </li></ul><ul><li>Protein: 1.2 – 1.5g pro/kg/d </li></ul><ul><li>Calories: </li></ul><ul><li>25 – 30 kcal/kg/d </li></ul><ul><li>29 - 33 kcals/kg/d Para </li></ul><ul><li>24 - 27 kcals/kg/d Quad </li></ul><ul><li>Use ABW & subtract 5-10 kcals/kg/d for obese </li></ul><ul><li>Fluid: </li></ul><ul><ul><ul><li>30 ml/kg; min of 1500 ml/d unless contraindicated </li></ul></ul></ul><ul><ul><ul><li>SCI: 35 ml/kg; min 2500 ml/d unless contraindicated </li></ul></ul></ul><ul><ul><ul><li>Add 10 – 15 ml/kg for air fluidized beds </li></ul></ul></ul><ul><ul><ul><ul><li>(Matrix Matress Replacement or Kinair) </li></ul></ul></ul></ul>
  9. 9. Recommended RD Actions: Stage 1 & 2 Pressure Ulcers : Without: H eavy exudate, VAC therapy, poor appetite, diarrhea, wt loss, Alb < 3.5 or PAB < 15 <ul><li>Complete nutrition assessment </li></ul><ul><li>First meet fluid needs </li></ul><ul><li>10 – 15 gm/d whey protein </li></ul><ul><li>7 – 15 gm/d arginine </li></ul><ul><li>Therapeutic multi vitamin min supplement </li></ul><ul><li>25 mg zinc along with 2 mg of Cu for 2 weeks or less </li></ul><ul><li>Follow up weekly </li></ul>
  10. 10. Stage 1 & 2 Pressure Ulcers With : heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 and/or PAB < 15 <ul><li>Nutrition Goal: </li></ul><ul><li>Protein: 1.5 – 2.5 gm pro/kg/d </li></ul><ul><li>Calories: 30 – 35 kcal/kg/d </li></ul><ul><li>33 - 35 kcals/kg/d Para </li></ul><ul><li>27 - 30 kcals/kg/d Quad </li></ul><ul><li>Use ABW & subtract 5-10 kcals/kg/d for obese </li></ul><ul><li>Fluid: </li></ul><ul><li>35 ml/kg; min of 2000 ml/d unless contraindicated </li></ul><ul><li>SCI: 35 ml/kg; min 2500 ml/d unless contraindicated </li></ul><ul><li>Add 10 – 15 ml/kg for air fluidized beds (Matrix Mattress or Kinair bed) </li></ul>
  11. 11. Recommended RD Actions: Stage 1 & 2 Pressure Ulcers With : heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 and/or PAB < 15 <ul><li>Complete Nutrition Assessment </li></ul><ul><li>First meet fluid needs </li></ul><ul><li>10 – 15 gm/d whey protein </li></ul><ul><li>10 – 20 gm/d arginine </li></ul><ul><li>Therapeutic multi vitamin min supplement </li></ul><ul><li>25 mg zinc along with 2 mg of Cu daily for 4-6 weeks or less </li></ul><ul><li>Check Oxandrolone guidelines for appropriateness if weight loss and skin breakdown present (See Oxandrolone guidelines) </li></ul><ul><li>If Tube Fed, use peptide based formula; avoid formulas high in simple CHO </li></ul><ul><li>Follow up at moderate to high risk (1-2 times/wk) </li></ul>
  12. 12. Stage 3 & 4 Pressure Ulcer Non Healing Wound <ul><li>Nutrition Goal </li></ul><ul><li>Protein: 1.5 – 2.0 gm/pro/kg/d </li></ul><ul><li>Calories: 30 - 35 kcals/kg/d </li></ul><ul><li>(35 – 40 if heavy exudate) </li></ul><ul><li>33-35 kcals/kg/d para </li></ul><ul><li>27 – 30 kcals/kg/d quad </li></ul><ul><li>Fluid: </li></ul><ul><ul><li>35 ml/kg; min of 2000 ml/day unless contraindicated </li></ul></ul><ul><ul><li>SCI: 35-40 ml/kg ; min 2500-3000 ml/d unless contraindicated </li></ul></ul><ul><li>Add 10 – 15 ml/kg for air fluidized beds </li></ul><ul><li>(Matrix Mattress or Kinair bed apply) </li></ul>
  13. 13. Recommended RD Actions: Stage 3 & 4 Pressure Ulcer/Non Healing Wound <ul><li>Complete Nutrition Assessment </li></ul><ul><li>First meet fluid needs </li></ul><ul><li>10 – 15 gm/d whey protein </li></ul><ul><li>10 – 20 gm/d arginine </li></ul><ul><li>Therapeutic multi vitamin min supplement </li></ul><ul><li>25 mg zinc along with 2 mg of Cu daily for 4-6 weeks </li></ul><ul><li>Check Oxandrolone guidelines for appropriateness if weight loss and skin breakdown present (See Oxandrolone guidelines) </li></ul><ul><li>If Tube Fed, use peptide based formula; with MCTs; avoid formulas high in simple CHO </li></ul><ul><li>RD follow at moderate to high risk (1- 3 times/wk) </li></ul>
  14. 14. Oxandrolone Action: amino acids driven into protein synthesis pathway; catabolic activity is decreased <ul><li>Actions/Benefits </li></ul><ul><ul><li>Relative low cost </li></ul></ul><ul><ul><li>Anti catabolic </li></ul></ul><ul><ul><li>Increased protein synthesis </li></ul></ul><ul><ul><li>Marked return of lean mass in conjunction with optimum nutrition vs nutrition alone </li></ul></ul><ul><ul><li>Wt gain approximately 75% lean body tissue </li></ul></ul><ul><ul><li>Acts on cell androgenic receptors </li></ul></ul><ul><ul><li>Cleared by kidneys, avoiding hepatotoxicity </li></ul></ul><ul><ul><li>Anabolic effect is dose dependent </li></ul></ul><ul><ul><li>Well tolerated for long-term use </li></ul></ul><ul><li>Contraindications/Side Effects </li></ul><ul><ul><li>Stimulation of androgen-sensitive tumors, mainly prostate CA </li></ul></ul><ul><ul><li>Known liver disease or LFTs greater than twice the upper limit of normal </li></ul></ul><ul><ul><li>Oral anticoagulation therapy e.g. warfarin </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Breast Cancer (male or female; hypercalcemic type) </li></ul></ul><ul><ul><li>Prostate CA </li></ul></ul><ul><ul><li>Nephrosis </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Uncontrolled diabetes </li></ul></ul>
  15. 15. Dosing of Oxandrolone <ul><li>Usual Dose: 10 mg twice daily </li></ul><ul><li>Renal insufficiency: 5 mg twice daily </li></ul><ul><li>Strive for adequate protein intake first </li></ul>
  16. 16. Conditionally Essential Amino Acids <ul><li>Arginine: </li></ul><ul><ul><li>Wound Healing (via IGF 1) </li></ul></ul><ul><ul><li>Required for collagen synthesis (precursor to polyamines) </li></ul></ul><ul><ul><li>Increased in collagen deposition in wound bed with 15g of arg/d </li></ul></ul><ul><ul><li>Average dietary intake 7.5g arg/day </li></ul></ul><ul><ul><li>Increased blood flow </li></ul></ul><ul><ul><ul><li>Nitric Oxide Pathway </li></ul></ul></ul><ul><ul><ul><li>NO levels decreased in DM </li></ul></ul></ul><ul><li>Glutamine: </li></ul><ul><ul><li>Nitrogen Shuttle </li></ul></ul><ul><ul><ul><li>Regulates protein turnover </li></ul></ul></ul><ul><ul><li>Stores depleted at 10 – 15% loss of lean body mass </li></ul></ul><ul><ul><li>Immunity </li></ul></ul><ul><ul><ul><li>Preferred fuel source for lymphocytes & enterocytes </li></ul></ul></ul><ul><ul><ul><li>N-Acetyl Cysteine + Glutamine = Glutathione which leads to decreased oxidative stress </li></ul></ul></ul><ul><ul><li>GI Function & Immunity </li></ul></ul><ul><ul><ul><li>Restores gut integrity & brush boarder which improves absorption & appetite (20 g gln/d) </li></ul></ul></ul><ul><ul><ul><li>Precursor for nucleotides </li></ul></ul></ul><ul><ul><li>Helps maintain </li></ul></ul><ul><ul><ul><li>Acid base balance </li></ul></ul></ul><ul><ul><ul><li>Ammonia production </li></ul></ul></ul>
  17. 17. Conclusions: <ul><li>These recommendations are from best practice organizations and the dietetics profession. </li></ul><ul><li>Several have not been tried here at HCMC and are worthy of trial. </li></ul><ul><li>Our challenge is to implement these guidelines and evaluate effectiveness in the population at HCMC. </li></ul>

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