A pressure sore/pressure ulcer/decubitis ulcer is an injury to the skin and underlying tissue. This happens when the oxygen and nutrient flow to that area of the skin is cut off, leaving the tissue to die. Sitting or lying in a hospital bed for a long time is a common cause of the formation of pressure ulcers. In fact, data from the National Nursing Home Survey in 2004 (Park-Lee) published by the CDC in 2009 found that the prevalence of pressure ulcers was 11% of the 159,000 nursing home residents surveyed.
Pressure ulcers are found in different stages, based on the layers of tissue affected. Stage 2 ulcers are the most common, according to the above survey. The NPUAP (National Pressure Ulcer Advisory Panel) has come up with 6 different stages/categories of pressure ulcers. The follow descriptions were found in the Academy of Nutrition and Dietetics Nutrition Care Manual.
- Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
- Stage I:Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
- Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
- Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
- Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
- Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed.
When I read through patients’ charts, there is a section where I see a score from the Braden Scale. The Braden Scale is a tool used to determine, upon a patient’s admittance to the hospital, their risk of developing a pressure ulcer. The Braden Scale takes into account:
- Sensory Perception– Ability to respond meaningfully to pressure-related discomfort. Does the patient have a limited ability to voice pain or discomfort or any sensory impairment?
- Moisture — Degree to which skin is exposed to moisture. Is the patient’s skin usually dry, or is there dampness detected on the sheets every time the patient is turned?
- Activity — Degree of physical activity. Does the patient take frequent walks, or is the patient confined to their bed?
- Mobility — Ability to change and control body position. Is the patient able to move themselves independently without assistance, or is the patient completely immobile?
- Nutrition — Usual food intake pattern. Does the patient eat all their meals, 4+ servings of protein per day, or does the patient rarely eat more than 1/3 of the food offered to them?
- Friction & Shear — Does the patient have sufficient muscle strength to lift completely up during a move, or does the patient slide against the sheets or slide down in their chair and need assistance?
Each of these 6 criteria is assessed and given a point value of 1-4. All of these points, added up, equal that patient’s Braden score. A score of 15-18 indicates a mild risk for a pressure ulcer, 13-14 indicates moderate risk, 10-12 indicates a high risk, and a score of 9 or less indicates a severe risk for developing a pressure ulcer.
Click here to see a PDF form used to assess pressure ulcer risk: Braden_Scale
Nutrition is a key component in the treatment of pressure ulcers. Here are some things to consider:
Goals of the Registered Dietitian & Support Team:
Facilitate wound healing
Decrease risk of infection
Maintain or replete nutrient stores
- Increase individual’s knowledge of food and nutrition intake needed for wound healing.
- Increase individual’s awareness of the risk factors associated with pressure ulcer development.
- Increase individual’s knowledge of dangers associated with over-supplementation of nutrients, especially zinc.
- Maintain adequate nutritional status by providing optimum dietary and fluid intake (Provide adequate energy to maintain or regain any lost weight, and provide adequate protein for positive nitrogen balance and to spare energy).
- Identify and treat causes of poor nutritional intake.
- Monitor weight status routinely to detect unexpected or unintentional weight loss.
- Select nutrition interventions to improve or maintain nutritional status.
- Patients should receive adequate nutrient and fluid intake to maximize potential for wound healing
- Recommended that patients receive 30-50 kcal per kg body weight per day
- Recommended that patients receive 1.2-1.8 g protein per kg body weight per day
- Fluid requirements may differ based on what each facility uses, but 30 mL per kg body weight can be used.
- Patients may also want to meet the RDI of vitamins A, C, and E; the mineral zinc; amino acids arginine and glutamine; and the compound beta-hydroxy-beta methylbutyrate (HMB). These nutrients play an essential role in tissue regeneration and maintaining the health and function of the skin. If patients are suspected or confirmed to have nutritional deficiencies, a multivitamin including the RDIs of these nutrients may be beneficial. However, if a patient is not deficient there is no evidence to suggest a supplement will aid in wound healing. Additionally, further research is needed to make any firm conclusions on the benefit of amino acids arganine and glutamine, and HMB in the area of pressure ulcer treatment.
- High doses of zinc should be avoided; tolerable upper intake level is 40mg/day. While zinc does assist in wound healing, high-dose zinc supplementation can adversely affect copper status (copper is an enzyme co-factor for collagen cross-linking) and immune response and may cause gastrointestinal side effects. There is no need to supplement with zinc unless a patient is zinc deficient.
A 63 year old female, 5’1″ and 140 lbs has a pressure ulcer. What are her kcal, protein, and fluid requirements?
- 140 lbs = 63.63 kg
- kcals = 35kcal/kg x 63.63kg = 2227 kcal/day (female & old, so on the lower calorie range)
- protein needs = 1.2g/kg x 63.63kg = 76g protein per day
- OR = 1.8g/kg x 63.63kg = 114g protein per day
- Fluid requirements: 30mL/kg x 63.63kg = 1908.9 mL, or 1910 mL fluid (8 cups)
Nutrition Monitoring & Evaluation:
- The Monitoring and evaluation of patients individualized according to the patient’s nutritional diagnosis. However, areas that are most relevant to pressure ulcer risk or treatment include:
- Laboratory tests (N-balance, electrolytes, glucose)
- Nutrient intake, quantity and quality (oral, enteral, parenteral)
- Wound stage/healing
- Hydration status (I&Os, BUN/Creatinine ratio, Hct)
- Follow a well-balanced diet with foods from each food group
- Make sure to eat foods high in protein with each meal (breakfast, lunch, dinner)
- Keep drinking fluids
|Food Groups||Recommended Foods|
|Meat and Other Protein Foods (2-3 servings)||Beef, veal, pork, lamb, poultry, fish and seafood, eggs and egg products, tofu, dried beans, peanut butter|
|Milk and Milk Products (2-3 servings)||Whole, reduced-fat, low-fat, nonfat: milk, buttermilk, cheese, yogurt|
|Grains (6 – 11 servings)||Bread, pasta, cereal (hot or cold), cornmeal, crackers, pretzels, rice|
|Fruit and Vegetables (5-6 servings)||All|
|Fats and oils||Oils, margarine, mayonnaise, cream cheese, salad dressings|
|Beverages||Fruit juices, decaffeinated coffee, and tea|