Question

Mrs. Ramona Garcia, a 76-year-old female, is admitted to a medical respiratory unit with pneumonia after 4 days of difficulty breathing, fever, and a productive cough with purulent sputum. She reports that she has been sleeping sitting upright in a chair for the past week because it was too difficult to breathe lying down. When Mrs. Garcia’s breathing is comfortable enough for her to be turned briefly for a full skin assessment, the nurse notes a 4-cm red area on the buttock over the left ischial tuberosity that does not blanch to pressure. Recognizing the reddened area as a stage I dermal ulcer likely related to the prolonged pressure from sitting, the nurse collaborates with the patient, family, and health team on a plan for prevention of further tissue breakdown, including frequent movement and positioning, adequate nutrition, hygiene for prevention of moisture collection from sweat or urine that might lead to skin maceration, and use of pressure-relieving devices.

Case Analysis

Mrs. Garcia has a serious medical problem that has kept her in a sitting position struggling for airflow over several days. Continuously sitting up to improve her air exchange has prevented her from relieving the pressure on her ischium, which she would normally have done by changing her position when she noticed discomfort. Poor perfusion from the near constant pressure on her ischium and a low capillary oxygen level from her respiratory illness have begun to cause damage at the tissue level. Mrs. Garcia’s nurse identifies a reddened area of skin that does not blanch to touch as a stage I dermal ulcer and realizes that any further injury to the area could result in deep tissue damage and an open wound. In order to promote tissue healing and prevent further injury, the nurse begins tissue integrity interventions promptly and recognizes that helping Mrs. Garcia maintain comfortable air exchange will encourage her to position herself off of the dermal ulcer.

Questions

1. What assessment findings would indicate that Mrs. Garcia’s dermal ulcer has progressed from stage 1 to stage 2?

2. When discussing the importance of adequate nutrition for Mrs. Garcia, which three nutrients would the nurse identify as most essential for her?

Answer 1

Bedsores also called as pressure ulcers or decubitus ulcers are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Pressure ulcers can progress in four stages based on the level of tissue damage. These stages help doctors determine the best course of treatment for a speedy recovery.

The above patient is having a stage I ulcer which is the mildest stage. It affects only superficial layer of skin and appears as a reddish discoloration on the skin that does not turn pale (blanches) when pressed firmly. The affected area may be sore to touch but has no surface breaks or tears. There may behave mild burning or itching too. And the texture and temperature of this developing sore will likely also be different from the surrounding normal tissues: firmer or softer, warmer or cooler.

Signs of progression of this pressure ulcer to stage II are

· Either skin breaks down broken creating a shallow, open wound. There may or may not be accompanying discharge of clear fluid or pus from the wound.

· Or appearance of a serum-filled (clear to yellowish fluid) blister that may or may not have burst.

· Skin of surrounding area may be swollen, warm, red and painful. This indicates some tissue death or damage.

· there is increase in degree of pain or discomfort from the ulcer.

Causes of pressure sores are pressure, friction and shearing forces.

Factors which increases risk of pressure sores are immobility, incontinence, lack of sensory perception (spinal cord injuries, neurological disorders), poor nutrition and hydration, medical conditions affecting blood flow like anaemia, diabetes, cardiovascular disorders, old age, malnourishment can increase the risk of tissue damage such as bedsores.

Both causative and predisposing factors need to be tackled for prevention and healing of pressure sores.

Consider the following guidelines related to diet for pressure-ulcer management

Incorporate them in discussing and planning diet with the patient.

Performing a nutrition screening for potential nutrition deficits - unintentional weight loss, changes in appetite or food and fluid intake, poor dental health, chewing and swallowing difficulties, poor self-feeding ability, gastro intestinal symptoms nausea, vomiting, diarrhoea can lead to nutritional deficits.

Identify malnutrition: look for presence of at least two of the conditions, if present it indicate the patient has malnutrition: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid retention that may mask weight loss, diminished functional (activity) status.

Nutritional requirement

Patients with pressure ulcers require sufficient calories and protein intake to support anabolism, nitrogen balance, collagen synthesis - the processes fundamental for wound healing.

1. Calorie requirement and macronutrients

Dietary carbohydrates and fat are the preferred energy sources because they spare protein for collagen production and cell structure. According to dietary reference intakes, adults should get 45% to 65% of calories from carbohydrates and 20% to 35% from fat. No recommendations exist for carbohydrate intake based on stage of pressure ulcers; however, hyperglycaemia is associated with impaired leukocyte production, which impedes wound healing and increases susceptibility to infection

There are no specific recommendations regarding intake of fat specific to patients with pressure ulcers, nor its role in wound healing has been established. However fats are dense energy source, provide essential fatty acids and help in absorption of fat-soluble vitamins.

Proteins are needed for cell regeneration, collagen production, fibroblast proliferation, and synthesis of enzymes involved in wound healing. Pressure-ulcer healing requires adequate protein; increased protein intake is associated with improved wound healing rates.

NPUAP/EPUAP/PPPIA guidelines recommend providing 1.25 to 1.5 g/kg/day of protein for adults who have, or are at risk, for pressure ulcers and malnutrition.

Patients with stage III/IV pressure ulcers or multiple wounds may need 1.5 to 2 g/kg/day.

Those with a protein intake as high as 2g/kg/day must be monitored for changes in renal function and hydration status.

Based on these recommendations’ patient is suggested for increased protein intake about 1.5 grams per kilogram body weight daily.

1. Hydration

Patients require adequate hydration to prevent and treat pressure ulcers. Sufficient fluid intake maintains skin turgor and delivery of oxygen and nutrients to both healthy and healing tissues. Current fluid intake recommendations are 30 mL/kg/day or 1 to 1.5 mL per calories consumed.

Hydration status should be carefully monitored because of high protein intake, fluid losses from breathing, sputum production, and wound, elevated temperature, sweating due to forceful breathing in this patient may increase fluid requirements, but at the same time need to be checked with respiratory diagnosis and restrictions imposed by it.

As patient is elderly, cognitive impairment if present may interfere with intake of water, so keep a reminder for taking water, and drinking water in reach of patient and maintain intake output chart.

2. Micronutrients

Micronutrients are vitamins, minerals, and trace elements that the body requires for cell metabolism in small but critical amounts. In particular, vitamins C and A and zinc play important roles in wound healing.

Vitamin C is crucial for collagen formation, angiogenesis, and fibroblast formation and wound healing. Patients with stage I or II pressure ulcers should receive 100 to 200 mg/day in vitamin C supplementation; those with stage III or IV ulcers should receive 1,000 to 2,000 mg/day.

Vitamin A stimulates the inflammatory phase of wound healing, maintains integrity of mucosal and epithelial surfaces, increases collagen formation. Patients with vitamin A deficiencies and pressure ulcers of any stage should receive 10,000 to 50,000 units/day for 10 days.

Zinc promotes cell replication and growth and aids protein and collagen synthesis. Supplements are recommended only for patients with zinc deficiency, which commonly accompanies malnutrition, malabsorption, diarrhoea, and hypermetabolic states.

Other factors to consider are repositioning in the patient in the bed/ chair and meticulous skin care.