The treatment of pressure ulcers involves a number of strategies includes both extrinsic and intrinsic factors. The extrinsic factors reduces the pressure duration at the skin surface by various measures such as repositioning, pressure-relieving cushions or mattresses. In intrinsic factors, the optimum tissue environment for wound healing by optimum hydration, circulation and nutrition. According to (Soriano et al. 2004) nutrition is very important for prevention and treatment of pressure ulcers. Nutrition assessment techniques and nutritional interventions are essential components of quality patient care for patients at risk for developing a pressure ulcer or who currently have pressure ulcers. It also discusses the importance of major nutrient factors and the inter-relationships in preventing and treating pressure ulcers. This essay focuses on the best practice in the management of nutrition for the prevention and treatment of pressure ulcers.
Accurate and reliable pressure ulcers diagnosis and classification are an important issue in nursing practice. According to (Dealy,p.13-16,2005) pressure ulcer is an area of skin damage appearing after some prolonged period of insufficient blood flow and it leads to both prolonged hospital stay and higher costs for the healthcare system. Pressure is the most important factor in the development of pressure ulcers especially with patients who are critically ill ,immobile and unable to change position. Although it is a complex phenomenon, and usually multidimensional with pressure, shear, friction, moisture and poor nutrition, contributing directly to the development of pressure ulcers(Hampton and Collins,p.211-215, 2004 )
Nutrition plays an important role in pressure ulcer prevention and treatment in patients at risk for developing a pressure ulcer or who currently have pressure ulcers are essential components of quality patient care. Nutrition includes adequate hydration preventing and healing the pressure ulcer and is critical in maintaining tissue integrity(Thomas,2001). On the contrary, inadequate nutrition, low body mass index (BMI), low serum albumin level, insufficient activity and poor food intake are the risk factors for pressure ulcers development(Sayar,2008). Thus, nurses and dietitians should ensure that the patient's dietary intake contains adequate nutrients to maintain or improve the patient's nutritional status, prevent pressure ulcer formation, to promote healing of pressure ulcers that should be included in the patient's care plan.
In the assessment of nutritional status it is essential to determine the comprehensive and appropriate nutritional care plan, in the identification of specific objectives such as increasing weight or fluid intake(Desneves et al.2005). Nurses are often the first clinicians to screen the nutritional status of a patient upon admission so as to be a vital link to the dietitian or physician by communicating those patients at nutritional risk(PUPPI,2007). As far as concerned with the clinical assessment which consists of a routine medical history, social history and physical examination to detect signs and symptoms associated with malnutrition and vitamin or mineral deficiencies. The most apparent signs and symptoms in malnutrition are the muscle and adipose wasting, but if several of these appears the likelihood of malnutrition is high(Samuriwo,2010). There is no single measures completely reflects nutritional status, data from a patient's clinical assessment anthropometric, biochemical and dietary intake information which contribute to a complete assessment of nutritional status.
In the anthropometric assessment ,the patient should be assessed for significant, unintentional weight loss which leads the patient at risk for malnutrition and subsequently, pressure ulcer development(Anderson,2005). Therefore, it is essential that any recent weight changes that has to be communicated to the dietitian or physician. So the dietitian should take the main responsibility for assessing a patient's anthropometric measures, nevertheless the nurse provides valuable information about the patient's height, weight, and weight changes(Huckleberry,2004). In addition to these assessments, biochemical parameters are also included which may cause an increase or decrease in albumin level making it difficult to determine the patients nutritional status or current condition. Increased risk of skin breakdown and reduced wound healing caused by decreased calorie intake, dehydration and low serum albumin ,leads to decrease the tolerance of skin and underlying tissue to pressure, friction and shearing force(Ahmed and Haboubi 2010). In this situation the nurse plays an important role in screening the patient's biochemical parameters. In life threatening situations, nurses should obtain the orders for these parameters and notify the physician or dietitian of out-of-range laboratory values that may be related to nutritional status.
Assessment of nutritional parameters plays an important role in patient's plan of care. A nutritional screening, must be done in preventing complications especially in patients with or at high risk for pressure ulcers. The clinical guideline recommendations (AHCPR 1994) for nutritional assessment and management of pressure ulcers are:- ensure adequate dietary intake in order to prevent malnutrition as per individual wishes(Paquay et al.2008) If it is impractical or impossible the nutritional support should be introduced into positive nitrogen balance .As per the Nutrition Screening Initiative, in order to achieve a shortened nutritional assessment ,it has to be done for at least three months with those who are at high risk for malnutrition(Zulkowski,2003). The Malnutrition Universal Screening Tool (MUST) is one of the effective tools used to identify the risk of malnutrition among adults. It is very efficient and quicker than other screening measures which has a high prognostic validity in hospital atmosphere(Edmonds,2007). The Mini Nutritional Assessment (MNA) tool is also used in detection of nutritional failure in patients. The MNA provides nurses with a rapid, cost-effective screening tool for patients who requires more intense assessment of nutritional status by a specialized nutritionist(Stechmiller,2003).
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel emphasizes the role of nutrition in pressure ulcer healing with adequate calories, protein, fluids, vitamins and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown(Kottner,2009). However, adequate intake of one nutrient alone does not prevent pressure ulcers but sufficient calories with all other essential nutrients are required to facilitate pressure ulcer healing(Posthauer,2006). Considering nutrition as a risk factor, even though there is no known role for specific nutrients, it plays an essential role in the treatment of pressure ulcer as it is an important aspect of a complete care plan for prevention and treatment.
The main macro-and micronutrient plays an important role in the process of preventing pressure ulcer .In macronutrients there is a wide range of components are required like proteins, carbohydrates, fat and about 20 vitamin substances and 16 mineral and trace elements (fat soluble substances, such as vitamins A, D, E, and K) are included for the normal health functions. Calories are essential for supplying energy in the body. The goal is to prevent pressure ulcer development or to promote pressure ulcer healing by maintaining or increasing current weight by the nutritional intervention of adequate calories. An increased risk of pressure ulcers result in weight loss(Leininger,2002). The protein plays a significant role in immunonutrition which benefit in the inflammatory stages of wound healing. According to (Wild et al .2010) high protein of oral nutritional supplements can significantly decrease the risk of developing pressure ulcers. Furthermore, high protein nutritional supplements provide tissue growth ,cell renewal, and repair after injury. A decreased protein intake is associated with pressure ulcer development.
Carbohydrates are the standard source of energy for the body and helps to maintain the high metabolic activity required for regeneration. According to(Fraser,2007) skin cells are dependent on glucose for energy. These energy factors include structural lubricant, transport, immunologic, hormonal, and enzymatic functions. The two carbon compound plays an important role in wound healing effects. As glucose it is used for inflammatory cell activity leading to removal of bacteria and necrotic material(Shephered,2003). On the other hand, lactate acts as a metabolic byproduct. Lactate stimulates collagen synthesis by fibroblasts and is an important activator of the genetic expression of many healing pathways in addition to its role as an energy source(Collins,2003).High intake of carbohydrate may delay wound healing which leads the patient at risk for hyperglycemia(Creda et al.2009) Decreased level of carbohydrate intake leads to increased breakdown of protein rather than carbohydrate for energy needs. These fluctuations leads the patient to take a large amount of vitamin or mineral supplement at the time of pressure ulcer treatment(Carison,1999).
Vitamin A and C are important in the management of pressure ulcer. Vitamin A is a fat soluble vitamin and is important at the early inflammatory response, wound debridement and strengthens the scar tissue((Ferguson et al. 2000).. The deficiency of this vitamin increases the chances of wound infection because of the decrease in the development of collagen and granulation tissue. It influences the dermal growth by the inhabitation of collagenase and decreases collagen stability and prone to infection. It is usually recommended as a supplementation for those who are immunosuppressive(Kallman,2009). Vitamin C (ascorbic acid) is a water-soluble vitamin, a powerful reducing agent that contributes to metabolism of trace metals iron and calcium metabolism for epidermal gradients, and immune response. The deficiency of this could lead to a slower healing rate and increase the risk of pressure ulcer and is associated with collagen defects, defective fibroblast responses, and abnormal scar tissue formation(Nazarko,2002).
Vitamin E interacts metabolically with selenium in controlling the metabolism of unsaturated fatty acids required for energy production in the human body .The role of vitamin E in human wounds inhibits the peroxidation of fatty acids and promote the expression of a vascular endothelial growth facts to repair in the treatment of pressure ulcer and involved in collagenesis, immune responsiveness and graft rejection(Collins et al.2005) Vitamin K has a special importance in haemostasis with vitamin-deficient patients becoming susceptible to haemorrhages, impaired wound repair, and infection. The role of vitamin E is the production of prothrombin and the clotting factors VII, IX and X. Thus it is significant in the haemostatic phase of wound healing and in the release of growth factors(Gray and Cooper 2001).
Vitamin D is a group of fat-soluble prohormones obtained from sunlight and involved in calcium metabolism by inhibiting secretion of calcitonin and parathyroid hormone. Vitamin E is a fat-soluble vitamin serves as an antioxidant by interacting with selenium-dependent glutathione oxidase to inhibit degradation of cell membrane fatty acids(Barrett et al.2010). Low levels of vitamin E have been reported in chronic wound patients. In such cases ischemia, necrotic tissue, and microbial flora trigger inflammatory cascades that enhance free radical formation. Arginine has an important position in cellular functions and interactions that occurs during inflammation and immune responses. It is also a main amino acid essential for collagen deposition and wound healing(Stechmiller et al.2005) Glutamine act as an indirect role in wound healing and it is known to act as a source of fuel for rapidly dividing cells such as fibroblasts. It attenuate immunosuppression and improve nitrogen balance after elective surgery.
The role of zinc supplementation encourage healing of pressure ulcer that of vitamin C and is a trace element present in the body . Zinc plays a key role in protein and collagen synthesis, wound healing, immunity and tissue growth. A reduced epithelialization and cellular proliferation occurs during the zinc deficit and decreases the possibility of wound healing(Langemo et al.2006).The inflammatory process results in hypoalbuminaemia because of the lower serum zinc concentration. The body's total mineral content is 99% of calcium, is a cofactor and regulator in soft tissues and skin. Calcium gradients in the epidermis regulate basal cell proliferation. An increased calcium occurs after skin injury that is sustained into the normalization phase of wound healing. These ions in wound exudates contribute to hemostasis (Berger et al.2007). Iron is a co-factor required for the synthesis of collagen and resistance of infection. It emphasizes the importance of wound healing, particularly in the proliferative and remodeling phases. Copper assists in the formation of red blood cells, and it joins with vitamin C to form elastin. The body's copper needs can be met with a balanced diet and a daily multivitamin/mineral supplement (Oppenheimer,2001).
Fluid is an another fundamental nutrient for the normal functioning of cells. Dehydration and electrolyte imbalance occurs through the fluid loss from the wound drainage of a pressure ulcer (McIlwaine,2003). As a result, there is reduced blood volume which causes decreased peripheral circulation, nutrient and oxygen supply to tissues. Dehydration leads to delay in wound healing as a result of epidermal hardening and dermal necrosis. Pressure ulcer patients are more susceptible to develop problems with fluid and electrolyte regulation due to physiological renal impairment and changes in thirst perception. Water balance regulation is crucial for optimal healing(Brown and Philips 2010). It is a cytoplasmic component that provides a medium for enzymatic repair processes. Hydration promotes cell proliferation and migration created by metal ions (eg, zinc and calcium), cytokines, and growth factors. The impaired fluid and electrolyte balance leading to reduced glomerular filtration rate, decreased ability to concentrate urine, less efficient sodium-conserving capacity, inability to excrete water load and altered thirst sensation(Lansdown,2004). The dietitian has the responsibility to settle on the patient's fluid needs based up on the current condition.
In conclusion, assessing, planning, monitoring and evaluating the nutritional needs of patients is a fundamental aspect in the holistic care of patients with pressure ulcer. Pressure ulcer prevention and treatment must include all aspects of patient care especially nutritional intervention. Nutrition plays an essential role in the prevention and treatment of pressure ulcer. Monitoring dietary habits, weight, food and fluid intake and output, and blood levels on an ongoing basis is important for prevention of pressure ulcer complications. Nurses must be more aware and involved in the patients nutritional status for the early intervention and the assessment of nutritional screening tool for the notification of the dietitian.
