MNT for Pressure Injuries Flashcards
What are other common names for a pressure injury?
-Pressure ulcer
-Decubitus ulcer
-Bed sore
Pressure injuries are localized damage to the skin and/or underlying tissue usually over a ___ ___, as a result of pressure or pressure in combination with shear and/or friction
Bony prominence
The tolerance of soft tissue for pressure and shear may also be affected by…
-Microclimate
-Nutrition
-Perfusion
-Comorbidities
-Condition of the soft tissue
Pressure injuries are among the most ____ conditions encountered in patients who are acutely hospitalized or in nursing homes
Common
It is estimated that there are ____ million pressure injury cases per year in the US
2.5
____ ulcers/injuries result from unrelieved pressure that occludes capillary blood flow, resulting in an inadequate supply of oxygen and nutrients to the epithelial and supportive tissue
Ischemic
Ischemic ulcers/injuries are usually located over ___ ___
Bony prominences
Common sites of ischemic ulcers/injuries:
-Sacrum
-Heels
-Hips
-Greater trochanters
-Ankles
-Elbow
-Shoulder
-Back of the head
-Inner knees
What are some primary risk factors for the development of pressure injuries?
-Unrelieved pressure over bony prominence
-Friction and shearing forces
-Moisture
-Immobility
What are some secondary risk factors for the development of pressure injuries?
-Malnutrition
-Body weight
-Fever
-Infection
-Anemia
-Vascular changes
-Neurological changes
-Decreased sensation
-Incontinence
-Iatrogenic factors (sedatives, restraints)
What two things occur as a body moves in a lateral plane?
-Frictional force between the skin and the surface
-Shear strain deep within the tissue
What are the stages of pressure injuries?
-Stage 1
-Stage 2
-Stage 3
-Stage 4
-Unstageable pressure injury
-Deep tissue pressure injury
What is a stage 1 pressure injury called?
Non-blanchable erythema of intact skin
Characteristics of a stage 1 pressure injury:
-Intact skin with non-blanchable redness of a localized area
-May be difficult to detect in those with darker skin tones
-Area may be painful and warm compared to adjacent tissue
What is a stage 2 pressure injury called?
Partial-thickness skin loss with exposed dermis
Characteristics of stage 2 pressure injury:
-Presents as a shallow, open ulcer with a red-pink wound bed without slough
-The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister
What is a stage 3 pressure injury called?
Full-thickness skin loss
Characteristics of a stage 3 pressure injury:
-Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
-Subcutaneous fat may be visible but bone, tendon, and muscle are not exposed
-Presents as a deep crater
-Slough (grey/yellow dead tissue that is full of bacteria) and/or eschar (black dead tissue that does not contain bacteria) may be visible
What is a stage 4 pressure injury called?
Full-thickness skin and tissue loss
Characteristics of a stage 4 pressure injury:
-Full-thickness skin loss with exposed muscle, tendon, ligaments, or bone
-Slough and eschar may be present
-Epibole, undermining, and tunneling often occur
-Can extend into muscle, tendons, and joint capsule
-Can result in osteomyelitis
An ____ pressure injury is full-thickness skin and tissue loss in which the actual depth of the ulcer and extent of the tissue damage is obscured by slough and/or eschar in wound bed
Unstageable
The true depth, and therefore stage, cannot be determined until the slough/eschar are removed, but will then either be a stage ___ or ___
3 or 4
A ___ ___ pressure injury is a persistent non-blanchable deep red, maroon, or purple discoloration due to intense and/or prolonged pressure and shear forces at the bone-muscle interface
Deep tissue
Complications from pressure injuries:
-Pain
-Infection: abscess, cellulitis, bacteremia, osteomyelitis
-Associated with decreased quality of life, prolonged hospital stay, increased health care costs, and increased mortality
____ is the goal with pressure injuries
Prevention
All patients should be ____ for pressure injury risk on admission to any health care agency and periodically reassessed
Screened
The Braden Scale for Predicting Pressure Sore Risk examines…
-Sensory perception
-Moisture
-Activity
-Mobility
-Nutrition status
-Friction/shear
A Braden Scale for Predicting Pressure Sore Risk score of___ or less indicates high risk for developing pressure injuries
12
For those determined to be at risk of pressure injuries, they should have a ____ skin assessment
Daily
The best way to prevent pressure injuries is to relieve ____
Pressure
To relieve pressure in a bed-bound person, they should be repositioned at least once every ____ hours
2
To relieve pressure in a chair-bound person, they should be repositioned every ____
Hour
People who are able should shift weight every…
15 minutes
What are some other ways to relieve pressure?
-Pressure-relieving mattress
-Pillows and foam wedges under or between bony prominences
-Increase activity/movement
Another way to prevent pressure injuries is to avoid friction and shearing by…
-Using lifting devices
-Maintaining HOB <30 degree angle (if appropriate with medical condition) for those on bed rest
What are some important ways to keep skin in good quality to avoid pressure injuries?
-Keep skin clean
-Avoid excessive moisture
-Avoid excessive dryness (using moisturizers as needed)
What are other methods to prevent pressure injuries?
-Bowel and bladder programs for incontinence
-Adequate hydration
-Maintain/replete nutrition stores
Treatment/management of pressure injuries:
-Interdisciplinary approach
-Improve tissue perfusion by eliminating pressure
-Wound cleansing and dressing
-Debridement of necrotic tissue
-Monitoring for and treatment of infections
-Operative repair: debridement, skin grafts
-Medical nutrition therapy
We can evaluate healing or lack of healing using the National Pressure Injury Advisory Panel’s ___ ____ ___ ___ ___
Pressure Ulcer Scale for Healing
Factors that interfere with wound healing:
-Malnutrition
-Infection
-Ischemia
-Smoking
-Disease/conditions: atherosclerosis, CHF, obesity, ischemia, immune deficiencies, diabetes, hyperglycemia
-Medications: immunosuppressant drugs, corticosteroids
____ is a risk for pressure injuries and inadequate calories, protein dehydration, and certain micronutrient deficiencies increase the risk of skin breakdown
Malnutrition
What should be included in the nutrition assessment for those with pressure injuries?
-Appetite
-Current weight and weight history (under- or overweight increases risk; unintentional weight loss)
-Adequacy of total nutrient intake: current and PTA
-Current medical status and PMHx
-Medications
-Functional status
-Ability to eat independently
-Chewing/swallowing
-GI status
-NFPE (muscle wasting, vitamin/mineral deficiencies, wound analysis-> number of injuries, staging and size, drainage)
What labs would give us an indication of someone’s hydration status?
-Serum Na
-BUN
-Osmolality
We should look at blood sugar because ____ can delay wound healing
Hyperglycemia
Wound healing requires energy for synthesis of…
-Collagen
-Cell metabolism
-Angiogenesis
____ impairs wound healing
Underfeeding
Energy requirements for someone with a pressure injury who is malnourished or at risk for malnutrition:
30-35 kcal/kg
We should individualize energy requirements based on what three things?
-Medical conditions
-Level of activity
-Intentional weight gain/loss
Sufficient protein is needed for…
-Cell synthesis
-Collagen and connective tissue formation
-Immune function
Protein can be lost in wound ___ and ____
Exudate and drainage
Protein ____ delays wound healing
Deficiency
The goal is to provide adequate protein for ____ nitrogen balance
Positive
We should provide ___-___ g/protein per kg for adults with pressure injury who are malnourished or at risk of malnutrition
1.25-1.5
Patients should consume ___-___ grams of high-quality protein at each meal to increase protein synthesis
25-30
____ is a conditionally essential amino acid during periods of acute metabolic stress and injury
Arginine
Arginine promotes the transport of ___ ____ into tissue cells
Amino acids
Arginine can enhance ___ ___ and ___ ___
Wound strength and collagen deposition
Arginine stimulates the release of what two things that improve wound healing?
-Growth hormone
-Insulin-like growth factor 1
Arginine may promote wound ____
Repair
Arginine may also improve ___ ___
Nitrogen balance
Arginine can also enhance ____ function
Immune
Clear and definitive ____ for arginine for safe and effective use have not yet been established
Guidelines
Adequate ____ intake is needed for good perfusion and oxygenation of healthy tissue and wounds
Fluid
We should monitor for signs of ____
Dehydration
What formulas are commonly used to determine fluid needs for someone with a pressure injury?
-30 mL/kg
-1 mL/kcal
We should provide additional fluid for those with…
-Heavily draining wounds
-Fever
-Dehydration
-Vomiting or diarrhea
High ____ intake may require additional fluids
Protein
Many ____ are necessary for optimal skin integrity and wound healing
Micronutrients
Exact micronutrient requirements for patients with ___ are unknown due to lack of conclusive studies
Wounds
Deficiencies in what 3 micronutrients can inhibit wound healing?
-Vitamin C
-Zinc
-Copper
We should encourage patients to eat a ____ diet to include good sources of vitamins and minerals
Balanced
We should provide/encourage vitamin and mineral supplementations only when dietary intake is ____ or ____ are confirmed or suspected
Inadequate; deficiencies
Vitamin C aids in ____ synthesis
Collagen
Vitamin C is also required for…
-Capillary formation
-Fibroblast formation
-Stimulation of neutrophil activity
Vitamin C deficiency has been associated with…
-Delayed wound healing
-Increased risk of wound infection and dehiscence
Since vitamin C is not readily stores in the body, deficiency can occur ____
Rapidly
Who is at risk for vitamin C deficiency?
-Individuals with alcoholism
-Elderly
-Severely injured individuals
-Smokers
-Individuals who eat no fruit and vegetables
In non-deficient individuals, vitamin C has not been proven to ____ wound healing
Enhance
If someone is deficient in vitamin C, they should receive…
-100 mg three times per day for 1 month
If someone is deficient in vitamin C and has renal failure, avoid supplementation over ____ mg/day due to the risk of renal oxalate stone formation
200
Zinc is required for…
-Protein and DNA synthesis
-Collagen synthesis
-Cell replication and growth
If someone has a zinc deficiency, they would have…
-Delayed wound healing
-Impaired immune function
There is a lack of studies showing significant benefit of zinc supplementation of pressure injury healing in the absence of zinc ____
Deficiency
What patients are at risk of zinc deficiency?
-Patients with diarrhea
-Patients with malabsoprtion
-Patients with metabolic stress
-The elderly
For zinc deficiency, the optimal supplemental dose is ____
Unknown
If clinical signs of zinc deficiency are present, provide…
25-40 mg/day of elemental zinc for 10 days
Doses of zinc over ___ mg/day may inhibit wound healing by interfering with copper absorption
50
We should provide high kcal and high protein fortified foods or oral nutrition supplements _____ meals
Between
If needed and consistent with patient wishes, use of supplemental tube feeding may be done using what type of formula?
-High protein, nutritionally complete formula
What should be included in an oral nutrition supplement or enteral nutrition formula for adults with a stage 2 or greater pressure injury who are malnourished or at risk of malnutrition?
-High kcal
-High protein
-Arginine
-Zinc
-Antioxidants
