Chapter 15 Skin Integrity

ulcer-prone individuals (13) Dehydration contributes to skin fragility and increases its susceptibility to break- down (14). In recent years, the diagnosis of malnutri- tion has undergone scrutiny, but it is no longer based solely on laboratory values like albumin and prealbu- min but instead on a comprehensive assessment (15). For more information on identifying malnutrition, see Chapter 6.

PREVENTION AND TREATMENT

OF PRESSURE ULCERS In the last decade, the NPUAP has established itself as a premier source of information and resources on prevention and treatment of pressure ulcers. In 2009, the NPUAP published “The Role of Nutrition in Pressure Ulcer Prevention and Treatment” and “Clinical Practice Guidelines for the Prevention and Treatment of Pressure Ulcers.” The Clinical Practice Guidelines were updated in 2014. These evi- dence-based guidelines provide the most current information related to nutrition screening, assess- ment, interventions, and care planning available to date (3). The committee that developed the guide- lines reviewed several levels of evidence and differ- ent types of studies and graded the evidence as outlined in Table 15.2 (see page 205). The guidelines are reprinted in Box 15.2 (see pages 208–210) with permission of the NPUAP with minor adaptations.

MONITORING AND EVALUATING

PRESSURE ULCER HEALING An RDN should monitor all pressure ulcers on a regular basis, particularly stage III and IV ulcers, until they are healed. Wound healing is frequently moni- tored using the Pressure Ulcer Scale for Healing (PUSH) Tool (Figure 15.3; see page 211), developed by the National Pressure Ulcer Advisory Panel (16). The tool is usually completed by a facility treatment nurse but should be available to the interdisciplinary team. The RDN should evaluate all nutrition aspects of wound healing, including weight and intake of meals and oral nutritional supplements. If necessary, inter- ventions should be changed in an effort to meet esti- mated nutritional needs and promote wound healing.

SUMMARY

Older adults are at risk for the development of pres- sure ulcers for multiple reasons, including physical limitations, disease conditions, and medical treat- ments. Nutrition interventions for those at risk can help prevent skin breakdown and can help treat pres- sure ulcers after they are identified. The RDN should be an active participant on the wound care team that

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monitors healing and recommends protocol changes to advance the healing process. Nutrition interven- tions are developed based on a detailed nutrition assessment and careful inspection of the skin. Interventions should be evidence-based and moni- tored frequently.

REFERENCES 1. Baranski S, Ayello EA, Tomic-Canic M, Levine JM. Skin: an essential organ. In: Baranoski S, Ayello EA, eds. Wound Care Essentials. 3rd ed. Ambler, PA: Lip- pincott Williams and Wilkins; 2012:57-82.

2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2014.

3. National Pressure Ulcer Advisory Panel. NPUAP pres- sure ulcer stages/categories. www.NPUAP.org/ resources/educational-and-clinical-resources/NPUAP- pressure-ulcer-stagescategories/. Accessed July 28, 2014.

4. Braden B, Bergstrom N. The Braden Scale for Predict- ing Pressure Sore Risk. 1988. www.bradenscale.com/ images/bradenscale.pdf. Accessed December 29, 2015.

5. Ayello E, Baranoski S, Lyder CH, Cuddigan JE, Harris W. Pressure ulcers. In: Baranoski S, Ayello E, eds. Wound Care Essentials. 3rd ed. Ambler, PA: Lippincott Williams and Wilkins; 2012:324-359.

6. Litchford MD, Dorner B, Posthauer ME. Malnutrition as a precursor of pressure ulcers. Adv in Wound Care. 2014;3(1):54-63.

7. Posthauer ME, Thomas D. Nutrition and wound care. In: Baranoski S, Ayello E, eds. Wound Care Essentials. 3rd ed. Ambler, PA: Lippincott Williams & Wilkins; 2012:240-264.

8. Litchford MD. The Advanced Practitioners Guide to Nutrition and Wounds. Greensboro, NC: Case Software; 2009.

9. Litchford MD. Nutrition Focused Physical Assessment: Making Clinical Connections. Greensboro, NC: Case Software; 2012.

10. Edsberg L, Langemo D. The Unavoidable Outcome: A Pressure Injury Consensus Conference. NPUAP webi- nar. June 4, 2014.

11. Green CJ. Existence, causes and consequences of dis- ease-related malnutrition in the hospital and the com- munity and clinical and financial benefits of nutritional intervention. Clinical Nutrition. 1999;18(suppl 2):3-28.

12. Izaka S, Okuwa M, Sugama J, Sanad H. The impact of malnutrition and nutrition-related factors on the devel- opment and severity of pressure ulcers in older patients receiving home care. Clin Nutr. 2010;29:47-53.

13. Yamamoto T, Fujioka M, Kitamura R, Yakabe A, Kimura H, Katagiri Y, Nagatomo H. Evaluation of nutrition in the healing of pressure ulcers: are the EPUAP nutritional guidelines sufficient to heal wounds? Wounds. 2009;21(6):153-157.