Nursing Home Residents With Poor Nutrition At Increased Risk of Pressure Sores

An article in the Advance for Long Term Care Management journal advocates that good nutrition plays an important role in pressure ulcer (pressure sore, bed sore, decubitus ulcer) prevention.

The article indicates that malnourished residents are twice as likely as well-nourished ones to develop pressure ulcers. One study found that among severely undernourished residents, 65 percent developed pressure ulcers, while no breakdown occurred in the mild, moderate or well nourished groups.

Although the literature clearly supports the correlation between malnutrition and pressure ulcer development, assuming that improved nutrition will result in pressure ulcer prevention is controversial. Some trials intended to prove this correlation have not yielded consistent results.

The article details the key nutritional elements and their impact on pressure ulcer prevention:

Calories. Consuming an adequate number of calories to meet the body's needs is imperative to maintaining good nutritional status. The recommended amount of calories is 30 to 35 calories/kg/day for pressure ulcer patients and those at risk of developing a pressure ulcer.

Involuntary weight loss is one of the most rampant problems facing nursing homes today. The incidence is estimated at greater than 24 percent. When the body is put under stress, it will break down protein from its store of lean body mass (muscle, enzymes, collagen, growth factors, visceral protein and antibodies) to release energy. This depletion of lean body mass jeopardizes vital organ function, muscle strength, immunity and skin integrity.

The resultant weight loss and depletion of visceral protein stores is associated with an increased risk of pressure ulcer development. At a 20 percent loss of lean body mass, decreased healing, increased weakness and infections develop. At a 30 to 40 percent loss, pressure ulcers will develop, existing pressure ulcers will fail to heal and death is a possible outcome.

Protein. Research indicates that decreased protein is the only nutrient that significantly predicts ulcer development, including total intake of calories, vitamin A and C, iron and zinc.

High protein intake is important in wound healing. But increasing a resident's protein intake—whether from a prevention or treatment standpoint—beyond 1.5 g/kg per day may not increase protein synthesis and may cause dehydration and place stress on the kidneys' ability to handle the higher load.

An alternative to dietary sources of protein is to provide an amino acid mix that contains the building blocks of protein. But although products that contain arginine and glutamine have shown good outcomes as enhancements to wound healing, no data exists to show they are helpful for pressure ulcer prevention.

Vitamin A. Vitamin A deficiency may result in delayed wound healing and increased susceptibility to infections. True vitamin A deficiency is rare, as it is stored in the liver. Deficiency of vitamin A is found among malnourished, elderly and chronically sick populations in the United States, but it is more prevalent in developing countries. Supplementation is indicated only for patients who are deficient, and the role of vitamin A in pressure ulcer prevention is unknown.

Vitamin C. Vitamin C contributes to the synthesis of connective tissue. It will increase the tensile strength of newly built collagen. Although vitamin C supplementation has been proven to enhance wound healing in deficient patients, the benefit in non-deficient patients remains unclear.

Zinc. Zinc is an essential trace mineral required for cell growth and replication. It is involved in DNA synthesis, cell division and protein synthesis. Zinc deficiency decreases protein and collagen synthesis, among other key processes.

Excess zinc can also adversely affect wound healing by interfering with copper metabolism, and can have adverse effects in the GI tract including nausea, vomiting and epigastric pain. Supplemental zinc should be given only to patients who are deficient. Dietary intake of zinc has not been shown to be a risk factor in developing pressure ulcers. Since there is no way to test for zinc deficiency, experts generally support supplementation for no more than two to four weeks.

Fluid. Dehydration often accompanies malnutrition and is therefore a risk factor for pressure ulcer development. Dehydration reduces blood volume, interferes with peripheral circulation, and decreases nutrient and oxygen supply to the tissues.

Dehydration can also increase a person's risk of pressure ulcer development by causing muscle fatigue, diminished appetite and bowel impaction. For more, read the article.

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Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia. 


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