Improve pressure ulcer outcomes with protocols

Pressure ulcers are costly and preventable, as is unintentional weight loss in elderly patients. Some experts believe a key component to preventing these problems is to focus on patients’ nutrition and diet.

The Chicago-based American Dietetic Association (ADA) has medical nutrition therapy protocols, developed by dietitians and published by the ADA and Mobile, AL-based Morrison Health Care. These protocols are for the prevention of unintentional weight loss and treating pressure ulcers.

"Every year, about 60,000 people die from complications related to pressure ulcers," says Jody Vogelzang, MS, RD, LD, FADA, president of JLV and Associates in Southlake, TX. Vogelzang chairs the dietetic practice group of the American Dietetic Association.

"Unintentional weight loss is an indicator of a lot of co-morbidities," Vogelzang says. "Malnour-ished older Americans can attract more infections and diseases, and surgery is riskier for them."

Patients with either a pressure ulcer or unintentional weight loss can result in high medical costs and poor outcomes in disease treatment or surgery recovery.

Home care agencies may use the protocols with their care pressure ulcer care pathways to help improve treatment. Here’s how they work:

1. Pressure Ulcer (Stages I-IV):

Before the initial session, the nurse would obtain baseline measurements of the patient’s biochemical/blood work within 30 days. The nurse also would obtain the patient’s baseline weight and clinical signs and symptoms of Stage I, II, III, or IV pressure ulcers.

The first step is to include nutrition standards in the nursing assessment, Vogelzang says. "If there is a nutrition risk, it should be flagged and something has to be done about it."

Nurses would assess these items, as well:

Functional outcomes:

- activities of daily living;

- Braden Scale for predicting pressure sore risk score;

- incontinence/urinary/fecal status;

- chewing and swallowing problems;

Quality of Life Evaluation

Behavioral Outcomes:

- whether oral intake is adequate in protein, calories, fluids, vitamin C, and zinc;

- what is patient’s knowledge of flood and drug interaction;

- review appropriate care and treatment as prescribed.

All of those items except for the biochemical measure would be evaluated three more times. The biochemical measure would be evaluated during the last intervention.

The expected outcomes would include the following:

• to improve, achieve, or maintain appropriate biochemical values when properly hydrated;

• to raise or maintain body weight as appropriate;

• to hydrate the wound and improve the wound status through healing without further breakdown;

• to have the patient be able to feed self and/or eat with assistance, and to raise the mobility and activity level;

• to raise the Braden Scale score;

• to reduce incontinence through bowel and bladder training;

• to have the patient consume the appropriate amount of food and fluid;

• to improve the patient’s quality of life;

• to have the patient consume adequate nutrients to heal the wound;

• to have the patient consume food and drugs at appropriate times and in appropriate amounts;

• to teach patient that wound care with adequate nutrition heals wounds.

Vogelzang says home care dietitians or nurses need to consider environmental factors that could negatively affect any of these measures. For example, the patient’s care plan may say the patient needs to increase protein, which generally is found in meat. But if the patient has ill-fitting dentures, the patient might have trouble chewing it.

"The meat will sit on the plate," Vogelzang says. "What looks good on paper may not translate into increased protein for that patient."

Solutions may be to have the patient puree meat or to obtain protein through a nutritional drink.

The ideal goals would be as follows:

• to have biochemical measures of less than 3.5 g/dL for Albumin; 11 g/dL of HgB, and 33% Hct.

• to have patient avoid weight loss of greater than or equal to 5% in 30 days or greater than or equal to 10% in six months;

• to have the patient consume nutrition as prescribed;

• to have a Braden Score of 17 or higher;

• to increase mobility and activity based on the patient’s health condition;

• to control incontinence to prevent further skin breakdown;

• to achieve or maintain adequate nutrition and hydration;

• to improve a quality of life that’s appropriate to the patient;

• to maintain an oral intake of 1.25-1.50 grams total protein per kilogram of body weight with 70% high biological value;

• to have a minimum of 30-35 mL/kg body weight;

• to have no evidence of food and drug interaction.

2. Prevention of unintentional weight loss:

Nurses would obtain baseline measures of the biochemical parameters of Albumin, HgB, Hct, BUN, and Creatinine. They also would assess the patient’s weight, height, and body mass index; hydration status, and blood pressure.

"Albumin shows the protein status, and it’s so important for the patient to have an adequate protein source," Vogelzang says. "Generally, it’s the protein source that is used for energy when weight loss is occurring."

Also, the nurse or dietitian would check to see if the patient has dry mucus membranes, which could indicate clinical dehydration.

Next, the nurse would look at functional outcomes, including:

• activities of daily living;

• exercise tolerance;

• whether patient demonstrates self-feeding skills.

Again, the quality of life would be evaluated, and these behavioral outcomes are assessed:

• food and meal planning;

• vitamins and mineral supplements with acceptable doses, if required;

• does the patient tolerate the consistency of foods served;

• does the patient have knowledge of food and drug interactions.

Expected outcomes are:

• laboratory tests repeated based on the client’s condition;

• weight increases or is maintained as appropriate;

• prevent dehydration and edema;

• blood pressure is within normal limits of client’s history;

• activities of daily living are maintained or improved;

• the patient’s mobility and activity level is raised;

• patient maximizes food intake through cueing, self-help devices, or feeding assistance;

• patient’s quality of life is improved;

• patient consumes nutrient-dense foods, snacks, and supplements with greater than 30 to 35 kcal/kg;

• if necessary, alternative nutrition support is provided to prevent further weight loss and reduce complications;

• patient is free from signs and symptoms of vitamin and mineral deficiencies;

• patient consumes 90% to 100% of meals, snacks, and supplements without distress;

• a dietary adjustment is made for food and drug interaction.

The ideal goals are:

• biochemical values of: Albumin at 3.5 g/dL; HgB at 11 g/dL; Hct at 33%; BUN at 8-20 mg/dL, and Creatinine at .7-1.5 mg/dL;

• patient maintains weight to greater than 85% of usual body weight;

• patient’s blood pressure is less than 120/80 mm Hg;

• patient is able to participate in exercise appropriate for tolerance;

• the quality of life is improved as appropriate to the patient;

• patient has an increase of intake of nutrient dense foods and maintains or increases weight gradually;

• prevent complications associated with low body weight, medication noncompliance, and vitamin or mineral deficiencies.

For each of the protocols, there are four interventions that are spaced two to four weeks apart, Vogelzang says.

The protocols also include flow charts and a second page with spaces for the clinician to check specific assessment items for each intervention date. The Braden Scale for predicting pressure sore risk is also included in the protocol packet.

[Editor’s note: The protocols were published by the American Dietetic Association in a manual, Medical Nutrition Therapy Across the Continuum of Care. The manual comes with a computer disk, so health care providers can alter the protocols to better fit their own organizations. The manual and disk cost $90 for nonmembers or $75 for members. Shipping costs 10% of total. For more information about the pressure ulcer and unintentional weight loss nutrition protocols, you may contact the American Dietetic Association at (800) 877-1600, ext. 5000.]


American Dietetic Association, P.O. Box 97215, Chicago, IL 60678. Telephone: (800) 877-1600.

Jody Vogelzang, MS, RD, LD, FADA, president, JLV and Associates, 903 Dowling Court, Southlake, TX 76092. Telephone: (817) 424-2627.