By Mary Ellen Posthauer RDN, CD, LD, FAND
The NPUAP/EPUAP Pressure Ulcer Prevention and Treatment Guidelines published in 2009 have been widely circulated around the globe and translated into 17 languages. Successful implementation of any guideline requires a "buy-in" by all the members on the interprofessional team. As a member of the wound care team at a long-term care facility, I participate in weekly wound care rounds. Prior to our meeting, the wound care nurse has measured the wounds and documented them on an information sheet that also includes the type of wound (pressure vs. circulatory etc.) plus support surfaces and nutrition interventions.
Three weeks ago a 75-year-old male was admitted from the hospital recovering from pneumonia. He had several stage II pressure ulcers and a stage IV on his coccyx, mild dementia and COPD. His speech was almost non-existent and he was too confused to feed himself. When assisted by staff at mealtime he clamped his mouth shut and refused to eat. I worked with him between meals and he finally ate ice cream and drank a little root beer. The social service director contacted his wife who was his caregiver but was homebound herself. She stated that her husband had lost so much weight his dentures no longer fit. She confirmed his lack of appetite and stated "it takes him an hour to eat."
My nutrition assessment confirmed that he was undernourished based on his weight loss, low BMI, and poor intake. He weighed 110 pounds, was 66" tall and had lost 16 pounds in 30 days or 8%. Following the nutrition guidelines I:
- Assessed the weight status/significant weight loss from usual body weight
- Assessed his ability to eat independently
- Assessed the adequacy of this total nutrient intake
- Provided him sufficient calories (30-35 kilocalories/kilogram body weight or 1500-1800 calories)
- Revised his dietary restrictions to a mechanical soft diet since he was edentulous
- Provided him enhanced food and an oral supplement between meals (root beer float made with ice cream) + a liquid protein supplement (17 grams/ounce) BID between meals
- Assessed his renal function and provided him 75 grams of protein daily
- Requested a multivitamin with minerals based on his poor dietary intake
Interventions for his initial care plan (week 1) included:
- Pain assessment and management to control pain during dressing changes and daily care
- Assessment and provision of a support surface (bed and wheel chair) that matched his need for pressure redistribution, shear reduction and microclimate control
- Staff education by the wound care nurse of appropriate positioning and transfer
- Wound care as determined by the wound care nurse and physical therapy staff
- Weekly weights
- Staff to totally assist resident with meals and snacks
- Food and fluid intake monitored and documented
- Acceptance of root beer floats and liquid supplement monitored and documented
During week 2 of the wound care rounds the charge nurse conveyed to the team that the resident was now eating independently, after staff sets up his tray (butter the bread, offer condiments) but he only eats if can sit at a table alone. His confusion has decreased probably due to his improved nutritional status. Meal intake is up to 25-50% and he gained 3 pounds. His wounds are showing gradual improvement. He enjoys sitting by the window between meals and he does verbalize some - a wink tells us more than any word. His care plan was adjusted to reflect the changes.
Last week was week three of his stay and he continues with gradual improvements in weight, nutritional and wound status. He is tired of his root beer floats but accepts a snack and beverage at hydration pass between meals. He continues to receive the liquid protein supplement. Physical therapy comments his increased strength during therapy sessions. He is a success story for the wound team proving that guidelines can improve care when implemented, monitored and adjusted to meet the individual’s needs.
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the Academy of Nutrition and Dietetics’s Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.