NPUAP Mission Mission The National Pressure Ulcer ... NEW Educational Slide Sets ... point zig-zag...

6/5/2017

1

©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

Why is this Wound Not Healing?June 8, 2017

Aimee Garcia, MD, CWS, FACCWSMary Litchford, PhD, RDN, LDN

npuap.org

NPUAP MissionThe National Pressure Ulcer

Advisory Panel (NPUAP) is

the nation’s leading

scientific expert in pressure

injury prevention and

treatment. Our goal is to

insure improved patient

health, and to advance

public policy, education

and research.


6/5/2017

2

Reduced Price for theInternational Guideline!

NPUAP in collaboration with the

European Pressure Ulcer Advisory

Panel (EPUAP) and the Pan Pacific

Pressure Injury Alliance (PPPIA) has

worked to develop a pressure injury

prevention and treatment the Clinical

Practice Guideline and Quick

Reference Guide. The price of these

books have recently been reduced.

Purchase your copy today at

www.npuap.org

npuap.org©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

NPUAP Monograph

Released in November 2012, the 254-page,

24 chapter monograph, Pressure Ulcers:

Prevalence, Incidence and Implications for the

Future was authored by 27 experts from NPUAP

and invited authorities and edited by NPUAP

Alumna Dr. Barbara Pieper.

The monograph focuses on pressure ulcer rates

from all clinical settings and populations; rates in

special populations; a review of pressure ulcer

prevention programs; and a discussion of the

state of pressure ulcers in America over the last

decade.

Purchase the monograph today at www.npuap.org

• E-version $49

• Individual Chapters $19npuap.org


6/5/2017

3

NEW Educational Slide Sets

npuap.org©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

• Pressure Injury Definition and

Stages

• Prevention of Pressure Injury

• Treatment of Pressure Injury

Each downloadable slide set includes

presentations, speaker notes and

handouts

Purchase the slide sets today at www.npuap.org


6/5/2017

4

THANK YOU to the following companies that have provided support for this webinar!

• Acelity

• American Medical

Technologies

• ArjoHuntligh

• Coloplast

• Dabir Surfaces

• HoverTech

International

• Leaf Healthcare

• Medline

The NPUAP webinar commercial supporters

did not have any input regarding the

content of this presentation.

THANK YOU to the following companies that have provided support for this webinar!

• Molnlycke

• Permobil

• Position Health

• Select Medical

• Sizewise

• Span America

• Stryker

• Tamarack Habilitation

Technologies

• Wellsense

The NPUAP webinar commercial supporters

did not have any input regarding the

content of this presentation.

6/5/2017

5

Faculty Disclosure


• Aimee Garcia, MD, CWS, FACCWSNo disclosures

Past President, NPUAP

• Mary Litchford, PhD, RDN, LDNPresident CASE Software & Books

Author of:•Nutrition Focused Physical Assessment: Making Clinical

Connections;

•Laboratory Assessment of Nutritional Status: Bridging Theory &

Practice

•Nutrition & Pressure Injuries: Putting New Guidelines into Practice

•Common Denominators of Declining Nutritional Status

Consultant for Prosynthesis Labs

Speaker’s Bureau Abbott Labs

Speaker’s Bureau Nestle Nutrition

President National Pressure Ulcer Advisory Panel

Planning Committee Disclosures

• Jeffrey Levine, MD

• Mary Litchford, PhD, RD, LDN

• Sally O’Neill, PhD

• Mary Sieggreen, MSN, CNS, NP, CVN

The planning committee members have listed

no financial interest/arrangements that would

be considered a conflict of interest.


6/5/2017

6

Objectives

• Understand the factors that might impact

wound healing

• Identify what work-up is required to

assess a non-healing wound

• Discuss the nutrition recommendations

for pressure injury treatment in a chronic

wound.

Non-healing wound

• A non-healing or chronic wound is defined

as a wound that does not improve after four

weeks or does not heal in eight weeks.

• Many factors can impact wound healing

6/5/2017

7

6/5/2017

8

Factors that Impact Wound Healing

• Medications

• Immobility

• Radiation Therapy/Chemotherapy

• Arterial / Venous Insufficiency

• Diabetes & Other Chronic Medical Diseases

• Aging

• Smoking

• Infection

• Nutrition

Medications

• Any medication that impacts the

inflammatory phase

– NSAIDS

– Steroids

– Immunosuppressive medications

6/5/2017

9

PRESSURE POINTS

Factors that impact wound healing

• Radiation Therapy/Chemotherapy

• Arterial / Venous Insufficiency

• Diabetes & Other Chronic Medical

Diseases

6/5/2017

10

Normal Changes in Elderly Skin

• Decreased blood flow to skin

• Decreased elastin

• Flattening of the rete ridges

• Loss of subcutaneous fat

• Decreased dermal-epidermal turnover

(Blackwell Science, Inc. Gilchrest BA. Histologic changes in aging normal skin. Journal of American

Geriatrics Society 1982;30:139.)

6/5/2017

11

Smoking

• Nicotine

• Carbon Monoxide

• Hydrogen cyanide

• Effects last for 1 hour after smoking

Bacterial Burden Negative Impact on Wound Healing

• Prolongs the inflammatory stage

• Induces additional tissue destruction

• Delays collagen synthesis

• Prevents epithelialization

6/5/2017

12

Sibbald RG, Woo K, Ayello EA. Adv Skin Wound Care 2006;19:447–63.

Levels of Bacterial Burden

• Contamination– Bacteria in a wound

• Colonization– Bacteria are replicating

– Host remains in control

– Usually polymicrobial• Surrounding skin

• External environment

• Endogenous sources

Landis SJ. Adv Skin Wound Care 2008;21:531-40.

6/5/2017

13


Levels of Bacterial Burden

• Critical Colonization– wounds with more than 100,000 organisms/gram

will not heal

– Suspect bacterial burden if a clean wound shows no improvement after 14 DAYS of topical therapy

• Infection– Invasion of the soft tissues

6/5/2017

14

Probability of Host Infection

P (Infection) = Bacterial burden x Virulence

Host resistance


Wound Cultures

• Traditional swab culture detects only surface

bacterial colonization/contamination

– may not reflect the invasive organism causing

infection

• Quantitative Wound Culture recommended for

determining infection

– documents bacterial burden

– identifies bacteria actually invading wound tissue

6/5/2017

15

Quantitative Analysis

• Superficial Swab

– Z swab

– Levine technique

• Needle aspiration

• Punch Biopsy

• Tissue sample

Z swab

• Swabs using the Z-stroke entail rotating the

swab between the fingers as the wound is

swabbed from margin to margin in a 10

point zig-zag fashion.

6/5/2017

16

Levine technique

• The Levine Technique consists of rotating

the swab over a 1 cm square area with

enough pressure to express fluid from within

the wound tissue

• The Levine Technique is best used when in

the wound is first cleaned and there is no

necrotic tissue or eschar

Tissue hypoxia

• Inhibition of oxidative burst activity in

polymorphonuclear leukocytes

– ↓ intracellular production of antimicrobial

metabolites

• Reduced leukocyte killing capacity

• Fecal contamination contains high

numbers of anaerobes

Hohn DC et al. Surg Forum 1976; 27: 18-20.

6/5/2017

17

Complications

• Osteomyelitis

• Fistulas

• Carcinoma

• Sepsis

Osteomyelitis

• Can occur in 1/3rd of pressure ulcers

• Osteomyelitis most common in:

– Pelvis

– Femoral head

– Ischial bones

– Calcaneus

• If bone is visible or palpable, likelihood

of osteomyelitis is >90%

6/5/2017

18

Osteomyelitis

• Work up

– Plain x-rays

– Lab analysis

• ESR, CRP

– Bone scans

– MRI

– Biopsy


Fistulas

• Abnormal passage between two

epithelialized surfaces that connect one

viscera to another or to the body surface

http://www.nhstaysideadtc.scot.nhs.uk/wound%20Formulary/Section%2010/Section%2011%20fistula%20as

%20attachment.pdf

6/5/2017

19

Fistulas

• Management goals:

– Management and free drainage of exudate

– Protection of surrounding skin

– Prevention of infection

– Removal of necrosis or slough

– Promotion of granulation from the base of the

wound

Sinus Tracts

• Discharging, blind-ended track that

extends from the surface of the skin to

an underlying abscess/cavity. May be

caused by infection, liquefaction or a

foreign body

http://www.nhstaysideadtc.scot.nhs.uk/wound%20Formulary/Section%2010/Section%2011%20fistula%20as

%20attachment.pdf

6/5/2017

20

Sinus Tracts

• Management goals:

– Allow cleansing and draining

– Do not plug

– Protection of surrounding skin

– Prevention of infection

– Removal of necrosis or slough

– Promotion of granulation from the base of the

wound

Carcinoma in Pressure Ulcers

• Marjolin’s ulcer

– Most commonly found in burn wounds and

osteomyelitis

– Most common type: squamous cell

carcinoma

– Other types:

• Basal cell

• Melanoma

• Fibrosarcoma

• Angiosarcoma

• Osteosarcoma

• Others

6/5/2017

21

Occurrence

• Most malignancies in pressure ulcers

occur in the sacral or iliac areas

• Rich lymphatic drainage to the pelvic

region

– Higher rates of metastasis

• Little support for chemo; Radiation can

be effective for palliation

Marjolin’s Ulcer

• Occurs in 1.7% of chronic wounds

• Incidence of SCCa in pressure ulcers is

0.5%

• Very aggressive

• Metastatic rate in pressure ulcers is 60%– Burns (38%)

– Osteo (14%)

• Biopsy if wound present for >6 months

6/5/2017

22

Prognosis

• Factors affecting prognosis

– Tumor type

– Location

– Rate of metastasis

• Survival rates

– 65-75% in 3 years

– 35-50% if metastatic disease present

SIRS

• Defined as a systemic response to

infection

• Criteria:– Fever of more than 38°C (100.4°F) or less than 36°C

(96.8°F)

– Heart rate of more than 90 beats per minute

– Respiratory rate of more than 20 breaths per minute or

arterial carbon dioxide tension (PaCO 2) of less than 32

mm Hg

– Abnormal white blood cell count (>12,000/µL or <

4,000/µL or >10% immature [band] forms)

6/5/2017

23

SIRS

• Non-specific

• Can be caused by multiple conditions:

– Infection

– Ischemia

– Trauma

– Inflammation

– Combination of above

Sepsis

• Bacteremia

– Not always related to SIRS or sepsis

• Sepsis

– Systemic response to infection

– SIRS + infection

• Associated with:

– Hypoperfusion

– Organ dysfunction

– Hypotension

6/5/2017

24


Nutrition

Mary Litchford, PhD, RDN, LDN

Two observations:

1. “Healing is a matter of time, but sometimes also a matter of opportunity.”

2. “Let food be thy medicine and medicine be thy food.”

48

Does Nutrition Really Make a Difference?

HippocratesImage from Dreamtime Photos

6/5/2017

25

Undernutrition-Malnutrition Continuum

49

• Organ function

• Food-Meds Issues

• Adapted from: Litchford, M. Nutr Clin Prac. Aug 2014 29:428.

• Food intake

• Weight loss

• Fat stores

• Muscle mass

• Physical strength

• Illness

• Injury or surgery

• Loss of reserves

• Too tired to shop or cook

• Too tired to eat

• Limited food budget

Poor dietary intake

Increased nutrient needs

Impaired nutrient transport

Undernutrition & malnutrition

2014 NPUAP-EPUAP & Pan Pacific Pressure Injury Alliance (PPPIA) CPG

Nutrition Recommendations

• Nutrition screening

• Nutrition assessment

• Care planning

• Energy intake

• Protein intake

• Hydration

• Vitamins and minerals

50

Image by Dreamtime

6/5/2017

26

Provide 30 to 35 kcalories/kg body weight for adults

with a pressure ulcer who are assessed as being at

risk of malnutrition.

Adjust energy intake based on weight change or level

of obesity. Adults who are under weight, or who have

had significant unintended weight loss, may need

additional energy intake.

Reassess Energy Requirements

© CSB, 201651


Reassess Energy Requirements: Action Plan

52

1.Collect more data on

actual food intake

over 2-4 days

2.Determine amount

and quality of protein

eaten per meal

3.Recheck height &

weight

4.Assess for chewing &

swallowing problems

5.Reassess need for

therapeutic diets

Image by Dreamtime

6/5/2017

27

Reassess Hydration Status

Provide and encourage adequate daily fluid intake for hydration for an individual assessed to be at risk of or with a pressure ulcer. This must be consistent with the individual’s comorbid conditions and goals.

Monitor individuals for s and sx of dehydration, including change in weight, skin turgor, urine output, serum Na, and/or calculated serum osmolality.

53


Images from Dreamtime Photos

Reassess Water Requirements: Action Plan

54

1. Collect more data on

actual intake water

over 2-4 days

2. NFPA for s/s

dehydration

3. Recheck weight

history

4. Assess for

swallowing problems

5. Assess need for

thickened liquids if

ordered

Image by Dreamtime

6/5/2017

28

Reassess Protein Requirements

Offer 1.25 to 1.5 gms protein/kg

body weight daily for adults with an

existing pressure ulcer and who are

assessed to be at risk of

malnutrition when compatible with

goals of care, and reassess as

condition changes.

Provide adequate protein for

positive nitrogen balance for adults

with a pressure ulcer.


55


Reassess Protein Requirements:Action Plan

56

1. Collect more data on

actual protein intake

over 2-4 days

2. Determine amount

and quality of protein

eaten per meal

3. Assess for chewing

& swallowing

problems

4. Reassess need for

therapeutic diets

Image by Dreamtime

6/5/2017

29

Protein Sources are Not Nutritionally Equal

57

Incomplete Protein Complete

Protein

Food For Thought

Which menu promotes tissue synthesis?

Menu 1 (no B, light L, heavy S)

Menu 2 (equal at each meal)

Menu 3 (light B, light L, heavy S)

No difference in outcomes

0

20

40

60

Breakfast Lunch Dinner

PR

O g

m

Meal

Protein Distribution at Meals

Menu 1

Menu 2

Menu 3

58

6/5/2017

30

Leucine Triggers Tissue Synthesis

0

20

40

60

80

100

120M

g l

eu

cin

e p

er

gm

pro

tein

Leucine ( mg/gm PRO)

Source Protein in Dietary Supplements per Selected Manufacturers' Websites & USDA Nutrient Analysis

Database

59

Options when Intake is Insufficient

Offer high calorie, high protein nutritionalsupplements in addition to the usual diet to adults with nutritional risk and pressure ulcer risk if nutritional requirements cannot be achieved by dietary intake.

Supplement with high protein, arginine, and micronutrients for adults with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers when nutritional requirements cannot be met with traditional high calorie and protein supplements.


60


6/5/2017

31

New Nutrition Prescription: Action Plan

61

1. Address each

problem:

2. Small appetite: use

fortified foods

3. Insufficient protein

intake: 30 gm protein

meal, supplements

4. Chewing/swallowing

problems:

consistency modified

diet

5. Fatigue: mealtime

assistantImage by Dreamtime

References1. Posthauer ME, Banks M, Dorner B, et al. The role of nutrition for pressure ulcer management:

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific

Pressure Injury Alliance white paper. Adv Skin Wound Care 2015 Apr;28(4):175-88; quiz 189-90.

http://journals.lww.com/aswcjournal/Fulltext/2015/04000/The_Role_of_Nutrition_for_Pressure_Ulcer.7

.aspx. Accessed June 10, 2016.

2. Litchford, MD. Counteracting the Trajectory of Frailty and Sarcopenia in Older Adults. Nutr Clin Prac.

Aug 2014 29:428-434.

3. Litchford M, Dorner B, Posthauer ME. Malnutrition as a precursor of pressure ulcers. Wound

2014;3(1):54-63. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899999/. Accessed June 10, 2016.

4. Evidence-based recommendations for optimal dietary protein intake in older people: a position

paper from the PORT-AGE study group. J Am Med Dir Assoc 2013;14(8):542-59.

http://www.sciencedirect.com/science/article/pii/S1525861013003265. Accessed June 10, 2016.

5. 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan

Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice

guideline. Haesler E, ed. Cambridge Media: Osborne Park, Western Australia.

6. Dorner B, Friedrich EK, Posthauer ME; American Dietetic Association. Position of the American

Dietetic Association: individualized nutrition approaches for older adults in health care communities.

J Am Diet Assoc 2010;110:1549-53.

7. Lim SL, Ong KC, Chan YH, et al. Malnutrition and its impact on cost of hospitalization, length of stay,

readmission and 3-year mortality. Clin Nutr 2012;31(3):345-50.


8. Rojer AG, Kruizenga HM, Trappenburg MC, et al. The prevalence of malnutrition according to the new

ESPEN definition in four diverse populations. Clin Nutr 2015;35(3):758-62.


62

http://journals.lww.com/aswcjournal/Fulltext/2015/04000/The_Role_of_Nutrition_for_Pressure_Ulcer.7.aspx

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899999/

http://www.sciencedirect.com/science/article/pii/S1525861013003265



6/5/2017

32

References9. White J, Guenter P, Jensen G, et al.; Academy of Nutrition and Dietetics Malnutrition Work Group;

A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement of the Academy

of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition: characteristics

recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad

Nutr Diet 2012:112(5):730-8. http://www.andjrnl.org/article/S2212-2672(12)00328-0/fulltext. Accessed

June 20, 2016.

10.Edsberg L, Langemo D, Baharestani M, et al. Unavoidable pressure injury: state of the science and

consensus outcomes. J Wound Ostomy Continence Nurs 2014 Jul-Aug;41(4):313-34.

11.van Anholt RD, Sobotka L, Meijer EP, et al. Specific nutritional support accelerates pressure ulcer

healing and reduces wound care intensity in non-malnourished patients. Nutrition 2010;26(9):867-72.

http://www.sciencedirect.com/science/article/pii/S089990071000167X. Accessed June 10, 2016.

12.Cereda E, Klersy C, Serioli M, et al.; Oligo Element Sore Trial Study Group. A nutritional formula

enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized,

controlled trial. Ann Intern Med 2015;162(3):167-74.

63

CE Test Information

To earn the 1.0 CE credit for today’s

webinar please visit the link below.

This information will also be emailed out to

webinar registrants ONE HOUR after the

conclusion of the webinar.

https://blueq.co1.qualtrics.com/jfe/form/SV

_1ChUkJSaolcDrGl

http://www.andjrnl.org/article/S2212-2672(12)00328-0/fulltext

http://www.sciencedirect.com/science/article/pii/S089990071000167X

https://blueq.co1.qualtrics.com/jfe/form/SV_1ChUkJSaolcDrGl

NPUAP Mission Mission The National Pressure Ulcer ... NEW Educational Slide Sets ... point zig-zag...

Documents

Transcript of NPUAP Mission Mission The National Pressure Ulcer ... NEW Educational Slide Sets ... point zig-zag...