It is important for nurses to assist in the healing of pressure ulcers. Apart from providing appropriate wound dressing, various nursing interventions are needed such as relieving pressure by providing special pads or air mattresses and turning or repositioning the patient at least every two hours. Arranging pillows under the ankles, back, head and arms, regular cleansing and drying of the skin, and providing good nutrition to support the healing process are also important (Cohen, 2009).
Optimal nutrition helps pressure ulcer healing, keeps immune competence and reduces risk of infection. On the other hand, when patients are in a poor nutritional state wound healing is impaired and more likely to be complicated by infection (Edmonds, 2007; Gillman, 2008). The treatment of pressure ulcers from NICE (National Institute for Health and Clinical Excellence) clinical guideline indicates that nutritional supplementation is recommended for all patients, especially those who have an identified deficiency.
Nursing Intervention Essay Example
Nutritional support of patients with pressure ulcers should be based on nutritional assessment using a recognised tool, general health status, patient preference, expert dietitian and/or specialist input to support in the decision-making process (ANJ, 2008; NICE, 2005; Rafferty, 2007). The Waterlow screening tool includes Malnutrition Screening Tool (MST), as evidence suggests that dehydration and malnutrition are related to pressure ulcers (Chamanga, 2010).
However, NICE recommends that nutritional screening should only be carried out by healthcare professionals with appropriate skill and the Malnutrition Universal Screening Tool (MUST) should be taken for all patients including those who already have pressure ulcers (NICE, 2005). The healing process of pressure ulcer demands an increase in the energy intake of nutrients due to an increase in metabolic need. Elderly or disabled people like Mrs. X probably have diminished dietary intake.
Patients with highly exudating ulcers are also likely to lose important nutrients through the wound exudates which will result in nutrient deficiency at cellular level (Mandal, 2006). That’s why it is important for nurses to do early identification of malnourished patients and quick referral to dietetic specialists. In the treatment of severe pressure ulcers, specialist nutritional advice is often necessary, particularly if there is a need for dietary supplementation (Schols, 2009) e. g. ensure drinks (oral nutritional supplement) or alternative feeding methods e. g. PEG tube or NG tube feeding.
In the case of Mrs. X, advice from an expert dietitian was required as she was provided nutrition with PEG tube feeding to maintain effective nutritional support (Edmonds, 2007). In different cases, biochemical indicators of nutritional state can be useful in guiding nutritional therapy. For instance, serum albumin levels can help to identify chronic malnutrition when used in conjunction with a range of other nutritional parameters (Riordan and Voegeli, 2009). Recent clinical protocols identify that patients are at high risk of malnutrition when plasma albumin levels are less than 3. g/dl. Low albumin levels beyond 26 weeks have been expected of low healing rates in pressure ulcers (Sherman, 2011).
During the inflammatory phase of healing, free radicals are released and can damage healthy tissue (Timms, 2011). Therefore, antioxidant vitamins A, C, E and selenium are needed to neutralise the free radicals. Vitamins are pervasive, vitamins appear a distinct potential to be instrumental in modern wound care (Sinno et al, 2011) Vitamin A is needed throughout healing; it facilitates the inflammatory response to granulation tissue formation and re-epithelialisation.
Supplementation with vitamin A may reverse the deleterious effects of corticosteroids, diabetes and malignancy on wound healing, and patients with severe injuries and large pressure ulcers (Benbow, 2008). Vitamin C (ascorbic acid) is a water-soluble molecule that has three major roles pertaining to wound healing: promoting collagen synthesis, modulating immune function and collagen cross linkage – vitamin B complex and copper as well. (Sinno et al, 2011). It also helps in the transfer of white blood cells to the wound, improves resistance to infection and increases capillary strength.
Since vitamin C is water-soluble, it is difficult to store it in the body, so a regular intake is necessary and dietary sources are green vegetables, potatoes, fruits like orange, kiwi and berries. (Timms, 2011). Vitamin K facilitates blood clotting, and Vitamin E (tocopherols) is a major lipophilic antioxidant of the skin and enhances immune response (Gillman, 2008). Another nutritional supplementation with such positive effectors as arginine can enhance wound healing. Arginine stimulates insulin and growth hormone secretion, which are elated to wound healing (Sherman, 2011). Wound healing also demands high energy needs of the patient. An increase in metabolic need causes an increase in demand for glucose, which is the major fuel source for collagen synthesis and the most efficient source of fuel for adenosine triphosphate synthesis compared with fat (Timms, 2011). Protein has an important role in growth and repair of body tissue. It is required for inflammatory process, the immune system and development of granulation tissue.
Requirements increase when extensive nitrogen losses can occur from draining wounds (Richardson, 2006). Insufficient energy intake causes fat and muscle wastage, because protein is broken down to produce glucose to provide the energy requirement. As a result, protein deficiency combined with loss of protein-rich exudates from wounds may lead to an extended inflammatory phase and hypoalbuminaemia and decrease fibroblast and collagen development, and it can also increase the risk of wound dehiscence and reducing the strength of scar tissue (Ripley, 2006).
Throughout the proliferation and maturation phase, zinc is needed for collagen synthesis. This element is also required for the proliferation of fibroblasts and keratinocytes and speed up the process of re-epithelialisation, while strengthening the wound. However, a study by Lim in 2004 found that high-dose zinc delayed healing due to increased zinc intake reducing copper absorption.