Mary Ellen Posthauer

National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System

The National Pressure Ulcer Advisory Panel has updated the definition of a pressure ulcer and the stages of pressure ulcers based on current research and expert opinion solicited from hundreds of clinicians, educators, and researchers across the country. The amount of anatomical tissue loss described with each stage has not changed. New definitions were drafted to achieve accuracy, clarity, succinctness, clinical utility, and discrimination between and among the definitions of other pressure ulcer stages and other types of wounds. Deep tissue injury was also added as a distinct pressure ulcer in this updated system.

The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper.

INTRODUCTIONThe purpose of this white paper is to review the available scientific evidence related to nutrition and hydration for pressure ulcer prevention and treatment in adults, introduce the nutrition recommendations from the new National Pressure Ulcer Advisory Panel (NPUAP)-European Pressure U

Unavoidable pressure injury: state of the science and consensus outcomes.

In the vast majority of cases, appropriate identification and mitigation of risk factors can prevent or minimize pressure ulcer (PU) formation. However, some PUs are unavoidable. Based on the importance of this topic and the lack of literature focused on PU unavoidability, the National Pressure Ulcer Advisory Panel hosted a multidisciplinary conference in 2014 to explore the issue of PU unavoidability within an organ system framework, which considered the complexities of nonmodifiable intrinsic and extrinsic risk factors. Prior to the conference, an extensive literature review was conducted to analyze and summarize the state of the science in the area of unavoidable PU development and items were developed. An interactive process was used to gain consensus based on these items among stakeholders of various organizations and audience members. Consensus was reached when 80% agreement was obtained. The group reached consensus that unavoidable PUs do occur. Consensus was also obtained in areas related to cardiopulmonary status, hemodynamic stability, impact of head-of-bed elevation, septic shock, body edema, burns, immobility, medical devices, spinal cord injury, terminal illness, and nutrition.

The Role of Nutrition in Wound Care

PURPOSETo provide the physician and registered professional nurse with an understanding of how nutrition impacts wound healing.TARGET AUDIENCEThis continuing education activity is intended for physicians and nurses with an interest in learning more about the role nutrition plays in wound healing and

Nutritional considerations in wound care.

Statistics show that malnutrition among older adult patients is a widespread problem in US health care facilities. The 2002 Nutritional Screening Initiative, a multidisciplinary coalition led by the American Dietetic Association and the American Academy of Family Physicians, has reported rather alarming facts on the nutritional status of this patient population: 40% to 60% of hospitalized older adults are either malnourished or at risk for malnutrition; 40% to 85% of nursing home residents are malnourished; and 20% to 60% of home care patients are malnourished. 1 This is a serious problem. Lack of proper nutrition can have a significant impact on a patient’s ability to recover from illness, disease, or surgery. Malnourished patients are prone to diminished muscle strength; development of pressure ulcers, infection, or postoperative complication; and poor wound healing. 2 In addition, malnourished older adults tend to be frail or fail to thrive, 3 increasing their risk for skin breakdown. Body Response in Wound Healing Having a major wound or infection increases the body’s energy and protein needs as a result of pathologic processes and stress-induced changes. The body’s protective inflammatory response precipitates a cascade of events, including increased blood flow to the site and an increase in metabolic rate (hypermetabolism). Glycogen and protein stores are mobilized by the increased metabolism to meet the needs for glucose and stress factors (cytokines and interleukin-1 and interleukin-6). With stress, hormonal changes cause a shift in insulin and counter-regulatory hormones, such as cortisol, glucagons, and catecholamines. This results in a greater increase in counterregulatory hormones than in insulin. Because insulin assists in carbohydrate and lipid storage and protein synthesis, metabolic and energy rates increase and deplete body protein stores. Hormonal changes also lead to increased glycogen breakdown and mobilization of free fatty acids. The breakdown of glucagons increases glucose production from amino acids, ultimately resulting in a reduced storage of glucose, fatty acids, and proteins. Fat is used as an energy source, albeit

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.

Nutrition and hydration play an important role in preserving skin and tissue viability and in supporting tissue repair for pressure ulcer (PrU) healing. The majority of research investigating the relationship between nutrition and wounds focuses on PrUs. This white paper reviews the 2014 National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance Nutrition Guidelines and discusses nutrition strategies for PrU management.

Nutrition: a critical component of wound healing.

PURPOSE To enhance the clinicians competence in using nutrition as an integral part of wound healing. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES After participating in this educational activity, the participant should be better able to: 1. Analyze the effects of specific nutritional deficiencies and patient parameters on wound healing capabilities. 2. Accurately interpret laboratory values related to nutritional status. 3. Apply evidence-based nutrition guidelines for improved wound healing.

Enteral Nutrition for Older Adults in Nursing Facilities

Older adults who reside in nursing facilities tend to be frail and to have multiple comorbidities, increased risk of unintended weight loss, and protein energy malnutrition. Approximately 5.8% of nursing facility residents in the United States receive enteral feedings. The prevalence is higher for residents with cognitive impairment, ranging from 18% to 34%. In cognitively impaired residents, the majority of tube feeding placements occur in the acute care setting and result in significant use of additional healthcare resources and high postinsertion mortality rates within 60 days of insertion. Nursing facilities must abide by state and federal regulations and undergo stringent survey evaluation while balancing complex decisions related to initial placement of feeding tubes. Informed choice, resident-centered care decisions, and the role of advance directives are essential in the decision-making process. In nursing facilities, it is often the registered dietitian who alerts the healthcare team to determine whether a feeding tube is appropriate. Once a tube is placed, healthcare practitioners must make careful decisions related to ordering, administering, and monitoring enteral nutrition (EN) delivery; adequacy of nutritional content; tolerance to feedings; monitoring for potential complications; and the possibility of return to oral feeding or, conversely, the decision to discontinue feedings. Further evidence-based research is needed to document effectiveness, along with research to support positive outcomes for residents in nursing facilities who receive EN. Optimal care requires careful coordination and an interdisciplinary approach across the continuum of care and between caregivers within the individual nursing facility.

Pressure Ulcer Guidelines: ''Minding the Gaps'' When Developing New Guidelines

Since the early 1990s, clinical practice guidelines have become an increasingly integral part of clinical practice. Health care professionals possess an intrinsic desire to provide the best care possible. As such, guidelines influence patients, providers, and payers. Practice guidelines based on the best scientific evidence available have the potential to enhance consistency of care, reduce morbidity and mortality, and improve quality of life, at least for some conditions. Much of the seminal work in guideline development methodology occurred in the 1990s. Since that time, a number of pressure ulcer guidelines have been developed by the industry, governmental agencies, and professional organizations. The methodological rigor involved in developing these guidelines varies, as does the currency of evidence supporting guideline recommendations. An analysis of existing pressure ulcer guidelines was undertaken by a task force of the National Pressure Ulcer Advisory Panel (NPUAP) in preparation for its collaborative venture with the European Pressure Ulcer Advisory Panel (EPUAP) to develop evidence-based international guidelines on pressure ulcer prevention and treatment. The results of this gap analysis are described below.

Enteral Nutrition for Older Adults in Healthcare Communities

Older adults living in healthcare communities (HCCs) have multiple comorbidities and are at increased risk of malnutrition and unintended weight loss. Aging affects nearly every system as well as body composition and structure, causing physiological changes that can affect nutrition status. A significant percentage (56%) of residents who live in nursing facilities require extensive help to eat and have dental problems such as ill-fitting dentures, missing teeth, and swallowing problems, which can lead to inadequate caloric intake and unintended weight loss. Alzheimer disease or dementia is prevalent in both nursing facilities and in assisted living/residential care communities, where it affects 45% of older adults. In cognitively impaired residents, most tube feeding placements occur in the acute care setting and result in significant use of additional healthcare resources, along with high postinsertion mortality rates within 60 days of insertion. Nursing facilities receiving Medicare or Medicaid funding must abide by state and federal regulations and undergo rigorous surveys while balancing complex decisions related to initial placement of feeding tubes. Healthcare professionals must recognize the importance of establishing nutrition treatment goals that are resident centered and that respect the unique values and personal decisions of the older adult. Informed choice, resident-centered care decisions, and the review of living wills and/or advance directives are essential in the decision-making process. After enteral nutrition is started, healthcare practitioners must carefully review the physicians orders and administer and monitor the residents tolerance, checking for potential complications.