http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?

id=114164

Originally posted August 2004

How to help wounds heal

SUE LEININGER HOGAN, RN, MSN
SUE LEININGER HOGAN is an advanced practice nurse at Allegheny General Hospital in Pittsburgh.

Successful wound healing depends upon proper nutrition. Here's how to

make the most of that connection and optimize your patient's recovery.

Jump to:

If a wound is not healing as it should, it could be that the patient is malnourished. In

the United States, approximately 40% of hospitalized patients—and 85% of patients
in nursing homes—suffer from malnutrition.1

Malnutrition might not be detected until obvious signs appear, in some cases because
clinicians were not aware that their patient was at risk. One study, for example, found
that nurses overestimated patients' dietary intake by 20%.2

Whether a patient's wound is the result of an injury or surgery, proper healing requires
optimal nutrition. Wound healing sets off a complex chain of events that involves
increased cellular activity and an intensified metabolic demand for nutrients.3 Patients
who don't have enough nutrients to meet this increased demand are at risk for delayed
healing, infection, longer hospital stays, and even death.1

Although a dietitian will ultimately determine your patient's nutritional needs, you
will be the first person to assess the patient's nutritional status and the condition of his
wound. To promote optimal wound healing, you'll need to understand the link
between nutrition and tissue repair, recognize when a patient is malnourished, and
inform the rest of the healthcare team of any changes in the patient's nutritional status.

The three phases of wound healing

Before we can explore the relationship between nutrition and wound healing, it's
important to briefly touch upon some wound-healing fundamentals. As you know,
wound healing occurs in three overlapping stages: the inflammatory phase, the
proliferative phase, and the remodeling phase.

The inflammatory phase begins at the onset of the injury and lasts up to six days.4
During this phase, blood vessels constrict and coagulation factors are activated,
preventing additional blood loss. The coagulation cascade causes the release of
leukocytes, which attack the bacteria in the wound, and monocytes, which remove
dead tissue, blood clots, and bacteria from the site. Protein and clotting factors also
permeate the wound.

The proliferative phase begins within seven days of the injury and lasts for two to
three weeks.4 During this phase, new blood vessels develop, which promote the
growth of granulation tissue. New tissue forms a protective covering over the wound.

Collagen, which is responsible for tissue repair, is produced by fibroblasts during the
proliferative phase. The collagen and the granulation tissue grow and cross-link to
form a scar.

The remodeling phase begins three weeks after the injury and is characterized by the
buildup and breakdown of collagen.4 The wound edges are pulled inward by
myofibroblasts, and scar tissue becomes softer and flattens out.

Scar tissue continues to strengthen throughout this phase, which can last for up to two
years.4 Over time, the scar will change from red to white and reach its full tensile
strength of 60% – 70% of the original tissue.

Essential to all phases of wound healing are adequate blood flow, tissue perfusion,
and oxygenation.5 Adequate blood flow and tissue perfusion help ensure that oxygen
and nutrients are delivered to the wound.

The production of collagen, for example, depends upon the availability of oxygen and
protein at the wound site.5 As collagen develops, other components of the healing
process—including white blood cell mobility, granulation tissue formation, and blood
vessel development—improve as well.

Take a careful look at nutritional status

Because wound healing is so dependent upon nutrition, a comprehensive nutritional
screening is critical. Begin with a diet history.6 Ask about the patient's daily intake,
food preferences, and eating environment, including when and how he eats. A change
in appetite may be the first indication of a nutrition problem. Find out if there are
functional or psychological factors, such as constipation or pain, that might affect
your patient's ability to eat.

Ask him if he uses nutritional supplements or herbs and if so, which ones. Also ask
about drug and alcohol use. A patient who abuses alcohol, for example, is likely to
have vitamin, protein, and calorie deficiencies.

Alcohol abuse is just one predictor of nutritional deficiencies. Others include a

decreased serum albumin level (<3.5 gm/dL); long-term medication use; impaired
immune system functioning; acute and chronic diseases, including diabetes mellitus
and liver and kidney disease; and weighing less than 80% or more than 120% of the
ideal body weight.4

Follow up the diet history with a physical assessment. Patients who are malnourished
may have hair that is dull, dry, thin, or easy to pull out.7 They may say that their hair
has lost its natural curl or changed color. You may observe yellowish lumps around a
patient's eyes, redness and fissures of the eyelid corners, or white rings around both
eyes.7

A patient who has nutritional deficiencies may have lips that are red or inflamed and
cracking (cheilosis).7 Gums may be red, spongy, swollen, or inflamed (gingivitis) or
may bleed easily. His tongue may be swollen, inflamed (glossitis), purplish, or
smooth with papillae, and he might complain of a diminished sense of taste. Teeth
may have gray-brown spots, and some may be missing.

Signs of a nutritional deficiency may also be evident in the patient's face. Look for
paleness, scaling of the skin around the nostrils, and hyperpigmentation.7 You'll also
want to assess the thyroid gland for enlargement.

Record your patient's weight on admission and frequently throughout his hospital
stay. Weigh him on the same scale at the same time each day. Ask him what he
usually weighs to determine if he has recently lost or gained weight. Remember to
record his height. The most accurate way to determine height is to measure the patient
while he's standing up.

Use your patient's height and weight to determine his body mass index (BMI). Divide
the weight (in kilograms) by the height (in meters squared). A healthy BMI for an
adult generally falls between 18.5 and 25.8 A BMI of 17 – 18.5 may indicate mild
malnutrition; 16 – 17, moderate malnutrition; and <16, severe malnutrition.6

Obese patients (BMI >30) should also prompt a second look. Even with a caloric
intake that's excessive, your patient may have a nutritional problem, such as a protein
or vitamin C deficiency, that can impair wound healing.

Completing the picture with lab work

Your nutritional screening should also include a review of the patient's lab results.
Pay particular attention to serum protein levels.9 The four serum proteins you should
look at are albumin (normal level is 3.5 – 5.0 gm/dL), transferrin (200 – 360 mg/dL),
prealbumin (16 – 40 mg/dL), and retinol-binding protein (2.6 – 7.6 mg/dL).6,9

Low albumin levels are associated with protein deficiency, protein-losing

gastrointestinal disease, and acute metabolic stress.9 However, because the half-life of
albumin is 20 days, a patient may become malnourished before a decrease in serum
albumin is noted.

Serum transferrin has a half-life of eight to 10 days and its levels respond quickly to
changes in protein intake. It is, therefore, a more sensitive indicator of protein
deficiency than albumin. Levels below 200 mg/dL indicate that protein stores are
becoming depleted.9

Prealbumin has a half-life of two to three days, so it's a very sensitive indicator of a
patient's protein status. Prealbumin levels will decrease rapidly when a patient is
underfed for even a brief period, and they will increase rapidly with dietary support.
Levels of <16 mg/dL are associated with malnutrition.6 Retinol-binding protein has a
half-life of approximately 12 hours; levels of <2.6 mg/dL reflect a protein deficiency.9

Serum protein levels, however, are just one indicator that the patient's nutritional
status is not optimal for wound healing. The results of two less commonly performed
immune system function tests can also identify nutritional roadblocks.

The first is the total lymphocyte count. If it is lower than 15,000 cells/mm3, the patient
may have a moderate protein deficiency. The second test is the skin antigen test, or
anergy panel, in which the patient is given antigens subcutaneously. The inability to
respond to the antigens—in the form of a rash—may be related to a nutritional
deficiency.10

Feeding your patient to help him heal

To avoid malnutrition and wound complications, patients need adequate calories,
protein, and fluid. Based on input from your history and physical assessment, a
dietitian will determine the amounts of carbohydrates, protein, fat, vitamins, and
minerals that your patient will need for wound healing. (For more information on how
these nutrients promote healing, see the "Nutrients provide fuel for healing" box.)

Calories are needed to supply the energy necessary for wound healing. As a general
rule, an adult critical care patient needs 25 – 30 calories per kilogram of body weight
per day.4 Patients with wounds also need adequate protein—1.5 – 3 gm/kg per day,
depending upon the severity of the wound and other factors.5

Water is essential for cells to function normally. Water balance, or hydration, is

present when a patient's fluid intake equals his output. Dehydration occurs when a
patient doesn't receive enough fluid, or when fluid loss exceeds intake. (Wound
drainage can be a source of fluid loss.) Dehydration reduces blood volume, which
further decreases circulation and reduces oxygen and nutrient delivery to the tissues.9
To help ensure that a patient is properly hydrated, 30 – 35 ml of fluid per kg of body
weight per day may be adequate unless contraindicated.9

Your patient may require tube feeding

A patient can meet his nutritional requirements orally by eating a balanced diet and, if
necessary, taking supplements. Patients who are unable to consume at least half of
their required calories and protein on their own may need enteral or parenteral
nutritional support.4 A general rule of thumb is that oral feeding is better than enteral
feeding, which is better than parenteral feeding.11

Clinicians consider many factors when determining which feeding route is best for a
patient, including the patient's current feeding route, the medications he's receiving,
and the procedures he'll undergo.10 Other factors to consider include:10

• Is the patient unconscious, mechanically ventilated, or otherwise unable to eat

safely?
• Does the patient have a hard abdomen or an absence of bowel sounds, which could
indicate an obstruction or other problem that might preclude enteral feeding?

• Does the patient have bed restrictions that might increase his likelihood of
aspiration?

• Does the patient have injuries to specific tissues or organs that would affect his
ability to consume and digest food?

• What are the future medical or surgical plans for the patient, and how long will
nutritional support be required?

• Is the patient's skin otherwise intact? Are there draining wounds, fistulas, or pressure
sores?

Enteral tube feeding is indicated when a patient with a functioning GI tract can't
consume the amount or type of nutrients needed by mouth. For example, a patient
may require enteral feeding because he's mechanically ventilated or at risk for
aspiration because of altered consciousness, or he has a diminished gag or cough
reflex.

One benefit of enteral feeding is that it promotes blood flow to the gut and helps
maintain mucosal integrity.11 If a patient will need enteral feeding for less than four
weeks, a nasogastric, nasoduodenal, or nasojejunal route should be considered. If
long-term feeding is necessary, a gastrostomy or jejunostomy tube can be inserted
surgically. Conditions such as facial fractures or CNS trauma may also dictate the
route used.2,10

Currently, more than 100 enteral formulas are available. There are "standard"
formulas that provide the recommended daily intake of vitamins and minerals,
formulas designed to strengthen a patient's immune system, ones that contain fiber,
and specialty formulas for patients with a specific disease or condition.

Several formulas are promoted as enhancing wound healing, including Boost HP,
Crucial, Isosource, and Promote. These formulas provide higher levels of protein,
vitamins (usually A and C), zinc, and sometimes arginine. However, patients with a
wound who also have other conditions such as diabetes, pulmonary disease, or
impaired liver or kidney function wouldn't receive one of these wound-healing
formulas. Instead, they would receive a formula designed specifically for their
particular condition.

If your patient is receiving enteral feeding, check tube placement regularly. Also
assess the tube's exit site for redness, swelling, skin breakdown, warmth, and
drainage.

Irrigating the tube frequently according to your facility's guidelines helps maintain its
patency. Determine how well your patient is tolerating the feeding by assessing for
bowel sounds, flatus, stools, residuals, and discomfort from distention, nausea,
vomiting, or diarrhea.
When parenteral feeding is necessary
Patients who can't tolerate enteral feeding will need parenteral nutrition. Peripheral
parenteral nutrition (PPN) is used for short-term therapy—up to seven days. Total
parenteral nutrition (TPN), which requires a central line, is indicated when parenteral
feeding will be needed for longer than a week.

Each bag of TPN contains glucose, amino acids, electrolytes, vitamins, trace
elements, a histamine blocker, and insulin as needed. Lipids are sometimes infused
separately and are especially useful for patients who have fluid restrictions.

A patient who'll be receiving TPN should have blood tests to establish baseline levels
of phosphorus, magnesium, triglycerides, and electrolytes. After that, monitor the
patient's glucose levels regularly, and watch for hyperglycemia.

The central line used to administer TPN raises a patient's risk of infection, so check
the patient for signs and symptoms of catheter-related infection. A patient who shows
signs of infection should have a fever workup, which may include blood cultures. If
you suspect that your patient has central line sepsis, the line should be replaced.10

Whether your patient's nutritional needs are complex or relatively straightforward,

your attention to the details will serve him well. Appropriate nutritional support can
help patients avoid malnutrition, delayed healing, and complications such as infection
or sepsis. And in the end, that will help improve his chances of a successful recovery.

REFERENCES
1. Williams L. (2002). Assessing patients' nutritional needs in the wound-healing process. J Wound Care, 11(6), 225.

2. Ferguson, M., Cook, A., et al. (2000). Pressure ulcer management: The importance of nutrition. Medsurg Nurs, 9(4), 163.

3. MacKay, D., & Miller, A. L. (2003). Nutritional support for wound healing. Altern Med Rev, 8(4), 359.

4. Kiy, A. M. (1997). Nutrition in wound healing: A bio-psychosocial perspective. Nurs Clin North Am, 32(4), 849.

5. Whitney, J., & Heitkemper, M. (1999). Modifying perfusion, nutrition and stress to promote wound healing in patients with acute
wounds. Heart Lung, 28(2), 123.

6. Huckleberry, Y. (2004). Nutritional support and the surgical patient. Am J Health Syst Pharm, 61(7), 671.

7. Ayello, E. A., Thomas, D. R., & Litchford, M. A. (1999). Nutritional aspects of wound healing. Home Healthc Nurse, 17(11), 719.

8. U.S. National Library of Medicine, National Institutes of Health. "Body mass index." 2003.
www.nlm.nih.gov/medlineplus/ency/article/007196.htm (25 May 2004).

9. Leininger, S. M. (2002). The role of nutrition in wound healing. Crit Care Nurs Q, 25(1), 13.

10. McQuillan, K. A. (Ed). (2002). Trauma nursing: From resuscitation through rehabilitation (3rd ed.). Philadelphia: W. B. Saunders.

11. Cheever, K. H. (1999). Early enteral feeding of patients with multiple traumas. Crit Care Nurse, 19(6), 40.
Click here to view full-size graphic

Nutrients provide fuel for healing

For a wound to heal successfully, patients need adequate amounts of nutrients,
including carbohydrates, protein, fat, vitamins, and minerals. Those who don't meet
their nutritional needs are at risk for delayed wound healing and other wound-related
complications. A dietitian will determine how much of each nutrient your patient
needs.

Carbohydrates are needed for energy. An adult's carbohydrate intake should account
for 45% 60% of total consumed calories; less than that may lead to the breakdown of
protein stores. The main carbohydrate is glucose, which is necessary for cellular
growth, fibroblastic mobility, and leukocyte activity.

Protein is necessary for tissue repair and maintenance. The recommended daily
allowance of protein is 0.8 gm/kg of body weight per day; a patient with a wound will
need 1.5 3 gm/kg per day, depending upon the severity of the wound and other
factors. Insufficient protein intake inhibits collagen and fibroblast production,
impairing wound healing. However, taking in too much protein increases protein
synthesis, which puts a burden on the kidneys and liver and can lead to dehydration.

Fat is a concentrated source of energy. It is essential for digestion, absorption, and

transport of the fat-soluble vitamins (A, D, and E). Fat should account for
approximately 20% of calorie intake.

Vitamins A and C are also essential for wound healing. Vitamin A is lipid-soluble and
stored in the liver. It is necessary for the early inflammatory phase of wound healing,
for wound debridement, and for scar tissue strengthening. Vitamin A can prevent the
delay in wound healing that steroids often cause. A deficiency decreases collagen and
granulation tissue development and increases the likelihood of wound infection. High
doses of vitamin A, however, can be toxic.
Vitamin C supports collagen synthesis. It's water-soluble; the body can't store it. A
patient who's deficient in vitamin C may have bleeding gums or small red spots
(petechiae) around the hair follicles, and may bruise easily and heal slowly. When
supplementation is necessary, the dosage should be 100 300 mg a day. There's no
evidence that vitamin C accelerates wound healing in patients who don't have a
deficiency.

Another requirement for wound healing is zinc. It supports collagen development, cell
division, and protein synthesis. A deficiency can lead to abnormalities in white blood
cell function, increasing the risk of wound infection. Supplementation typically
consists of 15 30 mg a day. Too much zinc, however, can impair wound healing and
cause GI distress. Other minerals&#151;namely, copper, iron, and
manganese&#151;reportedly help with tissue regeneration, but deficiencies of these
minerals have not been linked to impaired wound healing.
Sources: 1. Leininger, S. M. (2002). The role of nutrition in wound healing. Crit Care Nurs Q, 25(1), 13. 2. Kiy, A. (1997). Nutrition in
wound healing: A bio-psychosocial perspective. Nurs Clin North Am, 32(4), 849. 3. MacKay, D., & Miller, A. L. (2003). Nutritional
support for wound healing. Altern Med Rev, 8(4), 359.

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difference between albumin and

prealbumin, The
Advances in Skin &amp; Wound Care, Sep/Oct 2001
by Collins, Nancy
• 1
• 2
• 3
• Next

Nutrition Q&A

Q: What is the difference between albumin and prealbumin? When should they be
measured for patients with wounds? How are the results interpreted?

A: Before examining the specifics of albumin and prealbumin, practitioners need to

understand the underlying reason for measuring them.

Albumin and prealbumin levels are indicators of visceral protein status. For wound
healing to occur, any protein deficiency must first be corrected. Knowing the protein
status lab values allows the practitioner to determine the degree of protein
malnutrition and to initiate early nutritional intervention, if necessary. This is
important because early nutritional intervention has been shown to decrease the length
of stay, lower the risk of complications, decrease mortality, and improve wound
healing.1,2
More Articles of Interest

• Improving your patient's nutritional status

• Protein and wound healing
• Vitamin C and pressure sores
• Closing the Gap: How to Provide Protein without Increasing Total Calories
• The role of nutrition in wound healing

Albumin

Albumin is one of the most abundant proteins found in blood, accounting for more
than 50% of total serum proteins. The liver manufactures albumin; the albumin
concentration reflects the protein status of the blood and internal organs.3 The main
purpose of albumin within blood is to maintain colloidal osmotic pressure, which
keeps fluid within the vascular space.4 This is why patients with very depleted
albumin levels may develop edema, ascites, or pulmonary edema. Table 1 shows the
interpretation of serum albumin levels.

Evaluating albumin

There are several considerations to be aware of when evaluating albumin levels. First,
albumin has a relatively long half-life of approximately 20 days and a very large
serum pool. By the time albumin values are below normal levels, a sizeable amount of
the serum pool has been lost. Generally, albumin is considered a late indicator of
malnutrition-an important consideration now that the value of early nutritional
intervention is known.

Second, albumin is a negative acute-phase reactant. This means that albumin

concentrations rise slowly during nutritional therapy (refeeding) and in patients
recovering from stress.5 Reliable changes in albumin require at least 2 to 3 weeks of
nutritional intervention; earlier changes are likely due to hemoconcentration issues. In
other words, any condition that results in a decrease in plasma volume will cause
falsely elevated albumin levels. The reverse is also true: Patients with an expanded
plasma volume, such as patients with heart failure or renal disease, may appear to
have falsely depleted albumin levels.6 Hence, hydration status is an important factor
to consider when evaluating albumin levels.

Third, liver function should be considered when evaluating albumin levels. Because
albumin is formed in the liver, it is a measure of hepatocyte function. Diseases of the
liver cause the hepatocytes to lose the ability to synthesize albumin. Other disease
states that may interfere with the reliability of albumin as a protein status marker are
protein-losing enteropathies, protein-losing nephropathies, and diseases with
increased capillary permeability, such as lupus and other collagen vascular diseases.4

Fourth, zinc's main transport vehicle in the blood is albumin. The blood's
concentration of albumin has been suggested as a major determinant of zinc
absorption.7 Simply put, low serum albumin concentrations may decrease zinc
absorption. Because zinc is associated with improved wound healing, it is important
to closely monitor protein status and correct any deficiencies with early, aggressive
nutritional interventions.

The albumin level has a place in nutrition assessment. Albumin is readily available in
most patient records and routinely ordered in hospitals and long-term-care facilities.
Monitoring albumin levels over the course of several months can provide a long-term
picture of a patient's protein status.

Prealbumin

Prealbumin is another protein status indicator; it has a much shorter half-life and
smaller serum pool than albumin. The half-- life of prealbumin is approximately 2
days, making prealbumin a more timely and sensitive indicator of protein status.
Prealbumin is a tryptophan-rich protein, and like albumin, it is synthesized in the
hepatocytes of the liver. Prealbumin's main function is to serve as a binding and
transport protein.5 The term prealbumin is actually a misnomer-the prefix pre implies
that it is a precursor for albumin, which it is not. The more accurate name for
prealbumin is transthyretin. This name was chosen by the Joint Commission on
Biochemical Nomenclature to indicate that it is a serum transport protein for thyroxin
and retinol-binding protein.8

Evaluating prealbumin

Like albumin, prealbumin is a negative acute-phase reactant. This limits its use as a
screening tool for malnutrition because low levels could result from either inadequate
nutrition or inflammatory stress.6 Rather than a diagnostic tool, prealbumin should be
used as an indicator of nutritional improvement and as a measure of how well
nutritional interventions are working. The very short half-life and small serum pool
allows small changes in nutritional status to be identified in a short time frame.
Prealbumin levels can be drawn once or twice per week and used as a sensitive
monitor of nutritional progress. Prealbumin should be part of the nutrition assessment
for all patients with wounds because it provides the best monitor of current protein
status. This assay is not as easily affected by comorbities or hydration status as
albumin; however, it has been noted that elevated prealbumin levels may be seen in
patients taking corticosteroids and in patients with Hodgkin disease.9 Table 1 shows
the interpretation of serum prealbumin levels.

New laboratory techniques have made prealbumin a readily available and cost-
effective assay. In the past, most labs analyzed prealbumin levels using a process
called nephelometry. This technique has been replaced by more cost-effective
immunoturbidimetric technology. The cost of the test using this technology is
approximately $3.00; the national average reimbursement using CPT code 84134 is
$17.18.(10)

More Articles of Interest

* Improving your patient's nutritional status

 * Protein and wound healing

* Vitamin C and pressure sores

* Closing the Gap: How to Provide Protein without Increasing Total Calories

* The role of nutrition in wound healing

Albumin and prealbumin are both indictors of protein nutrition status. When
evaluating albumin results, the practitioner should keep in mind that low levels likely
reflect a longstanding nutritional deficiency (at least several weeks, and probably
months). Prealbumin is much more sensitive and provides more current information.
Prealbumin is the gold standard for monitoring nutritional progress because it
provides a quantitative way to document whether the nutrition care plan is working or
whether interventions need to be modified. New technology makes prealbumin a cost-
effective and valuable part of the nutrition assessment for every patient with a wound.

References

1. Brugler L, DiPrinzio MJ, Bernstein L. The five-year evolution of a malnutrition

treatment program in a community hospital. Jt Comm J Qual Improv 1999;4:191-206.

2. Sullivan DH, Sun S, Walls RC. Protein-energy undernutrition among elderly

hospitalized patients.JAMA 1999;281:2013-9.

3. Cataldo CB, DeBruyne LK, Whitney ER. Nutrition and Diet Therapy. 4th ed.
Minneapolis/St. Paul: West Publishing Co; 1995. p 338.

4. Pagana, KD, Pagana TJ. Mosby's Diagnostic and Laboratory Test Reference. 2nd
ed. St. Louis, MO: Mosby-Yearbook, Inc; 1995. p 657-9.

5. Mahan LK, Escott-Stump, S. Krause's Food, Nutrition & Diet Therapy. 1 Oth ed.
Philadelphia, PA:WB Saunders Co; 2000. p 384-5.
6. Chernoff R. Geriatric Nutrition. 2nd ed. Gaithersburg, MD: Aspen Publishers, Inc;
1999. p 403-S.

7. Whitney ER, Rolfes SR. Understanding Nutrition. 6th ed. Minneapolis/St. Paul:
West Publishing Co; 1993. p 420.

8. Prealbumin becomes transthyretin? IUPAC-IUBMB Joint Commission on

Biochemical Nomenclature and Nomenclature Committee of IUBMB. 1981.
Available at: http://www.them.qmw.ac.uk/iubmb/newsletter/misc/ prealb.html. Last
accessed April 4,2001.

9. Veldee MS. Nutrition. In: Burtis CA, Ashwood ER, eds. Tietz Textbook of Clinical
Chemistry.2nd ed. Philadelphia, PA:WB Saunders Co; 1994.p 1261-3.

10. Polymedco brochure. Polymedco, Inc. Cortlandt Manor, NY. 2001. Available at:
http://www.polymedco.com. Last accessed April 4,2001.

Nancy Collins, PhD, RD, LD/N, is a registered and licensed dietitian in private
practice in Pembroke Pines, FL. For the past decade she has served as a consultant to
health care institutions on issues regarding regulatory compliance, clinical nutrition,
and food service management and as a medical-legal expert to law firms involved in
health care litigation, Questions for future columns may be E-mailed to Dr Collins at
NCtheRD@aol.com.

Copyright Springhouse Corporation Sep/Oct 2001

Provided by ProQuest Information and Learning Company. All rights Reserved

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Collins, Nancy "difference between albumin and prealbumin, The". Advances in Skin
& Wound Care. FindArticles.com. 26 Oct, 2010.
http://findarticles.com/p/articles/mi_qa3977/is_200109/ai_n8963813/

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January 17, 2005

Adult Wound Care — Management of Pressure Ulcers

By Amy Fleishman, MS, RD, CDN
For The Record
Vol. 17 No. 1 Page 42

Increased incidence of pressure ulcers leads to lengthened hospital stays and greater costs.

When people heard of the circumstance surrounding the death of Christopher Reeve, most were
shocked to learn of the deadly turn taken by such a benign-sounding ailment. But pressure ulcers and
the resulting infections can be common occurrences for people who suffer from health problems such
as spinal cord and brain injuries, neuromuscular diseases, and Alzheimer’s.

Pressure ulcers, which are also referred to as decubitus ulcers, pressure sores, and bedsores, are a
significant and costly healthcare problem for patients and providers. They are defined by the National
Pressure Ulcer Advisory Panel as “…localized areas of tissue necrosis that develop when soft tissue is
compressed between a bony prominence and an external surface for a prolonged period of time.”1
Therefore, pressure ulcers are most likely to occur on the sacrum, hipbone, and heels.

Staging System
Pressure ulcers vary in severity and can be staged as 1, 2, 3, or 4. A stage 1 ulcer is a nonblanchable,
reddened area of intact skin. In darker skin tones, the ulcer may appear with red, blue, or purple hues.
A stage 2 ulcer is partial thickness skin loss involving the epidermis, dermis, or both. A stage 3 ulcer is
full thickness skin loss involving damage to or necrosis of subcutaneous tissue. A stage 4 ulcer is full
thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle or bone.2

Prevalence and Cost

The fourth national pressure ulcer prevalence survey found an overall 10.1% prevalence rate in 39,874
patients in acute care hospitals.3 Langemo et al found a 23% prevalence rate in a skilled care facility.4
An increased incidence of pressure ulcers leads to lengthened hospital stays and increased costs.
Complications of pressure ulcers lead to an annual death rate of approximately 60,000.5 The total
national cost of pressure ulcer treatment is at least $5 billion to $8.5 billion annually.6

Risk Factors
The following are several factors that put a patient at risk for developing a pressure ulcer7:

• restricted physical activity, such as being bedridden, wheelchair-bound, paralyzed, or in a coma;

• sensory impairment, such as having difficulty communicating or being unresponsive;

• damp skin, such as being bowel- and bladder-incontinent or perspiring often;

• poor circulation and reduced oxygen supply, as seen with diabetes and peripheral vascular disease;
and

• malnutrition.

Braden Scale
The Braden Scale is one of the tools recommended to assess the risk of developing a pressure ulcer. A
nurse usually documents the score, which is composed of six subscales: sensory perception, moisture,
activity, mobility, nutrition, friction, and sheer. Each category is scored on a scale of 1 to 4, except
friction and sheer, which use a 3-point scale. The scores range from 6 to 23, with 23 being the highest,
indicating the least risk for a pressure ulcer. Preventive measures should be initiated with a score of 18
or less. See www.bradenscale.com/braden.pdf for a copy of the Braden Scale chart.8

Malnutrition
There is a strong correlation between malnutrition and the risk of developing a pressure ulcer.9 In a
prospective study, patients who were malnourished on admission to the hospital were twice as likely to
develop pressure ulcers as nonmalnourished patients.10

Malnutrition may increase the risk for a pressure ulcer for several reasons. Weight loss and less
subcutaneous fat make the bones more prominent, which causes a steeper pressure gradient, thereby
putting the patient at increased risk. Malnutrition can also lead to edema and reduced blood flow in the
skin, causing ischemic damage, which is a risk factor for developing a pressure ulcer. Lastly,
malnutrition causes muscle loss and the inability to shift position, which leads the patient to spend a
longer time in one position and puts him or her at increased risk for a pressure ulcer.

Nutrition Assessment
When a patient is identified as being at risk for developing a pressure ulcer, or if a patient already has a
pressure ulcer, a dietitian must assess the patient and determine the necessary nutritional intervention.
There are many factors to consider that could put a patient at increased risk for malnutrition, such as
age. One study looked at adults over the age of 70 and found that 11.6% experienced pressure ulcers as
compared with only 6% of younger people.11

The diet order also plays a crucial role because if the patient is on a restricted diet, it may lead to
decreased intake. The patient’s diagnosis, medical history, swallow function, ability to feed oneself,
and skin integrity must also be taken into account. The dietitian must also assess psychosocial factors,
such as who pays for the food, who cooks, what the cooking facilities are like, and whether there are
any food or cultural food preferences.

A main part of the nutrition assessment is looking at food intake, anthropometrics, and labs. Asking
patients about their appetite and food intake are two different questions. Patients may have a good
appetite, but due to the aforementioned factors, they may be eating less than 50% of the meal. If
patients weigh less than 80% of their ideal body weight, they are at increased risk for developing a
pressure ulcer. In addition, if patients experience a 5% weight loss in one month or a 10% weight loss
in six months, they are at increased risk. The relationship between low albumin and decreased wound
healing has been well-documented.12 See Table 1 for albumin and prealbumin values that put patients
at risk.

Nutrition Intervention
After assessing whether patients are at risk for developing a pressure ulcer or if they already have one,
the dietitian must determine the appropriate intervention. The following recommendations are not
evidenced-based practice guidelines, but they will provide a review of the literature, which will help
when working with patients with pressure ulcers. Keep in mind that every patient is an individual with
different needs. Nutrient requirements will vary depending on several factors, such as the severity of
the pressure ulcer, comorbidities, age, and weight. See Table 2 for a summary of recommendations.

Calories are needed to spare the protein and allow for increased needs due to infection.
Recommendations for treating pressure ulcers are usually 30 to 35 calories per kilogram. There is no
known benefit of overfeeding on wound healing.9 Remember to use adjusted body weight when
determining the needs for an obese patient.

Inadequate protein delays wound healing and prolongs the inflammatory phase. Therefore, protein
recommendations for treating pressure ulcers are usually 1.2 to 1.5 grams per kilogram. Expressed as a
percentage of calories, other recommendations have been 20% to 24% of calories from protein. The
maximum recommendation is 2 grams per kilogram because excess protein may strain the liver and
kidneys.9

In a prospective, randomized, controlled study of 672 critically ill patients aged 65 and older treated
with high-protein nutrition supplements for 15 days, there was a reduction of pressure ulcer risk when
compared with controls.13 A study by Chernoff et al looked at the effects of high-protein tube feeding
on pressure ulcers. Two study groups, each with six patients on tube feedings, were monitored for eight
weeks to assess pressure ulcer healing. One group received a tube feeding that was 16% protein (1.2
grams of protein per kilogram), while the other group received a tube feeding that was 25% protein (1.8
grams of protein per kilogram). Both groups experienced healing of their pressure ulcers; however, the
group that received 25% protein showed more healing in the same time frame (70% improvement as
opposed to 40% improvement).14

Fluid is needed to maintain good skin turgor and blood flow to wounded tissues, which is essential for
the prevention of skin breakdown. Dehydration is a risk factor for pressure ulcers. Recommendations
for treating pressure ulcers are usually 30 to 35 milliliters per kilogram or 1 milliliter per calorie. More
fluid may be needed if the patient has a fever or fluid loss from an open wound.9 Less fluid may be
warranted if a patient is on a fluid restriction.

In addition to calories, protein, and fluid, specific micronutrients have received primary attention in the
prevention and treatment of pressure ulcers. If a patient’s diet does not meet 100% of the
Recommended Dietary Allowance, a multivitamin/mineral supplement is recommended in addition to
the following nutrients:

• Vitamin C aids in collagen synthesis and expedites wound healing. However, in patients who are not
vitamin C-deficient, no evidence has been found for wound healing with vitamin C supplementation.15
Recommendations for treating pressure ulcers are usually 1,000 to 2,000 milligrams per day in divided
doses if deficiency is suspected.9

• Vitamin A also enhances collagen formation, and a deficiency results in delayed wound healing and
increased vulnerability to infection.16 Vitamin A supplementation is warranted for wound healing that
has been delayed by vitamin A deficiency, steroid use, excessive vitamin E supplementation, radiation,
chemotherapy, or diabetes. Recommendations for treating pressure ulcers are usually 20,000 to 25,000
international units per day orally if deficiency is suspected. Vitamin A can become toxic and cause
liver abnormalities if taken in large doses for a long period of time, so vitamin A should be taken for 10
days and then the wound should be reassessed.9
• Zinc is required for collagen formation and protein synthesis. Low serum zinc levels have been
associated with impaired healing. Recommendations for treating pressure ulcers are usually 15 to 25
milligrams elemental zinc per day, which is 66 to 110 milligrams zinc sulfate.9 Improvement in wound
healing with zinc supplementation has not been shown in patients who were not zinc-deficient. In
addition, long-term excessive use of zinc supplementation can induce a copper deficiency, so zinc
should be taken for 10 days and then the wound should be reassessed.17,18,19

• Arginine and glutamine are helpful in healing pressure ulcers. They support muscle synthesis and
help maintain a healthy immune system.20,21 Arginine supplementation appears to benefit wound
healing even if the patient is not deficient. Oral supplementation of 17 to 24.8 grams free arginine per
day has been shown to affect wound healing. The safe maximum supplementation for glutamine is 0.57
grams per kilogram.9

Follow-Up Care
After the initial nutrition intervention is completed, patients must be monitored to assess whether their
plan of care is being followed and to see whether the pressure ulcer is healing. Communication
between all members of the medical team can provide invaluable information. Since the dietitian can’t
be with the patient at all meals, meal rounds and calorie counts are essential. A red flag is raised if
patients eat less than 50% of their food over three days when compared with their usual eating patterns.
Weekly weights and prealbumin should be checked to monitor the patient’s nutritional status. Albumin
has a longer half-life than prealbumin and therefore won’t be as good an indicator of the patient’s
current nutritional status.

If it is observed through meal rounds, calorie counts, or team meetings that the patient has poor intake,
he or she should eat small, frequent meals to consume an adequate amount of calories. The doctor may
also want to prescribe an appetite stimulant.

Nutrition supplements help increase the patient’s caloric, protein, and fluid intake. There are a variety
of supplements to choose from, ranging from 240 to 360 calories and 8 to 14 grams of protein per 8-
ounce serving. The supplements are available in clear liquid, full liquid, pudding, and powder form, as
well as being disease-specific, such as for patients with diabetes or kidney disease. Some formulas also
contain arginine and glutamine. Therefore, a supplement can be chosen based on the patient’s specific
medical condition.

Tube feeding and/or total parenteral nutrition may be necessary if the patient is not consuming enough
food and/or supplements. There are tube-feeding formulas available that provide 20% to 25% of
protein calories, the recommended amount of protein for healing pressure ulcers. Some of these
formulas are also rich in vitamin C and zinc, as well as fortified with arginine. Semielemental feeds are
recommended in patients with albumin <2.5 grams per deciliter.22

Nutrition plays a critical role in the prevention and management of pressure ulcers. The older
population (aged 65 or older) comprised approximately 13% of the U.S. population in 2003 and is
expected to more than double in number to 71.5 million, or 20% of the population, by 2030.23

Older adults experience an increased incidence of pressure ulcers. Since this population is growing, the
medical team must take an active role in assessing patients at risk for developing a pressure ulcer. The
sooner the intervention, the better the outcome.

— Amy Fleishman, MS, RD, CDN, is the clinical nutrition coordinator for the program for
surgical weight loss at Mount Sinai in New York City. She recently served on the New York
University Skin Care Committee and lectured to several hospitals on wound care.

References
1. National Pressure Ulcer Advisory Panel. Pressure ulcer prevalence, cost and risk assessment:
Consensus Development Conference statement. Decubitus. 1989;2:24-28.

2. National Pressure Ulcer Advisory Staging Report. 2003. Available at:

http://www.npuap.org/positn6.html. Accessed September 5, 2004.
3. Barczak CA, Barnett RI, Childs EJ, Bosley LM. Fourth national pressure ulcer prevalence survey.
Adv Wound Care. 1997;10:18-26.

4. Langemo DK, Olson B, Hunter S, et al. The incidence of pressure sores in acute care, rehabilitation,
extended care home health, and hospice in one locale. Decubitus. 1989;2:42.

5. Allman RM. Pressure ulcers among the elderly. N Engl J Med. 1989;320:850-853.

6. Beckrich K, Aronovitch SA. Hospital-aquired pressure ulcers: A comparison of costs in medical vs.
surgical patients. Nursing Economics. 1999;17:263-271.

7. Thomas DR. Improving outcome of pressure ulcers with nutritional interventions: A review of the
evidence. Nutrition. 2001;17:121-125.

8. Braden Scale for Predicting Pressure Ulcer Risk. 2001. Available at: http://www.bradenscale.com.
Accessed September 6, 2004.

9. Thompson CW. Nutrition and adult wound healing. 2003. Available at:
http://www.nutritioncare.org/listserv/wound%20healing.pdf. Accessed September 26, 2004.

10. Thomas DR, Goode PS, Tarquine PH, Allman R. Hospital acquired pressure ulcers and risk of
death. J Am Geriatr Soc. 1996;44:1435-1440.

11. Position of the American Dietetic Association: Liberalized diets for older adults in long-term care.
J Am Diet Assoc. 2002;102:1316-1323.

12. Anderson CF, Wochos DN. The utility of serum albumin values in the nutritional assessment of
hospitalized patients. Mayo Clin Proc. 1982;57:181-184.

13. Bourdel-Marchasson I, Barateau M, Rondeau V, et al. A multi-center trial of the effects of oral
nutritional supplementation in critically ill older inpatients. Nutrition. 2000;16:1-5.

14. Chernoff RS, Milton KY, Lipschitz DA. The effect of a very high-protein liquid formula on
decubitus ulcer healing in long-term tube-fed institutionalized patients. J Am Diet Assoc.
1990;90:A130-A139.

15. Rackett SC, Rothe MJ, Grant-Kels JM. Diet and dermatology. The role of dietary manipulation in
the prevention and treatment of cutaneous disorders. J Am Acad Dermatol. 1993;29:447-461.

16. Hunt TK. Vitamin A and wound healing. J Am Acad Dermatol. 1986;15:817-821.

17. Sandstead HH, Henriksen LK, Greger JL, et al. Zinc nutriture in the elderly in relation to taste
acuity, immune response, and wound healing. Am J Clin Nutr. 1982;36:1046-1059.

18. Kohn S, Kohn D, Schiller D. Effect of zinc supplementation on epidermal Langerhans’ cells of
elderly patients with decubital ulcers. J Dermatol. 2000;27:258-263.

19. Cario E, Jung S, Harder D’Heureuse J, et al. Effects of exogenous zinc supplementation on
intestinal epithelial repair in vitro. Eur J Clin Invest. 2000;30:419-428.

20. Kirk SJ, Hurson M, Regan MC, et al. Arginine stimulates wound healing and immune function in
elderly human beings. Surgery. 1993;114:155-160.

21. Barbul A, Lazarou SA, Efron DDT, et al. Arginine enhances wound healing and lymphocyte
immune responses in humans. Surgery. 1990;108:331-337.
22. Borlase BC, Bell SJ, Lewis EJ, et al. Tolerance to enteral tube feeding diets in hypoalbuminemic
critically ill, geriatric patients. Surg Gynecol Obstet. 1992;174:181-188.

23. A Profile of Older Americans: 2003. Washington, D.C.: Administration on Aging. 2003. Available
at: http://www.aoa.gov/prof/Statistics/profile/2003/2003profile.pdf. Accessed September 18, 2004.