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Patients who are cared for in the Intensive Care Unit (ICU) are often bedridden. Because of the lack of mobility, they are at a greater risk for pressure ulcers and venous stasis ulcers. Because of the critical nature of the illness or injury that has brought the patient to the ICU, these same patients are often not able to consume food orally. Research has been done to determine the contribution of nutrition to wound healing. This is a difficult subject to research because many factors can contribute or interfere with wound healing. A study done by a group of Japanese researchers in 2002 attempted to isolate nutrition related changes. There is a specific patient identified that may benefit from the results of this study.
This patient, DD, is a 69 year old single, white female. She has no known drug allergies, and a history of COPD, morbid obesity, hypertension, anemia, arthritis, sleep apnea, and chronic wounds on the left lower extremity secondary to venous insufficiency. She is a non-smoker, non-drinker, and has no history of drug abuse. She is disabled, and is non compliant with diet and exercise.
DD was brought to the hospital Emergency department by ambulance on September 18, 2010. Upon arrival to ED, the patient was intubated due to increased difficulty breathing. DD was transferred to the ICU with a diagnosis of respiratory failure. There, a nasogastric tube was inserted and she was placed in bilateral wrist restraints. The patient was given Diabetisource for nutrition on at 60mL per hour. On hospital day two, she extubated herself. She was placed on oxygen via a non-rebreather mask, then bi nasal cannula by day three. Additionally, at the end of day three, the nasogastric tube was removed and the patient passed two swallow tests. The patient was then allowed a regular diet. On day five, the patient was moved to the step-down unit. The patient was discharged home after an unknown number of days.
Nursing Diagnosis and Rationale with Interventions
The primary nursing diagnoses for this patient are: impaired skin integrity related to chronic venous congestion as manifested by venous stasis ulcer on the left ankle; and imbalanced nutrition less than body requirements related to reduced intake of certain nutrients as manifested by albumin level of 2.9 and ionized calcium of 0.86. Interventions applied to these diagnoses would be: assess site of wound for signs and symptoms of infection, including redness, swelling, and drainage daily (frequent assessment of wounds helps in early identification in order to treat and prevent spread of infection). Assess patient's nutritional status by reviewing lab results daily for nutrients and electrolytes in proper balance (the patient needs adequate supply of protein and vitamin C, as well as other vitamins and minerals to promote cell growth and enhance wound healing). Keep wound site clean and dry (because bacteria thrive in moist tissue, keeping the wound clean and dry inhibits infection). Administer multivitamin daily per physician's orders to ensure adequate vitamins and minerals available for proper body function. Administer tube feedings as ordered by physician for nutritional support while patient is unable to consume foods by mouth.
Description of the Study
The study was conducted to determine the effects of nutrition on wound healing. The researchers evaluated pressure ulcers for improvement related to change in diet. The pressure ulcers were measured weekly for eight weeks, four weeks prior and four weeks after a change in nutritional intervention (Omote, Sugama, Sanada, Konya, Okuwa, Kitagawa, 2005). The above mentioned patient has factors that mirror those of the subjects used in the study.
The researchers cited at least twenty-eight different sources in their report. Related to the basis of the study, seven different studies were identified. The major issue identified in the literature search was the difficulty in isolating nutrition as the sole factor in wound changes. This has caused a delay in clinical application (Omote, et. al, 2005). There are studies that refute the notion of nutrition enhanced healing, while other studies support it. Variances that have interfered with previous studies include lack of standard mattress types or positional changes, lack of wound care records, and lack of general information about the patient (Omote, et. al, 2005). The references supplied with the report of this study range from 1943 to 2004. This appears to be a relatively thorough literature review and encompasses a wide range of studies.
Methods and Design
This study used both qualitative and quantitative measurements. "The healing process
was measured qualitatively using wound sketches and quantitatively using wound surface area
and DESIGN score" (Omote, et. al, 2005). Fifteen subjects chosen for this study were patients who were elderly, had an existing pressure ulcer that had been staged as II or III, were residing in long term care facilities in Kanazawa City, Japan between December 2001 and October 2002, and who also had a change in their nutrition regimen. Certain patients were eliminated right away, such as those who were in a facility that did not provide "care according to the standards of the Prevention and treatment guidelines for pressure ulcers" (Omote, et. al, 2005, p. 85). Other reasons for elimination were deterioration of the general condition related to the primary disease, reaction to medications used for wound care, and no change in the nutritional regimen (Omote, et. al, 2005). The final seven patients meeting the criteria for the study were evaluated weekly for four weeks prior to a nutritional regimen and for four weeks after the change. Of the seven patients, two were on oral feedings and the remaining five were on tube feedings. All were prescribed increased protein in their diet (Omote, et. al, 2005). The data collection instruments used were: weekly photographs of the wound status using a single lens reflex camera and colored pencil sketches; the DESIGN (Depth, Exudate, Size, Inflammation, Granulation tissue, Necrotic tissue, and Pocket) tool for classifying severity and monitoring progress of the wound; nutritional intake measurements (for = 100% the facility's meal composition table was used, for <100%, the formula 100kcal/100g from the standard tables of food composition of Japan was used); anthropometrics (weight, height, BMI, and arm muscle circumference or AMC); biochemical analysis from the monthly chemical records (serum total protein, serum albumin, hemoglobin); and the Braden scale (Omote, et. al, 2005).
The study found that all seven of the patient showed improvement in their wounds after four weeks on the new nutritional therapy. "There was improvement after the change in the
nutritional regimen, particularly in wound surface area, depth of the wound, and the color and appearance of granulation tissue, which was reflected in changes in the DESIGN scores" (Omote, 2005, p.89). This intervention can be used to enhance wound healing. However, based on this study, more subjects should be evaluated to confirm the results that increased protein alone can induce healing. The overall quality of the study was good based on the care of the researchers to isolate those patients who could be evaluated on nutritional changes alone. This intervention could be applied to the patient listed above to improve the outcome of her stasis ulcer.
There are at least two national guidelines that include the implementation of nutritional support to treat pressure ulcers and other wounds. They are The Registered Nurses' Association of Ontario - Professional Association Guideline "Risk assessment & prevention of pressure ulcers" and The Hartford Institute for Geriatric Nursing - Academic Institution Guideline "Preventing pressure ulcers and skin tears. In: Evidence-based geriatric nursing protocols for best practice." Both of these guidelines can be found on the website www.guideline.gov. There one will find a link to the organizations that sponsor these guidelines. Based on the study findings, this intervention could greatly benefit the patient listed above, Ms. DD. She shows signs of malnutrition and has had a leg wound for several months that is slow healing. Providing better nutrition with increased amounts of protein would greatly enhance the healing process of her leg ulcer. However, since Ms. DD has a history of non-compliance, extra steps would have to be taken to keep her on track. She has at least two daughters that live in the area who may be able to help monitor Ms. DD's progress and ensure she is receiving the right nutrition. Including them in the assessment and treatment planning would be an excellent idea.
In conclusion, the study performed by the Japanese researchers was a good start on isolating the benefits of increased protein and calories on wound healing. More studies performed in a similar fashion with greater numbers of subjects would be much better. Although more research is needed, there would be no harm in implementing this intervention for patients who have no protein or calorie restrictions.