Nutrition & Skin for The Rural Nurse Residency program

1. Nutrition & SkinforThe Rural Nurse Residency program Presented by: Becky McCarver MS RD LD October 8, 2010

2. Objectives • Maintain skin integrity • Focus on health, maintenance & healing of skin • Focus on preventing skin breakdown & pressure ulcers • Recognize individuals at risk for developing a pressure ulcer • Identify interventions available to implement on individuals identified to be at risk

3. WHAT LIES BENEATH. . . The Largest Organ of the Body

4. Skin Assessment • Assess on admission to the hospital, daily, and any time the patient condition changes. • Skin breakdown risk factors • Hyperglycemia • Dehydration • Malnutrition • Just 5% unintentional weight loss in 30 days • Obesity • Fat does not provide good nutrients for healing • Edema • Immobility • Appliances • Skin Integrity • Age • Diagnosis/Medications • Incontinence

5. Skin Assessment • Look at areas of greatest risk on the skin • Bony prominences • Skin contact: anything that touches the skin • Braces, TED hose, Bi-PAP masks, tubes, O2 tubing, NG tubing, heel/elbow foot protectors, Foley catheter, I.V. tubing and hubs, jewelry etc. • If it is covered – uncover and inspect site • Turn patient to do head to toe skin assessment

6. Observe & Document • Breakdown • Redness • Abrasion • Poor skin turgor • Dry skin can also be a risk factor for ulceration • Look in all folds, cracks & crevices • DOCUMENT any variation from normal • Braden Scale

7. Braden Pressure Ulcer Risk Assessment Tool • A screening tool to be used in adjunct with critical thinking skills and clinical judgment • Different areas are assessed to identify patients at risk for breakdown: • Sensory perception • Moisture • Activity • Mobility • Friction/shear • Nutrition

8. NutritionAn ounce of prevention . . . • Biggest mistake made – Not identifying nutrition risk prior to development of a wound.

9. An ounce of prevention . . . • Risk factors are extrinsic or intrinsic • Extrinsic • pressure, physical restraints, friction, shear & moisture • Intrinsic • immobility, hip fracture - surgery, Cancer/steroid therapy, incontinence, age, CVD, edema, sepsis, COPD, PVD, DM, terminal dx, dialysis, depression, obesity, previous wound, recent weight loss, poor intake, malnutrition, dementia, substance abuse or dehydration

10. Indicators of malnutrition are the same for skin breakdown

11. Nutrition • No two wounds are created alike, assessment & treatment must be individualized. • Focused Nutrition/Skin Risk Assessment • Nutrition screen within 24 hr of admit • Physician ordered consult • Referral per nursing • Wound Care Team referral • Correction of nutritional deficiency • Macronutrient: Calories, protein & fluids • Micronutrient: vitamins, minerals & conditionally essential nutrients

12. Nutrition Assessment – A, B, C, D • Anthropometrics • Accurate ht/wt is essential to estimating kcal/protein & fluid needs • Assessment of weight change/BMI • Biochemical • Serum albumin – 21 day ½ life • Serum albumin changes with hydration status • C-reactive Protein/Pre-albumin • CRP/PAB Inversely proportional • Prealbumin is a better indicator of nutrition status • Prealbumin has a 2-3 day ½ life • Prealbumin doesn’t change with hydration status

13. Nutrition Assessment – A, B, C, D • Clinical • Medical Condition & Treatments • Nausea/Vomiting/ability to tolerate PO • Diarrhea • Past Medical History • Wound size, location, type & output/drainage • Patient understanding of the importance of good nutrition • Diet • Food & cultural preferences • Liberalize restricted diets as able (e.g. No Added Salt vs. 2 gm Na) to increase PO • Food intake & functional ability • Hydration

14. New International Pressure Ulcer Guidelines 2009 • 66 Recommendations • 12% of Recommendations “A” level • Nutrition Guidelines “A” level • NPUAP White Paper on Nutrition • 19 Statements • Screen & Assess Nutritional Status • Provide Sufficient Calories • Provide adequate but not excessive protein • 1.25-1.5 g protein/kg with PU • Modify for renal impairment • Provide & encourage fluid intake • Provide adequate but not excessive vitamins & mineral • More research needed

15. Nutrition Intervention for Wounds

16. Clinical Nutrition Intervention • Starts with thorough screening for nutrition • Based on individualized nutrition assessment • Typical interventions • Calorie count/intake study • Enhanced/Fortified meals • Extra foods of patient’s preference • 2 oz 2 kcal with med pass 4x/d vs. 8 oz supplements 3x/d • High kcal/high Pro snacks/6 small meals • Micronutrient & modular supplement • Nutrition Support considerations • Referral to multidisciplinary care team

17. Nursing Interventions for better Nutrition • Provide optimal meal time • Sit up, assistance prn, protect meal time • Monitoring to advance diets </=2-3 days from NPO/Clear Liquids • Offer snacks • HYDRATE • have water within reach of patient • Recording Intake Correctly • Daily Weights • Alert Dietitian with concerns • Other consults – Pharmacy, OT, ST, Social Services, Diabetes Ed, etc.

18. What are ideal snacks? • Carbohydrates, Protein & Fluids

19. Who is at higher risk for skin breakdown? Elderly Woman Middle Age Woman Age 45 Stable wt. Stable appetite Hip Fracture Depression BMI 42.5 • Age 90 • Unintentional Wt Loss • Poor Appetite • Pneumonia • Dementia • BMI 18.2

20. Case Study • 74 yo female with Tib Fib Fx • WCB x 1 year • Refusing to be turned • Incontinent & UTI • Depressed • BMI 48.4 • Poor PO & doesn’t like water • Alb 3.3 • Skin: • Braden scale score 13 • Stage 2 pressure ulcer on buttocks • skin ulcer on left lower leg • Reddened skin under pannus, breast and in groin • Wound Care Team consult ordered • “Nutrition Screen” = low risk

21. Case Study- What would you do? • What did I do? • Educated pt on nutrition & skin • Set up snacks with protein, fruit & Breeze • Educated pt that wt loss can be later • Encouraged her to eat & drink!

22. Nutrition • Let nothing which can be treated by diet be treated by any other means • Maimondes