Pressure ulcers in a spinal cord injury patient

1. Case Study:
Pressure Ulcers
in a SCI Patient
Presentation by Lily Doher, Dietetic Intern of MGL
December 5, 2014

2. Learner Objectives
• Learners should be able to…
• Gain a comprehensive understanding of how a patient’s
social, health and medical history can influence their
condition and recovery.
• Explain the pathophysiology of pressure ulcers.
• Recall conditions or factors that may increase a patient’s risk
for developing a pressure ulcer(s) and how these conditions
may complicate the treatment of pressure ulcers.
• Demonstrate the medical nutrition therapy and nutrition
care process for a patient with pressure ulcers.

3. Introducing the Patient
• A.L.
• 34 year old male
• Paraplegic T8 down
• Admitted Sept 6, 2014
• Dx: complicated UTI
• Severe pressure ulcers

4. Role of the RD in SCI
• Active in acute phase, rehabilitation setting and
community setting
• Evidence suggests MNT provided by RD results
in…
• Improved nutrition-related outcomes
• Adequate nutrient intake
• Weight
• Bowel management
• Dysphagia
• Pressure ulcers

5. Medical Nutrition Therapy

6. Nutrition Assessment
• Client history
• Food- and nutrition-related history
• Anthropometrics
• Nutrition-focused physical findings
• Biochemical and medical tests,
procedures

7. Medical History
• Anxiety, GERD, CKD
• Suicide attempt 09/2009– stab wound to RUQ
• Multiple ER visits for ETOH intoxication
• Pressure ulcers first appeared in 2012
• MGL 12/2013 for ulcers
• Per ER Triage: wounds neglected, down to the bone
• MGL 01/2014 for stage 4 pressure ulcers, osteomyelitis
• DKA 4 times, hyperglycemia 4 times

8. Medical History
• Type 1 diabetic for 26 years
• States BS well-controlled at home
• Checks BS at least 2x/day, usually 3 with meals
• Home medications
• Multivitamin
• Levemir– 40 units
• Long acting insulin
• Aspart Injection– 6 units
• Fast-acting mealtime insulin
• Preferably TID with meals

9. Social History
• July of 2011– lost house
• August 2011– bought new house in Lansing
• Needed repairs, which AL did himself
• Spent weeks working in moldy basement, no
mask
• Fell ill  Hospitalization  Dx of Transverse
Myelitis

10. What is Transverse Myelitis?
• Rare neurological disorder; inflammatory disease
that causes injury to spinal cord
• Exact cause is unknown
• “viral, bacterial, fungal and/or even parasitic […]
etiology.”
• Attacks of inflammation can damage/destroy myelin
• Creates nervous system scars that interrupt
communication between spinal nerves and rest of
body

11. What is Transverse Myelitis?

12. What is Transverse Myelitis?
• Symptoms advance in as little as hours to weeks
• 1/3= full recovery
• 1/3= fair recovery, some significant deficits
• Spastic gait
• Sensory dysfunction
• 1/3= no recovery
• Paraplegic or quadriplegic

13. Social History
• Earned GED
• LCC  MSU
• Licensed builder and certified mechanic
• Unemployed since becoming paraplegic
• Disability  Medicaid coverage

14. Social History
• Lives alone in apartment with his cat
• “Plain” and “boring” life
• No socialization outside of family
• Family support:
• Mother, brother and sister all live in same complex
• Very close with nephew
• Father passed away from renal disease

15. Social History
• Does not drink– Hx of ETOH abuse
• Smokes tobacco, chews tobacco @ hospital
• Sleeps 8-10 hours/night
• Does not exercise d/t paralysis
• Could do arm exercises but chooses not to
• No appetite
• Uses medical marijuana to increase PO intake

16. Appetite in SCI
• “A person with a [SCI] above the level of the abdomen cannot
feel if their stomach is hungry or full, so they have to remember
when to eat and how much to eat.”
• Visceral sensory information is transmitted to the brain
through the afferent vagus nerve
• Ghrelin, a peptide produced in the stomach, travels to the
hypothalamus to stimulate feeding
• A study done in rats found that blockade of the gastric vagal
afferent abolished ghrelin-induced feeding
• This explains why a person with a spinal cord injury does not feel
hunger sensations

17. Medical Marijuana and
Appetite
• Cannabinoids: natural compounds found in marijuana, act on
specific receptor sites within the brain and reflect the
physiological role of their natural ligands
• Ex: Delta-9-tetrahyrdocannibinol (THC)
• Endocannabinoids: substances occurring naturally in the body
that activate cannabinoid receptors
• Ex: N-arachidonoylethanolamine (anandamide)
• Cannabinoid receptors: cell membrane receptors that are
activated by three major groups of ligands: endocannabinoids,
plant cannabinoids and synthetic cannabinoids
• CB1 (located in central nervous system)
• CB2 (located in periphery)

18. Medical Marijuana and
Appetite
• Endocannabinoids initiate appetite by stimulation of CB1
receptors in the hypothalamic areas involved in the
control of food intake
• Endocannabinoids contribute to incentive processes and
to hedonic evaluation of food
• “wanting” and “liking”
• Induce a psychological craving for
food and not just a physiological

19. Nutrition Knowledge
• States knowledge of nutrition is “stellar”
• Food intake history:
• Lots of protein/meats
• Hamburgers, eggs, chicken, peanut butter, whey
• Drinks mostly water, no pop or sugary beverages
• Wide variety of vegetables
• Asparagus, squash, eggplant, Brussels sprouts
• Stays away from sugar
• Small portions d/t not being able to feel full

20. Demographics
AL
Food stamps
No grocery
stores in
walking
distance
Party store
access via
wheelchair
Homecare
nurse

21. Homecare Nurse
• 5 days/week, 8 hrs/day through Home Care
Alternatives
• Provides wound care (pt does not f/u w wound clinic)
• Per social work: pt regularly declines in-home skilled
care soon after he returns from the hospital 
repeatedly d/c from homecare for noncompliance
• Does not want strangers in his home
• Pt recently d/c with Sparrow Hospice  declined
visits from hospice nurse  discon’t for
noncompliance  admitted to MGL next day

22. Handicaps Related to Eating
• Does not cook for himself
• Able to take bus to grocery store if
needed
• Usually brother or caregiver shops for him
• Brother/caregiver prepares food
• 3 meals/day
• Snacks he gets himself

23. Anthropometrics
• Ht: 66”
• Current wt: 145#
• BMI: not to be used for pt’s with SCI
• IBW: 142#
• AIBW for paraplegia: see Metropolitan Life Tables
• UBW pre-paraplegia: 172#
• Wt Hx: 10/10/12 165#, 01/12/14 157#

24. Metropolitan Height and
Weight Tables

25. Nutrition-Focused Physical
Findings
• Gastrointestinal issues and bladder/bowel dysfunction
• Occur in 27%-62% of pt’s with a SCI
• Multiple UTI’s
• Unable to control bladder  need for catheter  increased risk
of infection
• Colostomy
• Dental issues
• Cavities  had to get 19 teeth pulled
• Full upper denture set
• States does not affect his eating

26. Nutrition-Focused Physical
Findings
Stage IV Ulcer Sacrum
• 3 cm long
• 2 cm wide
• .4 cm deep
• Slough pink
• Granulation pink
Unstageable Ulcer
Posterior Scrotum
• 2 cm long
• 1 cm wide
• .7 cm deep
• Moderate tan
drainage

27. Pressure Ulcers
• AKA bedsores, pressure sores, decubitus ulcers
• Injuries to skin and underlying tissue resulting from prolonged
pressure
• Often develop on skin that covers bony areas of the body
• Buttocks
• Hips
• Elbows
• Heels
• Shoulders
• Can quickly develop, often difficult to treat

28. Epidemiology
• Incidence:
• 2.3% to 23.9% in long-term care
• 0.4% to 38% in acute care
• 0% to 17% in home care
• Prevalence:
• 2.3% to 28% in long-term care
• 10% to 18% in acute care
• 0% to 29% in home care
• Higher level SCI lesions =  risk
• Fuhrer MJ, et al: 33 of 100 pt’s with stage II or greater

29. Pathophysiology
• Pressure disrupts normal circulation to skin and deep
structures
• Complex vascular system (large veins and capillaries)
runs throughout the dermis to supply the skin
• Arteriole capillary pressure  32 mmHG = disrupted
blood flow
• Venous capillary closing pressure  8-12 mmHG =
impedes return of flow
• Prolonged pressure  ischemia, necrosis, ulceration

30. Pathophysiology

31. Etiology
• Immobility
• Age
• Lack of sensory perception
• Weight loss
• Poor nutrition/hydration
• Excessive moisture or
dryness
• Bowel incontinence
• Medical conditions affecting
blood flow
• Smoking
• Limited alertness
• Muscle spasms

32. The Braden Scale

33. AL’s Risk Factors
• Braden Score 12/23
• Immobility
• Lack of sensory perception
• Bowel incontinence
• Smoker
• Poor nutrition (?)

34. Wound Staging

35. Stage I

36. Stage II

37. Stage III

38. Stage IV

39. Unstageable

40. Suspected Deep Tissue Injury

41. Medical Treatment
• Negative pressure wound therapy (NPWT)
• Vacuum pump, drainage tubing, foam or gauze wound
dressing, and an adhesive film dressing that covers and
seals the wound
• Wound V.A.C.
• Creates continuous or intermittent negative pressure
inside the wound to remove fluid, exudates, and
infectious materials
• Maggots
• To clean out the necrotic tissue

42. NPWT/Maggots
Medical Treatment

43. Medical Treatment
• Surgical/sharp debridement: use to remove
large amounts of thick eschar and infected
tissue; or need for urgent debridement
• Mechanical debridement: used on wounds
with moderate necrotic tissue (eschar)
• Pressurized irrigation device
• Low-frequency mist ultrasound
• Specialized dressings

44. Surgical/Mechanical
Debridement

45. Medical Treatment
• Autolytic debridement: used on wounds with small to
moderate amounts of eschar; enhances body’s
natural process of using enzymes to breakdown dead
tissue
• Hydrocolloids
• Hydrogels
• Transparent film
• Enzymatic debridement: used on wounds with a
significant amount of necrotic tissue; involves
applying chemical enzymes and appropriate dressings

46. Autolytic/Enzymatic
Debridement

47. Medical Treatments
• Skin flaps
• Portion of skin and tissue moved to fill defect
• Results in a new defect at donor site
• Often can be closed primarily, sometimes requires skin grafting
• Axial
• Random
• Rhomboid
• Rotation
• V-Y Advancement
• Muscle flaps
• Moving a local muscle to cover an exposed bone or
fracture

48. AL’s Surgical History

49. AL’s Infection
• On 9/10 found infection in wound
• Gram negative bacilli three colony types, proteus species
+/T/ group D enterococcus
• Enterococci are a part of the normal intestinal flora of
humans and animals
• One study found in its subjects group D enterococcus was
one of the most common aerobic isolates from pressure
ulcers

50. Hospital Medications
Medication Classification Use Mechanism Possible FDI
Rocephin
Cephalosporin
Antibiotic
Treat bacterial
infections
Inhibits
mucopeptide
synthesis in the
bacterial cell
wall
Anorexia, dry
mouth, metallic
taste, N/V,
diarrhea,
constipation
Diflucan
Anti-fungal
medicine
Treat infections
caused by
fungus
Inhibits fungal
cytochrome
dependent
enzyme
N/V, abdominal
pain, taste
changes
Lovenox
Anticoagulant Treat or
prevent a DVT
or PE
Binds to and
accelerates the
activity of
antithrombin III
Nausea,
diarrhea

51. Hospital Medications
Medication Classification Use Mechanism Possible FDI
Nicoderm
Smoking
cessation
adjunct
Reduce craving
and withdrawal
symptoms
associated with
smoking
Binds to
nicotine
receptors in
body
Nausea
Protonix
Proton pump
inhibitor
Treatment of
conditions such
as ulcers or
GERD that are
caused by
stomach acid
Suppresses final
step in gastric
acid production
by binding to
the H+, K+
ATPase enzyme
system
at the secretory
surface of
gastric parietal
cell
Long-term use
may may it
harder for your
body to absorb
vitamin B12,
weight
changes, N/V,
diarrhea, gas,
stomach pain

52. Hospital Medications
Drug Class Mechanism Use Possible FDI
Cipro Quinolone
antibiotic
Inhibits
enzymes
required for
DNA processes
Treat infections
of the skin,
bone, sinus,
lung, abdomen
and bladder
Do not take
along with
dairy products
or
multivitamins
NovoLog Insulin aspart Bind to insulin
receptors and
increase cellular
uptake of glucose
and inhibiting the
output of glucose
from the liver
Fast-acting
form of insulin
that acts to
lower blood
glucose
N/A
Levemir Insulin detemir See above Basal insulin
that acts to
lower blood
glucose
N/A

53. Biochemical
“Cross-sectional studies associate… low
serum albumin, low serum cholesterol and
low hemoglobin levels with pressure
ulcers.”

54. Biochemical
9/7 9/8 9/9 9/10
Hemoglobin
(14-17 g/dL)
10.7 10.8 10.2 9.3
Albumin
(3.4-5.0)
1.9 2.0

55. Biochemical
9/6 9/7 9/8 9/9 9/10
White Blood
Cells
(4.5-10.5)
12.7 13 12.7 12.5 10.3
C-Reactive
Protein
(0-0.9 mg/dL)
4.0

56. Glucose Bedside
49
158
128
83
238
0
50
100
150
200
250
0:00 4:48 9:36 14:24 19:12 0:00
9/7 AccuChecks
*
*
*

57. Glucose Bedside
45
84
61
101
218
0
50
100
150
200
250
0:00 4:48 9:36 14:24 19:12 0:00
9/8 AccuChecks
*
*
*

58. Glucose Bedside
92
146 147
263
0
50
100
150
200
250
300
0:00 4:48 9:36 14:24 19:12 0:00
9/9 AccuChecks
*
*
*

59. Glucose Bedside
222
66
142
405
0
50
100
150
200
250
300
350
400
450
0:00 4:48 9:36 14:24 19:12 0:00 4:48
9/10 AccuChecks
*
*

60. Glucose Bedside
175
62
21
49
194
233
0
50
100
150
200
250
0:00 4:48 9:36 14:24 19:12 0:00
9/11 AccuChecks
*
*
*

61. Diabetes and Wound Healing

62. Hyperglycemia

63. “self-perpetuating loop”

64. Infection
• “The healing process in diabetes is also jeopardized by the
patient’s susceptibility to infection due to deficiencies on
the innate immunity.” Berlanga-Acosta et al.
• Hyperglycemia reduces the function of immune cells and
increases inflammation
• Dysregulation of the inflammatory response can lead to
extensive tissue damage
• Excess glucose reduces the functional longevity of
neutrophils
• Once a wound becomes infected it has a lower
probability of healing

65. Now that we have gathered all of the factors
affecting AL’s disease process, we are able to
make an appropriate diagnosis.

66. Nutrition Diagnoses
• Common nutrition diagnoses
• Inadequate oral intake (NI-2.1)
• Inadequate fluid intake (NI-3.1)
• Increased nutrient needs (NI-5.1)
• Malnutrition (NI-5.2)
• Inadequate protein intake (NI-5.7.1)
• Inadequate vitamin intake (specify) (NI-5.9.1)
• Inadequate mineral intake (specify) (NI-5.10.1)

67. Nutrition Diagnoses

68. Nutrition Intervention
• Reduced metabolic activity d/t denervated muscles
• BMR reported to be 14-27% lower for SCI pt than able-
bodied individuals
• Increased fat mass and loss of fat-free mass
• Sympathetic blunting, cardiopulmonary dysfunction, reduced
work capacity, and diminished anabolic hormones
• “Without diet adjustment to new metabolic requirements
after SCI, energy intake quickly exceeds energy
requirements, resulting in weight gain.” Crane DA et al.
• Clinical observations suggest SCI pt become obese within
first 12 months after injury

69. Nutrition Intervention
• Energy needs in paraplegia without pressure ulcer present
• 27.9 kcal/kg
• Protein needs in paraplegia without pressure ulcer present
• 0.8-1 g/kg
• Energy needs in paraplegia with pressure ulcer present
• 30-35 kcal/kg
• Protein needs in paraplegia with pressure ulcer present
• 1.2-1.5 g/kg for stage II
• 1.5-2.0 g/kg for stage III and IV

70. Nutrition Intervention
• Normal fluid requirements: 30 ml to 40 ml/kg
• No less than 1 ml/kcal
• May need additional 10 ml to 15 ml/kg
• Evaporation of fluids from severe pressure ulcer
• Draining or open wounds
• Fever
• Use of air fluidized bed set at high temperature

71. Nutrition Intervention
• Zinc
• Decrease in collagen and protein synthesis and impaired immune
competence
• Recommendation: 50 mg elemental zinc BID for 2-3 weeks maximum
• Vitamin A
• Impaired wound healing and altered immune function
• Recommendation: 10,000-50,000 IU/day
• Vitamin C
• Delayed wound healing
• Recommendations:
• 100-200 mg/day for stage I and II pressure ulcers
• 1,000-2,000 mg/day for stage III and IV pressure ulcers

72. Nutrition Intervention
• Glutamine
• Conditionally essential amino acid
• Key role in immune system, deficiency can slow healing
• Arginine
• Semi-essential amino acid
• Promotion of nitrogen balance, cell proliferation, T
lymphocyte fxn, collagen accumulation
• HMB
• Metabolite of leucine
• Inhibits muscle proteolysis, modulates protein turnover

73. Nutrition Intervention
• Williams JZ, Abumrad N, Barbul A. Ann Surg Sept
2002.
• Double-blind, randomized trial
• 35 healthy, nonsmoking humans 70 yrs or older
• 18 received HMB, glutamine and arginine suppl.
• 17 received isonitrogenous, isocaloric nonessential AA suppl.
• “Collagen synthesis is significantly enhanced in
healthy elderly volunteers by the oral administration
of a mixture of arginine, HMB and glutamine.”

74. Nutrition Intervention
• Wong A, Chew A, Wang CM, et al. J Wound Care May 2014
• Placebo-controlled trial
• 23 inpatients with stage II, III or IV pressure ulcers in an acute
care hospital
A. HMB, arginine and glutamine mixture BID
B. Standard nutrition care + oral nutritional supplements
• “The use of specialised amino acid does not appear to reduce
wound size and PUSH scores but may improve tissue viability
after 2 weeks. Further confirmation on a larger scale is required
to determine the benefits of supplementing additional HMB,
arginine and glutamine in patients with pressure ulcers.”

75. AL’s Nutrition Intervention
• 1600-2000 kcal/day (25-30 kcal/kg)
• 79-99 g PRO (1.2-1.5 g/kg)
• 1980 ml fluid (30 ml/kg)
• Regular diet
• Fruit punch Juven BID
• Strawberry Glucerna TID

76. What Would I Have Done
Differently?
• 2200 ADA diet (33.4 kcal/kg)
• Increased kcal intake for wound healing
• ADA diet for better glucose control
• 99-132 g PRO (1.5-2.0 g/kg)
• Stage IV pressure ulcers
• Special K protein bars, Glucerna only BID
• 50 mg elemental zinc BID
• 10,000-50,000 IU vitamin A
• 1,000-2,000 mg vitamin C

77. Monitoring and Evaluation
• Weight
• Anthropometrics
• Nutrient intake
• Wound stage/healing
• Hydration status

78. Monitoring and Evaluation
• Weight was stable throughout hospital visit
• Per meal intake record AL was eating 80-100% of
meals
• See previous slides for laboratory tests
• Post-op:
• Unstageable pressure ulcer debrided to stage III
• 9/10 started getting bedside I and D’s
• For wound healing and to help clear the infection

79. Prognosis
• After 6 months of treatment
• > 70% of stage II
• 50% of stage III
• 30% of stage IV
• Often develop in pt’s receiving sub-optimal care
• Long-term outcome is poor if care cannot be improved
(even if short-term wound healing was accomplished)
• Agency for Health Care Research and Quality 2006
• Pressure ulcers as primary diagnosis: 1 in 25 ended in death
• Pressure ulcers as 2nd diagnosis: 1 in 8 ended in death

80. Prevention
• Repositioning (q 2 hrs)
• Specialty mattresses
• Foam, water, air to help with positioning
• Head of bed raised no more than 30° to prevent
shearing
• Adequate nutrition to maintain skin integrity
• With care to pt’s activity status to prevent obesity
• Smoking cessation

81. Health Care Cost
• Estimated cost of treating pressure ulcers in 2008
• $9.2 to $15.6 billion
• Factor in 7% per year for health care inflation to get today’s
cost
• Reported cost for treating a pressure ulcer in an acute-
care setting (Centers for Medicaid/Medicare Services)
• $43,180 per hospital stay
• Cost Factors
• Increased length of stay d/t pressure ulcer complications:
pain, infection, decreased functional ability

82. Cost Effectiveness
• Likely that cost of prevention less than
treatment
• Reduced hospital visits
• Less recurrence of pressure ulcers
• i.e. ensuring adequate protein and
micronutrient intake to promote healthy
skin integrity and reduce risk of developing
a pressure ulcer

84. References
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85. References
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86. References
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