3.Registered Dietitian’s Role in a Bedsore Team
Chief, Clinical Nutritional Management Team, Hamamatsu Medical Center
When the pressure against the tissue overcomes the tissue tolerance against the pressure, patients sometimes experience pressure gangrene. Some of the external factors which influence the tissue tolerance are friction, rub, and infiltration. And some of the internal factors are malnutrition, an advanced age, a low arterial pressure, and an underlying disease. Especially, malnutrition causes the deterioration of the general condition, decreases the tissue durability, and delays the recovery of wound. The wound healing needs a lot of nutrients as well as the cell growth factor. Therefore, the evaluation of the nutrition status and the nutritional therapy should be performed in an appropriate time frame.
Malnutrition and dystrophy
Malnutrition which causes pressure gangrene includes ①lack of energy, ②deficiency of protein amino acid intake, ③lose of protein amino acid and defficiency of protein synthesis, ④intake defective of fat (especially, essential fatty acid), ⑤deficiency of iron, ⑥deficiency of vitamin C, and ⑦deficiency of trace element. Advanced age also cause pressure gangrene. The elderly sometimes experience loss of appetite, unbalanced diet, the dysfunction of masticatory, difficulty of swallowing, diarrhea, and constipation. Occasionally, they can not take enough meal resulting in shortage of energy and potential malnutrition. Therefore, appropriate nutrition management is necessary to improve a nutritional status.
Nutritional condition of patients with pressure gangrene
Four years ago, the bedsore list of 5,543 patients revealed that 311 patients (18%) had pressure gangrene. At that time of the evaluation, nutritional routes for those patients were the oral intake 40%, the peripheral parenteral nutrition 35%, the passing tube 10%, and TPN 15%. Half of the patient with oral intake had difficulty of swallowing and/or masticatory function. Therefore, they were given the deglutition food. In addition, half of the patients assumed to have malnutrition because of low score of the body measurement and serum albumin.
System of nutrition management of our hospital
The NST activity team, the deglutition activity team, and the bedsore activity team cooperate under the total nutritional support and bedsore meeting. All teams can look at the nutrient status of patients through an electronic clinical record and can cooperate together with the same information. The nurses who evaluate the nutritional status of patients in the wards (we call them as “link nurse”) can get the information of loss of intake, loss of weight, pressure gangrene and can work together with the registered dietitians and the pharmacists.
The role of registered dietitians
The treatment of pressure gangrene needs enough nutrition. Some patients have the underling disease and the difficulty of swallowing resulting in insufficiency of nutrition. We should decide which route of nutrition and what kind of meal have to be chosen as soon as possible after the evaluation. Otherwise, patients can not get enough nutrition.
Avoidance of pressure to the tissue, skin care, position change are important factor. However, the pressure gangrene deteriorates easily if the nutrient state is defective. It is necessary to evaluate the nutrient state to prevent and care the pressure gangrene. Appropriate nutrition management and care should be performed for prevention and treatment.