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How Nutrition Plays a Role in Wound Healing. Kelsey L. Puffe Concordia College, Moorhead, MN September 25, 2008. Objectives:. Be able to describe pressure ulcers Identify contributing factors to development of pressure ulcers Identify the different stages of pressure ulcers

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how nutrition plays a role in wound healing

How Nutrition Plays a Role in Wound Healing

Kelsey L. Puffe

Concordia College, Moorhead, MN

September 25, 2008

objectives
Objectives:
  • Be able to describe pressure ulcers
  • Identify contributing factors to development of pressure ulcers
  • Identify the different stages of pressure ulcers
  • Identify recommended treatment and nutritional treatment for pressure ulcers
bed sore or pressure ulcers
Bed Sore or Pressure Ulcers
  • Pressure Ulcers- begin as tender, inflamed patches that develops when a person’s weight rests against a hard surface, exerting pressure on the skin and soft tissue over bony parts of the body.
    • 95% develop on the lower part of the body

Skin Problems & Treatments Health Center: Pressure Ulcers (2007): 15 Sept. 2008 http://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores

cause
Cause
  • This is most likely to happen when the person is confined to a bed or wheelchair for long periods of time and is relatively immobile.
    • Constant pressure on the skin and tissues
    • Sliding down in a bed or chair, forcing the skin to fold over itself
    • Being pulled across bed sheets or other surfaces
    • Moisture that stays on the skin
stage 1 of pressure ulcers
Stage 1 of Pressure Ulcers
  • The National Pressure Ulcer Advisory Panel (NPUAP) recommends classification of bedsores in 4 stages of ulceration based primarily on the depth of a sore at the time of examination.
    • Stage 1: Intact skin with redness (erythema) and sometimes with warmth
stage 2
Stage 2
  • Partial-thickness loss of skin, an abrasion, swelling, and possible blistering or peeling of skin
stage 3
Stage 3
  • Full-thickness loss of skin, open wound (crater), and possible exposed under layer.
stage 4
Stage 4
  • Full-thickness loss of skin and underlying tissue, extends into muscle, bone, tendon, or joint. Possible bone destruction, dislocations, or pathologic fractures (not caused by injury).
a doctor should be notified whenever a person
A doctor should be notified whenever a person:
  • Will be bedridden or immobilized for an extended period of time
  • Is very weak or unable to move
  • Develops redness (inflammation) and warmth or peeling on any area of skin
common places for pressure ulcers
Common Places for Pressure Ulcers
  • Bony parts of the body
    • Ankles
    • Back of the Head
    • Heels
    • Hips
    • Knees
    • Lower Back
    • Shoulder Blades
    • Spine
how to prevent pressure sores
How to prevent pressure sores
  • Prevent constant pressure on any part of the body.
  • Change positions
  • Turn often to reduce constant pressure on skin
  • Learn the proper way to move yourself to avoid folding and twisting skin layers
  • Spread body weight
  • Cushions, pad metal parts of wheelchair
  • GOOD NUTRIENT INTAKE IS ESSENTIAL
  • Barrier lotions or creams that have ingredients that can act as a shield to help protect the skin from moisture and irritation
immediate medical attention is required whenever
Immediate medical attention is required whenever:
  • Skin turns black or becomes inflamed, tender, swollen, or warm to the touch
  • The patient develops a fever during treatment
  • A bedsore contains pus or has a foul-smelling discharge
risk factors for impaired healing
Risk Factors for Impaired Healing
  • Advanced age
  • Diabetes
  • Impaired immunity
  • Underweight
  • Obesity
  • Malnutrition
  • Medications
  • Infections
  • Moisture
  • Cognitive impairment/ altered sensory perception
who is typically affected
Who is typically affected?
  • Older people and individuals with spinal cord injuries
  • Malnutrition, immobility, pressure, shear forces, friction, sensory perception, and skin exposure to moisture can contribute to pressure ulcer incidence
  • Bed-Bound
  • Paralyzed
  • Elderly patients undergoing treatment for other diseases
  • Poor physical function, less able to perform self-care, less mobile
statistics
Statistics
  • One million people in the United States develop bedsores at a treatment cost of $1 billion
  • Two thirds of all bedsores occur in people over age 70
  • Pressure sores have been noted as a direct cause of death in about 8% of paraplegics
  • 1992, Federal Agency for Health Care Policy and Research reported that bedsores afflicted
    • 10% of all hospital patients
    • 25% of nursing home residents
    • 60% of quadriplegics

Bedsores (2007): 15 Sept. 2008 http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html

concerns
Concerns
  • The number one concern is MALNUTRITION
  • Misdiagnosis
  • Care can be very costly and lengthy for patients and hospitals

- Increases nursing care time by 50%

- Prolonged hospitalizations

- 90% recurrence rate

- Higher hospital costs

- Costs increase as pressure ulcer stage advances

consequences
Consequences
  • Cellulitus- acute infection of connective tissue
  • Bone and joint infections
  • Necrotizing fasciitis- destroys tissues around muscle
  • Gas gangrene
  • Sepsis- blood infection
  • Cancer
ethical issues
Ethical Issues
  • Knowing that Pressure Ulcers are preventable
  • Nutrition Intervention is a great approach
  • Knowledge of how to prevent and treat Pressure Ulcers
  • Recognizing that hospitalized and wheelchair people are more susceptible to Pressure Ulcers
  • Reluctance of health care providers to diagnose Pressure Ulcers & at a early enough stage
    • Don’t want to take the blame for development
    • Increasing demands of healthcare intervention accountability by legal professionals
treatment
Treatment
  • Focuses on preventing a sore from getting worse and on making the skin healthy again
    • Relieving pressure on the area by changing positions often and spreading body weight evenly with special mattresses
    • Keeping the sore clean and covered, not letting it dry out
    • Eating a healthy diet with enough protein to help the skin heal
    • Keeping healthy tissue around a pressure sore clean and dry
    • Removing dead tissue and applying medicated ointments or creams to reduce the risk of infection.
treatment21
Treatment
  • Most stage 1 and 2 pressure sores will heal within 60 days with proper treatment
  • Stage 3 and 4 can take months or even years to heal
  • Progress is slow, continued care and treatment can prevent complications such as further tissue damage, infection, and pain
home treatment
Home Treatment
  • Use cushions
  • Use sheepskin layers or foam alternatives on chairs and beds
  • At least every 2 hours, reposition yourself
  • Avoid using doughnut-type devices or boots fill with air to support heals
  • Keep yourself active
  • Inspect skin daily, learn to recognize what a pressure ulcer is
  • Keep skin clean and free of sweat, wound drainage, urine, and feces
  • Moisturize skin with lotion, limited exposure to dry cold weather
  • Provide good nutrition through a healthy diet with enough protein to keep skin healthy and able to heal more quickly
  • Maintain a healthy weight
slide23

“Effective nutritional assessment and subsequent support are essential to the prevention and treatment of pressure ulcers.”Marti Andrews, PhD, RD

laboratory values
Laboratory Values
  • Serum albumin < 3.5 mg/dL
  • Prealbumin < 16 mg/dL
  • Hematocrit < 33%
  • Hemoglobin < 12 g/dL
  • Transferrin < 100 mg/dL
  • Serum Cholesterol < 160 mg/dL
  • Weight: >5% in 30 days, or >10% in 180 days
  • Fluid intake less than 1,500 ml/24 hours over past seven days
  • Total lymphocyte count <1800 mm
  • BUN/ Creatinine > 10:1
nutrition care
Nutrition Care
  • Patient screening and assessment
  • Nutrition Intervention
  • Monitor
  • Reassess
nutrition goals
Nutrition Goals
  • Provide adequate calories
  • Prevent/Treat protein-calorie malnutrition
  • Promote wound healing
  • Provide adequate macro and micronutrients during all stages of the wound-care process
healing foods pyramid recommended servings
Healing Foods Pyramid- Recommended Servings
  • Water:64 to 96oz daily
  • Fruits: 2 to 4 servings daily
  • Vegetables: 5 servings daily
  • Grains: 4 to 11 servings daily
  • Legumes/soy: 2 to 5 servings daily
  • Healthy Fats: 3 to 9 servings daily
  • Seasonings: a variety of spices & herbs daily
  • Dairy:1 to 3 servings, emphasizing low-fat choices daily
  • Eggs: up to 1 daily
  • Fish & Seafood: 2 to 4 servings weekly, emphasizing a high omega-3 fatty acid intake
  • Lean Meats: 1 to 3 servings weekly
  • Alcohol: up to 2 servings daily
  • Dark Chocolate: up to seven oz weekly
  • Tea: 2 to 4 cups daily

Bareuther, Carol M. Food to Help You Mend. Today's Diet &Nutrition (2007): 34-37.

calories
Calories
  • Poor calorie intake is associated with poor protein, vitamin and mineral intake.
  • Calories equal energy and it takes a lot of energy to heal a wound.
  • Eat enough calories to “spare” the use of protein for energy.
  • Calories in your diet should come from a variety of “healthy sources”
  • 30 kcal/kg to 35 kcal/kg body weight
    • Lean meat
    • Beans
    • Legumes
    • Whole grains/cereals
    • Milk and milk products
    • Fruits
    • Vegetables
basic principles cho energy
Basic Principles—CHO & Energy
  • Carbohydrate
  • 55-60% of diet
  • Provide as complex CHO
    • Glucose is the main energy source for cells
  • Give insulin for glucose >250 mg/dL and decrease intake if severe hyperglycemia
  • Energy
  • May need to increase calorie intake by 50% or more depending on the severity of the wound.
  • Minimum of 30-40 kcals/kg/day
  • Use the Harris-Benedict formula to figure the energy need
basic principles protein
Basic Principles--Protein
  • 20-25% of diet from protein
  • The “building blocks” for tissue and wound repair.
  • Is involved in the making of cells, enzymes (for chemical reactions) and building connective tissue.
  • Increased protein intake decreases the net nitrogen losses by increasing the amino acid flow into the protein synthesis channel
  • 1.2g to 1.5g of protein/kg body weight

Stage I- 1.0 g/kg

Stage II- 1.0-1.2 g/kg

Stage III- 1.25-1.5 g/kg

Stage IV- 1.5-2.0 g/kg

  • Foods that are good sources of protein
    • All meats, Cheese, Cottage Cheese, Milk, Dry Milk Powder, Instant Breakfast, Egg, Beans, Pudding/custard, Peanut butter, Yogurt, Ensure HP, Boost

MeritCare

basic principles fat
Basic Principles--Fat
  • 25-30% of diet
  • Essential for cell membranes and required for the absorption and function of fat-soluble vitamins
  • Fatty acid deficiency disrupts skin integrity
  • Need to keep triglycerides in check
basic principles fatty acids omega 3
Basic Principles--Fatty Acids/Omega 3
  • Type of polyunsaturated fatty acid
  • Essential fat because the body cant make it
  • Proper brain growth and development
  • An anti-inflammatory
  • Regulate mood by increasing serotonin levels
  • Recommended 2 to 3 oz servings of fatty fish per week
    • Cold water fish, wild game, walnuts, leafy greens, canola oil, flaxseed
basic principles micronutrient support
Basic Principles -- Micronutrient Support
  • Vitamin A
    • Important for maintaining healthy skin and mucous membranes
    • Plays a important role in our immune system
    • RDA is 5000 iu
    • In wound healing- take 3- 4 times the recommended RDA for 1-2 weeks
      • Tomato Juice, Apricots, Cantaloupe, Nectarine, Green Beans, Broccoli, Carrots, Squash, Brussels Sprouts, Yams, Sweet Potatoes

MeritCare

basic principles micronutrient support34
Basic Principles - -Micronutrient Support
  • Vitamin C
    • Plays an important role in the formation of collagen and cell production
    • RDA is 60 milligrams
    • Daily supplement of 500mg may be beneficial if a patient is deficient in Vit. C or has pressure ulcers
    • In wound healing- requirement is much greater. May be advised to take additional vitamin C in a pill form.
      • Orange Juice, Cranberry Juice, Honey dew, Tangerine, Brussels sprouts, Grapefruit, Kiwi fruit, Strawberries, Broccoli, V-8 Juices

MeritCare

basic principles micronutrient support35
Basic Principles - -Micronutrient Support
  • Calcium
    • A cofactor for some collagenases during remodeling
    • Necessary for normal blood coagulation
  • Dietary Nucleotides
    • Building blocks for DNA/RNA
    • Improve immune function
    • Assist in wound healing
    • Found in any animal protein
basic principles micronutrient support36
Basic Principles - - Micronutrient Support
  • Vitamin E
    • Important role as an “anti-oxidant”
    • Anti-oxidants help to protect cells from destruction
    • In wound healing- role in reducing atherosclerosis (heart disease)
    • RDA is 10mg for men & 8mg for women
    • To much may interfere with wound healing
      • Unprocessed whole grains, vegetable oils, margarine, salad dressings, nuts, poultry, fish, seeds, and eggs
  • Copper
    • Involved in making of red blood cells, absorption and transportation of iron, wound healing, RNA synthesis and making of collagen
    • RDA is 1.5-3.0mg/day
      • Legumes, seafood, shellfish, whole grains, nuts, seeds, and vegetables

MeritCare

basic principles micronutrient support37
Basic Principles - -Micronutrient Support
  • Zinc
    • Involved in over 200 enzyme systems, functions of the immune system, heals wounds, enhances ability to taste food
    • Necessary for metabolism of protein
    • Toxic if too much
    • RDA is 12-15mg
    • Can safely take up to 50mg daily for a 3 month time period to assist with wound healing
      • Seafood, meats, whole grains, milk & milk products, legumes

MeritCare

basic principles micronutrient support38
Basic Principles - -Micronutrient Support
  • Magnesium
    • Involved in 300 enzyme systems
    • Important for protein metabolism
    • Low levels can occur with diuretics, vomiting, diarrhea, stress on the body
    • Important in glucose and blood pressure control
    • RDA is 280-350mg
      • Unprocessed whole grains, legumes, buts, chocolate, dark green vegetables, and bananas

MeritCare

  • Iron
    • Involved in the electron transport chain, oxidative burst in phagocytosis, part of hemoglobin which transports oxygen to tissues
    • Inadequate iron decreases oxygen delivery to tissues & impairs the ability of leukocytes to kill bacteria, increasing risk of wound infection
    • RDA is 8mg/day for men and postmenopausal women, 18mg/day for premenopausal women
    • Iron supplementation should NOT be given to individuals with an active infection-can make it worse
    • Bacteria will use the iron-making it more difficult to fight the infection
basic principles micronutrient support39
Basic Principles- -Micronutrient Support
  • Arginine
    • Plays a role in lymphocyte production, RNA synthesis, collagen disposition, improved tensile wound strength, and bacterial killing by macrophages.
    • 17 to 24g/day for two weeks will improve the wound strength and collagen deposition in artificial wounds
    • Still need to meet energy and protein needs
    • Not for everyone especially those with renal and liver dysfunction.

Kline, Dale A. Healing From the Inside Out. Today’s Dietitian (2008): 12-17.

basic principles micronutrient support40
Basic Principles- - Micronutrient Support
  • Glutamine
    • Plays a central role in many of the metabolic pathways involved in wound healing- acting as a building block or substrate for many rapidly proliferating cells in the healing process
    • RDA is 0.57g/kg of body weight/day in divided doses
    • Should NOT be given to people with renal or liver impairments
basic principles micronutrient support41
Basic Principles- - Micronutrient Support
  • Fluids
    • Too little fluid impairs wound healing-same as too much
    • Dehydrations reduces the supply of oxygen & nutrients to the wound
    • Over hydration compromises the integrity of the skin and slows the inflammatory phase of wound healing
  • RDA is minimum of 1,500mL or 30mL/body weight or an amount equal to kilocalorie requirements
  • Water acts as a solvent for minerals, vitamins, amino acids, glucose-enabling them to diffuse in and out of the cells
  • Water transports vital materials to cells and waste away from cells
  • Maintains blood volume
guidelines 10 wt loss uncomplicated stage 1 2
Guidelines: < 10% Wt. Loss Uncomplicated Stage 1 & 2
  • Daily high potency vitamin-mineral
  • 20% above RDA
  • Vitamin C= 500mg
  • Vitamin A= 5000IU
  • Zinc sulfate = 220mg
  • Weekly weight
  • Weekly wound healing measurements
  • DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care. 2000 Jan-Feb; Volume 13, Supplement 1: 11-20
guidelines 10 weight loss healing stages 3 4
Guidelines: < 10% Weight loss Healing Stages 3 & 4
  • 2 high potency vitamin-minerals
  • > 1.5g/kg a day (with a protein supplements)
  • Vitamin C = 1g a day
  • Vitamin A = 400 IU
  • Zinc sulfate = 220mg
  • Weight weekly
  • Weekly wound healing measurement
  • DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care. 2000 Jan-Feb; Volume 13, Supplement 1: 11-20
guidelines 10 weight loss on going catabolism
Guidelines: > 10% Weight Loss On going Catabolism
  • Calories: 35-40 kcal/kg/d
  • Protein: 1.5-2.0g/kg/d
  • Glutamine: 10-20g/d
  • Zinc sulfate: 220 mg
  • Oxandrolone: 10 mg
  • Weekly weight and wound measurements
  • DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care. 2000 Jan-Feb; Volume 13, Supplement 1: 11-20
standards of practice
Standards of Practice
  • Nutrition Monitoring
  • Weight
  • Laboratory Values
  • Calorie, protein, fluids, and proper nutrient intake
  • Wound healing
in summary
In Summary
  • Pressure Ulcer is an area of the skin that breaks down when you stay in one position for too long without shifting your weight.
  • Prevention
    • Monitor your Nutrition
    • Be active
    • If you need to sit or be on bony parts of your body for a long time make sure its cushioned
  • To treat pressure ulcers relieve pressure regularly
    • Don’t sit or lie on the sore
    • Use pillows & cushions
    • Cleaning the sore regularly
    • See a doctor
    • Proper nutrition
references
References
  • Bareuther, Carol M. Food to Help You Mend. Today's Diet &Nutrition (2007): 34-37.
  • Bedsores (2007): 15 Sept. 2008 http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html
  • DeSanti, L. Involuntary Weight loss and the Nonhealing Wound. Advanced in Skin & Wound Care. 2000 Jan-Feb; Volume 13, Supplement 1: 11-20
  • Dorner, Becky. Medical Nutrition Therapy for Pressure Ulcers. Medical Nutrition Therapy for Pressure Ulcers (2005): 1-9. Science Direct. Concordia College.
  • Dorner, Becky. NPUANewly Revised Pressure P's Ulcer Staging System. Today's Dietitian (2007): 24-25.
  • Fleishman, Amy. Adult Wound Care. Today's Dietitian 7 (2005): 38-42. Science Direct. EBSCO. Concordia College, Moorhead. 17 Sept. 2008.
  • Hurd, Theresa. Nutrition and Wound-Care Management/Prevention. Wound Care Canada 2: 20-24. Science Direct. EBSCO. Concordia College, Moorhead. 17 Sept. 2008.
  • American Dietetics Association."Nutrition Guidelines for Pressure Ulcers."
  • Kline, Dale A. Healing From the Inside Out. Today’s Dietitian (2008): 12-17.
references49
References
  • Krasner, Diane. Chronic Wound Care. Baltimore: Health Management Publications, 1990. 189-212.
  • Lewicki, Linda & et al. (1997). Potential Risk Factors for Pressure Ulcers During Cardiac Surgery. AORN Journal, 65. 933-942.
  • Mackay, Douglas, and Alan L. Miller. "Nutritional Support for Wound Healing." Alternative Medicine Review 8 (2003): 359-377. Elsevier. EBSCO. Concordia, Moorhead. 17 Sept. 2008.
  • MeritCare. “Nutrition and Wound Healing.”
  • Sollinger, Christine. “Pressure Ulcers.” Today’s Dietitian (1999): 31-34.
  • Skin Problems & Treatments Health Center: Pressure Ulcers (2007): 15 Sept. 2008 http://www.webmd.com/skin-problems-and-treatments/tc/pressure-sores
  • 3M Innovation. Skin Health: A 3M Guide to Understanding Pressure Ulcers. 1998.
references50
References

Pictures

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