wound healing - wisconsin health care association healing food for thought ... lean body mass...

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AS A COURTESY TO THOSE AROUND YOU, PLEASE SILENCE YOUR CELL PHONE AND

OTHER ELECTRONIC DEVICES.THANK YOU FOR YOUR COOPERATION.

© 2013 AMT Education Division 1

WOUND HEALINGFOOD FOR THOUGHT

CHUCK GOKOO MD, CWSCHIEF MEDICAL OFFICER

AMERICAN MEDICAL TECHNOLOGIES

2© 2013 AMT Education Division

The information presented herein is provided for the general well‐being and benefit of the public, and is for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state.

The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.


DISCLAIMER PROGRAM OVERVIEW AND OBJECTIVES


Discuss the role of dehydration and malnutrition impeding wound healing

Discuss barriers impeding wound healing

Explain the role specific vitamins and minerals play in the wound healing process

A. D. A. M. Medical

Mayo Foundation for Medical Education and Research


ACKNOWLEDGEMENTSNursing Homes

≥500,000 residents may suffer from malnutrition or dehydration

50% of residents needs help with eating

21% are completely staff dependent for eating

50% ‐ 75% of nursing home residents have dysphagia

52% of hospital patients admitted with a diagnosis of dehydration will come from a nursing home

1999 and 2002 ‐ 13,890 nursing home residents nationwide died from malnutrition and dehydration

$6.5 million awarded to a Ohio widow

‐Nursing home lawsuit filed over the dehydration death of her husband allegedly caused when he was not provided with enough water during a temporary nursing home stay


HYDRATION AND NUTRITION

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WOUND MANAGEMENT


Barriers to

Wound Healing

Lack of Knowledge Aging

Peripheral Vascular Disease

Nutritional Deficiency

InfectionStress

Tumors

Metabolic Disorders

Impaired Immunity

MedicationsSkin

Breakdown

‐General catabolic state

‐Fight or flight (stress hormones)

‐Suppression of the synthesis of protein, glycogen, triglycerides

‐Protein energy malnutrition (PEM)

A resident with a PrU who continues to lose weight needs:

‐Additional caloric intake

‐Correction (where possible) of conditions that are creating a hypermetabolic state

Registered Dietician or nutritionist8© 2013 AMT Education Division

WOUND MANAGEMENT

Stress Response

catabolic hormones (cortisol and catechols)

metabolic rate

body temperature

glucose demand and liver gluconeogenesis

anabolic hormones (human growth hormones and testosterone

Rapid skeletal muscle breakdown

Amino acid use as an energy source

Lack of ketosis (fat not the major caloric source)

Unresponsiveness of catabolic to nutrient intake


WOUND MANAGEMENT

Body Mass Index

Sarcopenia

Underweight and overweight

‐Same nutritional risks

Diagnostic tool for both obesity and protein‐energy malnutrition

<16 = severe underweight

‐17 ‐ 18 = underweight

‐19 ‐ 24 = normal

‐25 ‐ 30 = grade I obesity (mild)

‐31 ‐ 40 = grade II obesity (moderate)

>40 = grade III obesity (severe)


WOUND MANAGEMENT

WOUND MANAGEMENT

Tube Feeding

‐7.5% ‐ 40.1% of resident population

≈20% LBM loss‐Decreased healing, weakness, increased infection, thinning of the skin, mortality increased by 30%

≥30% LBM loss‐Too weak to sit, PrUs develop, pneumonia, wound healing ceases, mortality increased by 50%


Muscle Mass Decrease

↓energy requirements decline

↓ protein reserves during periods of stress

↓ total body water increases chances of dehydration

↑ distribu on volume of fat‐soluble drugs

Elimination of fat‐soluble drugs is delayed


LEAN BODY MASS

Age 25 Age 70

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Creatine Height Index (%)

Marker for skeletal muscle mass

‐Creatine (degradation product) formed in active muscle at a constant rate in proportion to the muscle mass of a individual

‐Decreases (protein depletion)

‐Amount of creatine excreted in a 24 hour period divided by the amount of creatine excreted by a normal healthy individual of the same height and sex

>80% = normal protein

‐60% ‐ 80% = moderate protein depletion

<60% = severe protein depletion


LEAN BODY MASS

Anorexia

Loss of appetite/loss of interest in seeking and consuming food

A psychiatric eating disorder

‐Physical ‐ low body weight

‐Psychological ‐ image distortion

‐Emotional ‐ depression

‐Behavioral ‐ obsessive fear of gaining weight


ANOREXIA AND CACHEXIA

Cachexia

Loss of appetite in someone who is not actively trying to lose weight

‐Insidious loss of weight, muscle atrophy, fatigue and weakness

‐Directly related to inflammatory states

‐Rheumatoid arthritis, AIDS, chronic renal failure, COPD, Cancer, Immunodeficiency syndrome

Resistance to hypercoloric feeding

Tx dependent of diagnosis of underlying


WOUND MANAGEMENT

Registered

DieticianResident Nutrition

Assessment

Diagnosis

Intervention

Monitoring

Evaluation

Registered Dietician Assessment

Diet and intake history

Weight history

‐Regular weighing

Physical examination

‐Skin assessment

Hydration and nutritional diagnosis

‐Co morbidities (e. g. diabetes)

Estimation of hydration, nutrient requirements

Hydration, nutritional PoC


WOUND MANAGEMENT

Triggers for Assessment

Resident food consumption ‐ fluid, food and/or supplement served

Fluid amount accepted daily

Resident refusal of fluid, diet, meals or supplements (why, alternatives, notification, documentation)

Frequency of RD visit and discuss the PoC with the resident or staff

Residents weight status monitored (loss or gain)

Laboratory values requested ‐ appropriate

Frequency of PoC evaluated and updated

Hydration and nutritional component of the PoC appropriate

Competency of resident and staff to understand the risks and benefits of the hydration and nutritional intervention


WOUND MANAGEMENT

Hydration

Water

‐Approximately 72% of nonfat weight

‐Keeps the skin moist

‐Protects from tearing and abrasions

‐Plays a role in moving nutrients to the ulcer bed to promote new tissue growth

‐Assists in removing waste away from the ulcer


WOUND MANAGEMENT

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Exudate (Type)

Inflammatory

‐Serous ‐ watery plasma, thin, clear or light color

‐Serosanguinous ‐ plasma and red blood cells, thin, light red to pink

‐Sanguineous ‐ thin, red, bloody

Infection

‐Seropurulent ‐ contains some white blood cells and living or dead organisms, cloudy, yellow to tan

‐Purulent ‐ (pus) contains white blood cells and living or dead organisms, thick, creamy yellow, green, or brown

‐Bloody purulent

Exudate (Amount)‐Scant, Moderate, Heavy ‐ clinical judgment


WOUND MANAGEMENT

Moisture‐Associated Skin Damage (MASD)

Incontinence‐associated dermatitis

‐Intertriginous dermatitis

‐Periwound moisture‐associated dermatitis

‐Peristomal moisture‐associated dermatitis

Treatment

Use non‐alcohol based moisturizers

Establish continence training

‐Bowel or bladder training programs

Avoid skin contact with plastic surface to reduce sweating

‐Maceration, friction, shear


WOUND MANAGEMENT

Incontinence

Urine

‐Evaluate to identify whether reversible causes exist

‐Urea converted to ammonia (pH)

Reversible causes

‐Urinary tract infection

‐Medications

‐Confusion

‐Polyuria due to glycosuria or hypercalcemia

‐Restricted mobility due to restraints

‐Managing excessive moisture (sweating)


WOUND MANAGEMENT

Incontinence

Fecal

‐Bile acids and enzymes in feces

Differentiate between pressure ulcer and skin breakdown due to dermatitis

Feces irritate the epidermis and make the skin more susceptible to breakdown

Maceration, shear, friction

Fecal impaction


WOUND MANAGEMENT

Maintain Skin Integrity

Daily skin inspections‐Over bony prominences

‐Assess for compromised peripheral circulation

Promote skin hygiene‐Cleanse skin after soiling

‐Cleanse skin with saline and skin cleanser

‐Avoid alkaline agents which increase skin irritation

‐Avoid bioburden build up and risk of infection

‐Use skin protectants or barriers

‐Do not massage or rub over bony prominences

Moisture Control‐Use non‐alcohol based moisturizers

‐Establish continence training bowel or bladder training programs

‐Avoid skin contact with plastic surface to reduce sweating


WOUND MANAGEMENT

Support Surface (Powered)

Moderate ‐ high risk or resident has a PrU on turning surfaces and the ulcer

Residents unable to assume a variety of positions

‐Flexion contractures

‐Reduce pressure on bony prominences or prevent breakdown from skin‐to‐skin contact

Additional 10 to 15 ml fluid/kg of body weight

‐Prevent dehydration occurring from the drying effects of the specialty beds


WOUND MANAGEMENT

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Daily Fluid Intake vs. Daily Fluid Loss

Daily fluid intake

‐Liquid consumed + fluid in foods consumed + bodily by‐product water

Daily fluid losses

‐Any body fluid

‐Kidney use (urine) + GI tract use

(feces) + evaporation from skin + respiration

evaporation

The body does not store water


HYDRATION

Lungs(350 mL)

Skin(450 mL)

Excreted Fluids(1500 mL)

Metabolic Water(200 mL)

Ingested Foods(700 mL)

Ingested Fluids(1400 mL)

Water Gain Water Loss

Adapted from Krause’s Food, Nutrition & Diet Therapy, 11th Edition

Dehydration

Reduction in total body water

‐Hyponatremia (water and sodium loss)

‐Hyperosmolar (water loss ‐ due to ↑sodium or glucose)

‐Electrolyte imbalance (3% body weight)

Long Term Care

‐Sign of poor care

‐Combination of physiological or disease process

‐Not primarily due to lack of access to water


HYDRATION

Blunted Thirst Mechanisms

Aging

‐Homeostasis declines

Infection

‐Respiratory, GI, GU

Fluid loss or increased fluid need

‐Diarrhea, fever, vomiting

Incontinence

‐Reduce fluid intake

Fluid restriction

‐Renal dialysis

Medications

‐Diuretics, sedatives, antipsychotics, tranquilizers


HYDRATION

Cognitive or functional impairment

‐Aphasia ‐ unable to communicate effectively

‐Dementia or Alzheimer’s disease

Neurological impairment

‐Coma or decreased sensorium

Tube feedings

‐Dysphagia


NPO


Use of supplementation

‐Thick

‐Difficult to swallow 28© 2013 AMT Education Division

HYDRATION

Dehydration Screening

Pale skin

Sunken eyes

Red swollen lips

Swollen and/or dry tongue with scarlet or magenta hue

Dry mucous membrane

Poor skin turgor

Cachexia

Bilateral edema

Muscle wasting

Calf tenderness

Reduced urinary output

Dark urine

Persistent subclinical dehydration

‐Anxiety

‐Panic attacks

‐Agitation

Fluctuation in tissue hydration

‐Inattention

‐Hallucinations

‐Delusions

Severe dehydration

‐Somnolence

‐Psychosis

‐Unconsciousness


HYDRATION

Functional Decline of the Renal System

Abnormal lab values to identify dehydration

‐Abnormal glucose, calcium, potassium

‐Abnormal serum bicarbonate

‐Abnormal creatinine

Hemoglobin and hematocrit

Urine specific gravity

Serum sodium

Albumin

Blood Urea‐Nitrogen (BUN)*

*BUN is only useful in absence of renal disease


HYDRATION

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Intervention

Monitor fluid intake and output

‐Adult 30 ‐ 35 mL fluid/kg body weight/day

‐Minimum of 1500 mL/day

Maintain circulation blood volume (reduce hypovolemia ‐ fluid/salt)

Maintain fluid and electrolyte balanceSource: American Medical Directors Association Dehydration and Fluid Maintenance, Clinical Practice Guidelines, Columbia MD


HYDRATION

Prevention and Management

Education (staff and family members)

‐Barriers to getting water and ice to the resident

‐Difficulty to routinely fill water pitchers

‐Awareness of risk factors

‐Early identification of fluid imbalance and acute illness

”Sipper” takes a few sips at a time

‐May benefit from being offered frequent small amounts of fluid

Dementia resident

‐Able to drink but forgets

‐Use social cues

Identification of MASD risk factor


HYDRATION

Fluids With Special Problems

Caffeine (tea and coffee)

‐Inhibition of iron

Diet soft drinks

Alcohol

Best Type of Fluid

Un‐concentrated

Decaffeinated

Beverage resident will drink

Water is the best fluid for dehydration


HYDRATION

Hydration Strategies

Add cup holders to wheelchairs

Give residents water bottles to carry around facility

Offer beverages from beverage carts

Take fluids on outings and offer frequently

Include beverage break in all activities

Offer glasses of water in dining room while waiting for meals

Have fluids readily available

Encourage fluids

Offer choices

Offer fluids after providing care

Encourage ambulatory residents to drink all fluids offered with meals34© 2013 AMT Education Division

HYDRATION

Did You Know

Malnutrition in nursing homes 20% ‐ 54%

Residents

‐Having lost 5% of their weight in 30 days (acute) 9.9%

‐10% of their weight in 180 days (chronic) 9.9%

‐Having albumin levels below 3.5 g/dL 6% ‐ 43%PharMerica Educational Program Sept 14, 2000


NUTRITION

Weight

Reflects the balance between intake and utilization of energy (calorie and protein)

Before instituting a nutritional care plan assess:

‐Eating times (30 – 60 minutes)

Severity of nutritional compromise

‐Individual’s prognosis

‐Projected clinical course

‐Resident’s wishes and goals (offer relevant alternatives)


NUTRITION

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Weight Measurement

Admission or readmission

Weekly ‐ first 4 weeks after admission

Monthly (identify changes gain or loss)

Frequent

‐Food intake has declined and persisted (more than a week)

‐Evidence of altered nutritional status or fluid and electrolyte imbalance

‐Consider terminally ill


NUTRITION

Severity of weight loss

Severe weight loss

≥10% in 6 months

≥ 7.5% in 3 months

≥ 5% in one month

≥ 2% in one week

Walker G ed. Pocket Source for Nutritional Assessment, 6th ed. Waterloo IA

Undernutrition

Form of malnutrition in which inadequate nutrition results from lack of food or failure of the body to absorb or assimilate nutrients properly

38© 2013 AMT Education Divisionn

NUTRITIONAL ASSESSMENT

Malnutrition

Deficiency, excess or imbalance of energy, protein or other nutrients causing adverse effects on body form, function and clinical outcomes

‐Due to increased total protein turnover

‐Rapid loss of lean body mass

‐Insufficient energy intake

‐Weight loss

‐Loss of subcutaneous fat

‐Localized or generalized fluid accumulation ( may mask weight loss)

‐Diminished functional status (hand grip)

Laboratory Tests

None are specific or sensitive enough to warrant serial or repeated testing or determine a residents nutritional status

‐Determine whether the test will potentially change the resident’s diagnosis, management or quality of life

Laboratory test may be affected by age due to:

‐Hydration status

‐Chronic disease

‐Acute illness

‐Change in organ function


NUTRITIONAlbumin

‐Long half life (12‐21 days)

‐Poor indicator of visceral protein status

‐Negative acute phase reactants

‐Down regulated in inflammatory states

‐Decrease albumin levels reflect the presence of inflammatory cytokine production

‐3.5 ‐ 5.0 g/dL

Prealbumin (transthyretin/thyroxine‐binding albumin)‐Short half life (2 ‐ 3 days)

‐Subject to the same influences as albumin

‐Decreases rapidly when caloric/protein intake decreases

‐15.0 – 25.0 mg/dL

HgBA1c

‐Glycemic control


NUTRITION

Assessment Tool

Nutritional risks (six areas)‐Oral health status

‐Ability to eat

‐Proper diet

‐Eating patterns

‐Chronic diseases affecting appetite

‐Medications affecting appetite

Current weight status

Detect under and over nutrition

‐Malnutrition Screening Tool

‐Short Nutritional Assessment Tool



Pamela Charney, M.S., R.D. and Ainsley Malone, M.S., R.D.

Assessment Tool

Mini‐Nutritional Assessment (MNA)

‐Risk factors

‐Current nutritional status

‐Body Mass Index (BMI)

‐Left calf measurement

Simplified Nutritional Appetite Questionnaire (SNAQ)

‐Appetite

‐Satiety

‐Taste

‐Meal frequency42

© 2013 AMT Education Division


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At risk: 15 to 18

Moderate risk: 13 to 14

High risk: 10 to 12

Very high risk: 9 or below

Care RequirementsMonitor intake of food, tube feeding,

TPN

Food intake decreases ‐ offer supplement

Tube feeding or TPN decreases ‐monitor and ensure infusion of prescribed amount

Evaluate adequacy of prescribed amount

Dietitian evaluates intake of calories and protein if food intake is low

Consider vitamin supplement

Provide assistance with feeding as needed



Care Requirements

Baseline Labs

Dietitian evaluates and recommends intake goals

Supplements are provided, intake counted and recorded

Provide support with eating

Time meals, encourage family to feed

Encourage favorite food and snacks



Braden >18

Monitor intake and weight

Dietary Consult

‐Usual criteria on admission database

‐Intake consistently ≤75%

‐Metabolically stressed state (trauma, fever etc.)

Significant weight loss (non fluid)

‐2% in 1 week

‐5% in 1 month

‐7.5% in 3 months

‐10% in 6 months



Braden <18Inadequate hydration, protein

and/or weight loss‐Complete nutrition assessment

‐Meet fluid needs

‐Visual assessment

‐Follow up weekly

Correct source of poor intake‐Food preferences, constipation, illness depression, pain, medication causing poor appetite

Evaluate need for anabolic agent and/or nutrition support‐BMI <20 change diet to high calorie, high protein

‐Add therapeutic multivitamin/minimum supplement




Date: _________ RN-RD Pressure Ulcer Screening Assessment FormFor High Risk Populations (page 1)

Age __ Sex □ M □ F Ht __ Dx_______PMH _____ Risk Associated with Dx/PMH? □ Yes □ No□ >75y □ Recent Illness □ Trauma □ PEM □ Immobility □ Incontinence □ High risk comorbidities □ H/O Pressure Ulcer □ Smoking ____ppd □ Other

Patient Info

Addressograph

AppetiteInadequate intake?

□ Yes □ No□ Unable to assess

NPO Poor 0-50% Fair 50-80 % Good 80–100%(Downgrade by 1 level for presence of > Stage 3 or

multiple Stage 2 wounds)

Diet & MedicationsRisk Assessed?□ Yes (explain) □ No □ N/A to assess

□ Diet:_ □ Different than usual diet? □ P.O. □ P.O.+ Supplement □ P.O.+TF □ NPO+TF □ NPOTube Type: NG G/PEG PEJ Site Intact: Y N Food Allergies Meds/Supplements

Weight AssessmentDo Not Use Transfer WeightSignificant IWL? □ Yes □ No

Usual Wt ________ Per patient Per care giver□ Any IWL in the past 2-3 months?Actual Wt/Date __/____ □ With equipment Scale: □ Standing □ W/C □ Bed □ Lift □ Edema

BMI __ IBW _ % of IBW ___ % of UBW ___ ____ % Wt Loss or Gain over past ____

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GI Complications?□ Yes □ No

Date of last BM: __________ □ No C/O □ No BS □Diarrhea x ________ □ N/V x ________ □ Constipation x __________ □ Colostomy: Liquid Formed Hard Stool

Skin Areas of Concern?

□ Yes □ NoBraden ScaleScore _______(< 18 = at-risk)Gross Assessment Only see CWOCN note for detailed description of wound(s).Total # of Wounds: ___

1. _____________ (Location)

□ Pressure □ DTI □ Surgical □ Stasis

□ Intact Skin □ Foul Odor

Thickness: Partial Full

Drainage: Minimal Moderate Heavy Wound Bed: Beefy red Pale Dry Moist

Hyper-granulation Slough Eschar Tunneling Undermining S/S of Infection

Abnormal Lab Values?□ Yes □ No □ N/A□ Pending

Baseline Labs □ Hypoproteinemia □ Hypogonadism Date □ Hyperglycemia □ Dehydration

ALB BUN Creat GFR

PAB Na K Chol

BS HA1c CRP Testosterone

Proposed

Energy intake

‐Review food and nutrition history

‐Estimate energy needs over time

Interpretation of weight loss

‐Under or overhydration

‐Wt. change over time

‐Percent wt. loss from baseline

Body fat

‐Loss of subcutaneous fat

‐Orbital, triceps ribs



Muscle mass

‐Wasting of temples, clavicles shoulders, scapulaes, thigh and calf

Fluid accumulation

‐Extremities, scrotum/vulva edema

‐Wt. loss masked by fluid retention

Reduced grip strength

‐Measuring device

Oral Health Status

60 ‐ 90% of residents have severe periodontal disease‐Gum recession

‐Tooth loss (80%)

‐Oral pain

‐Mouth ulcers (30%)

‐Chewing Abnormalities

‐Dry mouth

‐Gingivitis

‐Periodontal disease

‐Ill fitting dentures (50%)

Swallowing Abnormalities (Dysphagia)‐Disease of the oropharynx and esophagus

‐Dementia

‐Stroke51© 2013 AMT Education Division


Inflammatory

‐Macrophages, neutrophils, blood clotting, vasodilatation

‐Vitamins and amino acids: A, K, Bromelain

Proliferative

‐Angiogenesis, fibroblasts, collagen deposition

‐Vitamins and minerals A, B6, C, Cu, Fe, Mg, Zn

Remodeling

‐Collagen maturation, stabilization, scar tissue mature

‐Vitamin and minerals C, Cu, Fe, Zn52© 2013 AMT Education Division

KEY MICRONUTRIENTS

KEY MACRONUTRIENTS

Calories

Resident with PrUs or at‐risk for

developement

‐25 ‐ 35 kcals/kg body weight/day*

Consuming enough calories, “spares”

the use of protein for energy

‐30 calories/kg (15 calories/pound) prevent

protein breakdown in non‐obese

Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and

Pathophysiology. Belmont: Thomson Brooks.


Calories

HEALING

Protein

Protein

Building block for repair

‐Angiogenesis

‐Collagen synthesis

‐Granulation tissue

‐Epidermal cell proliferation

‐Tensile strength

‐Resistance to infection

RDA

‐0.8 g/kg body weight

‐Stress 1.2 to 1.5 g/kg body weight

Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks.


KEY MACRONUTRIENTS

HEALING

Calories Protein

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Vitamin A

Facilitates macrophage entry into the wound and enhances angiogenesis

Antagonizes inhibitory affects of glucocorticoids (corticosteroids)

Stimulates fibroplasia to increase collagen synthesis

5000 ‐ 25000 International Units (IU) X 10 days


KEY MICRONUTRIENTS

Vitamin C (Ascorbic acid)

Not stored in the body

Enhances leukocyte, macrophage activation, fibroblast, collagen synthesis

Depressed levels found in elderly, smokers, and certain cancers

75g/day females and 90 mg/day males

Supplementation 500 ‐ 1000 mg/day for 2 weeks if deficiency suspected


KEY MICRONUTRIENTS

Vitamin E

Scar formation – conflicting reports

Adversely affects vitamin A benefits

May interfere with the healing of some types of wounds

Vitamin K

Co‐factor for coagulation

Monitor prothrombin times (PT) rations (INR)

Antibiotics may limit vitamin K


KEY MICRONUTRIENTS

L‐Arginine

Immune stimulant for lymphocytes

Stimulates release of insulin‐like growth factor‐I (IGF‐I)

Precursor collagen and connective tissue synthesis and cell multiplication

Therapeutic dose to promote healing is ~9 g/day

Copper

10 days till depletion following injury

Formation of red blood cells

Vitamin C + copper = elastin production

900 μg/d


KEY MICRONUTRIENTS

Zinc

Increased demand during collagen and protein synthesis

RDA

‐11 ‐ 15 mg/males (elemental zinc)

‐8 ‐ 12 mg/females (elemental zinc)

‐Limit 40 mg/day

Hypermetabolic state

‐Urinary loss of zinc

‐Zinc sulfate 220 mg tid

Supplementation with 25 ‐ 50 mg elemental zinc/day x 2 weeks

‐Stage III ‐ IV pressure ulcer

D/C in 6 weeks ‐may impair copper absorption


KEY MICRONUTRIENTS

Glutamine

60% intracellular amino acid pool

Primary fuel source for epithelial cell division

Stimulates lymphocytic proliferation

wound infection

2 g ‐ HGH release

0.3 ‐ 0.4 g/kg/day (burn patients)

Caution

‐Excess may result in ammonia levels


KEY MICRONUTRIENTS

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Current evidence does not definitively support any specific dietary supplement unless the resident has a specific vitamin or mineral deficiency

Multivitamins contain 7.5 to 15 mg of elemental zinc


NUTRITION

In Conclusion

Nutrition plays an essential role in wound healing

Implementing the nutritional plan and providing appropriate nutritional support to the individual requires involvement of the whole wound management team

By combining knowledge of the wound healing process together with best practice provision of nutrition, healthcare professionals can help decrease the morbidity and mortality associated with chronic wounds as well as reducing their cost and impact


WOUND HEALINGFOOD FOR THOUGHT

THANK YOUQUESTIONS?


Barbul A, Lazarou SA, Efron DT, et al: Arginine enhances wound healing and lymphocytes immune responses in humans. Surgery 1990; 108:331‐337.

Black JM, Edsberg LE, Baharestani MM, LangemoD, Goldber M, McNichol L, Cuddigan J. Pressure Ulcers :Avoidable or Unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management 2011;57(2): 24‐37.

Campbell, S. Maintaining hydration status in elderly persons: problems and solutions. Support Line, 1992;7‐10.

CMS Guidance for 483.25 (i)‐Nutrition F(325)

Demling RH, Nutrition, Anabolism and the Wound Healing Progress: An overview. Eplasty, 2009;65‐93.


REFERENCES

Dorner B. Posthauer ME, Thomas D, The Role of Nutrition in Pressure

Ulcer Prevention and Treatment: National Pressure Ulcer Advisory

Panel White Paper; 2009.

Dyck MJ, Schumacher JR, Using Evidence‐Based Organizational

Strategies to Prevent Weight Loss in Frail Elders Annals of Long‐Term

Care: Clinical Care and Aging. 2013;21(5):24‐30

Illinois Council on Long Term Care. Water: The Fountain of Life.

Retrieved March 30, 2007,

http://www.nursinghome.org/fam/fam_018.html

Kieselhorts K J, Skates J, & Prichett E, (2005). American Dietetic

Association: The Standards of practice in nutrition care and updated

standards of professional performance. Journal of the American

Dietetic Association, 105(4), 641‐645.


REFERENCES

Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the

elderly. Chest 2003;124(1):324‐336.

Malnutrition And Dehydration Plague Nursing Home Residents Lack Of

Adequately Trained Personnel Largely To Blame. The Commonwealth

Fund June 7, 2000.

Mentes J, (2006). Oral Hydration in Older Adults. American Journal of

Nursing, 106(6), 40‐49.

Morly JE. Hormones and the Aging Process. J AM Geriatr Soc 2003;51(7

Suppl):S333‐7.

Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and

Pathophysiology. Belmont: Thomson Brooks.


REFERENCES

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Posthauer ME, Collins N, Dorner B, Sloan C, Nutritional Strategies for Frail Old Adults. Advances in Skin &Wound Care, 2013;26(3):128‐140.

Szewczyk M T, Arkdiusz J, Kornelia K‐K, Moscicka P, Cwajda J, Cierzniakowska K, Brazis P, The Nutritional Status of Older Adults with and without Venous Ulcers: A Comparative Descriptive Study. Ostomy Wound Management 2008; 54(9):34‐42.

Thomas D T, Todd R C, Lawhorne L, Levenson S A, Rubenstein L Z, Smith D, Stefanacci R G, Tangalos E G, Morley J E, Dehydration Council (2008). Understanding Clinical Dehydration and its Treatment. JAMDA 9(5), 292 ‐301

Walker G ed. Pocket Source for Nutritional Assessment, 6th ed. Waterloo


REFERENCES

Wick J. Y. (1999). Prevention and Management of Dehydration. The Consultant Pharmacist, 14(8). Retrieved April 5, 2007, from http://www.ascp.com/publications/tcp/1999/aug/prevention.shtml

Williams JZ. Surg Clin N Am 2003.

www.dietetics.co.uk/article‐nutrition‐woundhealings.asp


REFERENCES

wound healing - wisconsin health care association healing food for thought ... lean body mass...

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