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Skin, Wounds and NutritionPart 4
Assessing Nutritional Needs
Energy or calorie requirements Protein requirements Micronutrient requirements
Energy Requirements May be up to 50% more calories than the
non-stressed individual Calculate using Harris Benedict formula,
Mifflin St Jeor, or indirect calorimetry
Protein Requirement Increased relative to increased demands for
protein synthesis and increased losses of amino acids
Needs Stage 1-- 1.0 gram/kg Stage 2--1-1.2 grams/kg Stage 3--1.25-1.5 grams/kg Stage 4--1.5-2.0 grams/kg
Note: Protein above 1.5 gm/kg may not help protein syntheses and may cause dehydration, particularly in the elderly or those with impaired renal function
Micronutrient Requirements Increased need for cellular function and
formation
Interventions to Promote Healing Provide optimum nutrition early
adequate energy and nutrient profile adequate protein necessary micronutrients
Use anabolic agents, if necessary Provide exercise stimulus to muscles, to
increase anabolism
Basic Principles--CHO 55-60% of diet Provide as complex CHO
glucose is the prime energy source for the cell Leukocytes apparently use glucose to
promote phagocytic activity of lymphocytes prior to fibroplasia
Maximum tolerated is 7-8 grams/kg/d for respiratory patients
Give insulin for glucose >250 mg/dL and decrease intake if severe hyperglycemia
Basic Principles--Protein 20-25% of diet from protein Increased protein intake decreases the net
nitrogen losses by increasing the amino acid flow into the protein synthesis channel
Essential for protein synthesis and new cell growth
Protein is the component of collagen and other structural components
Basic Principles--Protein Will need increased fluids Higher risk for dehydration BUN will probably increase
NOTE: Excessive protein does NOT encourage faster healing as the body does not store protein but turn it into sugars
Basic Principles--Fat 20-25% of the diet No more than 2 grams/kg/day Need to monitor triglycerides
keep triglycerides < 250 mg/dL
Fatty Acids/Omega 3 Synthesize prostanoids Normal cell membrane function Essential Fatty Acid Deficiency (EFAD) impairs
wound healing Often overlooked by RD
Can obtain in foods and oils salmon, mackerel, albacore tuna, sardines, flax canola and soybean oil
Basic Principles--Micronutrient Support Vitamin A
Normal inflammatory response Allows epithelization, collagen synthesis, and
collagen cross-linking Maintains normal humoral defense
mechanism Seems to limit complications Need a good source (DAILY) in wound
healing
Basic Principles--Micronutrient Support Vitamin A Supplements given:
to counteract catabolic effects of glucocorticoids
to corticosteroid dependent patients to promote healing
to those with poor nutrient stores or malabsorption
Note: Too much may exacerbate inflammatory response
Basic Principles--Micronutrient Support Vitamin C
works with Amino Acids proline and lysine during collagen synthesis
needed for carnitine production for fatty acid metabolism
Reduces risk of wound reopening Body does not store vitamin C
Basic Principles--Micronutrient Support Vitamin C deficiency--Scurvy
Symptoms may develop rapidly but reverse quickly with treatment
Interferes with fibroblast function Alters healing process of collagen synthesis No secretion of procollagen chains Impaired polymerization Wrong amino acid sequence Increased blood cell fragility
Basic Principles--Micronutrient Support Thiamine
necessary for oxidation, reduction reactions helps form lysyl oxidase to strengthen collagen necessary for adequate collagen formation
Vitamin K Responsible for normal coagulation of blood Prolonged bleeding times and hematoma formation
may hinder wound healing
Basic Principles--Micronutrient Support Vitamin E
Responsible for collagen synthesis Assists in wound healing DOES NOT prevent scar formation
Basic Principles--Micronutrient Support Zinc
Role in cellular proliferation and protein synthesis
Excess zinc may interfere with wound healing via affecting lysyl oxidase, an enzyme involved in collagen synthesis
Excess interferes with copper and iron absorption and metabolism
Basic Principles--Micronutrient Support Zinc--cont.
Needed for ALL enzymatic reactions Urinary losses increase with stress and weight
loss Body stores are often depleted in patients
with malnutrition, chronic diarrhea and chronic corticosteroid use
Basic Principles--Micronutrient Support Zinc cont.
In deficiency state, may find low rate of epithelialization
Deficiency causes decreased wound and collagen strength
Supplementation often done in wound management but no evidenced based studies to prove its need
Basic Principles--Micronutrient Support Copper
Cofactor for connective tissue production Collagen polymerization Formation of cross linkages to enhance scar
strength Erythrocyte formation
Basic Principles--Micronutrient Support
Magnesium Necessary for all phases of wound healing Translation and synthesis of peptide chains Depletion may occur in patients with chronic
diarrhea, fistulas, SBS Calcium
A cofactor for some collagenases during remodeling
Necessary for normal blood coagulation
Basic Principles--Micronutrient Support Iron
Enhances enzymatic activity of prolyl hydroxylase during hydroxylation of proline and lysine
Iron stores in the elderly are at their highest Make sure check true anemia not anemia of
chronic disease
Basic Principles--Micronutrient Support Arginine
Stimulates collagen synthesis Enhances cellular immune mechanisms,
especially T-cell function Assists cell growth and replication Helps promote wound healing Obligatory precursor for wound protein
synthesis
Basic Principles--Micronutrient Support Arginine--cont.
Made in the kidney May be consumed in diet Breakdown of body protein Can be found in enteral formulas with
immune-enhancing nutrients
Basic Principles--Micronutrient Support Glutamine
Precursor for purines and pyrimidines Fuels fibroblasts Anti-catabolic, anabolic properties Preserves LBM Stimulates release of Human Growth
Hormone
Basic Principles--Micronutrient Support Glutamine--cont
Levels drop dramatically during stress Found in abundance normally Enteral formulas or modular forms available 10-20 grams daily for supplement
Basic Principles--Micronutrient Support Dietary Nucleotides
Building blocks for DNA/RNA Improve immune function Assist in wound healing Found in any animal protein
Basic Principles--Water 30 ml per kg body weight unless
contraindicated 1 mL/cal for enteral tube feeding Additional 10-15 mL/kg/day when air
fluidized beds are used Additional for elevated temperatures
Basic Principles--Water Participates in most metabolic reactions Acts as a solvent for minerals, vitamins,
amino acids, glucose, and other small molecules enabling them to diffuse in and out of cells
Transports vital materials to cells and waste away from cells
Intervention Strategies Nonpharmacologic strategies
Counseling and education Patients should be told about and become involved
in decisions as should the families Optimizing food intake
Start with foods rather than supplements Calorie enhanced/protein enhance
Supplements Immune enhanced formulas 2 Kcal Med pass
Intervention Strategies Pharmacologic strategies
Appetite stimulants Megace
Metabolic nutrients Glutamine Arginine HMB
Anabolic agents Somatotropin—(can be very expensive) Oxandrolone
Calorie Needs in Wound Healing 30 kcal/kg body weight generally accepted >30 kcal/kg should promote positive
nitrogen balance Use indirect calorimetry if available and if
accuracy is critical Liberalize diet!!!!
Vitamin & Minerals Implicated in wound healing Remember, they do not hasten healing
once normal stores are present No question that information is conflicting
and confusing but with a litigation culture, we have become a supplement oriented society
Indication for Nutrition Support May facilitate wound healing Ability to optimize nutrient intake Must be monitored Must be in accordance with Advanced
Directives
AHCPRThe Agency for Health Care Policy and
ResearchP.O. Box 8547Silver Spring MD 20907
1-800-358-9295 (9 am to 5 pm ET)http://www.ahrq.gov/clinic/cpgonline.htm
NPUAPThe National Pressure Ulcer Advisory Panel
1255 Twenty-Third Street NW, Suite 200, Washington, DC 20037Phone: (202) 521-6789 Fax: (202) 833-3636
E-mail: npuap@npuap.org
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