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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 - PowerPoint PPT Presentation
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How Nutrition Plays a Role in Wound Healing
Kelsey L. PuffeConcordia College, Moorhead,
MNSeptember 25, 2008
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
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 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 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
Partial-thickness loss of skin, an abrasion, swelling, and possible blistering or peeling of skin
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:
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
Bony parts of the body Ankles Back of the Head Heels Hips Knees Lower Back Shoulder Blades Spine
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: 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 Advanced age Diabetes Impaired immunity Underweight Obesity Malnutrition Medications Infections Moisture Cognitive impairment/ altered sensory
perception
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
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 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
Cellulitus- acute infection of connective tissue
Bone and joint infections Necrotizing fasciitis- destroys tissues
around muscle
Gas gangrene Sepsis- blood infection
Cancer
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
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.
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
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
“Effective nutritional assessment and subsequent support are essential to the prevention and treatment of
pressure ulcers.”Marti Andrews, PhD, RD
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 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
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 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
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 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 weightStage I- 1.0 g/kgStage II- 1.0-1.2 g/kgStage III- 1.25-1.5 g/kgStage 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
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 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
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 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 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 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
vegetablesMeritCare
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, legumesMeritCare
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 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 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 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 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
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 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
Nutrition Monitoring Weight Laboratory Values Calorie, protein, fluids, and proper
nutrient intake Wound healing
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
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.
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.
References Pictures
www.selectmedical.co.uk/images/Shop/pug.jpg www.usc.edu/.../pups/images/stages/stage1.gif http://www.revolutionhealth.com/articles/stages-of-pressure-sores/
zm2442 http://catalog.nucleusinc.com/generateexhibit.php?ID=9476 www.answers.com/topic/bedsore www.napnes.org/etraining/courses.php jama.ama-assn.org/cgi/content/extract/296/8/1020