Wound Healing - Food for Thought KAHCF

2013 KAHCF Spring Education Conference

Session #16

Wound Management - Food for Thought

Speaker: Chuck Gokoo

4/17/2013

KBN: 5-0002-707-049-1217

3/8/2013

1

As a courtesy to those around you, please

silence your cell phone and other

electronic devices.

Thank you for your cooperation.

1© 2013 AMT Education Division

Wound Healing

Food for ThoughtChuck Gokoo MD, CWS

Chief Medical Officer

American Medical Technologies


2013 KAHCF Spring Education Conference

Session #16

Wound Management - Food for Thought

Speaker: Chuck Gokoo

4/17/2013

KBN: 5-0002-707-049-1217

3/8/2013

2

Disclaimer

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.


Program Overview and Objectives

© 2013 AMT Education Division4

Discuss the role of dehydration and malnutrition impeding wound healing

Discuss barriers impeding wound

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

3/8/2013

3


Hydration and Nutrition

Nursing 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

Between 1999 and 2002, 13,890 nursing home patients nationwide died

from malnutrition and dehydration contributed to the deaths of about

68,000 others

$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


3/8/2013

4

Wound Management

Transdisciplinary Team

Nursing Home Administration, Medical

Director, DON/ADON

-CNA, RD, MD, Nursing Staff, Pharmacists, NP, PT, OT,

MDS Coordinator, Case Manager, Social Service,

Hospice

-Care planning reflective of concerns identified in the

at-risk resident assessment protocol

-Past Hx of hydration and eating patterns and weights

-Clarify hydration and nutritional issues, needs and

goals in context to the resident's overall condition

-Input of the resident and family members


Wound Management

Barriers to Healing

Lack of knowledge

Aging

Peripheral Vascular Disease

Nutrition deficiency

Infection

Stress

Tumors

Metabolic disorders

Impaired Immunity

Medications


3/8/2013

5

Wound Management

Skin breakdown

-Visible evidence of a 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

Consult a registered dietician or nutritionist


Wound Management

Registered Dietician(RD)

Resident Nutrition

-Assessment

-Diagnosis

-Intervention

-Monitoring

-Evaluation


3/8/2013

6

Wound Management

RD Assessment

Diet and intake history

Weight history

-Regular weighing

Physical examination

-Skin assessment

Hydration, nutritional diagnosis

-Co morbidities (e. g. diabetes)

Estimation of hydration, nutrient requirements

Hydration, nutritional PoC


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


3/8/2013

7

Wound Management

Exudate (Type)

Inflammatory

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

-Serosanguineous - 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


Hydration

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


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

3/8/2013

8

Hydration

Dehydration

Reduction in total body water

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

-Hyponatremia (water and sodium loss)

-Electrolyte imbalance (3% body weight)

Long Term Care

-Seen as a sign of poor care

-Results from combination of physiological or disease process

-Not primarily due to lack of access to water


HydrationBlunted 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


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

3/8/2013

9

Hydration

Lab values

-Abnormal glucose, calcium, potassium

-Abnormal serum bicarbonate

-Elevated hemoglobin and hematocrit

-Increased urine specific gravity

-Elevated serum sodium

-Elevated albumin

-Increased Blood Urea-Nitrogen (BUN) level

-Abnormal creatinine

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


Hydration

Persistent subclinical dehydration

-Anxiety

-Panic attacks

-Agitation

Fluctuation in tissue hydration

-Inattention

-Hallucinations

-Delusions

Severe dehydration

-Somnolence

-Psychosis

-Unconsciousness


3/8/2013

10

Hydration

Functional Decline of the Renal System

Abnormal Lab Values to Identify Dehydration

-Increased Blood Urea-Nitrogen (BUN) level/3% weight loss

-Abnormal glucose, calcium, potassium

-Abnormal serum bicarbonate

-Abnormal creatinine

-Elevated hemoglobin and hematocrit

-Increased urine specific gravity

-Elevated serum sodium

-Elevated albumin


Hydration

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


3/8/2013

11

Hydration

Incontinence

Urine

-Adequate evaluation 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)


Hydration

Incontinence

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, friction, shear

Fecal impaction


3/8/2013

12

Hydration

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

-Maintain skin pH 6.8 to 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


Hydration

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 without bearing weight on the pressure ulcer (manual repositioning)

-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

-To prevent dehydration that can occur from the drying effects of these specialty beds


3/8/2013

13

Hydration

Intervention

Monitor fluid intake and output

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

-Minimum of 1500 mL/day

-Additional 10 - 15 mL/kg body weight/day if on an air fluidized bed (due to increase in body

warmth)

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

Maintain fluid and electrolyte balance

Source: American Medical Directors Association Dehydration and Fluid Maintenance, Clinical Practice Guidelines, Columbia

MD


Hydration

Prevention and Management

Education (staff and family members)

-What are barriers to getting water and ice

-What makes it hard 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 throughout the day

Dementia resident who is able to drink but forgets

-Use social cues

Identification of MASD risk factor


3/8/2013

14

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


HydrationHydration 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 meals


3/8/2013

15

Nutrition

Did You Know

Malnutrition in nursing homes 20% - 54%

Residents

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

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

Residents having albumin levels below 3.5 g/dL 6% - 43%

PharMerica Educational Program Sept 14, 2000


Nutrition

Weight

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


Weight

Accurate weight

-Time of day

-Clothing

-Scale

-Orthotics/prostheses

3/8/2013

16

Nutrition

Laboratory Tests

No ne 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


Nutrition

Albumin

-Poor indicator of visceral protein status

-Long half life (12-21 days) resident may be malnourished before drop in albumin occurs

-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

HgB A1c

-Glycemic control


3/8/2013

17

Nutrition

Weight

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

Before instituting a nutritional care plan assess:

-Severity of nutritional compromise

-Probably causes

-Individual’s prognosis

-Projected clinical course

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


Nutritional Assessment

Assessment Tool

Establish nutritional risks for all types of individuals

-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.

3/8/2013

18

Malnutrition

Assessment Tool

Mini-Nutritional Assessment (MNA)

-Risk factors

-Current nutritional status

-Not predictive for future nutritional status

Simplified Nutritional Appetite Questionnaire (SNAQ)

-Appetite

-Satiety

-Taste

-Meal frequency


Braden Score

At risk: 15 to 18

Moderate risk: 13 to 14

High risk: 10 to 12

Very high risk: 9 or below


3/8/2013

19

Nutritional AssessmentCare Requirements

Monitor 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

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

Consider vitamin supplement (especially with elderly or long term care individuals)

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


3/8/2013

20


Braden >18

Monitor intake and weight

Dietary Consult

-Usual criteria on admission database

-Intake consistently less than 75%

-Metabolically stressed state (trauma, fever etc.)

Significant weight loss (non fluid related)

2% in 1 week

5% in 1 month

7.5% in 3 months

10% in 6 months



Braden <18

Inadequate hydration, protein and/or weight loss

-Complete nutrition assessment

-Meet fluid needs

-Visual assessment

-Follow up weekly

Correct source of poor intake if able

-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


3/8/2013

21

Date: _________RN-RD Pressure Ulcer Screening Assessment Form

For 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 NoUnable 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 NPO

Tube 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 giverAny 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 ____ © 2013 AMT Education Division

41

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 Scale

Score _______

(< 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/APending

Baseline Labs Hypoproteinemia Hypogonadism Date Hyperglycemia Dehydration

ALB BUN Creat GFR

PAB Na K Chol

BS HA1c CRP Testosterone


3/8/2013

22


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

-Stroke


Key Nutrients

Calories

Resident with PrUs or at-risk for

developement

-25 - 35 kcals/kg body weight/day*

By 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.


3/8/2013

23

Key Nutrients

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




Key Micronutrients

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, Zn


3/8/2013

24

Key Micronutrients

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

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 Nutrients

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


3/8/2013

25

Key Nutrients

L-Arginine

Immune stimulant for lymphocytes

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

Precursor to proline hydroxyproline collagen

Therapeutic dose to promote healing is ~9 g/day

Copper

10 days till depletion

Formation of red blood cells

Vitamin C + copper = elastin production

900 μg/d


Key Nutrients

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

Zinc Sulfate 110 - 220 mg (23% elemental zinc)

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


3/8/2013

26

Nutrition

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

Multivitamins may be given


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

Malnutrition

Deficiency, excess or imbalance of

energy, protein or other nutrients causing

adverse effects on body form, function

and clinical outcomes

-Primary or secondary

-Due to increased total protein turnover

-Rapid loss of lean body mass

Undernutrition

Form of malnutrition in which

inadequate nutrition results from lack of

food or failure of the body to absorb or

assimilate nutrients properly


3/8/2013

27

Malnutrition

Marasmus

Develops over months

Primarily due to low intake (energy)

Muscle wasting

Edema not prominent

Weight loss prominent

Albumin usually normal

Mortality low

Kwashiorkor

Develops over weeks

Due to stress combined with low intake

of protein

Superficially appears well nourished

Edema characteristic

Weight loss may be absent

Albumin low

Mortality high


Anorexia and Cachexia

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

Immediate weight gain, especially

with those who have particularly

serious conditions that may require

hospitalization

Cachexia

Loss of appetite in someone who

is not actively trying to lose weight

-Insidious loss of weight, muscle atrophy,

fatigue, weakness

-Directly related to inflammatory states

-Rheumatoid arthritis, AIDS, chronic renal

failure, COPD

Resistance to hypercoloric feeding

Tx dependent of diagnosis of

underlying


3/8/2013

28

Lean Body Mass

Body Mass Index

Sarcopenia

Underweight and overweight

-Same nutritional risks

Diagnostic tool for both obesity

and protein-energy malnutrition

<16 = severe underweight

-16 - 18 = underweight

-19 - 24 = normal

-25 - 30 = grade I obesity (mild)

-31 - 40 = grade II obesity (moderate)

>40 = grade III obesity (severe)


Lean Body Mass (LBM)

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%

BMI

-Height and weight

≤18.5 kg/m2 - underweight


3/8/2013

29

Lean Body Mass

Muscle Mass Decrease

↓energy requirements decline

↓ protein reserves during

periods of stress

↓ total body water increases

chances of dehydration

↑ distribution volume of fat-

soluble drugs

Elimination of fat-soluble drugs

is delayed


Age 25 Age 70

Lean Body Mass

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


3/8/2013

30

Wound Healing Food for Thought

In Conclusion

Nutrition plays an essential role in wound healing and wound care

practices, and nutritional support needs to be considered a fundamental

part of wound management

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


I ain’t afraid of no wound

Thank YouQuestions?


3/8/2013

31

References

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, McNicholL, 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.

Dorner B. Posthauer ME, Thomas D, The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper; 2009.


References

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.

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.


3/8/2013

32

References



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


Documents

Wound Healing - Food for Thought KAHCF