Nutritional Nutritional Considerations in Wound Considerations in Wound

HealingHealing

Ronni Chernoff, PhD, RDRonni Chernoff, PhD, RD

Weight changes Weight changes (losses or gains) may (losses or gains) may be related to a variety be related to a variety

of risk factorsof risk factors

Weight should remain Weight should remain stable during healingstable during healing

Immobilization and Immobilization and deconditioning are major deconditioning are major

factors in negative factors in negative nitrogen balancenitrogen balance

To avoid or heal wounds To avoid or heal wounds of any type, nutrient of any type, nutrient

needs must be met to needs must be met to support homeostasissupport homeostasis

However, nutrient However, nutrient requirements may change requirements may change

with age due to with age due to physiological, health physiological, health

status, body composition, status, body composition, and activity level changesand activity level changes

Key nutrients needed for Key nutrients needed for wound healingwound healing

ProteinProtein EnergyEnergy Vitamin AVitamin A Vitamin CVitamin C ZincZinc

Protein requirements are Protein requirements are affected by:affected by:

decrease in total LBMdecrease in total LBM loss of efficiency in protein turnoverloss of efficiency in protein turnover increased need to heal wounds, increased need to heal wounds,

surgical incisions, repair ulcers, surgical incisions, repair ulcers, make new bone make new bone

infectioninfection immobilizationimmobilization

Protein requirements for Protein requirements for older adults is 1 g/kg older adults is 1 g/kg

body weightbody weight

Protein is necessary to Protein is necessary to make new tissue, fight make new tissue, fight

infection, heal fracturesinfection, heal fractures

Protein needs may be Protein needs may be as high as 2+ g/kg as high as 2+ g/kg

body weightbody weight

Energy needs increase Energy needs increase with demands for wound with demands for wound healing, fracture repair, healing, fracture repair,

infection responseinfection response

To maintain weight, 20-25 To maintain weight, 20-25 kcals/kg body weight is kcals/kg body weight is usually adequate in a usually adequate in a

relatively sedentary adultrelatively sedentary adult

For stress, wound For stress, wound healing, infection, healing, infection,

fracture, energy needs fracture, energy needs may increase to as much may increase to as much

as 35 kcals/kg body as 35 kcals/kg body weightweight

Vitamin A is needed for Vitamin A is needed for cell differentiationcell differentiation

Vitamin A requirements Vitamin A requirements in wound healing should in wound healing should not exceed 200% of the not exceed 200% of the

RDARDA

Vitamin CVitamin C

Status is related to dietary Status is related to dietary intakeintake

Institutionalization, Institutionalization, hospitalization and illness lead hospitalization and illness lead to sharp decreases in vitamin C to sharp decreases in vitamin C intakeintake

Vitamin CVitamin C

Decreases seen with chronic Decreases seen with chronic disease including disease including atherosclerosis, cancer, senile atherosclerosis, cancer, senile cataracts, lung diseases, cataracts, lung diseases, cognition, and organ cognition, and organ degenerative diseasesdegenerative diseases

Vitamin CVitamin C

Vitamin C is easily replacedVitamin C is easily replacedSmokers may need 2x RDA just Smokers may need 2x RDA just

to meet requirementsto meet requirements

Vitamin CVitamin C

Vitamin C is important in Vitamin C is important in wound healing because of its wound healing because of its role in hydroxylation but tissue role in hydroxylation but tissue saturation is achieved easily saturation is achieved easily and large doses are excreted in and large doses are excreted in urineurine

ZincZinc

Most older adults are not zinc Most older adults are not zinc deficientdeficient

Increased levels may be needed for Increased levels may be needed for wound healing but do not have to be wound healing but do not have to be very high (225mg/day in divided very high (225mg/day in divided doses)doses)

Large amounts of zinc interfere with Large amounts of zinc interfere with absorption of other divalent ionsabsorption of other divalent ions

Copper, iron, Copper, iron, magnesium, manganese magnesium, manganese may be affected by large may be affected by large

doses of zincdoses of zinc

Meeting fluid Meeting fluid requirements is often requirements is often

an issue in wound an issue in wound healing protocolshealing protocols

Fluid intake can be estimated Fluid intake can be estimated at 30 ml/kg body weight with at 30 ml/kg body weight with

a minimum of 1500 ml/daya minimum of 1500 ml/day

Sometimes pressure ulcers Sometimes pressure ulcers are unavoidable but optimal are unavoidable but optimal healing includes a nutrient healing includes a nutrient dense diet that addresses dense diet that addresses

the nutrient needs the nutrient needs describeddescribed

Pressure Ulcer Pressure Ulcer Management: Quick TipsManagement: Quick Tips

Molly Brethour RN, CWOCNMolly Brethour RN, CWOCN

CAVHS CAVHS

Little Rock, ArkansasLittle Rock, Arkansas

Wound Priorities Wound Priorities

Cause Cause CauseCause Cause CauseEstablish goalEstablish goal

Systemic factorsSystemic factorsEnvironmental modificationsEnvironmental modifications

ThenThen

Optimize wound Optimize wound

Determine CauseDetermine Cause

Unexpected Pressure Unexpected Pressure

EnvironmentEnvironment

VenousVenous Compression - complianceCompression - compliance

DiabeticDiabetic OffloadingOffloading Foot careFoot care

Pressure ulcers:Pressure ulcers: Reduce pressureReduce pressure Reduce shear / frictionReduce shear / friction Reduce moisture (Incontinence)Reduce moisture (Incontinence) Increase mobilityIncrease mobility

InterventionsInterventions

Reduce or eliminateReduce or eliminate Shear / friction Shear / friction

• socks, boots, transfer sheets,socks, boots, transfer sheets,• trapeze…trapeze…

Moisture / IncontinenceMoisture / Incontinence• Barrier creams / ointmentsBarrier creams / ointments• Bowel and bladder programsBowel and bladder programs• ContainmentContainment

PressurePressure• Repositioning bed and chairRepositioning bed and chair• Positioning devices, pressure reducing cushionsPositioning devices, pressure reducing cushions• Support surfaces (mattresses)Support surfaces (mattresses)• Bridging heelsBridging heels

Support the Host: Evaluate Support the Host: Evaluate Systemic FactorsSystemic Factors

Tissue PerfusionTissue Perfusion NutritionNutrition InfectionInfection MedicationsMedications DiabetesDiabetes AgingAging

Basic Principles to Optimize the Basic Principles to Optimize the Wound: Which dressing?! Wound: Which dressing?!

M oistureM oisture I nfectionI nfection N ecrtoic tissueN ecrtoic tissue D eadspaceD eadspace P rotectP rotect I nsulateI nsulate E xudateE xudate

Evidence-based PracticeEvidence-based Practice

Cleansing: Cleansing: Non-cytotoxicNon-cytotoxic Debridement: Debridement: Use caution if arterial Use caution if arterial

componentcomponent Dressing Choice: Dressing Choice: Base on ongoing wound Base on ongoing wound

assessment, principles of wound care, patient assessment, principles of wound care, patient and settingand setting

Address wound / dressing painAddress wound / dressing pain Address goal and progressAddress goal and progress

VHA Handbook 1180.2VHA Handbook 1180.2Assessment & Assessment &

Prevention of Pressure Prevention of Pressure UlcersUlcers

ONS Special Issues ForumONS Special Issues Forum

August 14, 2006August 14, 2006

Purpose of New HandbookPurpose of New Handbook

Establishes mandated procedures for Establishes mandated procedures for assessment and prevention of pressure assessment and prevention of pressure ulcers in ALL clinical settings at time of ulcers in ALL clinical settings at time of admission, upon inter- or intra-facility admission, upon inter- or intra-facility transfer, discharge, or other times as transfer, discharge, or other times as appropriateappropriate

ScopeScope

Identifies basic requirements for Identifies basic requirements for Interdisciplinary approaches to pressure Interdisciplinary approaches to pressure ulcer:ulcer:

AssessmentAssessment ReassessmentReassessment PreventionPrevention Documentation Documentation

Relevant to all areas of clinical practiceRelevant to all areas of clinical practice In patientIn patient OutpatientOutpatient Long Term CareLong Term Care

Scope (cont)Scope (cont)

Implements Braden Scale for:Implements Braden Scale for: Initial AssessmentInitial Assessment On going assessmentOn going assessment Risk factorsRisk factors

Collaborative assessment and treatment Collaborative assessment and treatment planning essential withplanning essential with Patient/residentPatient/resident Family/surrogate/authorized decision makerFamily/surrogate/authorized decision maker

Interdisciplinary ID TeamInterdisciplinary ID Team

Must be comprised of at least: Must be comprised of at least: Nurse (RN preferred, LPN &/or NA)Nurse (RN preferred, LPN &/or NA) Primary ProviderPrimary Provider DietitianDietitian Clinical Pharmacist SpecialistClinical Pharmacist Specialist Rehabilitation StaffRehabilitation Staff Wound Care SpecialistWound Care Specialist

Wound Care SpecialistWound Care Specialist

Inclusive of:Inclusive of: Wound Care Ostomy Continence Nurse Wound Care Ostomy Continence Nurse

(preferred but not required) AND/OR(preferred but not required) AND/OR Advanced Practice NurseAdvanced Practice Nurse Clinical Pharmacist SpecialistClinical Pharmacist Specialist Rehabilitation Staff Rehabilitation Staff OR OR any Clinicianany Clinician with specialized training in with specialized training in

wound carewound care

ID Team Responsibilities ID Team Responsibilities

Implement education to:Implement education to: StaffStaff Patient and/orPatient and/or Caregiver and/orCaregiver and/or Significant otherSignificant other

Assess all patients/residentsAssess all patients/residents

ID Team Responsibilities (cont)ID Team Responsibilities (cont)

Use Braden Scale by qualified member of ID Use Braden Scale by qualified member of ID Team at time of:Team at time of: AdmissionAdmission Inter or intra – facility transferInter or intra – facility transfer DischargeDischarge As appropriateAs appropriate

Document results on ID assessment for and Document results on ID assessment for and retain in CPRSretain in CPRS

Formulate plan of care based on assessmentFormulate plan of care based on assessment

ID Team Responsibilities (cont)ID Team Responsibilities (cont)

Acute Care:Acute Care: Reassess all patients identified at risk (Reassess all patients identified at risk (<< 18) every 48 18) every 48

hours & more frequently if risk increasedhours & more frequently if risk increased Long Term CareLong Term Care

Reassess all residents weekly for first 4 weeks & Reassess all residents weekly for first 4 weeks & thereafter monthly (no matter score)thereafter monthly (no matter score)

HBPCHBPC Reassess each visit if patient identified at riskReassess each visit if patient identified at risk

Outpatient DepartmentOutpatient Department Refer all patients assessed as high risk to Refer all patients assessed as high risk to

Interdisciplinary Team for comprehensive assessmentInterdisciplinary Team for comprehensive assessment

ID Team Responsibilities (cont)ID Team Responsibilities (cont)

Assess nutritional statusAssess nutritional status Provide nutritional supportProvide nutritional support Consultation must be obtained with Consultation must be obtained with

Wound Care Specialist on all patient Wound Care Specialist on all patient assessed with pressure ulcersassessed with pressure ulcers

Determine goalDetermine goal Determine orders for preventionDetermine orders for prevention

ID Team Responsibilities (cont)ID Team Responsibilities (cont)

Identify educational needIdentify educational need Record all treatmentRecord all treatment Complete summary upon transfer or Complete summary upon transfer or

discharge of progressdischarge of progress Document patient outcome measuresDocument patient outcome measures

Braden ScaleBraden Scale

Predicts individual’s level of risk for Predicts individual’s level of risk for developing pressure ulcersdeveloping pressure ulcers

Scoring Scoring 15-18 = at risk15-18 = at risk 12-14 = moderate risk12-14 = moderate risk ≤ ≤ 12 = HIGH RISK12 = HIGH RISK