Transcript Wound Healing - Concordia College, Moorhead, Minn

How Nutrition Plays a Role in
Wound Healing
Kelsey L. Puffe
Concordia College, Moorhead, MN
September 25, 2008
Objectives:
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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
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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.
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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
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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.
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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
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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.
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Stage 1:
Intact skin with redness (erythema) and sometimes with warmth
Stage 2
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Partial-thickness loss of skin, an abrasion,
swelling, and possible blistering or peeling of
skin
Stage 3
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Full-thickness loss of skin, open wound
(crater), and possible exposed under layer.
Stage 4
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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:
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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
Progression
Common Places for
Pressure Ulcers
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Bony parts of the
body
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Ankles
Back of the Head
Heels
Hips
Knees
Lower Back
Shoulder Blades
Spine
How to prevent pressure sores
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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:
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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
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Advanced age
Diabetes
Impaired immunity
Underweight
Obesity
Malnutrition
Medications
Infections
Moisture
Cognitive impairment/ altered sensory perception
Who is typically affected?
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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
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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
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10% of all hospital patients
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25% of nursing home residents
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60% of quadriplegics
Bedsores (2007): 15 Sept. 2008 http://www.surgeryencyclopedia.com/A-Ce/Bedsores.html
Concerns
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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
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Cellulitus- acute infection of connective tissue
Bone and joint infections
Necrotizing fasciitis- destroys tissues around
muscle
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Gas gangrene
Sepsis- blood infection
Cancer
Ethical Issues
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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
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Don’t want to take the blame for development
Increasing demands of healthcare intervention accountability
by legal professionals
Treatment
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Focuses on preventing a sore from getting worse
and on making the skin healthy again
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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
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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
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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
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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
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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 Care
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Patient screening and assessment
Nutrition Intervention
Monitor
Reassess
Nutrition Goals
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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 PyramidRecommended Servings
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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
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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
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Lean meat
Beans
Legumes
Whole grains/cereals
Milk and milk products
Fruits
Vegetables
Basic Principles—CHO &
Energy
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Carbohydrate
55-60% of diet
Provide as complex CHO
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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
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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 weight
Stage
Stage
Stage
Stage
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I- 1.0 g/kg
II- 1.0-1.2 g/kg
III- 1.25-1.5 g/kg
IV- 1.5-2.0 g/kg
Foods that are good sources of protein
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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
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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
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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
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Cold water fish, wild game, walnuts, leafy greens,
canola oil, flaxseed
Basic Principles -Micronutrient Support
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Vitamin A
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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
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Tomato Juice, Apricots, Cantaloupe, Nectarine, Green Beans, Broccoli,
Carrots, Squash, Brussels Sprouts, Yams, Sweet Potatoes
MeritCare
Basic Principles - Micronutrient Support
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Vitamin C
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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.
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Orange Juice, Cranberry Juice, Honey dew, Tangerine, Brussels sprouts,
Grapefruit, Kiwi fruit, Strawberries, Broccoli, V-8 Juices
MeritCare
Basic Principles - Micronutrient Support
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Calcium
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A cofactor for some collagenases during
remodeling
Necessary for normal blood coagulation
Dietary Nucleotides
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Building blocks for DNA/RNA
Improve immune function
Assist in wound healing
Found in any animal protein
Basic Principles - Micronutrient Support
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Vitamin E
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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
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Unprocessed whole grains, vegetable oils, margarine, salad dressings,
nuts, poultry, fish, seeds, and eggs
Copper
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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
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Legumes, seafood, shellfish, whole grains, nuts, seeds, and vegetables
MeritCare
Basic Principles - Micronutrient Support
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Zinc
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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
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Seafood, meats, whole grains, milk & milk products, legumes
MeritCare
Basic Principles - Micronutrient Support
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Magnesium
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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
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Iron
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Unprocessed whole grains, legumes, buts, chocolate, dark green vegetables, and bananas
MeritCare
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
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Arginine
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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
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Glutamine
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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
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Fluids
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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
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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
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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
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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
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Nutrition Monitoring
Weight
Laboratory Values
Calorie, protein, fluids, and proper
nutrient intake
Wound healing
In Summary
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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
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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
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Don’t sit or lie on the sore
Use pillows & cushions
Cleaning the sore regularly
See a doctor
Proper nutrition
Questions
References
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Bareuther, Carol M. Food to Help You Mend. Today's Diet &Nutrition (2007): 3437.
Bedsores (2007): 15 Sept. 2008 http://www.surgeryencyclopedia.com/ACe/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
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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
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Pictures
www.selectmedical.co.uk/images/Shop/pug.jpg
www.usc.edu/.../pups/images/stages/stage1.gif
http://www.revolutionhealth.com/articles/stages-of-pressuresores/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