Transcript WoundHealingNutritionPressureUlcer

Nutritional
Considerations in Wound
Healing
Ronni Chernoff, PhD, RD
Weight changes
(losses or gains) may
be related to a variety
of risk factors
Weight should remain
stable during healing
Immobilization and
deconditioning are major
factors in negative
nitrogen balance
To avoid or heal wounds
of any type, nutrient
needs must be met to
support homeostasis
However, nutrient
requirements may change
with age due to
physiological, health
status, body composition,
and activity level changes
Key nutrients needed for
wound healing
 Protein
 Energy
 Vitamin A
 Vitamin
 Zinc
C
Protein requirements are
affected by:
decrease in total LBM
 loss of efficiency in protein turnover
 increased need to heal wounds,
surgical incisions, repair ulcers,
make new bone
 infection
 immobilization

Protein requirements for
older adults is 1 g/kg
body weight
Protein is necessary to
make new tissue, fight
infection, heal fractures
Protein needs may be
as high as 2+ g/kg
body weight
Energy needs increase
with demands for wound
healing, fracture repair,
infection response
To maintain weight, 20-25
kcals/kg body weight is
usually adequate in a
relatively sedentary adult
For stress, wound
healing, infection,
fracture, energy needs
may increase to as much
as 35 kcals/kg body
weight
Vitamin A is needed for
cell differentiation
Vitamin A requirements
in wound healing should
not exceed 200% of the
RDA
Vitamin C
 Status
is related to dietary
intake
 Institutionalization,
hospitalization and illness lead
to sharp decreases in vitamin C
intake
Vitamin C
 Decreases
seen with chronic
disease including
atherosclerosis, cancer, senile
cataracts, lung diseases,
cognition, and organ
degenerative diseases
Vitamin C
 Vitamin
C is easily replaced
 Smokers may need 2x RDA just
to meet requirements
Vitamin C
 Vitamin
C is important in
wound healing because of its
role in hydroxylation but tissue
saturation is achieved easily
and large doses are excreted in
urine
Zinc
 Most
older adults are not zinc
deficient
 Increased levels may be needed
for wound healing but do not
have to be very high (225mg/day
in divided doses)
 Large amounts of zinc interfere
with absorption of other divalent
ions
Copper, iron,
magnesium, manganese
may be affected by large
doses of zinc
Meeting fluid
requirements is often
an issue in wound
healing protocols
Fluid intake can be estimated
at 30 ml/kg body weight with
a minimum of 1500 ml/day
Sometimes pressure ulcers
are unavoidable but optimal
healing includes a nutrient
dense diet that addresses
the nutrient needs
described
Pressure Ulcer
Management: Quick Tips
Molly Brethour RN, CWOCN
CAVHS
Little Rock, Arkansas
Wound Priorities
Cause Cause Cause
Establish goal
Systemic factors
Environmental modifications
Then
Optimize wound
Determine Cause
Unexpected Pressure
Environment
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Venous
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Diabetic
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
Compression - compliance
Offloading
Foot care
Pressure ulcers:
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Reduce pressure
Reduce shear / friction
Reduce moisture (Incontinence)
Increase mobility
Interventions

Reduce or eliminate

Shear / friction
• socks, boots, transfer sheets,
• trapeze…

Moisture / Incontinence
• Barrier creams / ointments
• Bowel and bladder programs
• Containment

Pressure
•
•
•
•
Repositioning bed and chair
Positioning devices, pressure reducing cushions
Support surfaces (mattresses)
Bridging heels
Support the Host: Evaluate
Systemic Factors
 Tissue
Perfusion
 Nutrition
 Infection
 Medications
 Diabetes
 Aging
Basic Principles to Optimize the
Wound: Which dressing?!
M
oisture
 I nfection
 N ecrtoic tissue
 D eadspace
 P rotect
 I nsulate
 E xudate
Evidence-based Practice
 Cleansing: Non-cytotoxic
 Debridement: Use caution if arterial
component
 Dressing
Choice: Base on ongoing wound
assessment, principles of wound care, patient
and setting
 Address
wound / dressing pain
 Address goal and progress
VHA Handbook 1180.2
Assessment &
Prevention of Pressure
Ulcers
ONS Special Issues Forum
August 14, 2006
Purpose of New Handbook
 Establishes
mandated procedures for
assessment and prevention of pressure
ulcers in ALL clinical settings at time of
admission, upon inter- or intra-facility
transfer, discharge, or other times as
appropriate
Scope

Identifies basic requirements for
Interdisciplinary approaches to pressure
ulcer:
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Assessment
Reassessment
Prevention
Documentation
Relevant to all areas of clinical practice
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In patient
Outpatient
Long Term Care
Scope (cont)
 Implements
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Braden Scale for:
Initial Assessment
On going assessment
Risk factors
 Collaborative
assessment and treatment
planning essential with
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Patient/resident
Family/surrogate/authorized decision maker
Interdisciplinary ID Team
 Must
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be comprised of at least:
Nurse (RN preferred, LPN &/or NA)
Primary Provider
Dietitian
Clinical Pharmacist Specialist
Rehabilitation Staff
Wound Care Specialist
Wound Care Specialist
 Inclusive
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of:
Wound Care Ostomy Continence Nurse
(preferred but not required) AND/OR
Advanced Practice Nurse
Clinical Pharmacist Specialist
Rehabilitation Staff
OR any Clinician with specialized training in
wound care
ID Team Responsibilities
 Implement
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education to:
Staff
Patient and/or
Caregiver and/or
Significant other
 Assess
all patients/residents
ID Team Responsibilities (cont)
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Use Braden Scale by qualified member of ID
Team at time of:
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Admission
Inter or intra – facility transfer
Discharge
As appropriate
Document results on ID assessment for and
retain in CPRS
 Formulate plan of care based on assessment
ID Team Responsibilities (cont)
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Acute Care:
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Long Term Care
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
Reassess all residents weekly for first 4 weeks &
thereafter monthly (no matter score)
HBPC


Reassess all patients identified at risk (< 18) every 48
hours & more frequently if risk increased
Reassess each visit if patient identified at risk
Outpatient Department
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Refer all patients assessed as high risk to
Interdisciplinary Team for comprehensive assessment
ID Team Responsibilities (cont)
 Assess
nutritional status
 Provide nutritional support
 Consultation must be obtained with
Wound Care Specialist on all patient
assessed with pressure ulcers
 Determine goal
 Determine orders for prevention
ID Team Responsibilities (cont)
 Identify
educational need
 Record all treatment
 Complete summary upon transfer or
discharge of progress
 Document patient outcome measures
Braden Scale
 Predicts
individual’s level of risk for
developing pressure ulcers
 Scoring
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15-18 = at risk
12-14 = moderate risk
≤ 12 = HIGH RISK