How Nutrition Plays a Role in Wound Healing

1
How Nutrition Plays a Role in Wound
Healing

• Kelsey L. Puffe
• Concordia College, Moorhead, MN
• September 25, 2008

2
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

3
Bed Sore or Pressure Ulcers

• Pressure Ulcers- begin as tender, inflamed
  patches that develops when a persons 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
4
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

5
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

6
Stage 2

• Partial-thickness loss of skin, an abrasion,
  swelling, and possible blistering or peeling of
  skin

7
Stage 3

• Full-thickness loss of skin, open wound (crater),
  and possible exposed under layer.

8
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).

9
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

10
Progression
11
Common Places for Pressure
Ulcers

• Bony parts of the body
• Ankles
• Back of the Head
• Heels
• Hips
• Knees
• Lower Back
• Shoulder Blades
• Spine

12
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

13
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

14
Risk Factors for Impaired Healing

• Advanced age
• Diabetes
• Impaired immunity
• Underweight
• Obesity
• Malnutrition
• Medications
• Infections
• Moisture
• Cognitive impairment/ altered sensory perception

15
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

16
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.surgerye
  ncyclopedia.com/A-Ce/Bedsores.html

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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

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Consequences

• Cellulitus- acute infection of connective tissue
• Bone and joint infections
• Necrotizing fasciitis- destroys tissues around
  muscle
• Gas gangrene
• Sepsis- blood infection
• Cancer

19
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
• Dont want to take the blame for development
• Increasing demands of healthcare intervention
  accountability by legal professionals

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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.

21
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

22
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

23
Effective nutritional assessment and subsequent
support are essential to the prevention and
treatment of pressure ulcers.Marti Andrews,
PhD, RD
24
Laboratory Values

• Serum albumin lt 3.5 mg/dL
• Prealbumin lt 16 mg/dL
• Hematocrit lt 33
• Hemoglobin lt 12 g/dL
• Transferrin lt 100 mg/dL
• Serum Cholesterol lt 160 mg/dL

• Weight gt5 in 30 days, or gt10 in 180 days
• Fluid intake less than 1,500 ml/24 hours over
  past seven days
• Total lymphocyte count lt1800 mm
• BUN/ Creatinine gt 101

25
Nutrition Care

• Patient screening and assessment
• Nutrition Intervention
• Monitor
• Reassess

26
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

27
Healing Foods Pyramid- Recommended Servings

• Water64 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
• Dairy1 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.

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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

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Basic PrinciplesCHO Energy

• Carbohydrate
• 55-60 of diet
• Provide as complex CHO
• Glucose is the main energy source for cells
• Give insulin for glucose gt250 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

30
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 weight
• Stage I- 1.0 g/kg
• Stage II- 1.0-1.2 g/kg
• Stage III- 1.25-1.5 g/kg
• Stage 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

31
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

32
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

33
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

34
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

35
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

36
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 vegetables
• MeritCare

37
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, legumes
• MeritCare

38
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

39
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.
  Todays Dietitian (2008) 12-17.

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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

41
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

42
Guidelines lt 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

43
Guidelines lt 10 Weight loss Healing Stages 3 4

• 2 high potency vitamin-minerals
• gt 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

44
Guidelines gt 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

45
Standards of Practice

• Nutrition Monitoring
• Weight
• Laboratory Values
• Calorie, protein, fluids, and proper nutrient
  intake
• Wound healing

46
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
• Dont sit or lie on the sore
• Use pillows cushions
• Cleaning the sore regularly
• See a doctor
• Proper nutrition

47
Questions
48
References

• Bareuther, Carol M. Food to Help You Mend.
  Today's Diet Nutrition (2007) 34-37.
• Bedsores (2007) 15 Sept. 2008 http//www.surgerye
  ncyclopedia.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.
  Todays Dietitian (2008) 12-17.

49
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. Todays
  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.

50
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?
  ID9476
• www.answers.com/topic/bedsore
• www.napnes.org/etraining/courses.php
• jama.ama-assn.org/cgi/content/extract/296/8/1020