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How Nutrition Plays a Role in Wound Healing

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Title: 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

17
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

18
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

20
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.

28
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

29
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.

40
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
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