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 C  Zinc

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, 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  Venous Compression - compliance Compression - compliance  Diabetic Offloading Offloading Foot care Foot care  Pressure ulcers: Reduce pressure Reduce pressure Reduce shear / friction Reduce shear / friction Reduce moisture (Incontinence) Reduce moisture (Incontinence) Increase mobility Increase mobility

Interventions  Reduce or eliminate Shear / friction Shear / friction socks, boots, transfer sheets,socks, boots, transfer sheets, trapeze… trapeze… Moisture / Incontinence Moisture / Incontinence Barrier creams / ointmentsBarrier creams / ointments Bowel and bladder programsBowel and bladder programs ContainmentContainment Pressure Pressure 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 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 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: Assessment Assessment Reassessment Reassessment Prevention Prevention Documentation Documentation  Relevant to all areas of clinical practice In patient In patient Outpatient Outpatient Long Term Care Long Term Care

Scope (cont)  Implements Braden Scale for: Initial Assessment Initial Assessment On going assessment On going assessment Risk factors Risk factors  Collaborative assessment and treatment planning essential with Patient/resident Patient/resident Family/surrogate/authorized decision maker Family/surrogate/authorized decision maker

Interdisciplinary ID Team  Must be comprised of at least: Nurse (RN preferred, LPN &/or NA) Nurse (RN preferred, LPN &/or NA) Primary Provider Primary Provider Dietitian Dietitian Clinical Pharmacist Specialist Clinical Pharmacist Specialist Rehabilitation Staff Rehabilitation Staff Wound Care Specialist Wound Care Specialist

Wound Care Specialist  Inclusive of: Wound Care Ostomy Continence Nurse (preferred but not required) AND/OR Wound Care Ostomy Continence Nurse (preferred but not required) AND/OR Advanced Practice Nurse Advanced Practice Nurse Clinical Pharmacist Specialist Clinical Pharmacist Specialist Rehabilitation Staff Rehabilitation Staff OR any Clinician with specialized training in wound care OR any Clinician with specialized training in wound care

ID Team Responsibilities  Implement education to: Staff Staff Patient and/or Patient and/or Caregiver and/or Caregiver and/or Significant other Significant other  Assess all patients/residents

ID Team Responsibilities (cont)  Use Braden Scale by qualified member of ID Team at time of: Admission Admission Inter or intra – facility transfer Inter or intra – facility transfer Discharge Discharge As appropriate As appropriate  Document results on ID assessment for and retain in CPRS  Formulate plan of care based on assessment

ID Team Responsibilities (cont)  Acute Care: Reassess all patients identified at risk (< 18) every 48 hours & more frequently if risk increased Reassess all patients identified at risk (< 18) every 48 hours & more frequently if risk increased  Long Term Care Reassess all residents weekly for first 4 weeks & thereafter monthly (no matter score) Reassess all residents weekly for first 4 weeks & thereafter monthly (no matter score)  HBPC Reassess each visit if patient identified at risk Reassess each visit if patient identified at risk  Outpatient Department Refer all patients assessed as high risk to Interdisciplinary Team for comprehensive assessment 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 = at risk = at risk = moderate risk = moderate risk ≤ 12 = HIGH RISK ≤ 12 = HIGH RISK