Nutrition in Chronic Wound Care Presented by Jesse M. Cantu, R.N., BSN, CWS Advanced Wound Management

Objectives ; Describe necessary nutritional elements for optimal wound healing. ; Discuss barriers to Pressure Ulcer prevention and treatment ; Formulate a Quality Improvement work plan to implement in the facility

3/13/20034 Wounds ; The problem: Wounds, particularly pressure ulcers, are a concern across health care settings  > 1 million patients develop pressure ulcers annually 1  Prevalence: –4 - 29% in acute care 2 – % in home care 2 – % in long-term care 2  Total national cost > $1.3 billion annually 3-5 –Cost ranges from $5000 to $60,000 per ulcer 6-8

Nutrition is VERY Important ; Assist with meals, snacks and hydration ; Document amount of intake ; Notify nurse if patient does not eat or has trouble eating

3/13/20036 Role of Nutrition ; Nutrition and hydration ; Critical for tissue integrity and wound healing ; Research shows a strong relationship between pressure ulcers and nutritional status 9-14 ; Poor nutritional status is a major risk factor for pressure ulcer development 11 ; Weight loss is associated with poor wound healing 9-11,13,14,17

Nutrition Interventions ; Dietitian Consult ; Nutritional Support ; Fluid Management ; Vitamin and Mineral Supplementation

3/13/20038 Catabolic State - Stress Response ; Amplified ‘fight-or-flight’ reaction ; Increased stress hormones ; Hypermetabolic-catabolic state ; Impairs ability to synthesize new tissue ; Energy demands increase ; Rapidly deplete lean body mass (LBM) ; Calories and protein alone not enough

3/13/20039  Arginine and Glutamine support protein synthesis  HMB increases lean mass by decreasing breakdown of protein from cells  Arginine and Glutamine support protein synthesis  HMB increases lean mass by decreasing breakdown of protein from cells Protein synthesis ENHANCE Proteinbreakdown SLOW HMBHMB GLUTAMINEGLUTAMINE ARGININEARGININE Targeted Nutritional Synergy

3/13/ HMB (ß-hydroxy-ß-methylbutyrate) ; Naturally produced in humans ; Metabolite of leucine ; Precursor to cholesterol synthesis inside cells ; Stress compromises HMB production  Helps reduce muscle damage  Increased cholesterol synthesis  Protects muscle from stress-related damage  Decreases muscle breakdown in disease states

3/13/ Arginine ; Conditionally essential amino acid Helps support immune function ; Helps promote wound healing ; Conditionally essential amino acid Helps support immune function ; Helps promote wound healing

3/13/ Glutamine ; Conditionally essential amino acid ; Regulates cellular protein synthesis ; Improves immune function ; Maintains gut integrity ; Conditionally essential amino acid ; Regulates cellular protein synthesis ; Improves immune function ; Maintains gut integrity

Lab Data

Intrinsic factors ; Health Status; PVD, DM, CA,CHF, COPD, Renal ; Age Factors: slower circulation, decrease sebaceous and sweat production, decrease cellular growth, collagen, elastic tissue inflammatory response ; Body build: thin vs obese ; Emotional Status: stress impairs healing

Medications Radiation Anti-inflammatory drugs Immunosuppressive agents Smoking Mobility Other factors

The Other 4 Big Ones!

It’s No Surprise: Older skin breaks down easily ; Skin gets thinner and weaker with age ; Be careful when turning & repositioning or bathing a resident.

“An ounce of prevention…”

Prevalence of Pressure Ulcers ; %Acute Care ; %Long Term Care ; 12.4 %Home Care

Definition of Terms ; Incidence: # of patients with PU during study ; Prevalence: The number of cases at any given point in time

Cost of Pressure Ulcers ; Money ; Morbidity ; Mortality ; Malpractice

AHCPR Guidelines: Goals ; Risk Assessment ; Skin Care and Early Treatment ; Mechanical Loading and Support Surfaces ; Education

Risk Assessment ; Goal: Identify at-risk individuals needing prevention and the specific factors placing them at risk

Intervention ; Select and use a method of risk assessment

Risk Assessment Tools ; Norton Scale ; Braden Scale ; Others

Braden Scale ; Tested extensively ; Evaluated in variety of settings ; Terms defined ; Good inter-rater reliability

Braden Scale Measures ; Sensory Perception ; Activity ; Mobility ; Skin Moisture ; Friction and Shear ; Nutrition

Braden Scale: Scoring ; 1-4 with the exception of friction & shear subscale 1-3 ; Range 4-23 ; The lower the score the higher the risk ; Eighteen or less: high risk older adult

HCFA Guidelines ; Pressure relief equipment ; Routine turning ; Careful handling by staff members ; Hydration ; Education of Patient and Family

AHCPR Guidelines ; P.O. Box 8547 Silver Spring, MD ; ;

Assess the Entire Patient ; Overall physical health ; Complicating conditions ; Nutritional status ; Pain ; Psychosocial health ; Wound etiology

Assessment of Wound ; Location /Etiology ; Dimensions ; Depth ; Exudate ; Wound Base ; Wound Edges ; Undermining ; Tunneling ; Necrotic Tissue ; Epithelial Tissue ; Granulation Tissue ; Periwound Skin ; S&S of Infection

Intervention ; Assess and document skin condition on admission and at regular intervals

Improving Clinical Outcomes through “Early Intervention” Formulate work plan to implement in your facility

Skin Care and Early Treatment ; Goal: Maintain and improve tissue tolerance to pressure in order to prevent injury

Intervention: ; Assess and treat incontinence

Scope of the Problem Need for QI ; 13 million adults ; $16.4 billion cost ; Major cause of institutionalization

Barriers/facing the challenge ; Budget ; Tension ; Communication… Bath & Skin report ; Resistance to Change ; Staff Turnover ; Job Responsibilities

Improving Clinical Outcomes ; Multidisciplinary ; Clinical pathway = positive outcomes ; Identifying barriers

; Prevent or Moisturize Dry SkinIntervention

; No Vigorous MassageIntervention

Protect Skin from Moisture ; Incontinence ; Perspiration ; Effluent ; Wound / fistula drainage

Uses ; Skin Preparations: P eriwound, peristomal skin, prior to adhesives, friction areas ; Protective Creams: Denuded skin and mixed incontinence

Protection Uses ; Ointments: E xposure to urine and feces ; Pastes: Severe fecal, mixed fecal/urinary and denuded skin

; Improve mobility and activity statusIntervention

Support Surfaces ; Goal: Protect against adverse effects of external mechanical forces: pressure, friction, shear

Interventions: ; HOB to 30 degrees or less, as tolerated ; Lift sheet ; Lubricants ; Transparent films

; Establish individualized repositioning schedule for bed/chairIntervention

Intervention ; Use pillows/wedges to separate bony prominences

Intervention ; Totally relieve heel pressures

Support Surfaces ; Pressure Relief: Device which consistently reduces pressure less than capillary closure. ; Pressure Reduction: Device which does not consistently reduce pressure to less than capillary closure, but does provide pressure readings less than a standard mattress or chair.

Pressure Relief Devices

Pressure Reduction Devices

Support Surfaces

; Use proper positioning, transferring and turning techniquesIntervention

Education ; Goal: Reduce the incidence of pressure ulcers through educational programs

Program Implementation/barriers ; Protocols ; Advanced wound care products ; Reimbursement ; Teamwork ; Nurse consultants ; Education ; Rounds ; Standardization ( Nissen, 1998 )

Questions? Thank You! Jesse M. Cantu, RN, BSN, CWS Certified Wound Specialist (210)