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 person’s 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.surgeryencyclopedia.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 • Don’t 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 < 3.5 mg/dL • Prealbumin < 16 mg/dL • Hematocrit < 33% • Hemoglobin < 12 g/dL • Transferrin < 100 mg/dL • Serum Cholesterol < 160 mg/dL • Weight: >5% in 30 days, or >10% in 180 days • Fluid intake less than 1,500 ml/24 hours over past seven days • Total lymphocyte count <1800 mm • BUN/ Creatinine > 10:1

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 • Water:64 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 • Dairy:1 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 Principles—CHO & Energy • Carbohydrate • 55-60% of diet • Provide as complex CHO • Glucose is the main energy source for cells • Give insulin for glucose >250 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. Today’s 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: < 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: < 10% Weight loss Healing Stages 3 & 4 • 2 high potency vitamin-minerals • > 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: > 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 • Don’t 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.surgeryencyclopedia.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. Today’s 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.” Today’s 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?ID=9476 • www.answers.com/topic/bedsore • www.napnes.org/etraining/courses.php • jama.ama-assn.org/cgi/content/extract/296/8/1020