Nutrition & Healing

1. Nutrition & Healing Presented by: Sarah Renaldi MS, RD, LD July 13th, 2011

2. Objectives • Maintain skin integrity • Focus on health, maintenance & healing of skin • Focus on preventing skin breakdown & pressure ulcers • Recognize individuals at risk for developing a pressure ulcer • Identify interventions available to implement on individuals identified to be at risk

3. WHAT LIES BENEATH. . . The Largest Organ of the Body

4. Skin Assessment • Assess on admission to the hospital, daily, and any time the patient condition changes. • Skin breakdown risk factors • Hyperglycemia • Dehydration • Malnutrition • Just 5% unintentional weight loss in 30 days • Obesity • Fat does not provide good nutrients for healing • Edema • Immobility • Appliances • Skin Integrity • Age • Diagnosis/Medications • Incontinence

5. Skin Assessment • Look at areas of greatest risk on the skin • Bony prominences • Skin contact: anything that touches the skin • Braces, TED hose, Bi-PAP masks, tubes, O2 tubing, NG tubing, heel/elbow foot protectors, Foley catheter, I.V. tubing and hubs, jewelry etc. • If it is covered – uncover and inspect site • Turn patient to do head to toe skin assessment

6. Observe & Document • Breakdown • Redness • Abrasion • Poor skin turgor • Dry skin can also be a risk factor for ulceration • Look in all folds, cracks & crevices • DOCUMENT any variation from normal • Braden Scale

7. Braden Pressure Ulcer Risk Assessment Tool • A screening tool to be used in adjunct with critical thinking skills and clinical judgment • Different areas are assessed to identify patients at risk for breakdown: • Sensory perception • Moisture • Activity • Mobility • Friction/shear • Nutrition

8. NutritionAn ounce of prevention . . . • Biggest mistake made – Not identifying nutrition risk priorto development of a wound.

9. An ounce of prevention . . . • Risk factors are extrinsic or intrinsic • Extrinsic • pressure, physical restraints, friction, shear & moisture • Intrinsic • immobility, hip fracture - surgery, Cancer/steroid therapy, incontinence, age, CVD, edema, sepsis, COPD, PVD, DM, terminal dx, dialysis, depression, obesity, previous wound, recent weight loss, poor intake, malnutrition, dementia, substance abuse or dehydration

10. TRUE or FALSE? • Risk factors for malnutrition are the same risk factors for skin breakdown TRUE!

11. Nutrition • No two wounds are created alike, assessment & treatment must be individualized. • Focused Nutrition/Skin Risk Assessment • Nutrition screen within 24 hr of admit • Physician ordered consult • Referral per nursing • Wound Care Team referral • Correction of nutritional deficiency • Macronutrients: Calories, Protein and Fluids • Micronutrients: Vitamins, minerals and conditionally essential nutrients

12. Nutrition Assessment – A, B, C, D • Anthropometrics • Accurate ht/wt is essential to estimating kcal/protein & fluid needs • Assessment of weight change/BMI • Biochemical • Serum albumin – 21 day ½ life • Serum albumin changes with hydration status • C-reactive Protein/Pre-albumin • CRP/PAB Inversely proportional • Prealbumin is a better indicator of nutrition status • Prealbumin has a 2-3 day ½ life • Prealbumin doesn’t change with hydration status

13. Nutrition Assessment – A, B, C, D • Clinical • Medical Condition & Treatments • Nausea/Vomiting/ability to tolerate PO • Diarrhea • Past Medical History • Wound size, location, type & output/drainage • Patient understanding of the importance of good nutrition • Diet • Food & cultural preferences • Liberalize restricted diets as able (e.g. No Added Salt vs. 2 gm Na) to increase PO • Food intake & functional ability • Hydration

14. International Pressure Ulcer Guidelines 2009 • 66 Recommendations • 12% of Recommendations “A” level • Nutrition Guidelines “A” level • NPUAP White Paper on Nutrition • 19 Statements • Screen & Assess Nutritional Status • Provide Sufficient Calories • Provide adequate but not excessive protein • 1.25-1.5 g protein/kg with PU • Modify for renal impairment • Provide & encourage fluid intake • Provide adequate but not excessive vitamins & mineral

15. Nutrition Intervention for Wounds

16. Nutrition Recommendations • ENERGY • 30 to 35 kcals/kg BW/day • 35-40 kcals/kg BW/day (underweight or losing weight) • PROTEIN • 1.25-1.5 gm/kg BW/day • 1.0-1.5 gm/kg BW/day • FLUID • 30-40 ml/kg BW/day • OR 1ml to 1.5 ml/kcal/day

17. Vitamin and Mineral Supplementation… • The use of Vitamin C and zinc supplementation is widely practiced but remains unsubstantiated and controversial. • Vitamin and mineral supplementation is warranted when a deficiency state is observed or suspected; however, unlikely that vitamin c supplementation will accelerate wound healing in non-deficient individuals. • No evidence exists to support the routine use of supplemental zinc to promote healing of pressure ulcers. • Supplemental zinc can have consequences related to interactions with medications and nutrient absorption. • High-Dose zinc supplementation can adversely affect copper status and immune response and may cause GI upset. • If supplementation is ordered, the patient should be monitored and the dose discontinued when the wound heals or if they do not appear to be making a difference in the wound-healing process.

18. Clinical Nutrition Intervention • Starts with thorough screening for nutrition • Based on individualized nutrition assessment • Typical interventions • Calorie count/intake study • Enhanced/Fortified meals • Extra foods of patient’s preference • 2 oz 2 kcal with med pass 4x/d vs. 8 oz supplements 3x/d • High kcal/high Pro snacks/6 small meals • Micronutrient & modular supplement • Nutrition Support considerations • Referral to multidisciplinary care team

19. Nursing Interventions For Better Nutrition • Provide optimal meal time • Pt awake and alert, sitting up, assistance with tray set-up and feeding, protect meal time • Monitoring to advance diets </=2-3 days from NPO/Clear Liquids • Offer snacks • HYDRATE • have water within reach of patient • Recording Intake Correctly • Daily Weights • Alert Dietitian with concerns • Other consults – Pharmacy, OT, ST, Social Services, Diabetes Ed, etc.

20. What are ideal snacks? • Carbohydrates, Protein & Fluids

21. Who is at higher risk for skin breakdown? Elderly Woman Middle Age Woman Age 45 Stable wt. Stable appetite Hip Fracture Depression BMI 42.5 • Age 90 • Unintentional Wt Loss • Poor Appetite • Pneumonia • Dementia • BMI 18.2

22. Case Study • 74 yo female with Tib Fib Fx • WCB x 1 year • Refusing to be turned • Incontinent & UTI • Depressed • BMI 48.4 • Poor PO & doesn’t like water • Alb 3.3 • Skin: • Braden scale score 13 • Stage 2 pressure ulcer on buttocks • skin ulcer on left lower leg • Reddened skin under pannus, breast and in groin • Wound Care Team consult ordered

23. Case Study- What would you do? • What did I do? • Educated pt on nutrition & skin • Diet liberalized per MD to No Concentrated Sweets • Select with assist for meals so that pt may receive preferred foods • Set up high protein snacks per pt preference • Educated pt that wt loss can wait • Encouraged her to eat & drink!

24. Resources • National Pressure Ulcer Advisory Panel • http://www.npuap.org/ • American Dietetic Association • www.eatright.org

25. Nutrition • “Let nothing which can be treated by diet be treated by any other means.” ~ Maimondes • “Let food be thy medicine, thy medicine shall be thy food.”  ~Hippocrates • “When diet is wrong medicine is of no use.When diet is correct medicine is of no need.” ~ Ayurvedic Proverb