Post on 23-Jul-2020
3/17/2016
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AS A COURTESY TO THOSE AROUND YOU, PLEASE SILENCE YOUR CELL PHONE AND
OTHER ELECTRONIC DEVICES.THANK YOU FOR YOUR COOPERATION.
© AMT Education Division 1
WOUND CARE AND DIET FOR HEALINGCHUCK GOKOO MD, CWSCHIEF MEDICAL OFFICER
AMERICAN MEDICAL TECHNOLOGIES
© AMT Education Division 2
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The information presented herein is provided for the general well‐being and benefit of the public, and is for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. Notwithstanding any educational information provided by American Medical Technologies, please refer to, and follow, your facility’s written policies and procedures.
The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.
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DISCLAIMER
PROGRAM OVERVIEW AND OBJECTIVES
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Describe how nutrition deficiencies impede the normal physiological processes of wound healing
Explain resident risks for skin breakdown due to impaired hydration and nutrition
Examine the role specific vitamins and minerals play in the wound healing process
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A. D. A. M. Medical
Mayo Foundation for Medical Education and Research
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ACKNOWLEDGEMENTS
Dehydration; Decubitus Ulcer Lawsuit – Suing a Nursing Home / Hospital for Dehydration
There is no excuse for patient dehydration. This is a telltale sign of patient neglect. If you or a loved one suffered from dehydration, decubitus ulcers, falls or a wrongful death in a nursing home or hospital, do not let the abuse go unpunished. Contact our qualified decubitus ulcer dehydration lawyers at . . . .
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ISSUES
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Nursing Homes
≥500,000 residents may suffer from malnutrition or dehydration
Malnutrition and dehydration rates ‐ 35% or higher
14% ‐ 56% of the residents have dementia and malnutrition
52% of hospital patients admitted with a diagnosis of dehydration will come from a nursing home
$6.5 million awarded to a Ohio widow
‐Nursing home lawsuit filed over the dehydration death of her husband allegedly caused when he was not provided with enough water during a temporary nursing home stay
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ISSUES
WOUND MANAGEMENT
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Barriers to
Wound Healing
Lack of Knowledge
Aging
Peripheral Vascular Disease
Hydration Nutrition
InfectionStressTumors
Metabolic Disorders
Impaired Immunity
Medications
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WOUND MANAGEMENT
Stress
Inflammatory mediators are released (fight or flight)
Hypermetabolic and catabolic state
Increased metabolic rate
Increasing nutritional needs
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WOUND MANAGEMENT
Increased breakdown of protein for glucose production
Protein energy malnutrition (PEM)
Inefficient use of fat stores for energy utilizing protein
Suppression of the synthesis of protein, glycogen, and triglycerides
Rapid depletion of lean body mass (LBM)
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WOUND MANAGEMENT
Exudate
Fluid loss
Zinc loss
Protein loss (≥30g/day)
Triggers inflammatory response
(catabolic state)Thomas B. Catabolic states. In: Thomas B, ed. British Dietetic Association Manual
of Dietetic Practice. Oxford, UK: Blackwell Scientific;1994:537–549.
EARTHINGS: UGLY BAGS OF MOSTLY WATER
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Body Composition
Water
‐Approximately 72% of nonfat weight
‐Keeps the skin moist
‐Protects from tearing and abrasions
‐Plays a role in moving nutrients to the ulcer bed to promote new tissue growth
‐Assists in removing waste away from the ulcer
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HYDRATION
Daily Fluid Intake vs. Fluid Loss
The body does not store water
3%
‐900 ml in case of 60 kg adult
‐Fatigue
4% ‐ 5%
‐Headache and dizziness
10%
‐Fatal
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HYDRATION
Adapted from Krause’s Food, Nutrition & Diet Therapy, 11th Edition
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Blunted Thirst Mechanisms
Aging
‐Homeostasis declines
Infection
‐Respiratory, GI, GU
Fluid loss or increased fluid need
‐Diarrhea, fever, vomiting
Incontinence
‐Reduce fluid intake
Fluid restriction
‐Renal dialysis
Medications
‐Diuretics, sedatives, antipsychotics, tranquilizers
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HYDRATIONCognitive or functional impairment
‐Aphasia ‐ unable to communicate effectively
‐Dementia or Alzheimer’s disease
Neurological impairment
‐Coma or decreased sensorium
Tube feedings
‐Dysphagia
‐Reduce fluid intake
NPO
‐Reduce fluid intake
Use of supplementation
‐Thick
‐Difficult to swallow
Dehydration
Reduction in total body water
3% body weight loss/increased serum osmolality
‐Water and electrolyte disturbance
‐Hyponatremia (water and sodium loss)
‐Hyperosmolar (water loss ‐ due to increased sodium or glucose)
Long Term Care
‐Sign of poor care
‐Combination of physiological or disease process
‐Not primarily due to lack of access to water
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HYDRATION
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HYDRATION
Dehydration Screening
Altered mental status/confusion
Weight loss (3%)
Muscle wasting
Pale skin
Sunken eyes
Red swollen lips
Swollen and/or dry tongue with scarlet or magenta hue
Dry mucous membrane
Poor skin turgor (forehead)
Tachycardia
Postural hypotension
Calf tenderness
Reduced urinary output
Dark urine
Functional Decline of the Renal System
Abnormal lab values
‐Abnormal glucose, calcium, potassium
‐Abnormal serum bicarbonate
‐Abnormal creatinine
Elevated
‐Serum osmolality
‐Serum sodium
‐Urine specific gravity
‐Blood Urea‐Nitrogen (BUN)*
*BUN is only useful in absence of renal disease
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HYDRATION
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Fluids With Special Problems
Caffeine (tea and coffee)
‐Inhibition of iron
‐Low levels of vitamin C
Diet soft drinks
Alcohol
Best Type of Fluid
Un‐concentrated
Decaffeinated
Beverage resident will drink
Water is the best fluid for dehydration
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HYDRATION
Intervention
Monitor fluid intake and output
‐30 ‐ 35 mL fluid/kg/day
‐Minimum of 1500 mL/day
‐1 mL/cal for enteral tube feeding
‐Additional 10 ‐ 15 mL/kg/day if on an air fluidized bed
Maintain circulation blood volume (reduce hypovolemia ‐ fluid/salt)
Maintain fluid and electrolyte balanceSource: American Medical Directors Association Dehydration and Fluid Maintenance, Clinical Practice Guidelines, Columbia MD
Touring the Nursing Home: Issues for the Elder Law Attorney, Nashville, TN, 2003
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HYDRATION
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HYDRATION/DEHYDRATION
Hydration Strategies
Schedule beverage breaks
Add cup holders to wheelchairs
Offer hot and cold beverages
Gelatins, fruit ices, ice chips, juices, supplements
Take fluids on outings and offer frequently
Offer glasses of water in dining room while waiting for meals
Offer fluids after providing care
Address fear of incontinence (risk factor)
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Nutrition
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NUTRITIONAL ASSESSMENT
Modulate inflammation & stress – control a catabolic state
Restore macro & micronutrient intake with glycemic control
Increase energy intake to~50% above daily needs
Increase protein intake to ~2 x RDS
Restore adequate calories to respond to wounding or to begin the process of lean mass gain
Undernutrition/Malnutrition
Severe weight loss
≥10% in 6 months
≥ 7.5% in 3 months
≥ 5% in one month
≥ 2% in one week
Walker G ed. Pocket Source for Nutritional Assessment, 6th ed. Waterloo IA
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NUTRITIONAL ASSESSMENT
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Disease ‐ Related Malnutrition
“...decline in lean body mass with the potential for functional impairment” at multiple levels
Jensen GL, Bistrian B, Roubenoff R, Heimburger, DC. Malnutrition syndromes: A conundrum vs continuum. JPEN J ParenterEnteral Nutr. 2009;33(6):710‐716
Three clinical syndromes characterized by underlying illness, injury and inflammation
‐Starvation‐related malnutrition no inflammation
‐Chronic disease associated with chronic condition that impose sustained inflammation of a mild‐to‐moderated degree
‐Acute disease or injury related to conditions that elicit marked inflammatory responses
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NUTRITIONAL ASSESSMENT
Anorexia
Loss of appetite/energy loss of interest in seeking and consuming food
A psychiatric eating disorder
‐Emotional ‐ depression
‐Physical ‐ low body weight
‐Psychological ‐ image distortion
‐Behavioral ‐ obsessive fear of gaining weight
‐Polypharmacy
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NUTRITIONAL ASSESSMENT
Cachexia
Loss of appetite in someone who is not actively trying to lose weight
‐Insidious loss of weight, muscle atrophy, fatigue and weakness
‐Directly related to inflammatory states
‐Rheumatoid arthritis, AIDS, chronic renal failure, COPD, Cancer, Immunodeficiency syndrome
Cytokine production decreases albumin
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At risk: 15 to 18
Moderate risk: 13 to 14
High risk: 10 to 12
Very high risk: 9 or below
Intensity/Duration
Tissue Tolerance
Intensity/Duration
Intensity/Duration
Tissue Tolerance
Tissue Tolerance
DRIP
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Care RequirementsMonitor intake of food, tube
feeding, TPN
Food intake decreases ‐ offer supplement
Tube feeding or TPN decreases ‐monitor and ensure infusion of prescribed amount
Evaluate adequacy of prescribed amount
Dietitian evaluates intake of calories and protein if food intake is low
Consider vitamin supplement
Provide assistance with feeding as needed
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NUTRITIONAL ASSESSMENT
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Care Requirements
Baseline Labs
Dietitian evaluates and recommends intake goals
Supplements are provided, intake counted and recorded
Provide support with eating
Time meals, encourage family to feed
Encourage favorite food and snacks
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NUTRITIONAL ASSESSMENT
Assessment Tool
ASPEN AND
Nutritional risks (six areas)
‐Oral health status
‐Ability to eat
‐Proper diet
‐Eating patterns
‐Chronic diseases affecting appetite
‐Medications affecting appetite
Current weight status
Detect under and over nutrition
‐Malnutrition Screening Tool
‐Short Nutritional Assessment Tool
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NUTRITIONAL ASSESSMENT
Pamela Charney, M.S., R.D. and Ainsley Malone, M.S., R.D.
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Assessment Tool
Mini‐Nutritional Assessment (MNA‐SF)‐Decline food/weight 3 months
‐Calf muscle circumferences
‐Functional impairment – mobility
‐Psychological issues, Neuropsychological problems
Simplified Nutritional Appetite Questionnaire (SNAQ)
‐Appetite
‐Satiety
‐Taste
‐Meal frequency
‐A score 14 indicates risk of at least 5% weight loss within 6 months
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NUTRITIONAL ASSESSMENT
Medium and High PrU Risk
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NUTRITIONAL ASSESSMENT
Criterion 1
‐If meal consumption is 50% or less for two meals in one day at least one time during the report week
Criterion 2
‐If there is any weight loss during the report week, determined by subtracting the current week's weight from the most recent weight
Medium risk
‐Residents meeting either one of the criteria
High Risk
‐Residents meeting both criteria
Agency for Healthcare Research and Quality (AHRQ)
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Triggers
Loss of appetite
2 meals with intake ≤50 percent in one day
‐Weekly meal intake averaging <50 percent
Significant assistance with key activities of
daily living
Change in body function
‐More than 3 days of bowel incontinence
Presence of a Foley catheter
Current pressure ulcer
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NUTRITIONAL ASSESSMENT
Laboratory Tests
Understand the metabolic basis for a lab test
Affecting factors‐Age
‐Hydration status
‐Chronic disease
‐Acute illness
‐Change in organ function
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NUTRITIONAL ASSESSMENT
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Muscle Mass Decrease
Energy requirements decline
Decreased protein reserves during periods of stress
Decreased total body water increases chances of dehydration
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NUTRITIONAL ASSESSMENT
Age 25 Age 70
Body Mass Index
Sarcopenia
Under and overweight
‐Same nutritional risks
Diagnostic tool
‐Obesity and PEM
<16 = severe underweight
17 ‐ 18 = underweight
19 ‐ 24 = normal
25 ‐ 30 = grade I obesity (mild)
31 ‐ 40 = grade II obesity (moderate)
>40 = grade III obesity (severe)
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NUTRITIONAL ASSESSMENT
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NUTRITIONAL ASSESSMENT
Loss of Muscle Mass
Face (temporalis and masseter)
Hands (interosseous and thenar)
Upper body (pectoralis, deltoids, scapular, trapezius, triceps and biceps)
Lower body (quadriceps, and gastrocnemius)
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NUTRITIONAL ASSESSMENT
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Loss of LBM Complications Mortality
10% Decreased immunity, Increased infections 10%
20% Decrease healing, weakness, infection 30%
30%Too weak to sit, pressure ulcers,pneumonia, no healing
50%
40% Death, usually from pneumonia 100%
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Creatine Height Index (%)
Marker for skeletal muscle mass
‐Amount of creatine excreted in the urine in a 24 hour period divided by the amount of creatine excreted by a normal healthy individual of the same height and sex
≥80% = normal protein
60% ‐ 80% = moderate protein depletion
≤60% = severe protein depletion
‐Creatine (degradation product) formed in active muscle at a constant rate in proportion to the muscle mass of a individual
2% muscle creatine converted to creatinine daily
‐Decreases due to protein depletion
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NUTRITIONAL ASSESSMENT
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Date: _________RN-RD Pressure Ulcer Screening Assessment Form
For High Risk Populations (page 1)
Age __ Sex □ M □ F Ht __ Dx_______
PMH _____ Risk Associated with Dx/PMH? □ Yes □ No□ >75y □ Recent Illness □ Trauma □ PEM □ Immobility □ Incontinence □ High risk comorbidities □ H/O Pressure Ulcer □ Smoking ____ppd □ Other
Patient Info
Addressograph
AppetiteInadequate intake?
□ Yes □ No□ Unable to assess
NPO Poor 0-50% Fair 50-80 % Good 80–100%(Downgrade by 1 level for presence of > Stage 3 or
multiple Stage 2 wounds)
Diet & MedicationsRisk Assessed?□ Yes (explain) □ No □ N/A to assess
□ Diet:_ □ Different than usual diet? □ P.O. □P.O.+ Supplement □ P.O.+TF □ NPO+TF □ NPOTube Type: NG G/PEG PEJ Site Intact: Y N Food Allergies Meds/Supplements
Weight AssessmentDo Not Use Transfer WeightSignificant IWL? □ Yes □ No
Usual Wt ________ Per patient Per care giver□ Any IWL in the past 2-3 months?Actual Wt/Date __/____ □ With equipment Scale: □ Standing □ W/C □ Bed □ Lift □ Edema
BMI __ IBW _ % of IBW ___ % of UBW ___ ____ % Wt Loss or Gain over past ____
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GI Complications?□ Yes □ No
Date of last BM: __________ □ No C/O □ No BS □ Diarrhea x ________ □ N/V x ________ □ Constipation x __________ □ Colostomy: Liquid Formed Hard Stool
Skin Areas of Concern?
□ Yes □ NoBraden ScaleScore _______(< 18 = at-risk)Gross Assessment Only see CWOCN note for detailed description of wound(s).Total # of Wounds: ___
1. _____________ (Location)
□ Pressure □ DTI □ Surgical □ Stasis
□ Intact Skin □ Foul Odor
Thickness: Partial Full
Drainage: Minimal Moderate Heavy Wound Bed: Beefy red Pale Dry Moist
Hyper-granulation Slough Eschar Tunneling
Undermining S/S of Infection
Abnormal Lab Values?□ Yes □ No □ N/A□ Pending
Baseline Labs □ Hypoproteinemia □Hypogonadism Date □ Hyperglycemia □DehydrationALB BUN Creat GFRPAB Na K Chol
BS HA1c CRP Testosterone
Electronic Medical Record
Early detection
Facilitate consistent comprehensive assessment
Laboratory studies and imaging
Rule out root cause
Provide updates
Monitor the results of PoC
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NUTRITIONAL ASSESSMENT
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Oral
Severe periodontal disease 60% ‐ 90%
‐Tooth loss (80%)
‐Ill fitting dentures (50%)
‐Mouth ulcers (30%)
‐Gum recession
‐Oral pain
‐Chewing abnormalities
‐Dry mouth
‐Gingivitis
‐Periodontal disease
Swallowing Abnormalities (Dysphagia)
‐Disease of the oropharynx and esophagus
‐Dementia
‐Stroke43
NUTRITIONAL ASSESSMENT
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Oral
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NUTRITIONAL ASSESSMENT
Glossitis ‐ Riboflavin, Niacin, folic acid, B12 , protein
Bleeding & spongy gums - vitamins C, A, K, folic acid & Niacin
Angular stomatitis, cheilosis & fissured tongue – vitamin B2,6, & Niacin
Leukoplakia ‐ vitamins A, B12, B complex, folic acid & niacin
Sore mouth & tongue - vitamins B12, 6, C, Niacin, folic acid & iron
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KEY MACRONUTRIENTS
Protein
Angiogenesis and collagen formation
‐RDA ‐ 0.8g/kg
1.25g/kg ‐ 1.50g/kg daily (PrU)
1.50g/kg ‐ 2.0g/kg (stress)
Calories
Resident with ulcers or ulcer risk
30 ‐ 35 kcals/kg/d
29 ‐ 33 kcals/kg/d (Para)
24 ‐ 27 kcals/kg/d (Quad)
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Protein Calories
KEY MACRONUTRIENTS
Protein Requirement
Stage I = 1.0 g/kg
Stage II = 1‐1.2 g/kg
Stage III = 1.25 ‐ 1.5 g/kg
Stage IV = 1.5 ‐ 2.0 g/kg
Protein level above 2.0 g/kg
‐May cause dehydration, particularly in the elderly or those with impaired renal function
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Fat
Aids in absorption of Vitamin A
Provide energy
20% ‐ 25% calories production
Linolenic acid – omega‐3 fatty acid
‐Anti‐inflammatory
‐Immune‐enhancing
Essential fatty acid deficiency may adversely affect wound healing
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KEY MACRONUTRIENTS
Inflammatory
‐Macrophages, neutrophils, blood clotting, vasodilatation
‐Vitamins and amino acids: A, K, Bromelain
Proliferative
‐Angiogenesis, fibroblasts, collagen deposition
‐Vitamins and minerals A, B6, C, Cu, Fe, Mg, Zn
Remodeling
‐Collagen maturation, stabilization, scar tissue mature
‐Vitamin and minerals C, Cu, Fe, Zn48© AMT Education Division
KEY MICRONUTRIENTS
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Vitamin A
Facilitates macrophage entry into the wound
Stimulates collagen synthesis, angiogenesis, and epithelialization
Antagonizes inhibitory affects of glucocorticoids (corticosteroids)
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KEY MICRONUTRIENTS
Vitamin A
Stage I ‐ II
10,000 – 25,000 IU x 10 days
Stage III ‐ IV
5000 IU per 1000 kcal
Concomitant glucocorticoid use
10,000 ‐ 15,000 IU x 7 days
Vitamin C (Ascorbic acid)
Enhances leukocyte, macrophage activation, fibroblast, collagen synthesis
Increased tensile strength
Decreases wound dehiscence
Depressed levels found in elderly, smokers, and certain cancers
Not to exceed 2000 mg/day
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KEY MICRONUTRIENTS
Vitamin C
Stage I ‐ II
100 mg ‐ 250 mg/day
Stage III ‐ IV
1000 mg/day (250 mg – 4x/day)
Renal failure
250 mg/day
Vacuum Dressing
1000 mg/day (250 mg – 4x/day)
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Vitamin D
Fat soluble
Calcium balance
Immunity (infection fighter)
Modulates cell differentiation
Proliferation of keratinocytes
1000 IU/d
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KEY MICRONUTRIENTS
Vitamin E
Scar formation – conflicting reports
Adversely affects vitamin A benefits
May interfere with the healing of some types of wounds
Vitamin K
Co‐factor for coagulation
Monitor prothrombin times (PT) rations (INR)
Antibiotics may limit vitamin K
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KEY MICRONUTRIENTS
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Zinc
Increased demand during collagen and protein synthesis
Transported through the body by albumin
Hypermetabolic state
‐Urinary/exudate loss of zinc
‐Zinc sulfate 220 mg/2wks
D/C in 3 ‐ 6 weeks ‐may impair copper and iron absorption and metabolism
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KEY MICRONUTRIENTS
Zinc
Stage III ‐ IV
11 mg‐ 15 mg/males (elemental zinc)
8 mg ‐ 12 mg/females (elemental zinc)
‐Limit 40 mg/day
‐Supplementation with 25 mg ‐ 50 mg elemental zinc/day x 2 weeks (not indicated)
Minerals ‐ Copper
10 days till depletion following injury
Formation of red blood cells
Vitamin C + copper = elastin production
‐900 μg/d
Amino Acids ‐ Arginine
Immune stimulant for lymphocytes
Enhances T‐cell function (immune mechanisms)
Precursor collagen and connective tissue synthesis and cell multiplication
5 g – 6 g/d
15 g – 25 g improves collagen formation
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KEY MICRONUTRIENTS
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Amino Acid ‐ Glutamine
60% of intracellular amino acid pool
Source for epithelial cell and fibroblasts
Stimulates lymphocytic proliferation
Stores depleted at 10 – 15% LBM loss
Supplemental 0.57 g/kg/d
0.3 g ‐ 0.4 g/kg/d (burn patients)
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KEY MICRONUTRIENTS
Current evidence does not definitively support any specific dietary supplement unless the resident has a specific vitamin or mineral deficiency
Multivitamins contain 7.5 mg to 15 mg of elemental zinc
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NUTRITION
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IN CONCLUSION
Nutrition plays an essential role in wound healing
Modulate inflammation & reduce stress
Control catabolic state
Restore macro and micronutrient intake with glycemic control
Increase energy intake to ~50% above daily needs
Reassess nutritional status at frequent intervals while
THANK YOU
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Barbul A, Lazarou SA, Efron DT, et al: Arginine enhances wound healing and lymphocytes immune responses in humans. Surgery 1990; 108:331‐337.
Black JM, Edsberg LE, Baharestani MM, LangemoD, Goldber M, McNichol L, Cuddigan J. Pressure Ulcers :Avoidable or Unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management 2011;57(2): 24‐37.
Campbell, S. Maintaining hydration status in elderly persons: problems and solutions. Support Line, 1992;7‐10.
Cataldo CB, DeBruyne LK, Whitney EN. Nutrition and Diet Therapy, Principles and Practice. Belmonth, CA: Wadsworth; 2003.
CMS Guidance for 483.25 (i)‐Nutrition F(325).
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http://www.nursinghome.org/fam/fam_018.html
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REFERENCES
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REFERENCES
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National Pressure Ulcer Advisory Panel and European Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, 2009.
Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks. Posthauer ME, Collins N, Dorner B, Sloan C, Nutritional Strategies for Frail Old Adults. Advances in Skin &Wound Care, 2013;26(3):128‐140.
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REFERENCES
Thomas D T, Todd R C, Lawhorne L, Levenson S A, Rubenstein L Z, Smith D, Stefanacci R G, Tangalos E G, Morley J E, Dehydration Council (2008). Understanding Clinical Dehydration and its Treatment. JAMDA 9(5), 292 ‐301.
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Wick J. Y. (1999). Prevention and Management of Dehydration. The Consultant Pharmacist, 14(8). Retrieved April 5, 2007, from http://www.ascp.com/publications/tcp/1999/aug/prevention. html.
Williams JZ. Surg Clin N Am 2003.
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REFERENCES