1. Nutritional Considerations in Wound Healing Ronni Chernoff, PhD, RD

2. Weight changes (losses or gains) may be related to a variety of risk factors

3. Weight should remain stable during healing

4. Immobilization and deconditioning are major factors in negative nitrogen balance

6. To avoid or heal wounds of any type, nutrient needs must be met to support homeostasis

7. However, nutrient requirements may change with age due to physiological, health status, body composition, and activity level changes

8. Key nutrients needed for wound healing  Protein  Energy  Vitamin A  Vitamin C  Zinc

9. 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

10. Protein requirements for older adults is 1 g/kg body weight

11. Protein is necessary to make new tissue, fight infection, heal fractures

12. Protein needs may be as high as 2+ g/kg body weight

15. Energy needs increase with demands for wound healing, fracture repair, infection response

16. To maintain weight, 20-25 kcals/kg body weight is usually adequate in a relatively sedentary adult

17. For stress, wound healing, infection, fracture, energy needs may increase to as much as 35 kcals/kg body weight

18. Vitamin A is needed for cell differentiation

19. Vitamin A requirements in wound healing should not exceed 200% of the RDA

20. Vitamin C  Status is related to dietary intake  Institutionalization, hospitalization and illness lead to sharp decreases in vitamin C intake

21. Vitamin C  Decreases seen with chronic disease including atherosclerosis, cancer, senile cataracts, lung diseases, cognition, and organ degenerative diseases

22. Vitamin C  Vitamin C is easily replaced  Smokers may need 2x RDA just to meet requirements

23. 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

24. 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

25. Copper, iron, magnesium, manganese may be affected by large doses of zinc

26. Meeting fluid requirements is often an issue in wound healing protocols

27. Fluid intake can be estimated at 30 ml/kg body weight with a minimum of 1500 ml/day

28. Sometimes pressure ulcers are unavoidable but optimal healing includes a nutrient dense diet that addresses the nutrient needs described

29. Pressure Ulcer Management: Quick Tips Molly Brethour RN, CWOCN CAVHS Little Rock, Arkansas

30. Wound Priorities Cause Cause Cause Establish goal Systemic factors Environmental modifications Then Optimize wound

31. Determine Cause

32. Unexpected Pressure

33. 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

34. 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

35. Support the Host: Evaluate Systemic Factors  Tissue Perfusion  Nutrition  Infection  Medications  Diabetes  Aging

36. Basic Principles to Optimize the Wound: Which dressing?!  M oisture  I nfection  N ecrtoic tissue  D eadspace  P rotect  I nsulate  E xudate

37. 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

39. VHA Handbook 1180.2 Assessment & Prevention of Pressure Ulcers ONS Special Issues Forum August 14, 2006

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. ID Team Responsibilities (cont)  Identify educational need  Record all treatment  Complete summary upon transfer or discharge of progress  Document patient outcome measures

50. Braden Scale  Predicts individual’s level of risk for developing pressure ulcers  Scoring 15-18 = at risk 15-18 = at risk 12-14 = moderate risk 12-14 = moderate risk ≤ 12 = HIGH RISK ≤ 12 = HIGH RISK