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

3. 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

5. 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 –19 - 29% in home care 2 –15 - 20% 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

6. 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

7. 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

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

9. 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

10. 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

11. 3/13/200310 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

12. 3/13/200311 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

13. 3/13/200312 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

14. Lab Data

15. 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

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

17. The Other 4 Big Ones!

18. 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.

19. “An ounce of prevention…”

20. Prevalence of Pressure Ulcers ; 3.5 - 29.5%Acute Care ; 2.4 - 23%Long Term Care ; 12.4 %Home Care

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

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

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

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

25. Intervention ; Select and use a method of risk assessment

26. Risk Assessment Tools ; Norton Scale ; Braden Scale ; Others

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

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

29. 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

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

31. AHCPR Guidelines ; P.O. Box 8547 Silver Spring, MD 20907 ; 1-800-358-9295 ; www.ahcpr.gov

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

33. 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

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

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

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

37. Intervention: ; Assess and treat incontinence

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

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

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

41. ; Prevent or Moisturize Dry SkinIntervention

42. ; No Vigorous MassageIntervention

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

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

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

46. ; Improve mobility and activity statusIntervention

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

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

49. ; Establish individualized repositioning schedule for bed/chairIntervention

50. Intervention ; Use pillows/wedges to separate bony prominences

51. Intervention ; Totally relieve heel pressures

52. 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.

53. Pressure Relief Devices

54. Pressure Reduction Devices

55. Support Surfaces

56. ; Use proper positioning, transferring and turning techniquesIntervention

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

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

59. Questions? Thank You! Jesse M. Cantu, RN, BSN, CWS Certified Wound Specialist (210) 326-9659 jcrncws@yahoo.com