Nutrition in Chronic Wound Care

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

2. 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

3. Why does skin break down?

4. Wounds • The problem: Wounds, particularly pressure ulcers, are a concern across health care settings • > 1 million patients develop pressure ulcers annually1 • Prevalence: • 4 - 29% in acute care2 • 19 - 29% in home care2 • 15 - 20% in long-term care2 • Total national cost > $1.3 billion annually3-5 • Cost ranges from $5000 to $60,000 per ulcer 6-8

5. 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

6. Role of Nutrition • Nutrition and hydration • Critical for tissue integrity and wound healing • Research shows a strong relationship between pressure ulcers and nutritional status9-14 • Poor nutritional status is a major risk factor for pressure ulcer development11 • Weight loss is associated with poor wound healing9-11,13,14,17

7. Nutrition Interventions • Dietitian Consult • Nutritional Support • Fluid Management • Vitamin and Mineral Supplementation

8. 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

9. ARGININE HMB GLUTAMINE Targeted Nutritional Synergy SLOW Protein breakdown ENHANCE Protein synthesis • Arginine and Glutamine support protein synthesis • HMB increases lean mass by decreasing breakdown of protein from cells

10. 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 • Helps reduce muscle damage • Increasedcholesterol synthesis • Protects muscle from stress-related damage • Decreases muscle breakdown in disease states

11. Arginine • Conditionally essential amino acid Helps support immune function • Helps promote wound healing

12. Glutamine • Conditionally essential amino acid • Regulates cellular protein synthesis • Improves immune function • Maintains gut integrity

13. Lab Data

14. 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

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

16. The Other 4 Big Ones! Pressure Friction Shearing Moisture

17. 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.

18. “An ounce of prevention…”

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

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

21. Cost of Pressure Ulcers • Money • Morbidity • Mortality • Malpractice

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

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

24. Intervention • Select and use a method ofrisk assessment

25. Risk Assessment Tools • Norton Scale • Braden Scale • Others

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

27. Braden Scale Measures • Sensory Perception • Activity • Mobility • Skin Moisture • Friction and Shear • Nutrition

28. 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

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

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

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

32. Location /Etiology Dimensions Depth Exudate Wound Base Wound Edges Undermining Tunneling Necrotic Tissue Epithelial Tissue Granulation Tissue Periwound Skin S&S of Infection Assessment of Wound

33. Intervention • Assess and document skin condition on admission and at regular intervals

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

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

36. Intervention: • Assess and treat incontinence

37. Scope of the ProblemNeed for QI • 13 million adults • $16.4 billion cost • Major cause of institutionalization

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

39. Improving Clinical Outcomes • Multidisciplinary • Clinical pathway = positive outcomes • Identifying barriers

40. Intervention • Prevent or Moisturize Dry Skin

41. Intervention • No Vigorous Massage

42. Protect Skin from Moisture • Incontinence • Perspiration • Effluent • Wound / fistula drainage

43. Uses • Skin Preparations: Periwound, peristomal skin, prior to adhesives, friction areas • Protective Creams:Denuded skin and mixed incontinence

44. Protection Uses • Ointments: Exposure to urine and feces • Pastes: Severe fecal, mixed fecal/urinary and denuded skin

45. Intervention • Improve mobility and activity status

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

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

48. Intervention • Establish individualized repositioning schedule for bed/chair

49. Intervention • Use pillows/wedges to separate bony prominences

50. Intervention • Totally relieve heel pressures