Download nutrition and lab values

NUTRITION AND
LAB VALUES
Contents
Identifying Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Estimating Nutritional Need . . . . . . . . . . . . . . . . . . . . . 8
Vitamins and Minerals . . . . . . . . . . . . . . . . . . . . . . . . . 12
Nutritional Intervention and Medical
Nutrition Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Reading Food Labels . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Wound Care-Related Lab Values . . . . . . . . . . . . . . . . . 19
1
One of the most troublesome yet fundamental risk factors
for the development and non-healing of chronic wounds is
malnutrition. Numerous studies cite a strong link between
deteriorating nutritional status and the development and
healing of chronic, non-healing wounds.
Many of the elderly suffer from malnutrition. It is no
wonder that they are also the group at highest risk for the
development of pressure ulcers.
Side effects of poor nutrition are:
•
•
•
•
•
DID YOU KNOW
TIPS!
Side effects of poor
nutrition are:
• Muscle and soft
tissue wasting
• Compromised
immune system
• Increased
susceptibility to
infection
• Loss of strength
• Increased level of
toxicity to drugs
Muscle and soft tissue wasting
Compromised immune system
Increased susceptibility to infection
Loss of strength
Increased level of toxicity to drugs
A nutritional assessment by a qualified registered dietitian can
help you identify whether a patient has nutritional risk factors
for impaired wound healing.
Wound nutrition is nothing more than whole body nutrition.
Patients with severe malnutrition are at higher risk for infection, sepsis, longer length of stay and ultimately death. Severe
protein and calorie malnutrition impairs tissue regeneration,
immune function and the inflammatory response, which is
necessary for wound healing.
Identifying Risk
When is a nutritional assessment indicated? There are many
warning signals that will alert you to the potential risk of
malnutrition. An obvious one is involuntary weight loss.
Some not so apparent indicators may include impaired
cognitive patterns; altered communication, hearing or vision;
impaired mood or behavior; diminished physical and functional capabilities, nothing by mouth (NPO) or very low intake
for 7 days or more, nausea, vomiting, and/or diarrhea for more
than 3 days.
A Braden Scale Pressure Sore Risk score below 18 can indicate
a risk for the development of pressure ulcers. This is an assessment that is most likely already being performed and can serve
as an early warning to initiate further nutritional investigation.
2
A nutritional assessment considers four basic categories:
A.
B.
C.
D.
Anthropometric information
Biochemical data
Clinical facts
Dietary history
Anthropometric Information
Anthropometry measures height, weight, and size of relevant body parts, including skinfolds, to examine and evaluate
the proportions under normal and abnormal conditions.
TIPS!
An easy way to
remember the nutritional assessment
categories is:
Anthropometric
Information
Biochemical
Data
Clinical
Facts
Dietary
History
To begin, it is necessary to obtain a "usual weight," which will
alert you to changes in weight. Usual weight is obtained by
reviewing patient records.
Following is a simple calculation for ideal body weight (IBW):
•
•
Men: A standard weight for a five foot tall male is 106 lb.
Add six lb. for every inch above five feet.
Women: A standard weight for a five foot tall female is 100
lb. Add five lb. for every inch above five feet.
A range of ± 10 percent accounts for differences in frame size.
For example, a female patient who is five feet three inches
tall would have an ideal body weight of 103.5 lb. to 126.5 lb.
(100 + 15 = 115 lb., - 10 percent = 103.5 lb., + 10 percent =
126.5 lb.).
Significant weight loss is considered greater than 5 percent of
a patient’s usual body weight in one month or greater than
7.5 percent in three months. The incidence of unintentional
weight loss in nursing homes is greater than 25 percent.
Several cross-sectional studies have demonstrated that
patients with pressure ulcers weigh significantly less than
patients without pressure ulcers.
Body Mass Index (BMI)
The most common method used to assess the amount of body
fat in relation to lean body mass is the body mass index
(BMI), a mathematical calculation based on height and weight.
The BMI is easy to use and helps predict the likelihood of developing health problems related to excessive weight.
3
BMI is an individual’s weight in pounds multiplied by 703,
and then divided twice by their height in inches. BMI tables
and calculators are readily available on the Internet. A BMI
of between 25 and 29.9 indicates that an individual is overweight, whereas an obese adult has a BMI of 30 or higher.
BMI is calculated as follows:
( Weight in Pounds ) X 703
((Height in Inches) X (Height in Inches))
The following are examples of BMI calculations:
Man: 6’0” who weighs 175 pounds:
175 X 703
72 X 72
= 23.7 BMI
Woman: 5’4” who weighs 165 pounds:
165 X 703
64 X 64
= 28.3 BMI
BMI Weight Classification
<18.5
18.6 to 24.9
25 to 29.9
>30
Underweight
Normal
Overweight
Obese
Biochemical Data
Biochemical data includes laboratory tests like serum albumin, serum pre-albumin, serum transferrin, total lymphocyte
count and nitrogen balance. See the end of the chapter for a
full description of lab values.
4
Nitrogen balance is also useful for assessment of protein
requirements, since protein is 16 percent nitrogen. Nitrogen
balance is the difference between nitrogen intake and
output. It helps determine needs for protein maintenance
and anabolism. Accurate measurements of food and fluid
intake over a 24-hour period and a 24-hour continuous
urine sample are needed. Nitrogen balance results can be
questionable in the presence of kidney disease.
Clinical Facts
A vitamin or mineral deficiency is determined by physical
assessment and other information that you are probably
already monitoring. These indications include increased
metabolic needs such as fever, infection, trauma, burns,
growth, pregnancy, heavily draining wounds and kidney
dialysis; chronic diseases such as diabetes, hypertension,
kidney or liver disease and cancer; gastrointestinal diseases
such as malabsorption, diarrhea and GI surgery; and assessment of gums, skin, face, eyes, mucous membranes, tongue,
lips, teeth and hair. An example of a clinical sign of deficiency
is cheilosis, or scaly red lips with fissures at the angular corners
of the mouth. This may indicate a vitamin B deficiency.
DID YOU KNOW
Indications of a
vitamin or mineral
deficiency:
increased
metabolic
needs
chronic diseases
gastrointestinal
diseases
clinical signs of
deficiency
Dietary History
Dietary history includes several questions about dietary
habits and an assessment of the patient’s food intake.
Ask these questions of your patient:
•
•
•
•
•
•
•
Have you had any recent changes in your appetite or
food intake?
Do you have any food allergies, intolerances or aversions?
Do you have any chewing or swallowing problems, nausea
or vomiting?
Do you use any vitamin, mineral or herbal supplements?
How much alcohol do you drink?
Have you noticed a loss of taste or smell?
Do you avoid any specific food groups or have any
cultural or religious food limitations?
It is imperative to collect information on what your patient
eats as well as any problems that could diminish his or her
nutritional status.
5
Food Diary
Keeping a food diary will allow you to identify the foods your
patient eats and recognize eating patterns that may need to be
changed. Be sure to include the following items in your chart
and ask your patient to be as accurate and honest as possible:
•
•
•
•
•
•
•
Food
Quantity
Time
Where
Alone or with company
Activity during meal
Physical activity
Some tips for your patients to remember:
•
•
•
Record everything you eat. Don’t forget that handful of
pretzels, condiments, sauces or the piece of chocolate.
Everything adds up!
Be truthful. You only hurt yourself if you are not including
everything you’ve eaten.
Estimate amounts to the best of your ability.
EXAMPLE FOOD DIARY
Meal
Food
Quantity
Time
Where
Alone or
w/company
Activity/
Physical
Activity
Breakfast
Snack
Lunch
Snack
Dinner
Snack
6
COMPLETED FOOD DIARY SAMPLE
Meal
Breakfast
Snack
Lunch
Snack
Dinner
Snack
7
Food
Quantity Time
Where
Alone or
w/company
5:30 a.m.
Home
Alone
Activity/
Physical
activity
Two miles on
the treadmill
Coffee
w/half & half
Eggs
Croissant
Butter
Bagel
Low-fat cream
cheese
8 oz.
2
1
1 tsp.
7:15 a.m.
Kitchen
With kids
Talking
1/2
1 tbsp.
9:30 a.m.
Work
Alone
None
Plain tomato
soup
Small ham and
cheese sandwich
Chocolate cake
with chocolate
frosting
Diet soda w/o
caffeine
1 cup
11:45 a.m.
Work
With
coworker’s
Lunch meeting –
working on
report
Chocolate chip
cookies
Coffee w/half &
half
2
2:45 p.m.
Work
Alone
None
Baked chicken
breast
White rice
Green beans
4 oz.
6:15 p.m.
Kitchen
With kids
Talking &
cooking
Popcorn with
butter
2 cups
8:30 p.m.
Family
room
Alone
Watching TV
9:00 p.m.
Family
room
Alone
50 sit-ups in
front of TV
1
3 in. pc.
1
8 oz.
1 cup
1 cup
Chapter 4 Nutrition and Lab Values
Estimating Nutritional Need
After a nutritional assessment, the next step is devising a plan
that estimates the nutritional needs of the patient, including
energy, protein, fluid, vitamins and minerals.
Worth
remembering ...
Energy
Similar to the
gasoline we put
in our vehicles,
some fuel is of
better quality
than others.
Our bodies are fueled by the energy or calories (kcals) of food.
Similar to the gasoline we put in our vehicles, some fuel is of
better quality than others. However, all food and calories are
not created equal. The Harris-Benedict Equation for basal
energy needs is used for calculating basal (resting) energy
expenditures (BEE). The large difference between male and
female BEE is due to differences in muscle mass and metabolic
rates. The Harris-Benedict Equation for the BEE of a resting
individual is calculated as follows:
Women: BEE = 655 + (9.6 x body weight in kg) +
(1.8 x height in cm) - (4.7 x age in years)
Men: BEE = 66 + (13.6 x body weight in kg) +
(5 x height in cm) - (6.8 x age in years)
To determine daily energy needs beyond resting, we must
account for physical activity, surgery, infection, or other
injuries such as pressure ulcers.
After calculating the BEE, the result is multiplied by both
an activity factor and a stress factor in order to calculate the
patient’s daily caloric requirements. Some reports have
shown that the Harris-Benedict Equation, with its activity
factors and stress factors, may overestimate needs. HarrisBenedict calculation factors are as follows:
Activity factors:
•
•
Ambulatory = 1.3
Bedridden = 1.2
8
Stress factors:
•
•
•
•
The entire equation should look like this:
BEE x activity factors x stress factors =
The patient's total daily caloric requirements
TIPS!
Continuous
monitoring is
essential to
evaluate whether
a patient's needs
are being met.
Minor surgery = 1.2
Skeletal trauma = 1.35
Major sepsis = 1.6
Severe burns = 2.1
Continuous monitoring is essential to evaluate whether a
patient's needs are being met.
A quick and easy way to calculate energy needs uses the
weight of the patient. In severely malnourished patients,
feeding should be gradually increased to prevent problems
with refeeding syndrome. Also, avoid overfeeding in metabolically stressed patients. Best practices often dictate utilizing an
adjusted weight if the patient is obese.
Calories
•
•
Normal or non-stressed patient: 20 to 25 kcals/kg
of body weight.
To heal severe or extensive wounds: 30 to 35 kcals/kg of
body weight for slightly hypermetabolic (greatly increased
metabolism), or 35 to 40 kcals/kg of body weight for a
severely stressed patient.
Carbohydrates
Carbohydrates (CHOs) are broken down by the body for
energy. Our body breaks the CHOs down into a simple sugar
that is absorbed into the bloodstream and used for energy
needs. There are simple sugars, such as table sugar or fruit sugars (fructose) and there are complex carbohydrates or starches,
such as grain products like rice and breads. Simple CHOs are
processed in the bloodstream faster and result in a hungry
feeling after consumption. Complex CHOs are processed
more slowly, usually leaving one with a satisfied feeling.
9
Fats
There are several types of dietary fats; in general they are
referred to as either saturated or unsaturated. Saturated
fats usually refer to the fat derived from animal products
such as beef, organ meats, milk and cheeses and plant
sources such as coconut and palm oils. Saturated fats are
responsible for high cholesterol levels, especially the LDL
or low density lipoprotein (the “bad” cholesterol) and
play a major role in coronary heart disease. Other fats,
the unsaturated fats – both polyunsaturated and
monounsaturated are found primarily in plant sources.
DID YOU KNOW
Protein
It is important to
know that the
benefits of arginine
are only observed
when supplementing a balanced
diet.
Amino acids and protein are the building blocks of collagen.
In order for wounds to heal the body must be in a positive
nitrogen balance, or anabolism, the building phase. Protein
deficiency can suppress the development of new blood vessels
(angiogenesis), decreasing wound healing.
Protein needs are calculated by using the following formulas:
•
•
•
Normal healthy adult: 0.8 grams of protein/kg/day
Moderate stress (partial-thickness wound): 1.2 to 1.5
grams of protein/kg/day
Severe stress (full-thickness wound, severe or multiple
wounds): 1.5 to 2.0 grams of protein/kg/day
Be alert for dehydration when supplementing protein
greater than 1.5 grams/kg/day. Fluid needs increase with
high supplementation.
10
Arginine
Arginine is a single-chain amino acid that appears to benefit
wound healing even if a deficient state is not present. Nitrogen
retention and immune function appear enhanced in many
studies where arginine was used; however, outcome studies
are needed to confirm a clinical benefit. Additionally, it is
important to know that the benefits of arginine are only
observed when supplementing a balanced diet.
Fluids
Our bodies are composed of 70 to 80 percent water. As you
know, we can live for days without food but not without
water. Unfortunately, most of our patients are chronically
dehydrated. Look for creative ways to increase daily fluid
intake such as frozen popsicles during warm summer days
and hot soup in the cooler months. Fluid needs can be
calculated in the following ways:
•
•
•
General recommendation: 1 ml/kcal ingested
Young healthy adult: 35 to 40 ml/kg of weight daily
Elderly: 30 ml/kg of weight daily
Be sure to monitor intake and output, especially when the
patient has a history of heart disease or kidney failure. Adequate hydration is necessary to replace losses in patients with
draining wounds, patients with fever, or those on high air-loss
beds (air-fluidized support surfaces). Also, beware of beverages
containing caffeine and alcohol. They act as diuretics and
actually cause the patient to lose fluids.
11
Vitamins and Minerals
Many registered dietitians include multivitamin or
mineral supplements such as vitamin C and zinc as part of
their preventive protocol for patients at high risk for ulcers or
with existing ulcers. Supplementation beyond the RDA is not
advised unless the patient has a known deficiency. Megadoses
should not be administered without the recommendation of a
physician or registered dietitian. Vitamin and mineral assays
are useful to confirm suspected deficiencies. Unless the
individual has a known deficit, supplementation has not
been shown to be of any benefit.
If the patient has a vitamin C deficit, up to 1 to 2 g/day of
vitamin C may be recommended to promote wound healing.
Since vitamin C is water soluble, dietary or supplemental
forms must be ingested daily. If a zinc deficit exists, which
is especially true of patients who are vegetarians or who have
high-output fistulas or exudating wounds, supplementation
with 15 to 30 mg/day is suggested. Zinc has not been shown
to accelerate wound healing in patients with normal zinc
levels. In fact, too much zinc may interfere with copper
metabolism. When supplementing this mineral, have
the patient take it with meals to avoid nausea, vomiting
and diarrhea.
12
Various vitamin and mineral supplements and their role in
wound healing:
13
Vitamin/
Mineral
Food Sources
Why it is Important
Vitamin A
Deep orange and yellow
fruits and vegetables,
leafy greens, tuna
Vitamin A promotes a healthy
immune system, is essential
for the growth and development of cells, and keeps the
skin healthy.
Vitamin B1
(thiamin)
Pork, sunflower seeds,
whole grains
The B vitamins help the body
convert carbohydrates into
energy and are necessary
for the heart, muscles and
nervous system to function
properly.
Vitamin B2
(riboflavin)
Liver, duck, mackerel,
dairy foods
Riboflavin is essential for
turning carbohydrates into
energy and producing red
blood cells. It is also important for vision.
Vitamin B3
(niacin)
Poultry, fish, veal
Niacin helps the body turn
food into energy. It aids in
digestion and is important
for nerve function.
Vitamin B6
(pyridoxine)
Potatoes, bananas,
chickpeas, prune juice,
poultry, fish, liver
Vitamin B6 is important for
brain and nerve function. It
also helps the body break
down proteins and make
red blood cells.
Vitamin B12
(cobalamin)
Fish, shellfish, liver
Vitamin B12 helps to build
DNA, create red blood cells
and is important for nerve
cell function.
Vitamin/
Mineral
Food Sources
Why it is Important
Vitamin C
Citrus fruits, melon,
strawberries, tomatoes,
dark leafy greens
Vitamin C is essential for
healthy bones, teeth, gums
and blood vessels. It aids in
wound healing, collagen synthesis, fibroblast formation,
tensile strength and contributes to brain function.
Vitamin D
Fish, fortified milk, dairy
Vitamin D strengthens bones
by helping the body absorb
bone-building calcium.
A healthy dose of the sun
also provides vitamin D
to the body.
Vitamin E
Nuts, blackberries,
apples, mangos
Vitamin E is an antioxidant
that helps protect cells from
damage and is important for
the health of red blood cells.
Vitamin K
Leafy green vegetables,
tomatoes, egg yolks
Vitamin K promotes blood
clotting and prevents
hemorrhaging.
Folate
Leafy greens, asparagus,
liver, wheat germ
Folate helps the body make
red blood cells, break down
proteins and helps keep the
heart healthy.
Calcium
Yogurt, milk, cheese
Calcium is vital for building
strong bones and teeth,
especially during childhood.
14
15
Vitamin/
Mineral
Food Sources
Why it is Important
Chromium
Whole grains, liver,
meats, cheese, some
fruits, broccoli, grape
juice, potatoes, garlic,
basil
Chromium enhances the
action of insulin and plays
a role in controlling Type
2 diabetes.
Copper
Shellfish, liver, dried
fruits, nuts, whole grains,
lentils, green vegetables
Copper helps regulate blood
pressure and heart rate, and
is needed for the body to
absorb iron. It also aids in
erythrocyte and elastin (a
protein similar to collagen)
formation.
Iron
Shellfish, meats, liver,
pumpkin seeds
Iron helps red blood cells
carry oxygen to all parts of
the body.
Magnesium
Nuts, fish, legumes,
whole grains, leafy
greens, fish
Magnesium helps muscles
and nerves to function, steadies the heart rhythm and
helps keep bones strong. It
also aids in wound healing.
Manganese
Whole grains, vegetables,
nuts, fruits
Manganese plays a role in
cholesterol and carbohydrate
metabolism, thyroid function,
blood sugar control, anticancer activity, and the
formation of bone, cartilage
and skin.
Potassium
Fruits, bananas, orange
juice, vegetables, fish,
milk
Potassium helps with muscle
and nervous system function.
It also helps the body to
maintain water balance in the
blood and body tissues.
Selenium
Shellfish, liver, nuts,
whole grains, meat, dairy
Selenium helps regulate
thyroid function and play a
role in the immune system.
Zinc
Shellfish, meats, liver
Zinc is important for normal
growth, strong immunity,
wound healing, collagen
synthesis, cell proliferation,
immune function and
epithelialization
Nutritional Intervention and Medical
Nutrition Therapy
TIPS!
Ask your patients for
their input into their
supplementation
plan. You might
be surprised!
Nutritional intervention and medical diet therapy is required
when the patient is deficient in calories, protein, fluids or
nutrients. They include oral feeding and supplements, enteral
or tube feeding, parenteral or total parenteral nutrition (TPN)
feeding, and adjunctive therapy such as anabolic agents. These
are directives prescribed by a physician in collaboration with a
registered dietitian.
Oral Feeding
The easiest and most pleasant way to supplement a patient is
with oral feeding. It also happens to be the least expensive
and most convenient way. Much of our social life revolves
around eating. A patient who is unable to consume food will
suffer more than gastrointestinal problems and possible malnutrition. Find foods that the patient enjoys. Make sure they
are calorie, vitamin and protein rich. Offer small frequent
meals or snacks. These tend to be much less intimidating than
large meals. Consider adding powdered milk to yogurt and
pudding. There are many palatable choices on the market, not
just supplemental shakes. Patients will not eat foods that
they do not like.
Ask your patients for their input into their supplementation
plan. You might be surprised!
One example of caring for long-term care patients involved an
elderly man whose weight continued to drop despite efforts to
supplement feedings and encourage his appetite. One evening,
he was quizzed on what he really enjoyed eating and why his
appetite had waned. He said he missed his evening treat of
M&M’s® candy. With that information, he received a small bag
of M&M’s each evening if he additionally drank a 16 oz. glass
of milk with it and tried to eat at least 50 percent of each of his
meals. In the months ahead his appetite, weight and outlook
improved! The name of the game is customization when it
comes to diet therapy and nutrition.
16
Enteral Nutrition
If enteral feeding is needed, it can be accomplished with a
small-bore feeding tube passed into the nares. Placement
should always be checked by x-ray before initiating feeding.
Mobile patients may prefer bolus feedings, or set amounts at
specific times of the day, instead of continual feedings that
often require a pump. Many formulas of tube feeding are
available for different needs. For example, certain formulas
are higher in protein, fiber or lower in carbohydrates. A
registered dietitian can customize the choice of formula to
the patient's needs. Complications of tube feeding include
diarrhea, hyperglycemia (high blood sugar) and constipation.
Total Parenteral Nutrition
If the gastrointestinal tract is failing, nonfunctioning, or needs
a rest, this is often a last resort for nutritional therapy. Total
Parenteral Nutrition (TPN) is delivered by means of a
central venous catheter (CVC) and dramatically increases the
chances of infection. It is extremely expensive. An intravenous
pump delivers the fluids; the components must be monitored
continually and the tubing must be changed daily. This form
of nutrition supplies everything that the body needs. The formula is calculated and customized especially for the patient by
the registered dietician.
Adjunctive Therapy
Anabolic agents such as the human growth hormone (HGH),
although not labeled for this use, are used when a patient
has lost 10 percent or more of his or her usual body weight.
Its use is contraindicated in patients with diabetes. HGH must
be administered parenterally and can cause edema and a 10
percent rise in basal metabolic rate. Testosterone and synthetic
derivatives are also used as adjunctive agents. One that is
currently being prescribed is oxandrolone (Anavar®). Other
drugs being utilized off-label to promote appetite include:
miratazapine (Remeron SolTab®), an antidepressant; megestrol
acetate (Megace®), which has shown promise in patients with
cancer and AIDS; and dronabinol (Marinol®), a drug that has
had particular success in patients with Alzheimer’s Disease.
17
Medical records should reflect the nutritional care and treatment
provided and should include the following information:
•
•
•
•
•
•
•
•
•
Is the patient consuming the food and/or supplements?
How much fluid is taken daily?
Does the patient need assistance to eat?
If the patient refuses a diet, have meal or supplement
alternatives been made?
How frequently does the dietician visit and discuss
the plan of care (POC)?
How often is the patient weighed?
Are labs requested?
Does the care plan reflect the nutritional care and
how often is it updated?
Does the patient understand the risks and benefits
of intervention?
Reading Food Labels
Reading and understanding food labels can be helpful when
planning meals, choosing snacks or purchasing food gifts.
The nutrition facts box on a food product provides valuable
information, but can also be confusing. The exact amount
of calories, carbohydrate (CHO) and grams of fat per serving
are found on the label.
Let’s take a look at a sample food label:
Serving size and servings
per container. This will give
the amount of the food
product that is equal to one
serving.
The number followed by
the “%” sign represents the
percent that this food product
provides based on the recommended daily amounts (RDA).
Notice that this particular
food product provides about
1/3 (29%) of the total sodium
level recommended. A diabetic
diet requirement may vary.
1
3
Nutrition Facts
Serving Size 1 Package (170g)
Servings per Container 1
2
Amount per Serving
Calories 280
Calories from Fat 70
% Daily Value*
Total Fat 8 g
Saturated Fat 3.5g
Trans Fat 0g
Polyunsaturated Fat 1.5 g
Monounsaturated Fat .5g
Cholesterol 25 mg
Sodium 690mg
Potassium 120 mg
Total Carbohydrate 32 g
Dietary Fiber 5 g
Sugars 3 g
Protein 21g
Vitamin A 15%
Calcium 25%
•
•
12%
17%
8%
29%
3%
11%
21%
Vitamin C 4%
Iron 15%
* Percent Daily Values are based on a 2,000
calorie diet. Your daily values may be higher
or lower depending on your calorie needs:
Calories
2,000
2,500
Total Fat
Less than 65g
80g
Sat Fat
Less than 20g
25g
Cholesterol Less than 300mg 300mg
Sodium
Less than 2,400mg 2,400mg
Potassium Less than 3,500mg 3,500mg
Total Carbohydrate
300g
375 g
Dietary Fiber
25g
30g
4
The second
section represents the
nutritional value of the
food product. In the
example,
notice there are 32
grams of carbohydrates — a typical
“diabetic lunch”
is approximately
30 grams.
The lower section
provides information on
the vitamin and minerals
present in the food
product. All food labels
provide the recommended daily values
based on a 2000 calorie
diet.
18
Worth
remembering ...
We are what
we eat!
Remember, it is always important to treat the patient
holistically. We must look at the "whole" patient, not
just the "hole" in the patient. If we are not metabolizing
(staying constant with regard to nutrition and energy) or
anabolizing (building or growing), we are catabolizing
(breaking down). In order to prevent or treat existing wounds,
it is necessary to offer adequate calories, fluids, proteins and
nutrients while monitoring nutritional risk and assessing
nutritional needs. It is recommended to involve a registered
dietician in your team assessment and treatment of patients
at risk of developing pressure ulcers or those with existing
pressure ulcers. Other elements such as mobility, activity,
sensory perception, pressure, shear, friction and moisture
reduction are all important parts of the equation. Pressure
ulcer prevention and treatment should be considered along
the continuum of care, which includes nutrition.
Wound Care-Related Lab Values
Wounds tell us what they need. They show signs of inflammation, evidence of filling and contracting and epithelialization,
and they also indicate when they are not changing. Complete
evaluation needs to include not only physical assessment,
but lab values to ascertain specifically what is missing or
is in abundance and affecting the ability of the wound
to close.
Several lab values that can lead us in the right direction include:
•
•
•
Assessment of red and white blood cells.
Are there enough to carry nutrients, oxygen and
other cellular components to promote wound closure?
Are there deficiencies that may cause the wound to
stop the healing process?
A complete blood count (CBC) is ordered as part of a general
assessment. The CBC is a simple blood collection that counts
the number of red and white blood cells in a cubic millimeter
(mm3) from a blood sample. The hemoglobin and hematocrit
are also determined. If the white blood cell (WBC) differential
is ordered, results for neutrophils, lymphocytes, monocytes,
eosinophils and basophils will be included. Other tests that are
commonly ordered include glucose, iron, certain electrolytes
and platelets, and protein levels.
19
Red Blood Cells (RBC)
Normal Values
•
•
Males: 4.7 to 6.1 M/µL
Females: 4.5 to 5.4 M/µL
This is an integral part of the evaluation of anemic patients.
The test is performed by counting the number of RBCs in
a 1 mm3 sample of peripheral venous blood. Every RBC
contains molecules of hemoglobin that permit the transport
and exchange of oxygen and carbon dioxide to the tissues.
Toward the end of the RBC’s life, the cell membrane becomes
less pliable, the aged RBC is lysed (dissolved), and extracted
from circulation by the spleen.
This impacts the cascade of healing by reducing the body’s
normal cellular response to close the wound. For example;
low blood volume cannot bring the necessary nutrients,
oxygen and cells that will activate the process for the
wound to close.
Below normal range
Above normal range
•
•
•
•
•
•
Anemia
Cancers: lymphoma,
multiple myeloma,
leukemia, Hodgkin’s
lymphoma
Cirrhosis
Dietary deficiency:
iron, vitamin B12
Fluid overload
Hemorrhage
Normal pregnancy
Renal disease
Rheumatoid/collagenvascular diseases
Red Blood Cells
•
•
•
•
•
•
•
•
Congenital heart disease
Erythrocytosis
Hemoglobinopathies
Severe chronic obstructive
pulmonary disease (COPD)
Severe dehydration (e.g.
severe diarrhea or burns)
White Blood Cells (WBC)
Normal Value
•
5.0 to 10.0 K/mm3
WBC is the total white cell count. It is helpful in the
evaluation of the patient with infection, neoplasm,
allergy or immunosuppression.
20
There are two components:
•
•
The number of WBCs (leukocytes) in 1 mm3 of
peripheral venous blood.
The differential count, which measures the percentage
of each type of leukocyte present in the specimen.
The major functions of WBC’s include fighting infection and
reacting against foreign bodies or tissues. In regard to wound
healing, if the body makes poor or malformed cells, then the
wound healing slows or halts and is often left in a state of
chronic inflammation.
Five types of WBCs are:
•
•
•
•
•
White Blood
Cells
Lymphocytes
Monocytes
Neutrophils
Basophils
Eosinophils
Below normal range
Above normal range
•
•
•
•
•
•
•
Autoimmune disease
Bone marrow failure
or infiltration
Dietary deficiency
(e.g. vitamin B12, iron)
Drug toxicity
Hypersplenism
•
•
•
•
Infection
Cancers: leukemia and
non-marrow cancers
Dehydration
Inflammation
Trauma, stress or
hemorrhage
Tissue necrosis
Mean Corpuscular Volume (MCV)
Normal Value
•
80 to 95 µ³
The mean corpuscular volume is the average volume of the red
blood cells in the body. MCV is used to classify various forms
of anemia. MCV is derived by dividing the hematocrit by the
total RBCs. Medications that may increase MCV results include
zidovudine (AZT or Retrovir®), phenytoin (Dilantin®) and
azathioprine (Imuran®). Wound healing can be delayed as
the volume of RBCs is decreased.
21
Mean Corpuscular
Volume
Below normal range
Above normal range
•
•
•
•
•
•
•
•
Anemia or chronic
illnesses
Iron deficiency
anemia
Thalassemia
Antimetabolite therapy
Alcoholism
Chronic liver disease
Folic acid deficiency
Pernicious anemia
Mean Corpuscular Hemoglobin (MCH)
Normal Value
•
27 to 31 picograms (pg)
The MCH is a measure of the average weight of hemoglobin
in an RBC. MCH is derived by dividing the total hemoglobin
concentration by the number of RBCs. Because macrocytic
(a mature erythrocyte) cells generally have more hemoglobin
and microcytic (smaller than normal) cells have less hemoglobin, the causes for these values closely resemble those for
MCV. If this value is low, wound healing can be affected by
not having sufficient oxygen and nutrient-containing cells
within the system.
Mean Corpuscular
Hemoglobin
Below normal range
Above normal range
•
•
•
Microcytic anemia
Hypochromic anemia
Macrocytic anemia
Mean Corpuscular
Hemoglobin Concentration (MCHC)
Normal Value
•
32 to 36 percent
The MCHC is a measure of the average concentration or percentage of hemoglobin in a single RBC. MCHC is derived by
dividing the total hemoglobin concentration by the hematocrit. When values are decreased, the cell has a deficiency of
hemoglobin and is said to be hypochromic. When values are
normal, the anemia is said to be normocytic (e.g., hemolytic
anemia). RBCs cannot be considered hyperchromic. Only 37
g/dL of hemoglobin can fit into an RBC. An alteration in the
22
shape of an RBC may cause automated counting machines to
indicate MCHC levels above normal.
Mean Corpuscular
Hemoglobin
Concentration
Below normal range
Above normal range
•
•
•
•
•
Iron deficiency anemia
Thalassemia
Intravascular hemolysis
Cold agglutinins
Spherocytosis
Neutrophils
Normal Value
•
55 to 70 percent
Neutrophils are the white blood cells essential for phagocytosis, or the removal of bacteria and debris, especially in wounds.
They are essential for the process of autolytic debridement,
where the body is “cleaning” the wound itself. The differential
count measures the percentage of each leukocyte present in
the specimen. An increase in the percent of one type of leukocyte means a decrease in another. When neutrophil production is significantly stimulated, early immature forms of
neutrophils enter the circulation. These immature forms are
called band cells. This occurrence, referred to as a “shift to the
left” in WBC production, is indicative of an acute bacterial
infection. A value of 8 percent or higher signals this left shift.
Below normal range (Neutropenia) Above normal range (Neutrophilia)
Neutrophils
•
•
•
•
•
•
23
Addison’s disease
Aplastic anemia
Chemotherapy
(myelotoxic agents)
Dietary deficiency
Infection: bacterial
or viral
Radiation therapy
•
•
•
•
•
•
•
•
Acute suppurative infection
Cushing’s syndrome
Eclampsia
Gout
Inflammatory disorders
Metabolic disorders
Myelocytic leukemia
Stress (physical or emotional)
Lymphocytes
Normal Value
•
20 to 40 percent
Lymphocytes develop in the bone marrow and comprise
roughly one quarter of the white cells in the human body.
They increase in numbers to respond to infection. Further
divided into both “T” and “B” cells, their main function is
to react to and protect against infection.
Below normal range
(Lymphocytopenia)
Lymphocytes
•
Drug therapy:
adreno-corticosteroids,
antineoplastics
Immunodeficiency
diseases
Leukemia (nonlymphocytic)
Sepsis (acute)
Radiation therapy
(current)
•
•
•
•
Above normal range
(Lymphocytosis)
•
Infection (chronic bacterial
and viral)
Infectious hepatitis
Lymphocytic leukemia
Multiple myeloma
Post-radiation therapy
•
•
•
•
Monocytes
Normal Value
•
2 to 8 percent
Another type of white blood cell, monocytes typically have
an oval or kidney-shaped nucleus.
Monocytes
Below normal range
(Monocytopenia)
Above normal range
(Monocytosis)
•
•
Drug therapy:
prednisone
•
•
•
•
Chronic inflammatory
disorders
Viral infections
Tuberculosis
Chronic ulcerative colitis
Parasites (e.g. malaria)
24
Eosinophils
Normal Value
•
1 to 4 percent
Slightly larger in diameter than the monocyte, this leukocyte
makes up a small fraction of the total white cell count.
Eosinophils
Below normal range
(Eosinopenia)
Above normal range
(Eosinophilia)
•
•
•
Increased adrenosteroid
production
Medication therapy
steroids
•
•
•
Allergies or allergic
reactions
Autoimmune diseases
Parasitic infections
Leukemia
Basophils
Normal Value
•
0.5 to 1 percent
Basophils are the smallest in number of all white blood cells.
Basophils
Below normal range
(Basopenia)
Above normal range
(Basophilia)
•
•
•
•
Acute allergic reactions
Hyperthyroidism
Stress reactions
•
•
Myeloproliferative disease
(e.g., myelofibrosis, polycythemia rubravera)
Leukemia
Inflammatory phase
of wound healing
Hemoglobin (Hb or Hgb)
Normal Values
•
•
Males: 14 to 18 g/dL
Females: 12 to 16 g/dL
Hemoglobin is the protein compound vehicle for oxygen
and carbon dioxide transport. Each red blood cell contains
approximately 200 to 300 molecules of hemoglobin. Testing
Hb can be used as a rapid indirect measurement of the RBC
count. It is an integral part of the evaluation of anemic
25
patients. The oxygen-carrying capacity of the blood is
determined by the Hb concentration. If the Hb is low,
there is strain on the cardiopulmonary system to
maintain its oxygen-carrying capacity.
Hemoglobin
Below normal range
Above normal range
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Anemia
Bone marrow failure
Cirrhosis
Dietary deficiency
Hematologic cancers
Hemoglobinopathy
Hemorrhage
Lymphoma
Normal pregnancy
Prosthetic valves
Renal disease
Rheumatoid/collagen
vascular diseases
(e.g., rheumatoid arthritis,
lupus, sarcoidosis)
•
Congenital heart disease
Erythrocytosis
Polycythemia vera
Severe dehydration (e.g.,
severe diarrhea, burns)
Severe COPD
Hematocrit (Hct)
Normal Values
•
•
Males: 42 to 52 percent
Females: 37 to 47 percent
Hematocrit is an indirect measurement of RBC number and
volume. It is used as a rapid measurement of RBC count. It
is repeated serially in patients with ongoing bleeding or as
a routine part of the complete blood count. It is an integral
part of the evaluation of anemic patients. Hematocrit is a
measure of the percent of the total blood volume that is
made up by the RBCs.
26
Below normal range
Above normal range
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Hematocrit
Anemia
Hemoglobinopathy
Cirrhosis
Hemorrhage
Dietary deficiency
Bone marrow failure
Prosthetic valves
Renal disease
Normal pregnancy
Rheumatoid/collagen
vascular diseases (e.g.,
rheumatoid arthritis,
lupus, sarcoidosis)
Lymphoma
Hematologic cancers
•
•
•
Erythrocytosis
Congenital heart disease
Polycythemia vera
Sever dehydration (e.g.,
severe diarrhea, burns)
Severe chronic obstructive
pulmonary disease
Glucose, fasting
Normal Value
•
70 to 115 mg/dL
This is the glucose level in the blood. It is commonly used to
evaluate patients with diabetes. Through an elaborate feedback
mechanism, glucose levels are controlled by insulin and
glucagon. While fasting, glucagon, which is made in the
alpha cells of the pancreatic islet of Langerhans, is secreted.
Glucagon breaks down glycogen to glucose in the liver and
blood glucose levels rise. If fasting persists, protein and
fatty acids are broken down under glucagon stimulation
and glucose levels continue to rise. Stress (e.g., trauma,
general anesthesia, infection or burns) and caffeine can
cause increased glucose levels. Patients receiving IV fluids
with dextrose may have increased glucose levels. Pregnant
women may experience glucose intolerance, called gestational
diabetes. Drugs that may increase glucose levels include
antidepressants (tricyclics), beta-adrenergic blocking agents,
corticosteroids, diuretics, epinephrine, estrogens, glucagons,
isoniazid, lithium and salicylates.
Elevated glucose levels can effect wound healing by damaging
cells such as fibroblasts and keratinocytes that are necessary for
the formation of granulation tissue and to fill any deficit of
the wound.
27
Below normal range
Glucose, fasting
•
•
•
•
•
•
Addison’s disease
Hypothyroidism
Hypopituitarism
Insulinoma
Insulin overdose
Starvation
Above normal range
•
•
•
•
•
•
•
•
Acute stress response
Acromegaly diabetes mellitus
Chronic renal failure
Corticosteroid therapy
Cushing’s syndrome
Diuretic therapy
Glucagonoma
Acute pancreatitis
Hemoglobin A1c or A1C
(Previously known as HbA1c)
Normal Value
•
6 to 8 percent
This test provides a long-term index of the patient’s
average blood glucose level and is used to monitor diabetes.
It measures the amount of A1c in the hemoglobin of the
blood. Hemoglobin A1c is the component that most strongly
combines with glucose. Approximately 70 percent of HbA1c is
glycosylated. The bond is not easily reversible. Only 20 percent
of A1a and A1b are glycosylated hemoglobin. HbA1c is fast
becoming the most common component measured. Hemoglobinopathies can affect results, because the quantity of
hemoglobin A (and, as a result, HbA1) varies considerably
in these diseases. Falsely elevated values occur when the
RBC life span is extended.
Hemoglobin
A1c or A1C
Below normal range
Above normal range
•
•
•
•
Chronic blood loss
Chronic renal failure
Hemolytic anemia
•
•
•
Diabetes (newly diagnosed
or poorly controlled)
Hyperglycemia (not
with diabetes)
Splenectomized patients
Pregnancy (especially in
gestational diabetes or
pre-diabetes)
28
Ferritin
Normal Value
•
15 to 200 ng/ml
Ferritin, the major iron-storage protein, is present in serum
in concentrations directly related to iron storage. Generally,
1 ng/ml of serum ferritin corresponds to approximately 8 mg
of stored iron. This is the most sensitive test to determine iron
deficiency anemia and is a good indicator of available iron
stores. Menstruating women may have decreased ferritin
levels as a result of monthly menses. Recent administration of
a radionuclide, transfusion, high iron diet or iron-containing
medications can affect this level. This key nutrient in the
maintenance of healthy red cells can be an indicator of the
oxygen-carrying capacity of the cells, and thus wound healing.
Ferritin
Below normal range
Above normal range
•
•
•
•
Hemodialysis
Iron deficiency anemia
Severe protein
deficiency
•
•
•
•
•
•
Anemia: hemolytic and
megaloblastic
Advanced cancers
Alcoholic/inflammatory
hepatocellular disease
Chronic illnesses such as
leukemia, cirrhosis,
chronic hepatitis or
collagen vascular diseases
Hemochromatosis
Hemosiderosis
Inflammatory disease
Electrolytes
Normal Values
•
•
•
•
•
•
Calcium: 8.8 to 10.5 mg/dL
Chloride: 90 to 110 mEq/L
Magnesium: 1.6 to 2.8 mEq/L
Phosphorus: 2.5 to 4.5 mg/dL
Potassium: 3.5 to 5.2 mEq/L
Sodium: 136 to 147 mEq/L
In general, electrolytes are compounds that can dissociate
into ions and are able to conduct electric current. Each
electrolyte serves specific functions. Calcium and potassium
are necessary for various muscle activity and sodium is essential for fluid balance within the body. These values are measured to help identify or evaluate functions that may be
29
Electrolytes, continued
affected by increased or decreased amounts of electrolytes.
Below normal range
Above normal range
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Electrolytes
Alkalosis
Burns, Hypoparathyroidism
Congestive heart failure
(CHF)
Diabetic acidosis
Diarrhea, high-output
fistula
Hypokalemia
Malabsorption
Malnutrition
Metabolic alkalosis
Osteomalacia
Over-hydration
Pancreatitis
Renal failure
Respiratory acidosis
Ricketts
Salt-losing nephritis
Vomiting, gastric suction
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Acromegaly, hyperthyroidism
Addison’s Disease
Dehydration
Excessive intake of saline
Hyperkalemia
Hyperparathyroidism
Prolonged immobilization
Lymphoma
Metabolic acidosis
Metastatic bone tumor
Milk-alkali syndrome
Renal insufficiency
Respiratory alkalosis
Rhabdomyolysis
Vitamin D intoxication
Coagulation Platelets
Normal Value
•
140,000 to 450,000/mm3
Platelets are formed in the bone marrow, stored in the spleen
and are the smallest cells in the blood. Platelets are necessary
for hemostasis and blood clotting. The count is the number of
platelets per mm3 of blood.
30
Coagulation
Platelets
Below normal range
Above normal range
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Chemotherapy
DIC
Graves disease
Hemorrhage
Hemolytic anemia
Hypersplenism
Infections (bacterial)
Leukemia
Pernicious anemia
Systemic lupus
erythematosus
Thrombocytopenia
•
Iron deficiency anemia
Malignant disorders
Polycythemia vera
Postsplenectomy syndrome
Rheumatoid arthritis
Total Protein
Normal Value
•
6 to 9 gm/dL
Protein is a complex organic compound that is made of amino
acids. Protein is the source of building material for many body
components including muscle, skin, hair, internal organs and
blood. There are more than 20 proteins identified as being
important to life, and nine of those are not made within the
body or essential. The essential proteins must be obtained
through food or nutritional supplementation. This test is
used indirectly to assess the body’s ability to grow and heal.
It measures the protein in circulating blood and is helpful in
diseases where there can be protein wasting. Low values can
result in poor wound healing, mental depression and slow
recovery from disease and infection.
Total Protein
Below normal range
Above normal range
•
•
•
•
•
•
•
•
•
31
Ascites
Burns
Increased capillary permeability
Inflammatory diseases
Liver disease
Malnutrition
Protein-losing processes
Over-hydration
Dehydration
Albumin
Normal Value
•
3.2 to 4.5 g/dL
Serum albumin is the major circulating plasma protein
produced by the liver. It is a common indicator of the
patient’s protein stores. Its half life (how long it will take
before you see decreases in lab data) is about three weeks;
therefore, the blood you draw from your patient today will
indicate their protein stores from three weeks ago. Mild
depletion is considered 3.5 gm/dL. An abnormally low
level of serum albumin in the blood (hypoalbuminemia)
is below 3.0 gm/dL. It is associated with tissue edema,
which further increases the risk of pressure ulcers. Serum
albumin levels are often used as an indicator of overall
nutrition. Low serum albumin increases the risk of
infection, morbidity and mortality. It impairs or prevents
wound healing and decreases wound tensile (tearing) strength.
Prealbumin
Normal Value
•
15 to 36 mg/dL
Serum prealbumin is a more sensitive indicator of visceral
(contained in the body's organs) protein status in acute stages
of malnutrition. Its half life is only two to three days and can
be helpful to evaluate the adequacy of nutritional therapy.
Mild depletion is less than 15 mg/dL. Severe depletion is less
than 5 mg/dL. If the patient has chronic kidney failure,
prealbumin may be falsely elevated since it is eliminated
in the kidneys.
Albumin/
Prealbumin
Below normal range
Above normal range
•
•
•
•
•
•
•
•
Malnutrition
Liver damage
Burns
Inflammation
Nephrotic syndrome
Hodgkin’s lymphoma
Chronic kidney disease
Pregnancy
32
Transferrin Saturation
Normal Value
•
30 to 40 percent
Serum transferrin has a half life of a little more than a week
and is also an indicator of protein stores. A level below 200
mg/dL is considered low. This blood test may not be useful in
the presence of liver disease or estrogen use, since transferrin
levels (a globulin in blood plasma that carries iron) will be
abnormally high. Additionally, liver disease, burns, cortisone
or testosterone therapy, and chronic infection can lower
serum transferrin levels.
Transferrin
Saturation
Below normal range
Above normal range
•
•
•
•
•
•
Anemia (hemolytic,
pernicious, sickle cell
iron deficiency
Cirrhosis
Hypoproteinemia
Inflammatory diseases
Malnutrition
•
•
•
•
•
•
Anemia, (iron deficiency and
hemolytic) - false elevation
Anemia, (iron deficiency and
hemolytic) - false elevation
Hemochromatosis
Hemosiderosis
Increase iron intake
Polycythemia vera
Pregnancy (late)
Total Lymphocyte Count
Normal Value
•
less than 2000 cells/mm3
Total lymphocyte count (TLC) reflects the immunosuppression
and immunity of the patient. TLC is more useful as a screening
parameter in non-critical individuals. Studies have shown that
the lower the count, the higher the patient risk for morbidity
and mortality.
Total Lymphocyte
Count
33
Below normal range
Above normal range
•
•
•
•
•
•
•
•
Immunosuppression
Malnutrition
Lymphoma
Lupus
Surgery
Alcohol intake
Autoimmune disorders
Smoking
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