Download Protein-energy malnutrition and wounds: nutritional

Skin, Wounds and Nutrition
Part 3
Friction Forces at the Skin
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Cause skin abrasions, damaging the
stratum corneum
Pulls at the skin producing shear in deeper
tissue layers
Shear Forces
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Causes tissue layers to slide and pull
against each other
Disassociates connective tissue and blood
vessels
Friction and Shear
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Provide a slippery bed surface to
prevent skin abrasion and tearing
of deeper tissues
Heat
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Remove excess heat to reduce the
oxygen and nutrient demands of
damaged/healing tissue
Effects of Heat on
Damaged Tissue
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Increases metabolism, nutrient and oxygen
demand, 10% per degree C
Accelerates ischemic tissue death by
oxygen and nutrient starvation
Sources of Excess Moisture
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Insensible transpiration
Perspiration
Urinary incontinence
Excess Skin Moisture
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Weakens the stratum corneum up to 95%
Increases liquid surface tension causing
high skin friction
Causes maceration by dissolving
connective tissue fibers
The RD and Nutrition
Important Components to
Wound Healing
The Healing Wound
Wounds heal when protein stores,
energy stores and anabolic stimuli
are adequate to support the healing
process
The Bottom Line
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Many patients with wounds will develop
protein calorie malnutrition
Malnourished patients upon hospital
admission are more likely to develop PUs
UWL in residents in LTC was associated
with 74% greater likelihood of developing
PU (Thomas)
Adverse Effects of PCM on the
Health Care System
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Reduces quality of life
Decreases response to tx interventions
Increases morbidity and mortality
Drains staff emotionally
Increases paperwork and documentation
Costs more to care for a patient with PCM
Clinically Evident Manifestations
of PCM
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Listlessness, apathy, weakness--all
exacerbated by anemia
Diminished functioning of diaphragm and
thoracic musculature--contributing to
respiratory compromise
Decreased skin turgor, muscle wasting,
peripheral edema, glossitis, hair loss or
changes in hair luster
Malnutrition
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Defined as a pathologic state resulting from
a relative or absolute deficiency
Clear correlation between malnutrition and
wound healing failure
Can occur in both obesity and underweight
PCM most common form of malnutrition
in America
Where to Begin
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Examine those with low body weight or
extremely obese
Any patient with UWL at any BMI
Low serum albumin
Dehydration
Underweight
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No protection from fat
Recent weight loss
Considered <90% IBW
Obesity
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Fat is poorly vascularized
Excessive weight placed on bony
prominences
More likely to have moisture between folds
Defined as > 130% IBW
Complications of UWL
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10% weight loss increases wound
complications
Increases risk of developing pressure ulcer
at any BMI
Increased urinary losses of zinc
Managing Weight is No. 1

Identify causes for weight changes
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physiological
psychological
Educate patient on the importance of
weight maintenance and maintenance of
LBM
Consider pharmacological interventions
Complications Relative to Loss of LBM
Lean Body Mass Complications
Associated
Mortality (%)
10
(% loss of total)
(related to lost lean mass)
10
Impaired immunity;
Increased infection
20
Decreased healing;
weakness; infection
30
30
Too weak to sit; pressure
sores; pneumonia; no
healing
50
40
Death, usually from
pneumonia
100
Source Demling,R. Stasik, L, Zagoren, A. Protein-energy malnutrition and wounds: nutritional
intervention. Curative Health Services 11/00
Effects of Losses in LBM
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<10%--wound healing has priority for any
protein substrate
>10%--the stimulus to restore LBM
competes with the wound for protein
>20%, correction of LBM takes precedence
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Wound healing stops
Lab Values
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Serum Transferrin < 170 mg/dL
Prealbumin < 16 mg/dL
Serum Albumin < 3.5 mg/dL (w/normal
hydration status
Hemoglobin < 12 g/dL
Hematocrit < 33%
Lab Values--cont.
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Serum Cholesterol < 160 mg/dL
Total Lymphocyte Count < 1800/mmm
Serum Osmolality > 295 mOsm/L
BUN/Creatinine > 10:1
Prealbumin (Transthyretin)
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Half life is about 2 days
Smaller serum pool
Binds and transports
Is affected by inflammation
Less affected by hydration status
Used to monitor current nutrition status
Albumin
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Half life is about 21 days
Common index of visceral proteins
A carrier protein
Formed in the liver
Affected by hydration as helps maintain
normal water distribution
Used to monitor long term stores
Cholesterol
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Are cholesterol lowering drugs being used?
May indicate malnutrition, especially in
those > 60 years of age
Total Lymphocyte Count
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Lymphocytes account for 20-40% of WBC
Measures immunocompetence
May be unable to mount effective immune
response if low
Not an appropriate indicator for critical
care patients, those with known immune
problems or those with infections