Download Skin, Wounds and Nutrition Part 4

Skin, Wounds and Nutrition
Part 4
Assessing Nutritional Needs
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Energy or calorie requirements
Protein requirements
Micronutrient requirements
Energy Requirements
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May be up to 50% more calories than the
non-stressed individual
Calculate using Harris Benedict formula,
Mifflin St Jeor, or indirect calorimetry
Protein Requirement
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Increased relative to increased demands for
protein synthesis and increased losses of
amino acids
Needs
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Stage 1-- 1.0 gram/kg
Stage 2--1-1.2 grams/kg
Stage 3--1.25-1.5 grams/kg
Stage 4--1.5-2.0 grams/kg
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Note: Protein above 1.5 gm/kg may not help protein syntheses and may
cause dehydration, particularly in the elderly or those with impaired
renal function
Micronutrient Requirements
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Increased need for cellular function and
formation
Interventions to Promote Healing
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Provide optimum nutrition early
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adequate energy and nutrient profile
adequate protein
necessary micronutrients
Use anabolic agents, if necessary
Provide exercise stimulus to muscles, to
increase anabolism
Basic Principles--CHO
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55-60% of diet
Provide as complex CHO
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glucose is the prime energy source for the cell
Leukocytes apparently use glucose to
promote phagocytic activity of lymphocytes
prior to fibroplasia
Maximum tolerated is 7-8 grams/kg/d for
respiratory patients
Give insulin for glucose >250 mg/dL and
decrease intake if severe hyperglycemia
Basic Principles--Protein
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20-25% of diet from protein
Increased protein intake decreases the net
nitrogen losses by increasing the amino
acid flow into the protein synthesis channel
Essential for protein synthesis and new cell
growth
Protein is the component of collagen and
other structural components
Basic Principles--Protein
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Will need increased fluids
Higher risk for dehydration
BUN will probably increase
NOTE: Excessive protein does NOT
encourage faster healing as the body does
not store protein but turn it into sugars
Basic Principles--Fat
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20-25% of the diet
No more than 2 grams/kg/day
Need to monitor triglycerides
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keep triglycerides < 250 mg/dL
Fatty Acids/Omega 3
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Synthesize prostanoids
Normal cell membrane function
Essential Fatty Acid Deficiency (EFAD) impairs
wound healing
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Often overlooked by RD
Can obtain in foods and oils
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salmon, mackerel, albacore tuna, sardines, flax
canola and soybean oil
Basic Principles-Micronutrient Support
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Vitamin A
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Normal inflammatory response
Allows epithelization, collagen synthesis, and
collagen cross-linking
Maintains normal humoral defense
mechanism
Seems to limit complications
Need a good source (DAILY) in wound
healing
Basic Principles-Micronutrient Support
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Vitamin A Supplements given:
to counteract catabolic effects of
glucocorticoids
 to corticosteroid dependent patients to
promote healing
 to those with poor nutrient stores or
malabsorption
Note: Too much may exacerbate inflammatory
response
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Basic Principles-Micronutrient Support
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Vitamin C
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works with Amino Acids proline and lysine
during collagen synthesis
needed for carnitine production for fatty acid
metabolism
Reduces risk of wound reopening
Body does not store vitamin C
Basic Principles-Micronutrient Support
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Vitamin C deficiency--Scurvy
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Symptoms may develop rapidly but reverse quickly
with treatment
Interferes with fibroblast function
Alters healing process of collagen synthesis
No secretion of procollagen chains
Impaired polymerization
Wrong amino acid sequence
Increased blood cell fragility
Basic Principles-Micronutrient Support
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Thiamine
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necessary for oxidation, reduction reactions
helps form lysyl oxidase to strengthen collagen
necessary for adequate collagen formation
Vitamin K
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Responsible for normal coagulation of blood
Prolonged bleeding times and hematoma formation
may hinder wound healing
Basic Principles-Micronutrient Support
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Vitamin E
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Responsible for collagen synthesis
Assists in wound healing
DOES NOT prevent scar formation
Basic Principles-Micronutrient Support
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Zinc
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Role in cellular proliferation and protein
synthesis
Excess zinc may interfere with wound
healing via affecting lysyl oxidase, an
enzyme involved in collagen synthesis
Excess interferes with copper and iron
absorption and metabolism
Basic Principles-Micronutrient Support
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Zinc--cont.
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Needed for ALL enzymatic reactions
Urinary losses increase with stress and weight
loss
Body stores are often depleted in patients
with malnutrition, chronic diarrhea and
chronic corticosteroid use
Basic Principles-Micronutrient Support
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Zinc cont.
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In deficiency state, may find low rate of
epithelialization
Deficiency causes decreased wound and
collagen strength
Supplementation often done in wound
management but no evidenced based studies
to prove its need
Basic Principles-Micronutrient Support
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Copper
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Cofactor for connective tissue production
Collagen polymerization
Formation of cross linkages to enhance scar
strength
Erythrocyte formation
Basic Principles-Micronutrient Support
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Magnesium
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Necessary for all phases of wound healing
Translation and synthesis of peptide chains
Depletion may occur in patients with chronic
diarrhea, fistulas, SBS
Calcium
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A cofactor for some collagenases during
remodeling
Necessary for normal blood coagulation
Basic Principles-Micronutrient Support
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Iron
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Enhances enzymatic activity of prolyl
hydroxylase during hydroxylation of proline
and lysine
Iron stores in the elderly are at their highest
Make sure check true anemia not anemia of
chronic disease
Basic Principles-Micronutrient Support
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Arginine
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Stimulates collagen synthesis
Enhances cellular immune mechanisms,
especially T-cell function
Assists cell growth and replication
Helps promote wound healing
Obligatory precursor for wound protein
synthesis
Basic Principles-Micronutrient Support
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Arginine--cont.
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Made in the kidney
May be consumed in diet
Breakdown of body protein
Can be found in enteral formulas with
immune-enhancing nutrients
Basic Principles-Micronutrient Support
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Glutamine
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Precursor for purines and pyrimidines
Fuels fibroblasts
Anti-catabolic, anabolic properties
Preserves LBM
Stimulates release of Human Growth
Hormone
Basic Principles-Micronutrient Support
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Glutamine--cont
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Levels drop dramatically during stress
Found in abundance normally
Enteral formulas or modular forms available
10-20 grams daily for supplement
Basic Principles-Micronutrient Support
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Dietary Nucleotides
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Building blocks for DNA/RNA
Improve immune function
Assist in wound healing
Found in any animal protein
Basic Principles--Water
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30 ml per kg body weight unless
contraindicated
1 mL/cal for enteral tube feeding
Additional 10-15 mL/kg/day when air
fluidized beds are used
Additional for elevated temperatures
Basic Principles--Water
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Participates in most metabolic reactions
Acts as a solvent for minerals, vitamins,
amino acids, glucose, and other small
molecules enabling them to diffuse in and
out of cells
Transports vital materials to cells and waste
away from cells
Intervention Strategies
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Nonpharmacologic strategies
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Counseling and education
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Patients should be told about and become involved
in decisions as should the families
Optimizing food intake
Start with foods rather than supplements
 Calorie enhanced/protein enhance
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Supplements
Immune enhanced formulas
 2 Kcal Med pass
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Intervention Strategies
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Pharmacologic strategies
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Appetite stimulants
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Megace
Metabolic nutrients
Glutamine
 Arginine
 HMB
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Anabolic agents
Somatotropin—(can be very expensive)
 Oxandrolone
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Calorie Needs in Wound Healing
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30 kcal/kg body weight generally accepted
>30 kcal/kg should promote positive
nitrogen balance
Use indirect calorimetry if available and if
accuracy is critical
Liberalize diet!!!!
Vitamin & Minerals
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Implicated in wound healing
Remember, they do not hasten healing once
normal stores are present
No question that information is conflicting
and confusing but with a litigation culture,
we have become a supplement oriented
society
Indication for Nutrition Support
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May facilitate wound healing
Ability to optimize nutrient intake
Must be monitored
Must be in accordance with Advanced
Directives
AHCPR
The Agency for Health Care Policy and
Research
P.O. Box 8547
Silver Spring MD 20907
1-800-358-9295 (9 am to 5 pm ET)
http://www.ahrq.gov/clinic/cpgonline.htm
NPUAP
The National Pressure Ulcer Advisory Panel
1255 Twenty-Third Street NW, Suite 200,
Washington, DC 20037
Phone: (202) 521-6789
Fax: (202) 833-3636
E-mail: [email protected]