AS A COURTESY TO THOSE AROUND YOU, PLEASE SILENCE …Describe how nutrition deficiencies ... Adapted from Krause’s Food, Nutrition & Diet Therapy, 11th Edition. 3/17/2016 8 Blunted

3/17/2016

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AS A COURTESY TO THOSE AROUND YOU, PLEASE SILENCE YOUR CELL PHONE AND

OTHER ELECTRONIC DEVICES.THANK YOU FOR YOUR COOPERATION.

© AMT Education Division 1

WOUND CARE AND DIET FOR HEALINGCHUCK GOKOO MD, CWSCHIEF MEDICAL OFFICER

AMERICAN MEDICAL TECHNOLOGIES


3/17/2016

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The information presented herein is provided for the general well‐being and benefit of the public, and is for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. Notwithstanding any educational information provided by American Medical Technologies, please refer to, and follow, your facility’s written policies and procedures.

The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.

3© AMT Education Division

DISCLAIMER

PROGRAM OVERVIEW AND OBJECTIVES


Describe how nutrition deficiencies impede the normal physiological processes of wound healing

Explain resident risks for skin breakdown due to impaired hydration and nutrition

Examine the role specific vitamins and minerals play in the wound healing process

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A. D. A. M. Medical

Mayo Foundation for Medical Education and Research


ACKNOWLEDGEMENTS

Dehydration; Decubitus Ulcer Lawsuit – Suing a Nursing Home / Hospital for Dehydration

There is no excuse for patient dehydration. This is a telltale sign of patient neglect. If you or a loved one suffered from dehydration, decubitus ulcers, falls or a wrongful death in a nursing home or hospital, do not let the abuse go unpunished. Contact our qualified decubitus ulcer dehydration lawyers at . . . .


ISSUES

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Nursing Homes

≥500,000 residents may suffer from malnutrition or dehydration

Malnutrition and dehydration rates ‐ 35% or higher

14% ‐ 56% of the residents have dementia and malnutrition

52% of hospital patients admitted with a diagnosis of dehydration will come from a nursing home

$6.5 million awarded to a Ohio widow

‐Nursing home lawsuit filed over the dehydration death of her husband allegedly caused when he was not provided with enough water during a temporary nursing home stay


ISSUES

WOUND MANAGEMENT


Barriers to

Wound Healing

Lack of Knowledge

Aging

Peripheral Vascular Disease

Hydration Nutrition

InfectionStressTumors

Metabolic Disorders

Impaired Immunity

Medications

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WOUND MANAGEMENT

Stress

Inflammatory mediators are released (fight or flight)

Hypermetabolic and catabolic state

Increased metabolic rate

Increasing nutritional needs


WOUND MANAGEMENT

Increased breakdown of protein for glucose production

Protein energy malnutrition (PEM)

Inefficient use of fat stores for energy utilizing protein

Suppression of the synthesis of protein, glycogen, and triglycerides

Rapid depletion of lean body mass (LBM)

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11© 2013 AMT Education Division

WOUND MANAGEMENT

Exudate

Fluid loss

Zinc loss

Protein loss (≥30g/day)

Triggers inflammatory response

(catabolic state)Thomas B. Catabolic states. In: Thomas B, ed. British Dietetic Association Manual

of Dietetic Practice. Oxford, UK: Blackwell Scientific;1994:537–549.

EARTHINGS: UGLY BAGS OF MOSTLY WATER


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Body Composition

Water

‐Approximately 72% of nonfat weight

‐Keeps the skin moist

‐Protects from tearing and abrasions

‐Plays a role in moving nutrients to the ulcer bed to promote new tissue growth

‐Assists in removing waste away from the ulcer


HYDRATION

Daily Fluid Intake vs. Fluid Loss

The body does not store water

3%

‐900 ml in case of 60 kg adult

‐Fatigue

4% ‐ 5%

‐Headache and dizziness

10%

‐Fatal


HYDRATION

Adapted from Krause’s Food, Nutrition & Diet Therapy, 11th Edition

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Blunted Thirst Mechanisms

Aging

‐Homeostasis declines

Infection

‐Respiratory, GI, GU

Fluid loss or increased fluid need

‐Diarrhea, fever, vomiting

Incontinence

‐Reduce fluid intake

Fluid restriction

‐Renal dialysis

Medications

‐Diuretics, sedatives, antipsychotics, tranquilizers


HYDRATIONCognitive or functional impairment

‐Aphasia ‐ unable to communicate effectively

‐Dementia or Alzheimer’s disease

Neurological impairment

‐Coma or decreased sensorium

Tube feedings

‐Dysphagia


NPO


Use of supplementation

‐Thick

‐Difficult to swallow

Dehydration

Reduction in total body water

3% body weight loss/increased serum osmolality

‐Water and electrolyte disturbance

‐Hyponatremia (water and sodium loss)

‐Hyperosmolar (water loss ‐ due to increased sodium or glucose)

Long Term Care

‐Sign of poor care

‐Combination of physiological or disease process

‐Not primarily due to lack of access to water


HYDRATION

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HYDRATION

Dehydration Screening

Altered mental status/confusion

Weight loss (3%)

Muscle wasting

Pale skin

Sunken eyes

Red swollen lips

Swollen and/or dry tongue with scarlet or magenta hue

Dry mucous membrane

Poor skin turgor (forehead)

Tachycardia

Postural hypotension

Calf tenderness

Reduced urinary output

Dark urine

Functional Decline of the Renal System

Abnormal lab values

‐Abnormal glucose, calcium, potassium

‐Abnormal serum bicarbonate

‐Abnormal creatinine

Elevated

‐Serum osmolality

‐Serum sodium

‐Urine specific gravity

‐Blood Urea‐Nitrogen (BUN)*

*BUN is only useful in absence of renal disease

© AMT Education Division

HYDRATION

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Fluids With Special Problems

Caffeine (tea and coffee)

‐Inhibition of iron

‐Low levels of vitamin C

Diet soft drinks

Alcohol

Best Type of Fluid

Un‐concentrated

Decaffeinated

Beverage resident will drink

Water is the best fluid for dehydration


HYDRATION

Intervention

Monitor fluid intake and output

‐30 ‐ 35 mL fluid/kg/day

‐Minimum of 1500 mL/day

‐1 mL/cal for enteral tube feeding

‐Additional 10 ‐ 15 mL/kg/day if on an air fluidized bed

Maintain circulation blood volume (reduce hypovolemia ‐ fluid/salt)

Maintain fluid and electrolyte balanceSource: American Medical Directors Association Dehydration and Fluid Maintenance, Clinical Practice Guidelines, Columbia MD

Touring the Nursing Home: Issues for the Elder Law Attorney, Nashville, TN, 2003


HYDRATION

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HYDRATION/DEHYDRATION

Hydration Strategies

Schedule beverage breaks

Add cup holders to wheelchairs

Offer hot and cold beverages

Gelatins, fruit ices, ice chips, juices, supplements

Take fluids on outings and offer frequently

Offer glasses of water in dining room while waiting for meals

Offer fluids after providing care

Address fear of incontinence (risk factor)



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Nutrition


NUTRITIONAL ASSESSMENT

Modulate inflammation & stress – control a catabolic state

Restore macro & micronutrient intake with glycemic control

Increase energy intake to~50% above daily needs

Increase protein intake to ~2 x RDS

Restore adequate calories to respond to wounding or to begin the process of lean mass gain

Undernutrition/Malnutrition

Severe weight loss

≥10% in 6 months

≥ 7.5% in 3 months

≥ 5% in one month

≥ 2% in one week

Walker G ed. Pocket Source for Nutritional Assessment, 6th ed. Waterloo IA



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Disease ‐ Related Malnutrition

“...decline in lean body mass with the potential for functional impairment” at multiple levels

Jensen GL, Bistrian B, Roubenoff R, Heimburger, DC. Malnutrition syndromes: A conundrum vs continuum. JPEN J ParenterEnteral Nutr. 2009;33(6):710‐716

Three clinical syndromes characterized by underlying illness, injury and inflammation

‐Starvation‐related malnutrition no inflammation

‐Chronic disease associated with chronic condition that impose sustained inflammation of a mild‐to‐moderated degree

‐Acute disease or injury related to conditions that elicit marked inflammatory responses



Anorexia

Loss of appetite/energy loss of interest in seeking and consuming food

A psychiatric eating disorder

‐Emotional ‐ depression

‐Physical ‐ low body weight

‐Psychological ‐ image distortion

‐Behavioral ‐ obsessive fear of gaining weight

‐Polypharmacy



Cachexia

Loss of appetite in someone who is not actively trying to lose weight

‐Insidious loss of weight, muscle atrophy, fatigue and weakness

‐Directly related to inflammatory states

‐Rheumatoid arthritis, AIDS, chronic renal failure, COPD, Cancer, Immunodeficiency syndrome

Cytokine production decreases albumin

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At risk: 15 to 18

Moderate risk: 13 to 14

High risk: 10 to 12

Very high risk: 9 or below

Intensity/Duration

Tissue Tolerance

Intensity/Duration

Intensity/Duration

Tissue Tolerance

Tissue Tolerance

DRIP

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Care RequirementsMonitor intake of food, tube

feeding, TPN

Food intake decreases ‐ offer supplement

Tube feeding or TPN decreases ‐monitor and ensure infusion of prescribed amount

Evaluate adequacy of prescribed amount

Dietitian evaluates intake of calories and protein if food intake is low

Consider vitamin supplement

Provide assistance with feeding as needed



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Care Requirements

Baseline Labs

Dietitian evaluates and recommends intake goals

Supplements are provided, intake counted and recorded

Provide support with eating

Time meals, encourage family to feed

Encourage favorite food and snacks



Assessment Tool

ASPEN AND

Nutritional risks (six areas)

‐Oral health status

‐Ability to eat

‐Proper diet

‐Eating patterns

‐Chronic diseases affecting appetite

‐Medications affecting appetite

Current weight status

Detect under and over nutrition

‐Malnutrition Screening Tool

‐Short Nutritional Assessment Tool



Pamela Charney, M.S., R.D. and Ainsley Malone, M.S., R.D.

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Assessment Tool

Mini‐Nutritional Assessment (MNA‐SF)‐Decline food/weight 3 months

‐Calf muscle circumferences

‐Functional impairment – mobility

‐Psychological issues, Neuropsychological problems

Simplified Nutritional Appetite Questionnaire (SNAQ)

‐Appetite

‐Satiety

‐Taste

‐Meal frequency

‐A score 14 indicates risk of at least 5% weight loss within 6 months



Medium and High PrU Risk



Criterion 1

‐If meal consumption is 50% or less for two meals in one day at least one time during the report week

Criterion 2

‐If there is any weight loss during the report week, determined by subtracting the current week's weight from the most recent weight

Medium risk

‐Residents meeting either one of the criteria

High Risk

‐Residents meeting both criteria

Agency for Healthcare Research and Quality (AHRQ)

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Triggers

Loss of appetite

2 meals with intake ≤50 percent in one day

‐Weekly meal intake averaging <50 percent

Significant assistance with key activities of

daily living

Change in body function

‐More than 3 days of bowel incontinence

Presence of a Foley catheter

Current pressure ulcer



Laboratory Tests

Understand the metabolic basis for a lab test

Affecting factors‐Age

‐Hydration status

‐Chronic disease

‐Acute illness

‐Change in organ function



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Muscle Mass Decrease

Energy requirements decline

Decreased protein reserves during periods of stress

Decreased total body water increases chances of dehydration



Age 25 Age 70

Body Mass Index

Sarcopenia

Under and overweight

‐Same nutritional risks

Diagnostic tool

‐Obesity and PEM

<16 = severe underweight

17 ‐ 18 = underweight

19 ‐ 24 = normal

25 ‐ 30 = grade I obesity (mild)

31 ‐ 40 = grade II obesity (moderate)

>40 = grade III obesity (severe)



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Loss of Muscle Mass

Face (temporalis and masseter)

Hands (interosseous and thenar)

Upper body (pectoralis, deltoids, scapular, trapezius, triceps and biceps)

Lower body (quadriceps, and gastrocnemius)




Loss of LBM Complications Mortality

10% Decreased immunity, Increased infections 10%

20% Decrease healing, weakness, infection 30%

30%Too weak to sit, pressure ulcers,pneumonia, no healing

50%

40% Death, usually from pneumonia 100%

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Creatine Height Index (%)

Marker for skeletal muscle mass

‐Amount of creatine excreted in the urine in a 24 hour period divided by the amount of creatine excreted by a normal healthy individual of the same height and sex

≥80% = normal protein

60% ‐ 80% = moderate protein depletion

≤60% = severe protein depletion

‐Creatine (degradation product) formed in active muscle at a constant rate in proportion to the muscle mass of a individual

2% muscle creatine converted to creatinine daily

‐Decreases due to protein depletion




Date: _________RN-RD Pressure Ulcer Screening Assessment Form

For High Risk Populations (page 1)

Age __ Sex □ M □ F Ht __ Dx_______

PMH _____ Risk Associated with Dx/PMH? □ Yes □ No□ >75y □ Recent Illness □ Trauma □ PEM □ Immobility □ Incontinence □ High risk comorbidities □ H/O Pressure Ulcer □ Smoking ____ppd □ Other

Patient Info

Addressograph

AppetiteInadequate intake?

□ Yes □ No□ Unable to assess

NPO Poor 0-50% Fair 50-80 % Good 80–100%(Downgrade by 1 level for presence of > Stage 3 or

multiple Stage 2 wounds)

Diet & MedicationsRisk Assessed?□ Yes (explain) □ No □ N/A to assess

□ Diet:_ □ Different than usual diet? □ P.O. □P.O.+ Supplement □ P.O.+TF □ NPO+TF □ NPOTube Type: NG G/PEG PEJ Site Intact: Y N Food Allergies Meds/Supplements

Weight AssessmentDo Not Use Transfer WeightSignificant IWL? □ Yes □ No

Usual Wt ________ Per patient Per care giver□ Any IWL in the past 2-3 months?Actual Wt/Date __/____ □ With equipment Scale: □ Standing □ W/C □ Bed □ Lift □ Edema

BMI __ IBW _ % of IBW ___ % of UBW ___ ____ % Wt Loss or Gain over past ____

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GI Complications?□ Yes □ No

Date of last BM: __________ □ No C/O □ No BS □ Diarrhea x ________ □ N/V x ________ □ Constipation x __________ □ Colostomy: Liquid Formed Hard Stool

Skin Areas of Concern?

□ Yes □ NoBraden ScaleScore _______(< 18 = at-risk)Gross Assessment Only see CWOCN note for detailed description of wound(s).Total # of Wounds: ___

1. _____________ (Location)

□ Pressure □ DTI □ Surgical □ Stasis

□ Intact Skin □ Foul Odor

Thickness: Partial Full

Drainage: Minimal Moderate Heavy Wound Bed: Beefy red Pale Dry Moist

Hyper-granulation Slough Eschar Tunneling

Undermining S/S of Infection

Abnormal Lab Values?□ Yes □ No □ N/A□ Pending

Baseline Labs □ Hypoproteinemia □Hypogonadism Date □ Hyperglycemia □DehydrationALB BUN Creat GFRPAB Na K Chol

BS HA1c CRP Testosterone

Electronic Medical Record

Early detection

Facilitate consistent comprehensive assessment

Laboratory studies and imaging

Rule out root cause

Provide updates

Monitor the results of PoC



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Oral

Severe periodontal disease 60% ‐ 90%

‐Tooth loss (80%)

‐Ill fitting dentures (50%)

‐Mouth ulcers (30%)

‐Gum recession

‐Oral pain

‐Chewing abnormalities

‐Dry mouth

‐Gingivitis

‐Periodontal disease

Swallowing Abnormalities (Dysphagia)

‐Disease of the oropharynx and esophagus

‐Dementia

‐Stroke43



Oral



Glossitis ‐ Riboflavin, Niacin, folic acid, B12 , protein

Bleeding & spongy gums - vitamins C, A, K, folic acid & Niacin

Angular stomatitis, cheilosis & fissured tongue – vitamin B2,6, & Niacin

Leukoplakia ‐ vitamins A, B12, B complex, folic acid & niacin

Sore mouth & tongue - vitamins B12, 6, C, Niacin, folic acid & iron

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KEY MACRONUTRIENTS

Protein

Angiogenesis and collagen formation

‐RDA ‐ 0.8g/kg

1.25g/kg ‐ 1.50g/kg daily (PrU)

1.50g/kg ‐ 2.0g/kg (stress)

Calories

Resident with ulcers or ulcer risk

30 ‐ 35 kcals/kg/d

29 ‐ 33 kcals/kg/d (Para)

24 ‐ 27 kcals/kg/d (Quad)


Protein Calories

KEY MACRONUTRIENTS

Protein Requirement

Stage I = 1.0 g/kg

Stage II = 1‐1.2 g/kg

Stage III = 1.25 ‐ 1.5 g/kg

Stage IV = 1.5 ‐ 2.0 g/kg

Protein level above 2.0 g/kg

‐May cause dehydration, particularly in the elderly or those with impaired renal function


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Fat

Aids in absorption of Vitamin A

Provide energy

20% ‐ 25% calories production

Linolenic acid – omega‐3 fatty acid

‐Anti‐inflammatory

‐Immune‐enhancing

Essential fatty acid deficiency may adversely affect wound healing


KEY MACRONUTRIENTS

Inflammatory

‐Macrophages, neutrophils, blood clotting, vasodilatation

‐Vitamins and amino acids: A, K, Bromelain

Proliferative

‐Angiogenesis, fibroblasts, collagen deposition

‐Vitamins and minerals A, B6, C, Cu, Fe, Mg, Zn

Remodeling

‐Collagen maturation, stabilization, scar tissue mature

‐Vitamin and minerals C, Cu, Fe, Zn48© AMT Education Division

KEY MICRONUTRIENTS

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Vitamin A

Facilitates macrophage entry into the wound

Stimulates collagen synthesis, angiogenesis, and epithelialization

Antagonizes inhibitory affects of glucocorticoids (corticosteroids)


KEY MICRONUTRIENTS

Vitamin A

Stage I ‐ II

10,000 – 25,000 IU x 10 days

Stage III ‐ IV

5000 IU per 1000 kcal

Concomitant glucocorticoid use

10,000 ‐ 15,000 IU x 7 days

Vitamin C (Ascorbic acid)

Enhances leukocyte, macrophage activation, fibroblast, collagen synthesis

Increased tensile strength

Decreases wound dehiscence

Depressed levels found in elderly, smokers, and certain cancers

Not to exceed 2000 mg/day


KEY MICRONUTRIENTS

Vitamin C

Stage I ‐ II

100 mg ‐ 250 mg/day

Stage III ‐ IV

1000 mg/day (250 mg – 4x/day)

Renal failure

250 mg/day

Vacuum Dressing

1000 mg/day (250 mg – 4x/day)

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Vitamin D

Fat soluble

Calcium balance

Immunity (infection fighter)

Modulates cell differentiation

Proliferation of keratinocytes

1000 IU/d


KEY MICRONUTRIENTS

Vitamin E

Scar formation – conflicting reports

Adversely affects vitamin A benefits

May interfere with the healing of some types of wounds

Vitamin K

Co‐factor for coagulation

Monitor prothrombin times (PT) rations (INR)

Antibiotics may limit vitamin K


KEY MICRONUTRIENTS

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Zinc

Increased demand during collagen and protein synthesis

Transported through the body by albumin

Hypermetabolic state

‐Urinary/exudate loss of zinc

‐Zinc sulfate 220 mg/2wks

D/C in 3 ‐ 6 weeks ‐may impair copper and iron absorption and metabolism


KEY MICRONUTRIENTS

Zinc

Stage III ‐ IV

11 mg‐ 15 mg/males (elemental zinc)

8 mg ‐ 12 mg/females (elemental zinc)

‐Limit 40 mg/day

‐Supplementation with 25 mg ‐ 50 mg elemental zinc/day x 2 weeks (not indicated)

Minerals ‐ Copper

10 days till depletion following injury

Formation of red blood cells

Vitamin C + copper = elastin production

‐900 μg/d

Amino Acids ‐ Arginine

Immune stimulant for lymphocytes

Enhances T‐cell function (immune mechanisms)

Precursor collagen and connective tissue synthesis and cell multiplication

5 g – 6 g/d

15 g – 25 g improves collagen formation


KEY MICRONUTRIENTS

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Amino Acid ‐ Glutamine

60% of intracellular amino acid pool

Source for epithelial cell and fibroblasts

Stimulates lymphocytic proliferation

Stores depleted at 10 – 15% LBM loss

Supplemental 0.57 g/kg/d

0.3 g ‐ 0.4 g/kg/d (burn patients)


KEY MICRONUTRIENTS

Current evidence does not definitively support any specific dietary supplement unless the resident has a specific vitamin or mineral deficiency

Multivitamins contain 7.5 mg to 15 mg of elemental zinc


NUTRITION

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IN CONCLUSION

Nutrition plays an essential role in wound healing

Modulate inflammation & reduce stress

Control catabolic state

Restore macro and micronutrient intake with glycemic control

Increase energy intake to ~50% above daily needs

Reassess nutritional status at frequent intervals while

THANK YOU


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American Medical Directors Association (2008) Pressure ulcers in the long‐term care setting. AMDA.

Barbul A, Lazarou SA, Efron DT, et al: Arginine enhances wound healing and lymphocytes immune responses in humans. Surgery 1990; 108:331‐337.

Black JM, Edsberg LE, Baharestani MM, LangemoD, Goldber M, McNichol L, Cuddigan J. Pressure Ulcers :Avoidable or Unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Management 2011;57(2): 24‐37.

Campbell, S. Maintaining hydration status in elderly persons: problems and solutions. Support Line, 1992;7‐10.

Cataldo CB, DeBruyne LK, Whitney EN. Nutrition and Diet Therapy, Principles and Practice. Belmonth, CA: Wadsworth; 2003.

CMS Guidance for 483.25 (i)‐Nutrition F(325).


REFERENCES

Demling RH, Nutrition, Anabolism and the Wound Healing Progress:

An overview. Eplasty, 2009;65‐93.

Dorner B. Posthauer ME, Thomas D, The Role of Nutrition in Pressure

Ulcer Prevention and Treatment: National Pressure Ulcer Advisory

Panel White Paper; 2009.

Dyck MJ, Schumacher JR, Using Evidence‐Based Organizational

Strategies to Prevent Weight Loss in Frail Elders Annals of Long‐Term

Care: Clinical Care and Aging. 2013;21(5):24‐30

Illinois Council on Long Term Care. Water: The Fountain of Life.

Retrieved March 30, 2007,

http://www.nursinghome.org/fam/fam_018.html


REFERENCES

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Kieselhorts KJ, Skates J, & Prichett E, (2005). American Dietetic

Association: The Standards of practice in nutrition care and updated

standards of professional performance. Journal of the American Dietetic

Association, 105(4), 641‐645.

Lee S K, Posthauer M E, Dorner B., Redovian V, & Maloney M J. (2006).

Pressure ulcer healing with a concentrated, fortified, collagen protein

hydrolysate supplement: a randomized controlled trial. Advances In Skin

& Wound Care, 19(2), 92‐96.

Litchford, MD (2010) Advanced Practitioner’s Guide to Nutrition &

Wounds. Greensboro, NC: CASE Software & Books.

Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly.

Chest 2003;124(1):324‐336.


REFERENCES

Malnutrition And Dehydration Plague Nursing Home Residents Lack Of

Adequately Trained Personnel Largely To Blame. The Commonwealth

Fund June 7, 2000.

Mentes J, Oral Hydration in Older Adults. American Journal of Nursing.

2006;106(6):40‐49.

Morly JE. Hormones and the Aging Process. J AM Geriatr Soc 2003;51(7

Suppl):S333‐7.

Jamshed N, Schneider E L. Is the Use of Supplemental Vitamin C and Zinc

for the Prevention & Treatment of Pressure Ulcers Evidence‐Based?

Annals of Long Term Care. 2010. 18(3):28‐32


REFERENCES

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National Pressure Ulcer Advisory Panel and European Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, 2009.

Nelms, M, Sucher, K, & Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont: Thomson Brooks. Posthauer ME, Collins N, Dorner B, Sloan C, Nutritional Strategies for Frail Old Adults. Advances in Skin &Wound Care, 2013;26(3):128‐140.

Pompeo M. (2007). Misconceptions about protein requirements for wound healing: results of a prospective study. Ostomy/Wound Management, 53(8), 30.

Szewczyk M T, Arkdiusz J, Kornelia K‐K, Moscicka P, Cwajda J, Cierzniakowska K, Brazis P, The Nutritional Status of Older Adults with and without Venous Ulcers: A Comparative Descriptive Study. Ostomy Wound Management 2008; 54(9):34‐42.


REFERENCES

Thomas D T, Todd R C, Lawhorne L, Levenson S A, Rubenstein L Z, Smith D, Stefanacci R G, Tangalos E G, Morley J E, Dehydration Council (2008). Understanding Clinical Dehydration and its Treatment. JAMDA 9(5), 292 ‐301.

Walker G ed. Pocket Source for Nutritional Assessment, 6th ed. Waterloo

Wick J. Y. (1999). Prevention and Management of Dehydration. The Consultant Pharmacist, 14(8). Retrieved April 5, 2007, from http://www.ascp.com/publications/tcp/1999/aug/prevention. html.

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REFERENCES

Documents

AS A COURTESY TO THOSE AROUND YOU, PLEASE SILENCE …Describe how nutrition deficiencies ... Adapted from Krause’s Food, Nutrition & Diet Therapy, 11th Edition. 3/17/2016 8 Blunted