Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
1
NutritionandWoundHealing
© FoodSolutions2017
Overview
§ BackgroundonWounds§ RiskFactorsforWounds§ TheroleofNutritionforWound
Healing§ StepsforNutritionSupportin
WoundHealing§ QuickQuiz
AimsandObjectives
Aim:• Toincreasegeneralknowledgeofnutritionandwoundhealing
toimproveoutcomesforresidentswithwounds
Objectives:• Toidentifythosewithwoundswhoarealsoatnutritionalrisk• Toidentifytherolenutritionplaysinwoundhealing• Toidentifywaystoincreasenutritionsupportforthosewith
woundsorpoorwoundhealing
2
BackgroundonWounds
54.8%ofallwoundtypesinelderlyareskintears
>4%of>65yohavechroniclegulcers(vs1-2%)
PressureinjuryprevalenceamongstAustraliansinagedcare~26%
Nearly25%inRACFswillhaveawoundofsometypeatonetime
NegativeConsequencesofchronicwounds
ReducedmobilityDecreasedQOL
ReducedindependencePainanddiscomfort
DepressionIncreasedmorbidityandmortality
Increasedhealthcosts
RiskFactorsforWounds
• Increasedage• Comorbidities(T2DM,RF,PVD)• Polypharmacy• Poorimmunesystem• Poorskinintegrity• Incontinence• Malnutrition• Dehydration
3
Currentguidelinesfornutrition&woundhealing
RoleofNutritioninwoundhealing
Nutrientdeficienciesimpedewoundhealing• extendinflammatoryphase• alterthesynthesisofcollagen• decreaseproliferationoffibroblasts
RoleofNutritioninwoundhealing
Nutritionalrequirementshigherforwoundhealing• Needforincreasedcellproliferation,enzymeactivityandproteinsynthesis
• Requiresenergyfromcalories,plusincreasedsubstratessourcedfromproteinandmicronutrients
• Glutamine(anaminoacid)isthepreferredenergysourceoffibroblasts&increasescollagendeposition
4
NutrientsrequiredforWoundHealing
• Macronutrients– Energy(kJ/calories)fromcarbohydrates,fats&protein– ExtraProteinincludingArginineandGlutamine
• Micronutrients– Zinc,Copper,VitaminA&C
MoreEnergy
• Bothmalnutritionandpressureinjuriescanproduceahypermetabolicstateà increaseenergyrequirements
• Extraenergyisrequiredtoproducecollagen+maintainnormalbodyfunctions• Ifcaloricneedsarenotmet,dietaryproteinbecomesanenergy
sourceinsteadofbeingusedforwoundhealing
• Increasingcaloricintakepromotesanabolism,nitrogenandcollagensynthesis
Sources:Breads,Oils/Fats,Cereals,Tofu,Legumes,Beans,Nuts,Seeds,MeatandDairy
Energy
5
MoreProtein
• Normalrequirement:0.8-1.0g/kg/day• PIStage2andabove:1.25-1.5g/kg/day• HeavilyexudatingVLU,burnsandsevere
wounds: 1.5-2g*/kg/day
Highproteinfoods:beef/chicken/fish,eggs,tofu,soy,milk,yoghurt,cheese,nuts,legumes
*2g/kgofproteincanbedehydratingandisnotrecommendedforthosewithrenalorhepaticimpairment
MoreProtein
• Reducesmuscleloss• Protein=buildingblockoftissues• Synthesizesenzymesinvolvedinhealing,
cellmultiplication&collagensynthesis• Enhancesbloodsupplytowounds,aids
re-vascularisation &lymphaticformation• Argininealsopromotescollagen
deposition,improvesimmunity&increasestensilestrengthofwound
Protein
6
SupplementUse
• Usenutritionalsupplementsifinadequateoralintakeofmeals(oftencontainprotein+mixofvitamins/minerals)
• PatientswithPEMwouldnotbenefitfromasupplementwithonlyVitaminC+Arginine dueto needing allessentialaminoacidswithinasupplement
SupplementUse
• Woundspecificsupplementscanbeusedforchronicandslowtohealwounds(ie >4-6weekstoheal),pressureulcers,diabeticulcers,skinbreakdownandburninjury
• Forwoundspecificsupplements– useforatleast2weeksbutshouldseeprogressafter3+weeks
Micronutrients
Zinc:collagenproduction,immunity,andforcatalyticactivityof~100enzymesfortissueregeneration. Sources:redmeat,fish,dairy,wholegraincereals,eggs
Copper:addsstrengthtohealingwoundandscarduringgranulation. Sources:organmeats,seafood, wholegrains,nuts,legumes
7
Micronutrients
Vit A: stimulatesinflammatoryresponse, epithelialisation andassistsincollagensynthesis. Sources:eggyolk,dairy,fish,orange coloured fruit&vegetables
Vit C: promotescollagenandnewbloodvesselsynthesis,helpstransitionfrominflammatoryphasetoproliferativephaseofwoundhealing toreducecelldamage. Sources:citrusfruits,berries,tomato,capsicum,broccoli
VitaminsandMinerals
Fluid
• Dehydratedskinislesselastic,morefragile,susceptibletobreakdown
• Hydrationimprovescirculation,importantforbloodandoxygensupplytothewound
• Hightemperature,vomiting,sweating,diarrhoea andheavilydrainingwoundscontributetofluidlosswhichmustbereplaced
Encouragefluidintakevia:water,milk,juice,yoghurt,custard,jelly,icecream,icy-poles,soup,t/c.
8
Fluid
NutritionalSupport:4mainsteps
Step1:MNA/MSTScoreNutritionscreeningusingtheMalnutritionScreeningTool(MST)orMiniNutritionAssessment(MNA)inadditiontousualwoundassessment
MalnutritionScreeningTools(MST):Step1
• Identifiesthoseatnutritionalrisk
• Asks2questionstocaptureunintentionalweightlossanddecreasedoralintake
• AddsuptoMSTscore• 0-1Normalnutritionstatus• 2+Atriskofmalnutrition
9
MiniNutritionalAssessment(MNA):Step1
• 6sections- Oralintake,Weightloss,Mobility,Acuteillness,Neurological,BMI/calfcircumference
• AddsuptoaScreeningScore- 0-7Malnourished- 8-11AtriskofMalnutrition- 12-14NormalnutritionalStatus
Nutritionalsupport:4mainsteps
Step2:Improve&MonitorNutritionalIntakeIftheMSTScoreis>2and/orMNAScore0-11à ceaseanydietaryrestrictions,commence
HEHPdietwithfortifiedfoods/drinks,HEHPmidmealitemsandHEHPmilkshakesBD
àmonitororalintakeviaa3dayfoodandfluidrecord
à ifsuspectedchewing/swallowingissuesconsiderreferringforfurtherassessmentifneeded
Nutritionalsupport:4mainsteps
Step3:IntensiveDieteticInterventionIfnoimprovementafter2-3weeksofHEHPdietrefertodietitianforacomprehensivenutritionalassessmentàDietitiansfurtherindividualiseaHEHPdiet,educateresidents
onnutritionandwoundhealing,considercomplianceissues&oralnutritionalsupplementsincludingargininetomeetrequirements30-35ckal,1.25-1.5gprotein,&30-35mlfluid/kg
à Continuedieteticinterventionfor2-3moreweeksoruntilwoundhealing
10
Nutritionalsupport:4mainsteps
Step4:FurtherInvestigationIfthewoundstillpersists,recommendinvestigationintonutritionaldeficienciesincludingiron,copper,zinc*withpossiblecommencementofmultivitamin
*Notehighdosagesofzincbeyond40mgwillinterferewithcopperabsorption,onlysupplementindividualsifdeficient
Step4:FurtherInvestigation
Step3:IntensiveDieteticIntervention
Step2:Improve&MonitorOralIntake
Step1:MST/MNAScore MST 0-1 OR MNA 12-14 OR MST 2+ OR MNA 0-11(Normal Nutritional Status) (At risk of malnutrition)
monitor progress of wound healing over
2 weeks
wound healed
monitor & improve oral intake by:ceasing dietary restrictions, commencing HEHP
/fortified diet, HEHP milkshakes BD & encouraging fluids
recording 3 day food & fluid chartmonitoring swallow/chewing issues, refer for Ax
if needed
if delayed healing after 2-3 weeks, refer to dietitian
dietitian comprehensive Ax, EER + EPR to 30-35kcal (125-145kJ/kg), 1.25-1.5g protein
& EFR 30-35ml/kg, may include supplements & arginine
if wound persists after 2-3 weeks of intervention, refer for investigation into nutritional deficiencies & consider vitamin/mineral
supplementation if deficient (Zinc, Copper)
NutritionandWoundHealingQuickReferenceTool
if no improvement
in 2 weeks &/or wt loss >2kg 1/12
wound healed
wound healed
References
1. Sussman G.WoundHealingandcostimpactsofinterventionsbypharmacistsincommunitysettings.VictorianCollegeofPharmacyMonashUniversity.Forthcoming.2003.
2. Addade LPFetal.2011Venousulcer:clinicalcharacteristicsandriskfactors.Int JDermatol 50:405-11.3. BanksMetal.2010MalnutritionandpressureulcerriskinadultsinAustralianhealthcarefacilities.
Nutrition26:896-901.4. NationalPressureUlcerAdvisoryPanel,EuropeanPressureUlcerAdvisoryPanelandPanPacificPressure
InjuryAlliance.PreventionandTreatmentofPressureUlcers:QuickReferenceGuide.EmilyHaesler (Ed.).CambridgeMedia:Perth,Australia;2014.
5. Sussman G&GoldingM.Skintears:shouldtheemphasisbeonlytheirmanagement?WoundPracticeandResearch19(2)2011.
6. BestPracticeStatement.CareoftheOlderPerson’sSkin.London:WoundsUK,2012(2nd Ed).7. DornerBetal.2009.TheRoleofNutritioninPressureUlcerPreventionandTreatment:NationalPressure
UlcerAdvisoryPanelWhitePaper.8. TransTasmanDieteticWoundCareGroup.Evidencebasedpracticeguidelinesforthedietetic
managementofadultswithpressureinjuries.DietitiansNZandDietitiansAssociationofAustralia;2011.9. AustralianWoundManagementAssociationInc andNewZealandWoundCareSociety.AustralianandNew
ZealandClinicalPracticeGuidelineforPreventionandManagementofVenousLegUlcers.CambridgePublishing;2011.
10. LeBlancK&Baranoski S.Skintears:Bestpracticesforcareandprevention.Nursing44(5)2014.11. ShermanA&BarkleyM.NutritionandWoundHealing.JofWoundCare20(8)2011.