Nancy Collins

Nutrition: a critical component of wound healing.

PURPOSE To enhance the clinicians competence in using nutrition as an integral part of wound healing. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES After participating in this educational activity, the participant should be better able to: 1. Analyze the effects of specific nutritional deficiencies and patient parameters on wound healing capabilities. 2. Accurately interpret laboratory values related to nutritional status. 3. Apply evidence-based nutrition guidelines for improved wound healing.

Obesity and wound healing.

Defining Obesity A patient is considered obese if he or she weighs more than 120% of his or her desirable body weight.1 The Hamwi formula is often used by professionals to calculate ideal body weight (IBW) (Ta b l e 1 ) .I B W, h o w ev e r, has limited clinical utility and simply provides a starting point for nutrition assessment. Obtaining a patient’s usual body weight (UBW), which depends on patient re c a l l , or a p a t i e n t ’s adjusted body weight (AdjBW) can be more clinically useful (Table 2). AdjBW provides a more realistic picture of an overweight patient and should be used for nutritional assessment rather than IBW when a client is obese.2 Over the past several years, the concept of IBW has slowly been replaced by body mass index (BMI).3 BMI assesses body weight relative to height and classifies the result as underweight, healthy, or progressively worsening levels of obesity (Table 3). Obtaining a patient’s BMI has come to the forefront as an assessment parameter because it brings the concept of body composition to nutritional assessment. Clinical judgment must still be used because BMI may not be a reliable indicator of body composition for patients with edema, m u s c u l a r patients, or very short or very tall patients.

Diabetes, nutrition, and wound healing.

have diabetes with elevated blood glucose levels. How does this affect wound healing? Can nutrition help? A: Approximately 17 million people in the United States, or 6.2% of the population, have diabetes. Although an estimated 11.1 million people have been diagnosed, 5.9 million (or one third) are unaware that they have the disease.1 Diabetes is often undiagnosed because many symptoms seem harmless, including frequent urination, excessive thirst, extreme hunger, unusual weight loss, increased fatigue, irritability, and blurry vision.1 The 2002 American Diabetes Association Clinical Practice Recommendations2 include criteria for confirming a diagnosis of diabetes (see Criteria for Diagnosing Diabetes) and new classifications for fasting plasma glucose (FPG), as follows: • normal fasting glucose—an FPG <110 mg/dL (6.1 mmol/L) • impaired fasting glucose—an FPG >110 mg/dL (6.1 mmol/L) and <126 mg/dL (7.0 mmol/L) • provisional diagnosis of diabetes—an FPG >126 mg/dL (7.0 mmol/L).

The right mix: using nutritional interventions and an anabolic agent to manage a stage IV ulcer.

1039. Presented at the 44th Annual Meeting of the American Society for Therapeutic Radiology; October 19-23, 2003; Salt Lake City, UT. 11. Demling R, De Santi L. Closure of the “non-healing wound” corresponds with correction of weight loss using the anabolic agent oxandrolone. Ostomy Wound Manage 1998;44:58-68. WWW.WOUNDCAREJOURNAL.COM 39 ADVANCES IN SKIN & WOUND CARE • JANUARY/FEBRUARY 2004

Nutritional strategies for frail older adults.

The objectives of this continuing education article are to analyze the aging process and its effect on the nutritional status of frail older adults; determine how sarcopenia, anorexia, malnutrition, and Alzheimer disease increase the risk for pressure ulcer development and impact the healing process; and to apply evidence-based nutrition guidelines and implement practical solutions for wound healing.

Arginine and wound healing: a case study.

Mr P, a 77-year-old man who resides at home with his wife, suffers from coronary heart disease, hypertension, glaucoma, an enlarged prostate, and involuntary weight loss. Clinical evaluation of the patient reveals a nonhealing surgical wound 8 weeks after coronary artery bypass grafting. The wound is located on the lower right leg, where a vein had been harvested for the procedure. The wound bed contains a significant amount of slough, with signs and symptoms of infection, including increased redness and exudate, and pain. After a deep swab culture reveals the presence of Staphylococcus aureus, antibiotics and appropriate acute medical care are initiated for Mr P. The health care provider requests a consultation with the registered dietitian for nutrition evaluation and care. Nutritional Interventions

Vitamin C and pressure ulcers.

orating health for the past 2 years. Six months before admission to a wound center from her long-term-care residence, Mrs P suffered a small right intracerebral hemorrhage resulting in temporary left hemiparesis. Clinical assessment reveals a cachectic woman with a Stage III pressure ulcer measuring 2.5 x 3 cm on her left buttock. She also has skin tears on both arms. Consistent with best practices, an interdisciplinary approach was used to develop a management program to promote the healing of Mrs P’s pressure ulcer and prevent further skin breakdown. Local wound care consisted of debridement and a dressing to absorb exudates while maintaining adequate moisture to promote healing. In addition, the nutrition protocol prescribed by the dietitian included a routine vitamin C supplement, based on the physiologic role of vitamin C in collagen formation, the AHCPR guideline, and reports in the literature.1-7 This article takes a closer look at the possible role of vitamin C in wound healing.

Response to "Clinical Order Sets: Defining Laboratory Tests for Pressure Ulcers".

We readwith great interest theApril 2015Practice Points article, ‘‘Clinical Order Sets: Defining Laboratory Tests for Pressure Ulcers,’’ by Cathy Thomas Hess, BSN, RN, CWOCN. As thought and content experts in the field ofnutrition andwound healing, we would like to clarify the use of albumin as a basic screening tool for nutritional status and its perceived direct relationship to the severity of protein deficiency. In addition, we would like to comment on the common conflation about prealbumin as a ‘‘better indicator of acute nutritional status changes than albumin.’’ Current research indicates that using negative acute phase reactants, such as albumin and prealbumin, to measure nutritional status is no longer appropriate. Negative acute phase reactants are affected by the presence of inflammation, stress, hydration status, and renal function. Cytokine mediators, interleukin 1A, interleukin 6, and tissue necrosis factor, redirect the liver to synthesize positive acute phase reactants, such as C-reactive protein and ferritin, rather thannegative acute phase reactants. During this period of inflammation and/or stress, albumin is pulled from the extravascular space to the plasma and returned back to the extravascular space when inflammation declines. Albumin and prealbumin levels increase with dehydration and decrease with overhydration; this does not impact nutritional status. Studies support that the entire class of hepatic proteins is a better indicator of morbidity and mortality than it is of nutritional status. This makes these hepatic proteins useful as indicators of illness severity.Hepatic protein levels do not accurately measure nutrition repletion, thus making them poor markers of malnutrition. The Academy of Nutrition Dietetics and the American Society of Enteral andParenteralNutrition’s (ASPEN) 2012 article, ‘‘Characteristics recommended for the identification and documentation of adult malnutrition’’ defines an etiologybased approach to describe a standard set of diagnostic characteristics to define malnutrition. These characteristics include reduced energy intake, weight loss, and decline inmusclemass. The 2014 National Pressure Ulcer Advisory Panel, European PressureUlcerAdvisory Panel, and Pan Pacific Pressure Injury Alliance Guidelines for the Prevention and Treatment of Pressure Ulcers do not recommend the use of laboratory tests of acute phase reactants as indicators ofmalnutrition based on the lack of research. Registered dietitians are an integral part of the wound care team and can bring current information and research to light as the field is rapidly growing as more research is published. Registered dietitians are your best source of accurate and current nutrition information. Also featured in the April issue of Advances in Skin & Wound Care is the continuing education article, ‘‘The Role ofNutrition for PressureUlcerManagement: National Pressure Ulcer Advisor Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance White Paper,’’ which provides additional information on this topic. This article offers a complete understanding of current nutritional recommendations for pressure ulcers.&

Diarrhea and wound healing.

Q: Many of my patients have pressure ulcers on the coccyx or sacrum. Frequent bouts of diarrhea make it difficult to care for these ulcers and healing is often impeded. Can you provide guidelines on managing diarrhea? A: Diarrhea is characterized by frequent loose or liquid stool. If stool contaminates a pressure ulcer, treating and healing the wound may be more difficult. Prompt and effective treatment of diarrhea involves a multidisciplinary approach to identify its cause and begin the proper nutritional, medical, and pharmaceutical regimen.