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Case Study: WOUND HEALING November 17, 2014

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Page 1: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Case Study:

WOUND HEALING

November 17, 2014

Page 2: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

INTRODUCTION

“The problem of pressure ulcers is

timeless. Despite increasing

technology enabling us to diagnose

and treat disease, few problems

develop so quickly, persist so

tenaciously and heal so slowly.”

(Pajik et al, 1989, Dealey, 1992)

Page 3: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Introducing Mr.K WHY is he CURRENTLY here in the hospital???

Admitted 10-25-14 for:

multiple pressure ulcers in both feet

and bilateral ankle pressure ulcers

with underlying bone involvement.

Page 4: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

HISTORY:

●Mr. K: 50 year old male who is a T8-9

paraplegic resulting from an MVA in 1978

Page 5: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology
Page 6: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

HISTORY continued:

●Source of income: receives a NSC VA

pension

●Additional Info:

●Mr. K’s wife died 5 years ago and his 29

year old son lives in the home with him.

●Son is involved with his care and ADL,

assisting Mr. K in transfers, dressing,

etc. Mr. K has no in-home care at this

time.

Page 7: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

MEDICAL HISTORY:

●Pt has had chronic bilateral ankle ulcers for >1 year

●Bilateral feet/ankle x –rays were done 10/09/14 and

showed evidence of osteomyelitis.

●ADMISSION statement: multiple pressure ulcers in both

feet and bilateral ankle pressure ulcers with underlying

bone involvement.

What is OSTEOMYELITIS?

Page 8: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

MEDICAL HISTORY:

●Hx of right buttock/hip ulcer with underlying

osteomyelitis in 2008.

●Also:

oCAD & syncope: pacemaker placed 2001

oSeizures: pt declined therapy

oRight eye: “nearly blind”

Page 9: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Clinical findingsoPhysical exam

o notable for 12 separate wounds identified

(grade 2-4)

oLeft extremity: 4 Stage III wounds, 2 Stage

IV wounds, 1 Stage II wound

oRight extremity: on physical exam not much

damage but still with 3 stage II wounds, 1

stage III wound, and 1 stage IV wound.

oHeight: 68 inches

oIBW: 131 lbs ((based on HAMWI & adjusted for

AKA and paraplegia)

oWeight @ Admission: 157 lbs (120% IBW)

Page 10: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Clinical findings

Teeth all intact with no report of problems chewing or swallowing as reported by patient and patient’s son who does most of the cooking at home.

Markers of nutritional deficiencies: none noted at initial exam:

Hair/nails/teeth all normal during initial exam

No indication of sunken eyes/temporal wasting

oBilateral feet/ankle x-rays: evidence of

osteomyelitis in left extremity.

Page 11: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Can you think of any Labs you

would want to check to better

understand his nutrition status

while he is admitted?

Biochemical evaluation:

Albumin Prealbumin CRP

Reference: 3.4-4.8 23-42 0-.30

10/25/14 2.8 <10 16.42

10/30/09 2.8 10.5 12.95

12/07/09 3.0 10.1 17.77

Page 12: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

PRESENT PRIMARY DISEASE PROCESS:

-each group responsible for one of the

STAGES

***if you saw ___________

you would typically expect

it to be Stage___

Page 13: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Stage I

intact skin

The ulcer appears as a defined

area of persistent redness in lightly

pigmented skin,

For darker skin tones, the ulcer may

appear with persistent red, blue, or

purple hues.

indicators as compared to the

adjacent or opposite area on the

body may include changes in one or

more of the following:

skin temperature

tissue consistency (firm or boggy feel)

and/or sensation (pain, itching).

http://www.medivisuals.com/decubitus-ulcer.aspx

Page 14: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Stage 2 Partial-thickness skin loss

involving the epidermis,

dermis, or both.

The ulcer is superficial

and presents clinically as

an:

abrasion

blister

or shallow crater.

Page 15: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Stage 3Full-thickness skin loss

involving damage to or

necrosis of

subcutaneous tissue

May extend down to but

not though underlying

fascia.

The ulcer presents

clinically as a deep crater

with or without

undermining of adjacent

tissue.

Page 16: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Stage 4 Full-thickness skin loss

with extensive destruction

tissue necrosis and/or

damage to muscle, bone,

or supporting structures

(such as tendon or joint

capsules)

Undermining and sinus

tracts also may be

associated with stage IV

pressure ulcers.

REMEMBER: Mr.K = grade 2-4! And

has 12 of them…

Page 17: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

What are nutritional factors to consider in patients with chronic wounds?

1. Increased Protein & calorie needs

2. Increased Vitamin A

3. Increased Vitamin C

4. Possibly Increased Zinc, Arginine,

Magnesium, Glutamine, Copper,

Selenium, Omega 3 Fatty acids,

and/or Vitamin E.

5. Adequate fluids

6. Will nutrient dense foods & small

frequent meals if appetite is poor

be enough to meet needs????

Page 18: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

NUTRITIONAL ASSESSMENT:

●Estimation of Nutrient Needs for Mr.K:

Kcals= 2200-2500 kcal

(30-35 kcals/kg)

Protein= 110-150 grams

(1.5-2.0 g protein/kg/day)

Fluids= 2200+ ml/day

Page 19: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

PROTEIN: how would you meet

his needs?

What foods are high in protein?Meats (beef, chicken, pork, turkey,

etc.)

Eggs

Beans

Nuts

Dairy

www.keepitoff.org

Page 20: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Diet History for Mr.K:

oUsed to consume whey protein regularly but

d/c 2 months ago & very concerned with a

“natural” diet

oHe is not a strict vegetarian but eats animal

foods rarely because meat is expensive and

in the last few years he has become more

concerned with a more natural diet.

oReports appetite low for a few months PTA

Page 21: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Knowing about Mr. K’s diet

preferences how can you meet

his protein needs? 1st: Need to ask him more questions about food

preferences. In current state what animal based

products is he ok eating??

When he talks about a more natural diet that could mean A LOT of

things? Does he have a problem with animal meats only? Is he ok

eating eggs? Dairy products? Processed foods???

If a vegetarian, need to know what kind and then

may consider foods to meet protein needs such as:

Peanut butter and other nuts

Tofu

Soy milk (or milk depending on what he tells you…)

Beans

Cheese products (ie: cottage cheese), yogurt, etc.

Page 22: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Hospital Dietary evaluation

Prior to admission appetite LOW, and pt is very

specific about foods he would/would not eat…

Reports “tired of food here”

Eating less than 50% of meal due to nausea

and some vomiting, but appetite has been

steadily improving since admission 2 weeks ago

Page 23: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

He is sick and nauseated so what

adjustments can you make to meet

his protein and calorie needs? Small frequent meals

Ask him about snacks he like to eat to try and increase appetite

Can speak with a RD and/or a foodservice staff member about

fortifying the foods he is currently eating. (oatmeal, pudding,

shakes)

Avoid foods with strong odors?

Provide meal replacement beverages (ie: Ensure with high protein version)

Make sure he has clear liquids available near bedside

Avoid giving him lots of fried foods and high fiber foods at this

time.

Suggest foods like: applesauce, baked chicken, banana, clear

broths, crackers, dry toast, eggs cooked without fat, juices,

potato, pretzels, rice, sherbet, yogurt.

Page 24: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

WHAT IF ALL OF THIS IS NOT

ENOUGH TO MEET HIS NEEDS???

Has anyone heard of tube feeding or been exposed

to this before?

If Mr.K continue to have N/V and other indicators such

as low intake and nutritional status is decreasing he may need this…

Kcals= 2200-2500 kcal

(30-35 kcals/kg)

Protein= 110-150 grams

(1.5-2.0 g protein/kg/day)

Fluids= 2200+ ml/day

Page 25: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

TUBE FEEDING 2 main types:

1: Enteral- “nutrition provided through the GI

tract via tube, catheter, or stoma that delivers

nutrients distal to the oral cavity” (ND-2.1)

Timing can be really important, and depending

on pt early Enteral nutrition support can be

associated with a reduction of infections and

complications in the critically ill pt.

Different types depending on placement (ie:

NG tube), most formulas are commercially

prepared.

2: Parental (PPN/TPN)- “infusion of intravenous

nutrients via peripheral or central veins. PN

completely bypasses the normal process of

ingestion, digestion, and absorption of

nutrients…”

May be an appropriate intervention if pt has

altered GI function and/or is unable to tolerate

oral or enteral nutrition

Type typically depends on the available

access, duration needed, and pt’s nutrient

requirements (including fluid needs).

http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&ncm_toc_id=255696&ncm_heading=Nutrition%20Care&ncm_content_id=111458#DefinitionofEnteralNutrition

http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=11&ncm_toc_id=255697&ncm_heading=Nutrition%20Care&ncm_content_id=111471#DefinitionofParenteralNutrition

Page 26: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

MR. K’s current diet and

compliance:

oCurrent diet: High Protein

(2700 kcal/120g protein/day)

oCompliance with nutrition interventions:

Initially low but has been steadily

improving since he was admitted…

Page 27: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Mr. K’s current medications:

VA Prescribed:

●MVT/MIN

●Zinc Sulfate

●Acsorbic Acid

●Collagenase Ointment

Page 28: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

From this medication list do you

notice a Vitamin from your

reading that is not prescribed?

Vitamin A

Group activity: Group 1: What does Vitamin A do in the body to

potential help with wound healing?

Group 2: Sources of Vitamin A?

Group 3: What is an Upper Limit? Does Vitamin A have

one?

Group 4: What are the current DRI’s (Dietary reference

intakes) for Vitamin A in healthy adults? What about

to enhance wound healing?

Page 29: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

What does Vitamin A do in the

body to potential help with

wound healing?

replication and proliferation of cells

Increases the number of macrophages and monocytes during inflammation

Stimulates epithelialization and increases collagen deposition by fibroblasts

Page 30: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Sources of Vitamin A? Animal sources: eggs, meat, fortified milk, cheese, cream,

liver, kidney, cod, and halibut fish oil. (not that many have

been fortified with Vitamin A…)

Sources of beta-carotene include:

Fruits such cantaloupe & apricots

Carrots, pumpkin, and sweet potatoes.

Other sources of beta-carotene include broccoli, spinach, and

most dark green, leafy vegetables.

**The more intense the color of a fruit or vegetable, the higher

the beta-carotene content.

Page 31: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

What is an Upper Limit? Does

Vitamin A have one?

A Tolerable Upper Intake Level

UL = “the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. Unless otherwise specified, the UL represents total intake from food, water, and supplements.”

Vitamin A UL: 3,000 ug/d

Toxicity: Hypervitaminosis A:

Acute: nausea, vomiting, double vision, headache, dizziness, and general desqamation of the skin.

Chronic vitamin A toxicity: may see anorexia, dry, itchy, and desquamating skin, alopecia (hair loss), and coarsening of the hair, headache, bone and muscle pain, conjunctivitis, and ocular pain

Excess has also been shown to be TERATOGENIC

Page 32: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

What are the current DRI’s (Dietary

reference intakes) for Vitamin A in

healthy adults? What about to

enhance wound healing?

EAR:

Males: 623 microg/d

Females: 500 microg/d

RDA:

M: 900 microg/d

F: 700 microg/d

Documented recommendations include a range from 10,000 to 50,000 IU/d orally for wound healing…

Page 33: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Mr. K’s current medications:

VA Prescribed:

●MVT/MIN

●Zinc Sulfate

●Acsorbic Acid

●Collagenase Ointment

●Carbamazepine

Page 34: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Vitamin C

GROUP 4: Sources of Vitamin C?

GROUP 3: Why would we want to give additional Vitamin C to Mr.K? (what role does it play & what happens if Vit C deficient)

GROUP 2: Thinking about Mr.K’s current condition what supplementation amount might you prescribe? How does this compare to a healthy adult male?

GROUP 1: UL? How much would that be? What are the concerns with high doses vitamin C? Why might UL not be the same for Mr.K?

Page 35: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 4: Sources of Vitamin C?

Fruits high in vitamin C include: Cantaloupe, Citrus fruits and juices,

Kiwi fruit, Mango, Papaya, Pineapple, Strawberries, Blueberries,

Cranberries, and Watermelon.

Vegetables with the highest sources of vitamin C include: Broccoli,

Brussels sprouts, Cauliflower, Green and Red peppers, Spinach,

Cabbage, Sweet and white potatoes, Tomatoes, Winter squashes.

Some foods are also fortified with vitamin C.

Note that Vitamin C is water-soluble vitamin so storing it for a long

time, and cooking them certain ways may cause some loss of

vitamin C.

Page 36: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 3: Why would we want

to give additional Vitamin C?

Functions in the synthesis of collagen connective tissue protein

at the level of hydroxylation of procollagen.

Acts on:

fibroblast proliferation

Capillary formation

Neutrophil activity

If deficient in Vitamin C possible consequences include:

Clinical scurvy

Poor wound healing (remember it is a cofactor of hydroxylating

enzymes involved in synthesis of collagen…)

Weakness and fatigue

Psychological disturbances

Page 37: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 2: Thinking about Mr.K’s

current condition what supplementation

amount might you prescribe? How does

this compare to a healthy adult male?

Mr. K:

1,000 to 2,000 mg/d orally has been suggested until healing occurs

Complex wound

Stage III and IV pressure ulcers

Multiple wound sites and bone infection involved

Vitamin C for a HEALTHY ADULT Male:

EAR

Males: 75 mg/d

RDA:

Males: 90 mg/d

F: 75

Page 38: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 1: UL? How much

would that be? Why might UL

not be the same for Mr.K?

Vitamin C Upper Limit: 2,000 mg/d

He is not a Healthy adult and these guidelines are dealing with someone

without the problems Mr. K is dealing with!

UL = “the highest level of daily nutrient intake that is likely to pose no risk of

adverse health effects to almost all individuals in the general population. Unless

otherwise specifid, the UL represents total intake from food, water, and

supplements.”

Most common side effect with ingestion of large amounts of vitamin C = GI problems characterized by abdominal pain and osmotic diarrhea.

Page 39: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Mr. K’s current medications:

VA Prescribed:

●MVT/MIN

●Zinc Sulfate

●Acsorbic Acid

●Collagenase Ointment

●Carbamazepine

Page 40: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

ZincNOT A vitamin but is an essential MINERAL.

GROUP 2: What does zinc do in the body?

Why would it be prescribed to Mr. K?

(collagen synthesis)

GROUP 3: Zinc Requirements? Zinc

requirements for Mr. K?

GROUP 4: Sources of zinc in the diet?

GROUP 1: UL for Zinc? Why might excess zinc

be a bad thing? What signs and symptoms

would you look for with Mr. K to see if the Zn

supplement produces acute adverse effects?

Page 41: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 2: What does zinc do in

the body? Why would it be

prescribed to Mr. K?

Zinc is involved in the activity of ~100 enzymes

Plays a role in:

immune function*

DNA synthesis

Protein and collagen synthesis*

Cellular proliferation*

Wound healing*

Page 42: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 3: Zinc Requirements? Zinc

requirements for Mr. K?

Note that supplementation is only recommended in

people with zinc deficiency….

Mr.K is likely in a hypermetabolic state (stress, venous ulcers, and

has a serious injury)

General population:

EAR:

Male: 9.4 mg/d

Female: 6.8 mg/d

RDA:

M: 11 mg/d

F: 8 mg/d

Mr. K’s requirements now are likely:

Up to 40 mg for 10 days

Page 43: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 4: Sources of zinc in the

diet?

Zinc content of food will vary widely!

Beans, dried peas, legumes

Eggs

Meat, fish, poultry, shellfish*

Peanut butter, peanuts

Wheat germ, whole grains such as bran cereal and

whole wheat bread

Page 44: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

GROUP 1: UL for Zinc? Why might excess zinc

be a bad thing? What signs and symptoms

would you look for with Mr. K to see if the Zn

supplement produces acute adverse effects?

UL: 40 mg/d

There is no data indicating adverse outcomes from zinc found in foods; HOWEVER, adverse nutrient interactions are possible with zinc supplementation.

ZINC may Interfere with absorption of other nutrients if given in high doses for long periods of time (Iron and copper)...

Adverse effects can include: suppression of immune response, decrease in HDL, and reduced copper status

ACUTE adverse effects of zinc:

Epigastric pain

N/V/D

Loss of appetite

Abdominal cramps

Headaches

Page 45: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Nutrition and Wound healing

http://online.liebertpub.com/action/showImage?doi=10.1089%2Fwound.2012.0415&iName=master.img-003.jpg&type=master

Page 46: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

So What Happened to Mr. K????

Admitted with 12 pressure ulcers and underlying bone

involvement

Wound VAC placed on right extremity & debridement

completed bilaterally

Left AKA amputation performed and source of infection

appears to be eliminated

Right heal with new drainage & new necrotic wound

developed

Pt was informed of diminished blood supply to right

extremity due to PVD , and the increased risk for infection

and wound healing…. 2 weeks later his right lower extremity

was also amputated.

Page 47: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

What is PVD? Why is it such a problem for Mr. K? Peripheral Artery Disease

Page 48: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

What are nutritional factors to consider in patients with chronic wounds?

1. Increased Protein & calorie needs

2. Increased Vitamin A

3. Increased Vitamin C

4. Possibly Increased Zinc, Arginine,

Magnesium, Glutamine, Copper,

Selenium, Omega 3 Fatty acids,

and/or Vitamin E.

5. Adequate fluids

6. Will nutrient dense foods & small

frequent meals if appetite is poor

be enough to meet needs????

Page 49: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Each group will be given a nutritional

factor to consider the following: 1. what is it? (vitamin, mineral, amino acid, macronutrient)

2. how does it function in the body?

3. what specific role might it have in wound healing?

4. does your group think there is enough evidence to

recommend it be included in nutrition interventions for wound

patients?

GROUP 1: Arginine

GROUP 2: Glutamine

GROUP 3: Vitamin E

GROUP 4: Selenium

Page 50: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Arginine 1. Amino acid= conditionally essential AA

2. how does it function in the body?

Stimulates insulin secretion

Promotes transport of AA into tissue and supports formation of protein.

Roles in immune function

Precursor for proline and ornithine (important in collagen synthesis and nitric oxide production)

3. what specific role might it have in wound healing?

Contained in standard tube feeding formulas

Enhance immune function

Can enhance wound tensile strength in acute wounds

Studies have seen that it mainly helps by accelerating wound healing by increasing collagen deposition

4. does your group think there is enough evidence to recommend it be included in nutrition interventions for wound patients?

Chow 2014: “As a single agent, it is the best-studied component of immunonutrition, and the weight of the evidence suggests that arginine is beneficial to wound healing.”

Page 51: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Glutamine 1. Amino acid= conditionally essential AA

2. how does it function in the body?

Nitrogen donor for synthesis of other AA

Critical for synthesis of nucleotides (fuel source for fibroblasts, epithelial cells, and macrophages)

Essential for gluconeogenesis and involved in immune function

Can modulate and preserve gut function, which is often compromised in severe stress…

3. what specific role might it have in wound healing?

Important in stimulating the inflammatory response during inflammatory phase

May be able to improve nitrogen balance and enhance immunity after surgery to reduce infectious complications (note that Mr. K did end up having surgery!)

4. does your group think there is enough evidence to recommend it be included in nutrition interventions for wound patients?

May be useful if he is showing signs of infection, but “there has not been consistent evidence supporting a direct benefit to wound healing… role in wound healing is one that is still under considerable debate.” (Chow 2014)

Supplemental glutamine has NOT been shown to improve wound healing. (NPUAP, 2009)

Page 52: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Nutrition and Wound healing

http://online.liebertpub.com/action/showImage?doi=10.1089%2Fwound.2012.0415&iName=master.img-003.jpg&type=master

Page 53: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Vitamin E 1. Vitamin

2. how does it function in the body?

Antioxidant

Maintenance of membrane integrity, including possible physical stability, in body cells.

Demonstrated to modulate cellular signaling and gene expression (Hobson, 2014)

3. what specific role might it have in wound healing?

Influence on connective tissue growth factor (CTGF)

Role as an antioxidant may improve wound healing

May be helpful in the case of burns to promote healing topically once the wound has healed (new skin has formed).

4. does your group think there is enough evidence to recommend it be included in nutrition interventions for wound patients?

“it appears that antioxidants have the capacity to expedite wound healing in certain clinical situations, but further studies are needed to elucidate the role of oxidative stress in wound healing.” (Chow 2014)

Hobson review in 2014: “The literature review revealed that there is a significant dearth of robust studies establishing the effects of vitamin E on wound healing, and further research is clearly warranted.” (note that review included acute and chronic wound studies)

Page 54: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Selenium Mineral= essential mineral found in small amounts in the body and it

is a nonmetal that exists in several oxidation states

2. how does it function in the body?

Some of its roles are not completely understood…

Antioxidant, especially when combined with Vitamin E

Plays a role in thyroid function and the immune system

Note that selenium is destroyed when foods are refined and processed…

3. what specific role might it have in wound healing?

May expedite wound healing

May be enhancing host defense and early wound healing mechanisms that

are complementary to the roles of zinc.

4. does your group think there is enough evidence to recommend it

be included in nutrition interventions for wound patients?

“Supplementation of Vitamin A, C, and SELENIUM benefit wound healing,

partly through antioxidant mechanisms’ (Chow, 2014)

“Parenteral zinc, copper, and selenium combined appear effective for

wound healing in humans” (Mirastschijski et al, 2013)

Page 55: Case Study: WOUND HEALING - Erin M. Green, RD · Case Study: WOUND HEALING November 17, 2014. INTRODUCTION “The problem of pressure ulcers is timeless. Despite increasing technology

Summary Nutritional management of chronic wounds:

Imperative that you assess nutritional status and ability to meet nutritional needs orally of the pt.

Increased need for calories & protein are typical, as well as fluids

depending on the pt’s condition!

If deficient supplement with Vitamin A, Vitamin C, and a MVT/MIN in

most cases. Depending on the type of wound and the nutritional

status of the pt other nutrients may also need to be considered when treating a pt.

Mr. K was a case about bone infection and pressure ulcers but

many of the nutrition recommendations explored today can be

generalized to other types of wounds (chronic wounds, non-

healing surgical wounds, diabetic ulcers, etc.)

Important to have a basic awareness of nutritional considerations and be able to then individualize your care based on the actual

pt!