As bodies age, organs do not always function as well as they once did. The skin, which is the largest organ of the body, is no exception. Skin integrity can be compromised by vascular deficiencies, decreased mobility and ability to reposition weight, uncontrolled blood sugars, dehydration and malnutrition, and other comorbidities that come with advancing age. Not only can wounds (especially pressure ulcers) begin a cascade of health problems, they also can send a facility’s Quality Measure and Five-Star Rating downhill. So if there is a resident with or at risk of developing a pressure ulcer, your Nutrition Care Systems dietitian is an important piece of the inter-disciplinary team to get the skin back on the road to healing.
A comprehensive nutrition assessment is needed to determine if a resident’s nutritional status is adequate to maintain skin integrity and/or support healing. One indicator is weight loss. If there is unintended weight loss greater than 10% in six months, wound healing is often impaired1. If the unintended weight loss exceeds 20%, wound healing stops and new wounds are likely to develop1. In addition to significant unintended weight loss, The Academy of Nutrition and Dietetics also states that two or more of the following signs indicate malnutrition: inadequate oral intakes over time, loss of body fat or muscle, fluid accumulation, and reduced hand grip strength2. See our previous article Hypoalbuminemia to learn why the serum albumin level is not a reliable indicator for malnutrition or protein status.
Energy and protein needs are increased when someone is malnourished or has a pressure ulcer as the body is in an increased metabolic state. Recommended daily calorie requirements increase to 30-35kcals/kg of body weight per day, and protein needs are increased to 1.25-1.5 grams of protein/kg of body weight3. This range has been found to minimize inflammation, increase collagen synthesis, boost cell multiplication, and promote wound contraction3. Some amino acids, the building blocks of protein, are more crucial to wound healing than others, one of those being arginine. Arginine aids in vasodilation and enhances proline synthesis which is needed to produce collagen1. Because the body does not produce arginine on its own, all arginine needs must be met through the diet. However not all arginine supplements are created equal, your Nutrition Care Systems dietitian can help guide you to the most effective ones.
It is important to avoid dehydration and deficiencies in micronutrients to support continued healing. Fluid balance can be delicate in the elderly population, especially when CHF and edema are present, but should be kept in consideration as dehydration can lead to skin to becoming fragile and lose elasticity4. Blood pressure, the concentration of urine, and electrolyte levels are good ways to measure hydration status. Often the micronutrients, vitamin C and zinc, get a lot of attention when care teams are treating wounds. While they each have a function in wound healing, it is hard to truly diagnose a deficiency because their serum levels are influenced by inflammation3. There also has not been enough compelling research to support a separate therapeutic dose for each micronutrient; a multivitamin that contains minerals is currently deemed as sufficient3.
Not only is the dietitian responsible for assessing what the resident needs for healing, but also for recommending a nutrition intervention that is individualized and appropriate. Serving an additional serving of protein at a meal(s) for a resident with a good appetite may be considered to ensure protein needs are supported. An obese resident may require a dose of liquid protein a day to avoid excessive calorie intake. A resident who has experienced significant weight loss and decreased appetite may benefit most from a concentrated 2 kcal/mL med pass supplement. It is important to communicate with the dietitian if the resident likes or dislikes the intervention. Sometimes it is a matter of trial and error to find one that works.
Additionally, there is such thing as too much protein. When protein intake surpasses needs, the kidneys are responsible for processing the excess. This is taxing on the kidneys and harmful to those with chronic kidney disease. If a resident has a non-healing wound and is consuming enough protein, it is important to look at other factors that are needed for wound healing i.e. blood glucose control, turning and repositioning, incontinence, etc.
Invite your Nutrition Care Systems dietitian to the table to discuss the prevention and treatment of wounds. We are here to here to help boost residents’ nutrition status as well as your Quality Measures score.
- Collins N. The Changing Healthcare Landscape in Long Term Care: Focus on Pressure Ulcers and Wounds. Abbott Laboratories. 2017.
- Hand RK, Murphy WM, Field LB, et al. Validation of the Academy/A.S.P.E.N. Malnutrition Clinical Characteristics. Journal of the Academy of Nutrition and Dietetics. 2016; 116(5):856-864. http://jandonline.org/article/S2212-2672 (16)00105-2/abstract. Accessed April 28, 2017.
- Posthauer ME. Feeding Your Wound: Fuel to Heal. Nutricia Learning Center. http://www.nutricialearningcenter.com/globalassets/pdfs/specialized-adult-nutrition/feeding-your-wound-webinar_5-28-15_handouts.pdf. Published May 29, 2015. Accessed April 28, 2017.
- Collins C. Nutrition and Wound Care. Clinical Nutrition Highlights. 2006; 2(3):2-7.