Board Review Wound Care

Medical Nutrition Therapy For Wound Care

Cynthia Fleck, BSN, MBA, RN

Cynthia Ann Fleck, BSN, MBA, RN discusses normal nutrition and malnutrition. Ms Fleck reviews the methods available for diagnosis of a malnourished patient, nutritional risk assessment, effects of malnutrition to the body, and guidelines and interventions for prevention of malnourishment.

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Goals and Objectives
  1. Describe the criteria and tools for diagnosis of a malnourished patient
  2. Describe the advantages and disadvantages of vitamin and mineral supplementation
  3. Review the guidelines for maintaining a healthy nutritional status
  4. Recognize how malnutrition impacts the human body and wound healing
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  • CPME (Credits: 0.75)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.75 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Cynthia Fleck, BSN, MBA, RN

    President and CEO, Cynthia Fleck & Associates, LLC, St. Louis, Missouri.

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    Cynthia Fleck has disclosed that she is an employee of Vomaris Innovations.

  • Lecture Transcript
  • Dr. Robert Frykberg: Okay. Now we have these horribly sick patients with ulcers, with infections, with Charcot foot, morbidly obese and yet malnourished. We need to pay attention to their nutrition. It is for that reason that I’ve asked our nursing co-chair, Ms. Cynthia Fleck to come and instruct us into what we need to consider in terms of our patient’s nutrition. So let us welcome Cynthia Fleck.

    Cynthia Fleck: Good afternoon, ladies and gentlemen. Thank you Dr. Frykberg. It’s great to be back in front of all of you this final day. It is pouring. It’s raining cats and dogs if you haven’t taken a look. Strange time in November in Phoenix. In the spirit of full disclosure I want to let you know who I am, who I represent. All of my affiliations are clearly articulated on the slide before you. We’re going to take a fast and furious approach to and perhaps kind of turn your ideas upside down about what you think of a malnourished resident, patient, or veteran looking like. Also, change our approach to how you consider your diagnostics and your treatment. So without further ado let’s go ahead and get started. This is a very, very young Cynthia who was being tantalized by grandma Florence’s cake frosting. So this is not nutrition and my mother had nothing to do with this, but she is the reason that I have a sweet tooth, grandma Florence. I’ll just read this really poignant quote to you. It says, “One must eat to live, not live to eat.” How many of you agree with that? I don’t know. I kind of go both ways. Eating is life, isn’t it? Everything that we do is pivotal to a meal, to a celebration, and food goes hand in hand with that experience. Alright. Checking the audience. How many of you have either A, ever said this, uttered this, or have been on the receiving end and have ever heard this? You know who you are. Just checking albumin, our pre albumin. Let’s go back for a moment and review that an albumin simply looks back at about 14 to 21 day time period. So it has a half-life that’s very, very long. If you were to draw a serum albumin on me today, it would literally look back two to three weeks in the past to where why somatic protein stores resided. So it’s really not giving you a good representation of where my hepatic liver storage of good quality protein resides. If I were to take it a level further and I were to ascertain or draw a prealbumin, that would tell me approximately two to three days which is definitely a more sensitive indicator, the transthyretin level. However, what we find with an albumin and prealbumin is it’s an indicator of an inflammatory process. Where are our wounded individuals that we treat? Generally in that stuck phase of inflammation, correct? So often times you will get a falsely elevated either albumin or prealbumin level which is troubling. So I like you to think beyond that albumin and prealbumin. Best practice in dietetic and diabetic care dictates that we lie not solely on these hepatic proteins. I do want to give you a disclaimer here. I am not a dietician. I do have a minor in nutrition and I try to follow it very carefully in the literature. But I’ll tell you about some of my heroes that I carefully follow their literature. So what then for instance if we’re looking beyond an albumin or prealbumin level? Should we be ordering and or assisting or asking our referral sources for an order? I recommend in the literature it elucidates this. By the way, all of my slides are clearly marked with the literature that supports that data. A retinol-binding protein. The beautiful thing about a retinol-binding protein is that it is a true sensitive indicator of protein status. Its half-life is only ten hours. So if you were to draw one me right now, it would tell you within a ten hour period how well-nourished I was with regard to protein status.

    It also, just a note, liver disease, renal failure, and stress, can affect its accuracy. So be aware that most of us as we walk in everyday life as well as most of our patients and residents, are stressed. So we have to take that cortisol level into play. Another lab value that we should hone in on is the total lymphocyte count. Keep in mind that total lymphocyte count also reflects the immunity of that human host. Certainly looking at the H&H because they are tearing vital nutrients and the transferrin level. This is also going to reflective of protein and iron status as well as inflammatory process. So those of you providers who are ordering these lab values, I want you to consider looking or ordering that retinol-binding protein. Those of you providers who are perhaps the wind beneath that individual’s wings, both the patient and the physician or nurse practitioner or provider that’s writing orders, make sure that you are an advocate for that patient, and that you are parlaying this information as important. Remember, we see one, do one, learn one. So you’re all infected vectors with nutritional information and you’re to go out into the field and make sure that this is disseminated to all the troops. I love the MNA. The MNA is a research-validated tool that is generally used in the elderly. It’s been around for over 20 years. It is literally a snapshot as to the overall nutritional capacity of that human host. It was developed a long time ago. It originally had 18 questions. It was a bit laborious. We found that our RDs generally were ascertaining this information. But we wanted that -- the Dietetic Association wanted to hone this in and make it a little more specific and also make it friendly for all of we in the field to be able to quickly ascertain a full-on mini nutritional assessment. It really provides not only an advantage overlooking just visceral protein but the holistic embodiment of what nutrition is. I’ll go through some of the specifics. It looks that now 60 areas, and you can see them here, food intake, mobility, BMI, history of weight loss, psychological stress, acute disease and dementia or other psychological conditions. If you’re interested in getting more information, I know I’m not allowed to say trade names but you can see that there’s a particular company up here. Most of your nutritional support companies will have this available to you, both in electronic as well as paper format. So if you’re not familiar with it, make sure that your registered dietician or perhaps you can be the conduit of this great information. So a score of 11 or fewer is considered to need further investigation. I like to use this in my practice as sort of my land in the sand when I need to bring in my registered dietician. So the MNA tool. It’s been a long three days, hasn’t it? As troopers. The other thing, those of you where are my nurses from the audience? Salami, salami, baloney. Love my nurses. Love all of you. But I am a nurse by trade and nursing professionals are very attuned to using the Braden risk assessment score. Barbara Braden and Nancy Bergstrom from out of the University of Nebraska brought us this tool back in the late 80s. What I particularly like about the Braden score is that it not only looks at pressure ulcer risk, but it has a specific area just for nutrition. That subset is a trigger to every bedside nurse across these great 50 states, this wonderful nation that we live in, to be able to quickly ascertain whether or not a patient or a resident is at risk. A value of 18 or fewer on average is considered to be at risk. But keep in mind that nutrition is a subset of this tool. Another little piece of pearl of wisdom and that is ASPEN. Those of you who aren’t aware of ASPEN, ASPEN is an acronym that stands for the American Society of Parenteral and Enteral Nutrition. They have some of the great literature and nice pieces that you can simply take away and use in your practice multiple guidelines for specific disease states, as well as standards, physician papers, et cetera.


    So those of you who want to take a little bit deeper dive, take a look at ASPEN’s site which is depicted on my slide in front of you today. Another guideline that perhaps you’re not aware of that came out in 2009. This came from three very well-known, not only nutritional therapist but also in the realm of pressure ulcer care. This comes from both the US, the National Pressure Ulcer Advisory Panel, as well as our European cousins, the European Pressure Ulcer Advisory Panel. They developed a guideline that specifically targets the needs of nutrition in a pressure ulcer patient. However, I found that the information is anecdotal to every other patient who is wounded. So if you’ve not seen this yet, you can actually go to the NPUAP’s website and take a look at that information. One of my heroes in the nutritional world is a lady by the name of Dr. Nancy Collins. Nancy, those of you who know her, she’s very practical. She always has not only some great research that she’s involved in, but she makes it very simple. Her pneumonic is PEARLS. It reminds us of all the important nutrients. Protein, energy, amino acids, RDAs and RDIs, lab data, and Sarcopenia. Anybody know what Sarcopenia means? I think they remember. Again, been a long day, a long week. It’s wasting away of human flesh. We often see that in the patients we care for. Let’s take a quick look at what we’re actually looking specifically at when we’re assessing nutrition. We’re not only looking at the intake or in other words the food consumption, but their need for assistance. Imagine today for instance that if you needed help to nourish yourself. I had the pleasure of being able to get ready in my hotel room and being with my mother. I was running around like I’m always and I’m on my computer and taking calls and running to the meeting. She was peeling my orange for me and getting me ready. She was like here, darling. I don’t need help but imagine if every bite that you took required assistance. Many of the individuals that we treat have challenges that require help. That’s a big component of what makes someone at risk. Anthropometric measurements are tried and true. This is really where we can focus our efforts. Height and weight is standard. So when a patient comes in, what do we always do? Or a patient I thought we get measured and we get weighed. That should be done at minimum of every three months. Generally, it’s not a specific height and weight that we should be looking at. The literature points to weight loss in excess of 10% of the patient’s usual weight. So as Dr. Frykberg mention when he was introducing me, that just because that little cachexic individual, we know beyond the shadow of a doubt, is malnourished. That obese person with a BMI greater than 40 could very much be just as malnourished as the others. So we want to look at usual weight, not just what the weight should be. Anybody ever heard the term skinny mini before? Yeah? This is the original skinny mini. It isn’t just a term. This is a true woman. I believe this was back in the 1920s. This is a broad term, malnutrition. It’s not just a little bitty skinny minis. Often times the individuals who look much like these little folks, these little cutties at the bottom of our slide here, there are elders in their 7th, 8th, 9th decades, our centurians who look well nourished. But yet if we look at the literature, up to 40% of patients who are hospitalized are malnourished. 50% of patients in sub-acute – are you ready for this? Put on your seatbelt. This is a big one. Up to 85% of residents and institutional elderly are actually malnourished. Can I get a wow on that? Okay. I at least got a chuckle. That was good [Laughs]. The effects of malnutrition are substantial. Tissue wasting is obvious but specifically our ability are our gas and our tank. It would be absurd for me to submit to any of you that you would get in a jet and get from wherever you came to Phoenix for this conference that there wasn’t some good quality jet fuel in that 737.


    Wherever you’re going to be driving in the next week to get over the river and to the woods to grandmother’s house for thanksgiving, you couldn’t get there without some kind of fuel in that vehicle. But yet, we not only expect this beautiful thing we call the human body to function but we expected to heal without good quality fuel in the tank. That’s really all it is. Getting back to malnutrition. With a malnourished individual we have a compromised immune system. We have an increased susceptibility to infection. We have a loss of strength and obviously an increased level of toxicity to drugs. So let’s talk a little bit about energy expenditure by weight. For very many years, in fact when I was a college student and undergrad and when I was studying nutrition and studying for my minor, I was taught this long complicated, convoluted formula for looking at how many kilocalories a human needed in a 24 hour period. It was called the Harris-Benedict Formula. What I will now submit to those of you who have been around in the world of wound healing as long as I’ve been, is that the Harris-Benedict Formula is no longer considered the gold standard. It’s so much more simple. You know what, I love the easy button. So I’m going to teach you the easy button. If you know the individual’s weight in kilograms, you can simply multiply by a multiplier of 20 to 25. 25 to 25 kilocalories which is essentially a unit of measure in food substance per kilogram of bodyweight. That’s for a non-stressed individual, if we were kept in a perfect atmosphere, we were non-stressed, we weren’t running marathon, we weren’t even getting up and going to work. To heal a severe or extensive wound, we need up to 40, almost double the number of calories in order to heal a wound especially in an individual that is stressed. Best practice once again dictates that we should be using an adjusted weight if the client is obese. So some good food for thought, pardon the pun. Some easy interventions. If we start crossing that bridge from looking at diagnostics to specifically how are we going to treat that individual, many nutritional assessment, that MNA that we talked about, very simple to use. It’s all within our scope of practice as members of the healthcare team monitoring those key lab values, thinking beyond an albumin and prealbumin, making sure that we know when to get that RD or a registered dietician on our team better earlier in the game than later in the game. I recommend in my practice, and I’ve also got some good literature to support this, that a hundred percent RDA, recommended daily allowance, vitamin and mineral supplement should be utilized. There was a huge longitudinal study that was done by Harvard University that recommended that every adult receive a hundred percent of RDA. Now keep in mind. When you go into your nutrition store or into Walmart or Costco or wherever you shop, there are so many different types and varieties of supplements. I want you to look for a couple of key things. Number one. That it has no more than a hundred percent of the recommended daily allowance. If you remember back from your early days of being a practitioner, there is a pneumonic for fat-soluble versus water-soluble vitamins. It’s ADEK, A-D-E and K. Those are your fat-soluble vitamins that cannot be flushed out. They are maintained so we can become hypervitaminosed very easily if we’re taking huge gigantic doses of vitamin A, D, E, or K. So be aware that these – generally I recommend trade names like Centrum or Centrum Silver, that are adjusted specifically. I will give you one great caveat as they’re now available for men and women. You probably shrug your shoulders and say, “Why do we have differences for men and women?” I’m going to tell you about that in just a minute because it’s really important. Supplement at regular meals and look at fluid balance. As we increase the protein that an individual is taking in exogenously, we need to make sure that their fluid is going hand in hand with that because protein can suck up a lot of the fluid needs. Now I’m going to throw everything upside down. So Harvard says we all need a vitamin and there’s this huge another longitudinal study that actually came out in I believe 2011, yes.


    It came out of one arm at the University of Finland and another one at the University of Minnesota. It looked at middle-aged women between the age of 55 and 69. It was over a 19 year period. 40,000 women were studied. What the study found was that there was increased mortality rate for the individual women who took a vitamin supplement. Now, keep in mind that it was 2.2 for multivitamins, it was 3.9 for iron, and it was 18% for copper. So what I took away from that study is that iron supplementation increases the incidence of heart disease in post-menopausal women. They’re no longer having the menses. They’re no longer needing that 18 milligrams of ferrous sulfate, which by the way just happens to be the RDA for men. So that’s what a hundred percent of the RDA was up until the point where companies like Centrum started differentiating men’s and women’s formulas. Now I understand. Now I get it right. People who take vitamins with the study, with the take away, individuals who take vitamins tend to make more risky health choices because they think, “Oh well, my vitamin will take care of it.” Interesting food for thought once again. Protein. How do we figure out how much protein we need? Well, I’ll just admit to all of you that I am what I call a fun-sized human. I’m a small individual. I weight about 45 kilograms on a good day. If you were you ascertain my protein needs, I need about 36 grams of protein a day. Just to put it in perspective, we are the most well-nourished nation I think in all the world. One little McDonalds hamburger. I’m not talking about all of the specialty burgers that you have. But the one that’s in the happy meal has 12 grams of protein. So in my world, that’s all I have to have, are three a day. If I were on that crazy show Supersize Me, that would be all the protein that I would need to get me through my day. So we really need to look at what that patient’s eating. Is it tea and toast? Is it a little bit of coffee at lunch? Maybe some chicken noodle soup which have you ever looked at a can of Campbell soup? There’s not a whole lot of protein in it. We’ve got to make sure that we’re actually getting protein to that individual. Arginin. Anyone’s heard of this single chain amino acid? You’ve probably? Perhaps even ordered it as a supplement or maybe a well-meaning clinician has recommended that you order this. It has a couple of interesting nuances. One, is it stimulates insulin secretion in the human body. It promotes the transport of amino acids which is key to wound healing and truly all tissue cells. It also supports the formation of protein in the cells. What I will tell you is that studies related to wound healing are controversial. When I did this literature review, what I found was that the studies that were solid actually showed that they were supplementing that individual above and beyond a normal healthy protein intake. So it can’t be used just simply as a supplement but also as an adjunct to that patient’s exogenous oral intake. There appears to be benefits in limited studies. Again, high caloric intake as well as good quality protein in conjunction with the arginine. Zinc and copper is another one I see often ordered as a supplement. I think certainly your mind is in the right direction because zinc has been hypothesized for decades to promote wound healing. However, there their research is really unconfirmed and lacking. Be aware that zinc is a trace element and it has very, very specific uses and need in the human body. In these oliguric, very, very small quantities, it can completely throw off the rest of the chemistry within the human body, specifically the copper. So beware of giving too much zinc without actually ascertaining a zinc level, a serum zinc level, because it can throw off our copper metabolism which can be toxic. What I will tell you is zinc is – in the thought processes, zinc is carried by albumin. Zinc deficiency is really difficult to diagnose. So often it’s supplemented simply as a default. It should not be prescribed indiscriminately.


    So if you know that yourself or you see someone again, raise the awareness. Be an advocate for that patient. Another supplement that I see often which is fairly safe because it is a water-soluble vitamin and that’s ascorbic acid or vitamin C. Vitamin C has, as you know, a major function in collagen synthesis. So important to the genesis of collagen. But again, despite benefits, research really has not proven that taking either anything above and beyond the recommended daily allowance has any benefit to wound healing. These are some fun facts that I want you to take away from today because I know it’s been a long day. I not only want you to think about the residents and our veterans and the patients that you treat every day, but your own bodies because we feel them. We get up every morning and we take on a day and we need good quality fuel. So be aware, ladies especially, because we tend to have more osteoporosis, especially the pale-skinned ladies that appear like I do. Coffee inhibits calcium absorption. So if you’re going to have your morning coffee, you may want to have your morning skim milk or your yogurt, your greek yogurt or maybe even your calcium supplement later on in the day. Same goes for the supplementation of your patients and residents. Make sure, because most of us are coffee drinkers that you’re shifting that schedule. Black tea. I’m not a coffee drinker but like my father, I love black tea. It actually inhibits iron absorption. So in the morning I tried to stay clear of my tea and I wait maybe until lunch time or mid-morning because that’s when I’m taking my hundred percent RDA of my vitamins and my minerals. Calcium. Here’s another interesting one. Calcium reduces zinc absorption. So we want to make sure that we’re giving our calcium and zinc. Are you getting that this is so complicated and we need our friends, our registered dieticians as our pals and our references? They need to be given at different times during the day as well. Vitamin B6 will increase the absorption of the zinc. So if we want to make sure that we have a robust absorption, we want to give those two together. Omega 3 fatty acids. Probably the majority of you in the room are taking fish oil. I know I’m taking it. I’ll share a little fun factor about my mother and me. We both take it together. It’s the most commonly used non-vitamin, non-mineral supplement. Pre-clinical research has shown that it can increase the deposit of collagen deposition which is great. This is really important especially in the formation – in scar formation. Supplementation may increase the fatty acid levels that affect production of proinflammatory mediators that regulate the inflammatory process. So it’s hypothesized. Again, this is simply an anecdotal or as we’ve seen research, the sea level nursing research. There isn’t good quality other than opinion to parlay this information, that it could perhaps decrease the inflammatory response of a wounded patient. Lastly, for all you guys in the audience, men with the highest level of omega 3s have the lowest risk of dying of heart disease, and that is well documented in the literature. Vitamin D, oh my goodness. Vitamin D is the world’s oldest hormone. What we’re finding is that a majority of us who are up and walking upright are vitamin D deficient. In fact one billion people worldwide. The highest risk of individuals are nursing home residents and, you’re ready for this, sorry docs, physicians are at high risk. Why? Because you’re indoors the majority of the time. So exogenous exposure to direct sunlight for 10 hours – excuse me. 10 hours, my word. 10 minutes a day, you’re certainly going to get a whole lot more in Phoenix than you are in the northern areas of the country. But it’s not recommended because the American Dermatology Association has shown this to be an increased incidence of skin cancer. Exogenous dietary intake is highly encouraged. In fact, milk has been supplemented for many years as long as I’ve been alive. If you’re going to be supplementing, make sure that you’re using the vitamin D3 level which is the most bio available variety. The goal is at 50 nanograms per milliliter. That’s achieved with huge doses. Keep in mind that vitamin D – I believe the RDA. I’m totally going out of memory, is 400 international units.


    The achieved balance in order to get a patient to that desired level is about 5,000 to 10,000 international units. So it’s very large doses that we’re giving. Just a quick. I know we’re running out of time here so I’m going to keep it quick. This is a great word that you can kick around at the dinner table tonight. Cholecalciferol, which is short or long for vitamin D. But keep in mind that new research reports findings the higher a person’s vitamin D level is, the higher risk of non-melanoma skin cancer such as basal cell carcinoma and squamous cell carcinoma. So those are great aha for each and every one of us. Likes and dislikes. Keep in mind that there are some great products on the market. It goes beyond that shake, that chocolate shake that sits by the patient’s bedside. Or perhaps that I ask my mother, “Hey. You’re not feeling so great today. Did you drink your boost?” That’s her reminder and she’ll do the same thing for me. But there are some wonderful products on the market today such as brownies, coffee, other cookies that have the same amount of protein as a full glass of milk or a hamburger. So ask that key question because your registered dieticians are attending the ASPEN meeting and the American Dietetic Association where they have all these wonderful products, much like we had in our exhibit hall. This is my favorite part of the program because I get to thank Dr. Frykberg and my friends Allen, Steve, Michael, Darryl, and all my great people at PRESENT e-Learning. It has been my sincere pleasure to be with all of you this 10th Annual Desert Foot. My mother is saying thank you for listening to my daughter. Thank you very much.