Escolar Documentos
Profissional Documentos
Cultura Documentos
S a m antha
Ko ter w as
Th e U nive rsity
of M ar yland ,
C olle g e Pa rk
D iete tic Int ern
OUTLINE
Overview of Condition
Meet the Patient
Nutritional Considerations
Nutritional Assessment and Therapy
Conclusions and Summary
OVERVIEW OF THE
CONDITION
DIABETIC WOUNDS
Uncontrolled diabetes can lead to serious
complications, commonly including neuropathy
High blood sugar interferes with the ability of nerves to
transmit signals, and also weakens the walls of capillaries
that supply nerves with oxygen and nutrients
E duc a t ion
Emphasizing patient responsibility for their own health
Blo od su ga r c on trol
Keeping blood glucose values <220 mg/dL
Wo und de br idem e n t
Frequent debridement to improve wound healing time
Adv a nc ed dressin gs
Using dressings that promote moisture balance, protease
sequestration, growth factor stimulation, antimicrobial activity and
oxygen permeability
Surger y
Utilizing vascular foot surgery to improve blood fl ow before
amputation is necessary
2015 NIH
Strategies
GENERAL INFORMATION
MP is a 62 year old Caucasian male
BMI: 42.31
Seen outpatient at the wound clinic PTA
Patient was already scheduled to have a transmetatarsal
foot amputation 9/23 at Meritus
Social/Family History
Physical Examination:
Medical History
Morbid obesity
Poorly controlled type 2
diabetes
Atrial fibrillation
Diabetic polyneuropathy
Peripheral vascular
disease
Dyslipidemia
HTN
End-stage renal disease
Peritoneal dialysis
Gangrene
Surgical History
NUTRITIONAL HISTORY
Diet History
Patient denies change in appetite or weight change PTA
MP is completely cared for by his wife, who states she does
not follow a diabetic or renal diet at home
Have been educated multiple times at outpatient visits,
patient is followed by a dietitian at the Dialysis center at
least on a monthly basis
Physical Activity
Patient is very limited in motility
During hospitalization, patient was no ambulatory
NUTRITIONAL HISTORY
Weight History
Weight fl uctuations r/t to multiple amputation
procedures, fl uid accumulation, and fl uid removal
procedures.
WOUND DOCUMENTATION
Arterial ulcers of the toes of the right foot with dry
gangrene of the right forefoot. These have now
coalesced into one large mummifi es wound extending
to involve 4 or 5 of the toes
Open wound, right lower extremity, venous ulcer
Stage 3 pressure ulcer, left BKA amputation stump
Traumatic wound, right index and middle fi nger
Non-healing surgical wound in the abdomen
History of multiple traumatic wounds, stage 4
pressure ulcers, Fourniers gangrene
NUTRITIONAL
CONSIDERATIONS
Signs of catabolism
Dietary History to determine typical protein intake
Weight history to determine unintended weight loss
Laboratory values to identify catabolism and infl ammation
Losses through Dialysis
NUTRITION
ASSESSMENT AND
THERAPY
NUTRITION DIAGNOSIS
NUTRITION PRESCRIPTION
Using ABW of 247#
Energy: 2600-3120 kcals (25-30 kcal/kg)
Protein: 156-177 grams (1.5-1.7 gm/kg)
Fluid: Per MD
CCD-high
NAS
4oz Nepro Supplements BID
Double portions of protein with trays
NUTRITION INTERVENTION
1 . C o l l a b o r a t i o n w i t h o t h e r c a re p ro v i d e r s ( RC - 1 . 3 )
D i s c u s s w i t h M D i n c re a s e d n u t r i e n t n e e d , c h a n g e d i e t o rd e r f ro m Re n a l t o
CCD-high, NAS
N u r s i n g i s a w a re t h a t P O i n t a ke a n d w e i g h t s h o u l d b e m o n i t o re d c l o s e l y
Goal: Diet is changed in 24 hours
2 . P ro t e i n - m o d i fi e d d i e t ( N D - 1 . 2 . 3 )
A d d d o u b l e p o r t i o n s o f p ro t e i n ( m e a t , fi s h , a n d e g g ) t o p a t i e n t s t r a y s t o
e n s u re a d e q u a t e p ro t e i n i n t a ke
G o a l : D i e t m o d i fi c a t i o n a d d e d i n 2 4 h o u r s
3. Supplements (ND-3.1)
S e n d 4 o z N e p ro s u p p l e m e n t B I D t o e n s u re a d e q u a t e p ro t e i n i n t a ke
G o a l : Pa t i e n t c o n s u m e s > 5 0 % o f s u p p l e m e n t s
4. Survival Information (E-1.3)
S p e a k w i t h p a t i e n t re g a r d i n g t h e n e e d f o r a h i g h c a l o r i e , h i g h p ro t e i n d i e t f o r
wound healing
G o a l : Pa t i e n t s P O i n t a ke i m p ro v e s t o > 7 5 %
Indicator
Criteria
Food Intake
Supplement Intake
CONCLUSIONS
KEY POINTS
For obese patients, it is imperative to recognize
situations when a patient requires additional nutrition
support
May be provided through modifying meal trays, adding scheduled
snacks, or ordering supplements.
THANK YOU
REFERENCES
( 1 ) L i p s ky B A , B e re n d t A , D e e r y H G , e t a l . , f o r t h e I n f e c t i o u s D i s e a s e s S o c i e t y o f
A m e r i c a . D i a g n o s i s a n d t re a t m e n t o f d i a b e t i c f o o t i n f e c t i o n s . C l i n I n f e c t D i s . 2 0 0 4 ;
39(7):885-910.
( 2 ) Ta n g , Yu n a n , e t a l . " P ro re s o l u t i o n t h e r a p y f o r t h e t re a t m e n t o f d e l a y e d h e a l i n g
of diabetic wounds."Diabetes2013; 62.2: 618-627.
( 3 ) Po s t h a u e r , M a r y E l l e n . " T h e ro l e o f n u t r i t i o n i n w o u n d c a re . " A d v a n c e s i n S k i n
& Wound Care 2012;25.2: 62-63.
( 4 ) C o l l i n s , N a n c y , a n d A . S c h n i t z e r. " H o w d i e t a r y p ro t e i n i n t a ke p ro m o t e s w o u n d
healing."Wound Care Advisor 2013;2.6: 16-19.
( 5 ) Ya z d a n p a n a h , L e i l a , M o r t e z a N a s i r i , a n d S a r a A d a r v i s h i . " L i t e r a t u re re v i e w o n
t h e m a n a g e m e n t o f d i a b e t i c f o o t u l c e r. " W o r l d J o u r n a l o f D i a b e t e s 6 . 1 ( 2 0 1 5 ) : 3 7 .
( 6 ) Z h a n g , C h e n y i n g , e t a l . " F OXO 1 d i ff e re n t i a l l y re g u l a t e s b o t h n o r m a l a n d
diabetic wound healing."The Journal of Cell Biology209.2 (2015): 289-303.
( 7 ) C o l l i n s , N a n c y , a n d C . S l o a n . " D i a b e t i c Wo u n d H e a l i n g T h ro u g h N u t r i t i o n a n d
G l y c e m i c C o n t ro l . " To d a y s W o u n d C l i n i c 7 . 2 ( 2 0 1 3 ) .