Long-Term Care Survey Alert

Published on Wed Sep 24, 2003 PDF

Wow surveyors with these dietary best practices.

Wounds do not heal by medical and nursing care alone. Proper healing also requires the right diet, and surveyors are getting savvier about checking to see if your facility is providing it.
 
"At a minimum, surveyors will expect the facility to address the wound-care resident's protein and calorie needs, within the limitations of the person's medical diagnosis, advance directives and/or stated preferences," says Karen Clay, a nursing consultant with Kare 'N Consulting in Brimfield, MA.
 
The standard of care requires the facility's registered dietitian to review the wound care patient's status and make recommendations for nutritional support. But the interdisciplinary staff should also look at the resident's lab results to support the need for nutritional supplementation, and to monitor the resident's response to dietary therapy, Clay suggests. "For example, the quantity of protein consistently correlates to wound healing rates," she notes, and lab results can help you identify the resident's protein reserves.
 
Prealbumin levels will give you the most accurate picture of a resident's current protein status, experts say. "Prealbumins also don't take as long to show changes once you start the resident on supplementation - either orally or by tube feedings," notes Mary Foot, a wound specialist and principal of Wound Care on Wheels in Naperville, IL.
 
Tip: Before you start nutritional supplements, get a CBC with a differential lymphocyte count, advises Foot. "A low hemoglobin or hematocrit will compromise the patient's healing, and a low lymphoctye count (below 1,800) means the resident is seriously immunocompromised and the staff will have to use some strict infection control measures."
 
How much protein does someone require for wound healing?    "Normally, a person needs approximately 0.8 g//kg per day. But wounds increase that requirement to 1.25 to 2.0 g/kg/day," Clay explains. "And if a wound has heavy exudation (drainage), protein needs may be even higher," Clay adds. 
 
Tip: Keep in mind that residents with compromised renal function may not be able to handle the same amount of protein as someone with healthy kidneys, cautions Maria Whybark, adjunct professor of nutrition at Madonna University in Livonia, MI.
 
In addition, residents need appropriate amounts of micronutrients to heal, including essential amino acids, trace minerals and vitamin C.    "Typically, you'd expect to see a resident with a wound taking a multivitamin with minerals and vitamin C," Clay says.
 
Facilities have a number of options for providing extra calories and protein required for wound healing; these run the gamut from protein- and calorie-rich meals and snacks to protein powders, liquid supplements and "super foods." The latter include mashed potatoes loaded with butter and cream or cereal swimming in brown sugar, butter and cream. Temporary enteral feedings are also an option if oral intake alone isn't doing the trick.
 
"In addition, medications are sometimes used to stimulate appetite or anabolic agents to increase the rate of the restoration of lean body mass," Clay reports.
 
Glenburn Home in Linton, IN limits the amount of liquid supplements like Ensure because they are expensive and residents don't always drink it all, says facility dietitian Lisa Berns. "Instead, we give residents 4-ounce, high-calorie, high-protein items [as supplements] and add large meat portions to meals to provide the extra protein for healing and to maintain muscle mass," she reports. The facility also serves orange juice at each meal to help ensure adequate vitamin C intake. "And we've had good results with appetite stimulants like Megace," Berns adds.
 
Tip: Heavier isn't always better. Yes, you want to provide ample calories and protein for healing, but without putting extra pounds on the already obese resident.
 
"Obesity can aggravate pressure ulcers," notes Whybark. And weight loss in an overweight patient can help resolve a venous stasis ulcer, Foot adds.