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Nutrition andWound HealingContent Creators:Members of the South West Regional Wound Care Program’s Clinical Practiceand Knowledge Translation Learning CollaborativeL

Learning Objectives2. Describe the role of nutrients in wound healing3. Identify nutritional requirements based on theetiology of the wound4. Describe available nutritional supports for thoseunable to meet their nutritional needs orallySouth West Regional WoundCare Program1. Describe the various aspects of nutritionalscreening and assessment2

South West Regional WoundCare ProgramNUTRITIONAL SCREENING ANDASSESSMENT3

Nutritional Screening1 Purpose - to pinpoint individuals who are malnourished or atnutritional risk: Malnutrition is associated with increased length of stay, costs,and morbidity/mortality Nutritional supports can help: Increase physical strength; Speed recovery and wound closure, and; Decrease the risk of infection.South West Regional WoundCare Program “The process of identifying characteristics known to beassociated with nutritional problems”4

Persons at Risk1 Inadequate absorption: Irritable Bowel Syndrome, Crohn’s, Colitis Diarrhea or vomiting Increased losses: Colostomy, ileostomy Fistula Wounds Increased requirements: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease,pneumonia, asthma Wound healingSouth West Regional WoundCare Program Inadequate intake: Cerebral vascular accident (CVA) Elderly Reduced access to food Poor dentition or mouth sores Dysphagia Esophagitis5

Functional limitations Difficulty chewing, swallowing Inability to physically prepare meals or travel to dining room Poor hearing, vision Altered mental status Difficulty self feeding Inability to understand importance of eating Advanced dementia weight loss, dysphagia, malnutrition Drug therapy: Nausea/vomiting side effects Corticosteroids inhibit protein synthesis and cause depletion of vitamin A fromliver Impaired localized blood flow Poor appetite/intake Decreased thirst response Decreased ability to concentrate urine Intentional fluid restriction Advanced ageSouth West Regional WoundCare ProgramAdditional Risk Factors16

NESTLE NUTRITION INSTITUTE MININUTRITIONAL ASSESSMENT (MNA ) Allows for earlier intervention to provide adequate nutritionalsupport Six questions The screening score (max 14 points): 12‐ 14 points normal nutritional status 8‐11 points at risk of malnutrition 0 ‐7 points malnourishedSouth West Regional WoundCare Program MNA is a screening and assessment tool that identifies individualsage 65 and above who are malnourished or at risk of malnutrition7

South West Regional WoundCare ProgramMNA Form8

Nutritional Assessment1 The “interpretation of data from the (nutritional) screeningprocess” Purpose is to allow for the development of a nutritional careplanSouth West Regional WoundCare Program Includes a review of data from all disciplines9

Physical Conditions1-2 Skin condition: Signs of dehydration Edema Ascites Signs of weight loss Loose skin Non-healing wounds Purpura/bruisesSouth West Regional WoundCare Program Dry, flaky skin Skin that tents10

BMI1 Body mass index (BMI) Indicator of obesity (highly correlated with body fat) A BMI of 21 with unintentional weight loss puts a person atrisk for pressure ulcer developmentSouth West Regional WoundCare Program Weight to height ratio11

Height and Weight1 Regular and frequent weight monitoring is themost non-invasive, time-efficient, inexpensive andmost reliable indicator of nutritional adequacySouth West Regional WoundCare Program Weight and body composition change with age: Weight peaks in 60’s and decreases beyond 70’s Proportion of body fat increases with age12

Significant UnintentionalWeight Loss 5% loss of usual weight over one month 7.5% loss of usual weight over three months 10% loss of usual weight over six monthsSouth West Regional WoundCare Program Significant nutrition/health risk 13

South West Regional WoundCare ProgramROLE OF NUTRIENTS IN WOUNDHEALING14

CarbohydratesProteinFatsVitaminsWaterMineralsSouth West Regional WoundCare ProgramKey Nutrients in Wound Healing15

Nutrition is ParamountA wound healed without optimal nutrition will be weak and ismore likely to break down againSouth West Regional WoundCare ProgramNutrients involved in wound healing function in cellular,structural, and immune processes and in all phases of woundhealing16

Carbohydrates1 Most readily available source of energy Regulate metabolism Provide flavor, color, variety to the diet Provide 4 kcal/g energySouth West Regional WoundCare Program Spare protein for building and maintaining tissues17

Food Sources of Carbs1GrainsCerealsLegumes (peas and beans)PastaBreadNatural sugars in fruits, veggies, and milkAdded sugarsSouth West Regional WoundCare Program 18Sources of CarbohydratesImages Source: National Cancer Institute (Renee Comet - Photographer

Synthesis of enzymes and hormones involved in wound healing Cell multiplication Synthesis of collagen, epidermal cell proliferation, skin integrity, andresistance to infection and immune response Supplies structural and binding material of muscle, cartilage,ligaments, skin, hair, and fingernails A component of antibodies and immune system function Helps to maintain the fluid and mineral composition of various bodyfluids Helps transport needed substances, such as lipids, mineral andoxygen, around the body Serves as building material for growth and repair of body tissues 4 kcal/gSouth West Regional WoundCare ProgramProtein119

Meat, fish, poultryEggsDairy products (milk, cheese, yogurt)LegumesSeedsGrains*Protein from animal sources are better as they have the amino acidsessential to human nutrition in adequate amountsSouth West Regional WoundCare ProgramFood Sources of Protein120Sources of ProteinImages Source: National Cancer Institute (Renee Comet – Photographer)

Maintains normal cell membrane function Permit fat-soluble substances to move in and out of thecell Provide insulation under the skin Cushion the kidneys and other organs from injury Provide flavor and aroma in foot Carry fat soluble vitamins Serve as the most concentrated source of heat andenergy: 9 kcal/g Provide energy during periods of food deprivationSouth West Regional WoundCare ProgramFats121

Meat Dairy products Fish and vegetable oils Nuts Some fruits, i.e. avocados and olivesSouth West Regional WoundCare ProgramFood Sources of Fat122Sources of FatImages Source: National Cancer Institute (Renee Comet – Photographer)

Facilitate various chemical reactions in the body Key role in normal cell functioning and cell’s ability to useenergy Participate in protein synthesis and cell replication Various therapeutic properties:VitaminPropertiesVitamin ARequired for inflammatory processVitamin BRequired for cross-linking of collagen fibersVitamin CCan increase activation of leukocytes and macrophagesSouth West Regional WoundCare ProgramVitamins123

A, D, E, KDerived from fatty and oily parts of certain foodsStored in fatty tissue and liver until neededLack of vitamin A can retard epithelialization and decreasecollagen synthesisSouth West Regional WoundCare ProgramFat Soluble Vitamins124

B, C, D, EDerived from the water components of foodsDistributed throughout water compartments of the bodyNot stored – excreted with concentration becomes too highVitamin B needed to produce energy from glucose, aminoacids, and fat Vitamin B6 helps maintain cellular integrity and helps formblood cells Thiamine and riboflavin needed for cross-linking andcollagenationSouth West Regional WoundCare ProgramWater Soluble Vitamins125

Vitamin C1 Required for production of strong collagen Facilitates leukocyte migration to the wound, increasing Needed for neutrophil superoxide formation and bacterialkilling Increases the activation of macrophages at the wound siteSouth West Regional WoundCare Programresistance to infection26

Aids in hydration of wound site and oxygen perfusion Acts as a solvent for minerals, vitamins, amino acids, glucose,and other small molecules, and enables them to diffuse in andout of cells Transports vital materials to cells and carries waste away fromcells Serves as a lubricant Maintains body temperatureSouth West Regional WoundCare ProgramWater127

Dehydration in the OlderAdult4 Total body water decreasesKidneys can’t concentrate urine as wellDecreased thirst sensationChanges in hormone levels that affect the kidneyEffects of medications, i.e. diureticsChanges in mobility, cognition and independenceSelf-imposed fluid restrictions – fear of incontinenceSouth West Regional WoundCare Program One of the most common reasons for hospitalization As people age:28

Hydration status intake – outputRecommended fluid intake for average person 27-30mL/KgMinimal fluid intake for older adults 1500mL/dayYounger people need 35mL/Kg/dayConsider all routes of fluid losses: Gastrointestinal tractUrinary tractFever/sweatingWound exudateNegative pressure wound therapyAir-fluidized bedsRespiratory tractSouth West Regional WoundCare ProgramMonitoring Fluid Status429

Decreased urine outputDark, concentrated and/or strong smelling urineFrequent urinary tract infectionsDry lips/mouth and thick, stringy salivaConstipationOrthostatic hypotensionConfusion or change in mental statusWeight loss of 3.5Lbs in less than a weekFeverDecreased skin elasticitySunken eyeballsSouth West Regional WoundCare ProgramSigns of Deficiency1, 430

Tips to Increase Fluids1, 4Jell-O½ cup120mLPudding½ cup100mLIce Cream/Sherbet½ cup60mLPopsicle190mLYogurt½ cup90mLCanned fruit½ cup100mLSoup1 ½ cups165mLSouth West Regional WoundCare ProgramApproximate Fluid Provision from Common Foods Ice chips, ice cubes31

Build body structures Maintain fluid balance Activate enzyme systems Skeletal system depends on calcium, magnesiumand phosphorus for its structural integritySouth West Regional WoundCare ProgramMinerals132

Microelements1 Zinc Iodine Iron Copper Manganese MagnesiumSouth West Regional WoundCare Program Needed in small amounts:33

Needed for protein synthesis, collagen synthesisRe-epithelializationDNA synthesis, cell division, and proliferationDisposal of damaging compounds produced byleukocytes during wound debridement Trace mineral and component of 200 enzymesSouth West Regional WoundCare ProgramFunctions of Zinc in Wound Healing134

Meat, poultry, fish/seafood (especially oysters)LiverEggsMilkLegumesWhole wheat productsWheat germSouth West Regional WoundCare ProgramFood Sources of Zinc135Sources of ZincImages Source: National Cancer Institute (Renee Comet – Photographer)

South West Regional WoundCare ProgramNUTRITION BASED ON WOUNDETIOLOGY36

Burns1 Hypermetabolism accompanied by exaggerated proteincatabolism for energy and increased urinary nitrogenexcretion forcing use of protein for energy Protein loss through wound exudateSouth West Regional WoundCare Program Energy requirements can increase 100% depending onextent/depth of burn37

Skin Tears1 Protein Calories FluidsSouth West Regional WoundCare Program If limited improvement of wound after seven days, consideraddition of:38

Diagnose the causeImprove tissue perfusion if possibleProvide compressionManage concurrent diseasesSupport alterations in lifestyle: Weight loss Proper diet Smoking cessationSouth West Regional WoundCare ProgramLeg Ulcers139

Dermatitis1 PregnancyOral contraceptivesAntibiotic therapyDiabetesSkin macerationSteroid therapyEndocrinopathiesSouth West Regional WoundCare Program Candida albicans Normally found in mouth, vaginal tract, gut Candidiasis results from:40

Pressure Ulcers Depending on severity of the ulcer: Zinc should be reassessed at 10 days and discontinued if normal Protein: 1-2g/Kg Calories: 25-40Kcal/Kg Fluids: 20-45cc/KgSouth West Regional WoundCare Program Multivitamin supplementation if intake inadequate Vitamin C 500mg PO BID Elemental zinc 25mg PO BID41