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NutritionandWoundHealing

© FoodSolutions2017

Overview

§ BackgroundonWounds§ RiskFactorsforWounds§ TheroleofNutritionforWound

Healing§ StepsforNutritionSupportin

WoundHealing§ QuickQuiz

AimsandObjectives

Aim:• Toincreasegeneralknowledgeofnutritionandwoundhealing

toimproveoutcomesforresidentswithwounds

Objectives:• Toidentifythosewithwoundswhoarealsoatnutritionalrisk• Toidentifytherolenutritionplaysinwoundhealing• Toidentifywaystoincreasenutritionsupportforthosewith

woundsorpoorwoundhealing

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BackgroundonWounds

54.8%ofallwoundtypesinelderlyareskintears

>4%of>65yohavechroniclegulcers(vs1-2%)

PressureinjuryprevalenceamongstAustraliansinagedcare~26%

Nearly25%inRACFswillhaveawoundofsometypeatonetime

NegativeConsequencesofchronicwounds

ReducedmobilityDecreasedQOL

ReducedindependencePainanddiscomfort

DepressionIncreasedmorbidityandmortality

Increasedhealthcosts

RiskFactorsforWounds

• Increasedage• Comorbidities(T2DM,RF,PVD)• Polypharmacy• Poorimmunesystem• Poorskinintegrity• Incontinence• Malnutrition• Dehydration

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Currentguidelinesfornutrition&woundhealing

RoleofNutritioninwoundhealing

Nutrientdeficienciesimpedewoundhealing• extendinflammatoryphase• alterthesynthesisofcollagen• decreaseproliferationoffibroblasts

RoleofNutritioninwoundhealing

Nutritionalrequirementshigherforwoundhealing• Needforincreasedcellproliferation,enzymeactivityandproteinsynthesis

• Requiresenergyfromcalories,plusincreasedsubstratessourcedfromproteinandmicronutrients

• Glutamine(anaminoacid)isthepreferredenergysourceoffibroblasts&increasescollagendeposition

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NutrientsrequiredforWoundHealing

• Macronutrients– Energy(kJ/calories)fromcarbohydrates,fats&protein– ExtraProteinincludingArginineandGlutamine

• Micronutrients– Zinc,Copper,VitaminA&C

MoreEnergy

• Bothmalnutritionandpressureinjuriescanproduceahypermetabolicstateà increaseenergyrequirements

• Extraenergyisrequiredtoproducecollagen+maintainnormalbodyfunctions• Ifcaloricneedsarenotmet,dietaryproteinbecomesanenergy

sourceinsteadofbeingusedforwoundhealing

• Increasingcaloricintakepromotesanabolism,nitrogenandcollagensynthesis

Sources:Breads,Oils/Fats,Cereals,Tofu,Legumes,Beans,Nuts,Seeds,MeatandDairy

Energy

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MoreProtein

• Normalrequirement:0.8-1.0g/kg/day• PIStage2andabove:1.25-1.5g/kg/day• HeavilyexudatingVLU,burnsandsevere

wounds: 1.5-2g*/kg/day

Highproteinfoods:beef/chicken/fish,eggs,tofu,soy,milk,yoghurt,cheese,nuts,legumes

*2g/kgofproteincanbedehydratingandisnotrecommendedforthosewithrenalorhepaticimpairment

MoreProtein

• Reducesmuscleloss• Protein=buildingblockoftissues• Synthesizesenzymesinvolvedinhealing,

cellmultiplication&collagensynthesis• Enhancesbloodsupplytowounds,aids

re-vascularisation &lymphaticformation• Argininealsopromotescollagen

deposition,improvesimmunity&increasestensilestrengthofwound

Protein

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SupplementUse

• Usenutritionalsupplementsifinadequateoralintakeofmeals(oftencontainprotein+mixofvitamins/minerals)

• PatientswithPEMwouldnotbenefitfromasupplementwithonlyVitaminC+Arginine dueto needing allessentialaminoacidswithinasupplement

SupplementUse

• Woundspecificsupplementscanbeusedforchronicandslowtohealwounds(ie >4-6weekstoheal),pressureulcers,diabeticulcers,skinbreakdownandburninjury

• Forwoundspecificsupplements– useforatleast2weeksbutshouldseeprogressafter3+weeks

Micronutrients

Zinc:collagenproduction,immunity,andforcatalyticactivityof~100enzymesfortissueregeneration. Sources:redmeat,fish,dairy,wholegraincereals,eggs

Copper:addsstrengthtohealingwoundandscarduringgranulation. Sources:organmeats,seafood, wholegrains,nuts,legumes

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Micronutrients

Vit A: stimulatesinflammatoryresponse, epithelialisation andassistsincollagensynthesis. Sources:eggyolk,dairy,fish,orange coloured fruit&vegetables

Vit C: promotescollagenandnewbloodvesselsynthesis,helpstransitionfrominflammatoryphasetoproliferativephaseofwoundhealing toreducecelldamage. Sources:citrusfruits,berries,tomato,capsicum,broccoli

VitaminsandMinerals

Fluid

• Dehydratedskinislesselastic,morefragile,susceptibletobreakdown

• Hydrationimprovescirculation,importantforbloodandoxygensupplytothewound

• Hightemperature,vomiting,sweating,diarrhoea andheavilydrainingwoundscontributetofluidlosswhichmustbereplaced

Encouragefluidintakevia:water,milk,juice,yoghurt,custard,jelly,icecream,icy-poles,soup,t/c.

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Fluid

NutritionalSupport:4mainsteps

Step1:MNA/MSTScoreNutritionscreeningusingtheMalnutritionScreeningTool(MST)orMiniNutritionAssessment(MNA)inadditiontousualwoundassessment

MalnutritionScreeningTools(MST):Step1

• Identifiesthoseatnutritionalrisk

• Asks2questionstocaptureunintentionalweightlossanddecreasedoralintake

• AddsuptoMSTscore• 0-1Normalnutritionstatus• 2+Atriskofmalnutrition

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MiniNutritionalAssessment(MNA):Step1

• 6sections- Oralintake,Weightloss,Mobility,Acuteillness,Neurological,BMI/calfcircumference

• AddsuptoaScreeningScore- 0-7Malnourished- 8-11AtriskofMalnutrition- 12-14NormalnutritionalStatus

Nutritionalsupport:4mainsteps

Step2:Improve&MonitorNutritionalIntakeIftheMSTScoreis>2and/orMNAScore0-11à ceaseanydietaryrestrictions,commence

HEHPdietwithfortifiedfoods/drinks,HEHPmidmealitemsandHEHPmilkshakesBD

àmonitororalintakeviaa3dayfoodandfluidrecord

à ifsuspectedchewing/swallowingissuesconsiderreferringforfurtherassessmentifneeded

Nutritionalsupport:4mainsteps

Step3:IntensiveDieteticInterventionIfnoimprovementafter2-3weeksofHEHPdietrefertodietitianforacomprehensivenutritionalassessmentàDietitiansfurtherindividualiseaHEHPdiet,educateresidents

onnutritionandwoundhealing,considercomplianceissues&oralnutritionalsupplementsincludingargininetomeetrequirements30-35ckal,1.25-1.5gprotein,&30-35mlfluid/kg

à Continuedieteticinterventionfor2-3moreweeksoruntilwoundhealing

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Nutritionalsupport:4mainsteps

Step4:FurtherInvestigationIfthewoundstillpersists,recommendinvestigationintonutritionaldeficienciesincludingiron,copper,zinc*withpossiblecommencementofmultivitamin

*Notehighdosagesofzincbeyond40mgwillinterferewithcopperabsorption,onlysupplementindividualsifdeficient

Step4:FurtherInvestigation

Step3:IntensiveDieteticIntervention

Step2:Improve&MonitorOralIntake

Step1:MST/MNAScore MST 0-1 OR MNA 12-14 OR MST 2+ OR MNA 0-11(Normal Nutritional Status) (At risk of malnutrition)

monitor progress of wound healing over

2 weeks

wound healed

monitor & improve oral intake by:ceasing dietary restrictions, commencing HEHP

/fortified diet, HEHP milkshakes BD & encouraging fluids

recording 3 day food & fluid chartmonitoring swallow/chewing issues, refer for Ax

if needed

if delayed healing after 2-3 weeks, refer to dietitian

dietitian comprehensive Ax, EER + EPR to 30-35kcal (125-145kJ/kg), 1.25-1.5g protein

& EFR 30-35ml/kg, may include supplements & arginine

if wound persists after 2-3 weeks of intervention, refer for investigation into nutritional deficiencies & consider vitamin/mineral

supplementation if deficient (Zinc, Copper)

NutritionandWoundHealingQuickReferenceTool

if no improvement

in 2 weeks &/or wt loss >2kg 1/12

wound healed

wound healed

References

1. Sussman G.WoundHealingandcostimpactsofinterventionsbypharmacistsincommunitysettings.VictorianCollegeofPharmacyMonashUniversity.Forthcoming.2003.

2. Addade LPFetal.2011Venousulcer:clinicalcharacteristicsandriskfactors.Int JDermatol 50:405-11.3. BanksMetal.2010MalnutritionandpressureulcerriskinadultsinAustralianhealthcarefacilities.

Nutrition26:896-901.4. NationalPressureUlcerAdvisoryPanel,EuropeanPressureUlcerAdvisoryPanelandPanPacificPressure

InjuryAlliance.PreventionandTreatmentofPressureUlcers:QuickReferenceGuide.EmilyHaesler (Ed.).CambridgeMedia:Perth,Australia;2014.

5. Sussman G&GoldingM.Skintears:shouldtheemphasisbeonlytheirmanagement?WoundPracticeandResearch19(2)2011.

6. BestPracticeStatement.CareoftheOlderPerson’sSkin.London:WoundsUK,2012(2nd Ed).7. DornerBetal.2009.TheRoleofNutritioninPressureUlcerPreventionandTreatment:NationalPressure

UlcerAdvisoryPanelWhitePaper.8. TransTasmanDieteticWoundCareGroup.Evidencebasedpracticeguidelinesforthedietetic

managementofadultswithpressureinjuries.DietitiansNZandDietitiansAssociationofAustralia;2011.9. AustralianWoundManagementAssociationInc andNewZealandWoundCareSociety.AustralianandNew

ZealandClinicalPracticeGuidelineforPreventionandManagementofVenousLegUlcers.CambridgePublishing;2011.

10. LeBlancK&Baranoski S.Skintears:Bestpracticesforcareandprevention.Nursing44(5)2014.11. ShermanA&BarkleyM.NutritionandWoundHealing.JofWoundCare20(8)2011.