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1 Nutrition and Wound Healing ©Food Solutions 2017 Overview § Background on Wounds § Risk Factors for Wounds § The role of Nutrition for Wound Healing § Steps for Nutrition Support in Wound Healing § Quick Quiz Aims and Objectives Aim: To increase general knowledge of nutrition and wound healing to improve outcomes for residents with wounds Objectives: To identify those with wounds who are also at nutritional risk To identify the role nutrition plays in wound healing To identify ways to increase nutrition support for those with wounds or poor wound healing

Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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Page 1: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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NutritionandWoundHealing

© FoodSolutions2017

Overview

§ BackgroundonWounds§ RiskFactorsforWounds§ TheroleofNutritionforWound

Healing§ StepsforNutritionSupportin

WoundHealing§ QuickQuiz

AimsandObjectives

Aim:• Toincreasegeneralknowledgeofnutritionandwoundhealing

toimproveoutcomesforresidentswithwounds

Objectives:• Toidentifythosewithwoundswhoarealsoatnutritionalrisk• Toidentifytherolenutritionplaysinwoundhealing• Toidentifywaystoincreasenutritionsupportforthosewith

woundsorpoorwoundhealing

Page 2: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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

Page 3: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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Currentguidelinesfornutrition&woundhealing

RoleofNutritioninwoundhealing

Nutrientdeficienciesimpedewoundhealing• extendinflammatoryphase• alterthesynthesisofcollagen• decreaseproliferationoffibroblasts

RoleofNutritioninwoundhealing

Nutritionalrequirementshigherforwoundhealing• Needforincreasedcellproliferation,enzymeactivityandproteinsynthesis

• Requiresenergyfromcalories,plusincreasedsubstratessourcedfromproteinandmicronutrients

• Glutamine(anaminoacid)isthepreferredenergysourceoffibroblasts&increasescollagendeposition

Page 4: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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

Page 5: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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

Page 6: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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

Page 7: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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.

Page 8: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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Fluid

NutritionalSupport:4mainsteps

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

MalnutritionScreeningTools(MST):Step1

• Identifiesthoseatnutritionalrisk

• Asks2questionstocaptureunintentionalweightlossanddecreasedoralintake

• AddsuptoMSTscore• 0-1Normalnutritionstatus• 2+Atriskofmalnutrition

Page 9: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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

Page 10: Nutrition and Wound Healing handout - Food Solutions · 2018-10-22 · on nutrition and wound healing, consider compliance issues & oral nutritional supplements including arginine

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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.