Nutrition and Wound Healing

Handouts you should have…

• Outline for taking notes

• Braden Scale

• Diagram of pressure points

• “Cascade of wound healing events”

• RDA vs. Needs in the wounded patient

• Nutritional assessment algorithm

• Bibliography/references

Outline

• Introduction

• What are wounds?

• Mechanisms of healing

• Nutritional therapy in the wounded patient

• Q & A

Introduction

• Most wounds, surgical or otherwise, WILL HEAL– A non-healing wound places the pt at increased

risk of death

• Malnourished patients have a higher risk of wound-related problems– But obesity is more of a risk than malnutrition!

• Wounds heal at a molecular level

What are wounds?

• A wound is tissue destruction that triggers an inflammatory response geared towards restoration of skin integrity

• The difference between a chronic and an acute wound is that chronic wounds have a constant source of infliction that needs to be removed in order for the wound to heal.

What are wounds?

• Acute wounds– Scrapes and lacerations– Surgical wounds, intact or dehisced– burns

Surgical wound, dehisced

What are wounds?

• Chronic wounds– Decubitus ulcers/pressure ulcers– Diabetic foot ulcers– Venous stasis wounds– Arterial stasis wounds

Diabetic foot ulcers

• Peripheral neuropathy

• “The princess and the pea” syndrome

• Uncontrolled blood sugars

• Typically on the planter surface of the food

• Number one cause of amputations in diabetics

Diabetic foot ulcers

Venous and arterial stasis wounds

• Think back to normal leg vascularization• The calf-pump mechanism fails because of

– Obstruction (DVT or extraluminal masses)– Regurgitation (valve weakness)– Venous incompetence (proximal DVT)– Vein weakness (primary varicose vein

syndrome)– Muscle failure (ankle trauma or surgical fusion)

Pressure Ulcers

• Pressure ulcers occur when capillary blood flow is cut off from the tissue

• They occur from the inside to the outside

• Primary causes of pressure ulcers– Pressure– Friction– Shear

Pressure ulcer areas

CoccyxScapulaGreater trocanterOccitiputElbowsHealsknees

Staging of Pressure Ulcers

• Stage I: redness and warmth

• Stage II: shallow ulcer with distinct edges

• Stage III: full-thickness loss of skin

• Stage IV: involvement of fascia, connective tissue, muscle and bone

• Stage V: area covered with black eschar (aka scab)

Stage I

Stage II

Stage III

Stage IV

Stages and Characteristics

• Inflammation– Within the 1st 72 hours after wound formation– Vascular dilitation– Leukocyte and macrophage migration– Clot formation

Stages and Characteristics

• Fibroplasia– Occurs 2 weeks after inflammation stage– Collagen fibrils and ground substance

producing matrix for the new connective tissue is formed

– Vitamins A and C and protein are required for collagen formation

Stages and Characteristics

• Contraction– Edges of the wound are drawn together– Degree of contraction is directly related to

elasticity of the underlying tissue– 80% of all acute wounds will heal by

contraction alone

Stages and Characteristics

• Epithelialization– Epithelial cell migration across surface of the

wound– Requirements for migration include tissue

oxygenation, moisture, nutrition, temperature, and lack of infection

– Aka “healing by secondary intention”

Stages and Characteristics

• Maturation– Continuous remodeling and organization of

collagen– Nutritional deficiencies may produce

degeneration and weakening of the collagen network

Objectives of Nutrition Tx

• Restore nutrient intake, correcting CPM• Monitor Branden Scale Scores• Heal the ulcer and prevent further breakdown• Improve infection, fever, diarrhea, and vomiting• Assess intake using calorie counts• Maintain skin integrity once healed• Support immune system

Assessment of the wound patient

• Profile– Height, weight, weight changes, IBW– Stage of ulcer(s)– Braden scale– Meds– BUN/Cr, H/H, TP, Alb/prealbumin, N balance, Glue,

TLC, Serum Zn and B12– Appetite, usual intake, current intake– Nausea, vomiting, diarrhea, general bowel fct– Estimated intake from TEN or TPN– Meds

Dietary Recommendations

• Provide a high protein diet

• Provide kcal at ~25-35 kcal/kg CURRENT weight

• Tube feed or parentally feed if necessary

• Small frequent feedings if intake is poor

• Supplement with MVI, Vit A, Vit C, thiamin, and zinc

Specific nutrient effects

• Protein- tensile strength

• Vitamin C- collagen formation

• Copper- cross linking of collagen fibers*

• Iron- immune function

• Arginine- collagen precursor, stimulates insulin and GH secretion, enhances collagen accumulation

Specific nutrient effects

• Vitamin A- antioxidant, counteracts steroids• Vitamin C- increases collagen synthesis • Zinc- immune function, increases healing only if

there’s a deficiency in the first place• Vitamin E- clinical relevance not yet established• B Vitamins- collagen production and cross linking• Omega-3 fatty acids- cause weaker wounds by

interfering with spatial orientation of fiber