Nutrition for Wound Healing – A Definitive Guide
- Janet S. Mackenzie, MD, ABPS, CWSP, AAGP
- April 6, 2023
How Poor Nutrition Impacts Wound Healing?
- Poor nutritional status negatively impacts collagen synthesis, the effectiveness of phagocytosis, B and T cell function, the general mechanical strength of the skin, and progression through the inflammatory stage of wound healing. It is associated with an increased risk of infection, decreased immune competence in general, and an increased risk of developing additional wounds.
- Bodily stress caused by malnutrition decreases lean muscle mass, which further compromises a patient’s ability to shift position and offload pressure points. Patients may also be at increased risk of pneumonia with both compromised immune function and diminished respiratory effort associated with decreased muscle mass.
Case Study Of Patient - Ms. Artemis
In this article, we shall observe how poor nutrition can impact wound healing with the help of the patient’s case – Ms. Artemis.
Ms. Artemis is an 82-year-old woman who presented to the hospital following a fall at home. She has a history of moderate dementia, diabetes mellitus, and chronic renal insufficiency. She underwent surgery for a femoral neck fracture and was transferred to a post-acute facility for rehabilitation. On admission, she was noted to be underweight with a BMI of 18.0. A stage 3 pressure injury was noted on her sacrum.
The dietician evaluated Ms. Artemis’ nutritional status on admission and followed her intermittently throughout her stay. The staff noted 25-50% meal intake and began feeding assistance; calorie counts were performed and demonstrated inadequate caloric intake.
Assessment by the speech-language pathologist revealed dysphagia and a modified texture diet was implemented. She has been placed on multivitamins and mineral supplements as well as high-calorie protein shakes. Despite this, she sustained a 5# weight loss over the first month of treatment and her sacral wound made no progress toward healing. Some of her medications were adjusted; intake improved somewhat and she became more alert. Unfortunately, she subsequently developed pneumonia and, after a course of antibiotics, developed c difficile diarrhea. Her po intake dropped off and her sacral wound significantly deteriorated.
In the case study above, the patient had numerous risk factors and physical findings indicative of inadequate nutrition. While this patient had only two wounds (the sacral pressure wound and the post-surgical wound), her poor nutritional state put her at a significantly increased risk for developing additional wounds. Studies have demonstrated a substantially increased incidence of pressure wound formation in malnourished hospitalized patients compared to those with good nutrition.
How much Nutrition is necessary for Wound healing?
Baseline energy needs for adult patients can be estimated based on a patient’s size, activity level, and bodily stressors such as trauma, surgery, presence of wounds, fractures, infection, and limited mobility or paralysis. Calculation of energy requirements with formulas such as the Harris-Benedict equation may be inaccurate in significantly malnourished or extremely obese patients, so clinical assessment remains a critical part of the diagnosis.
The presence of a pressure wound increases the patient’s caloric needs. As an example, an elderly female patient with intact skin may require 28-35 kcal/kg/day. The same patient with a stage 4 or unstageable wound may require 35-40 kcal/kg/day.
Dietary protein requirements can be estimated with the patient’s albumin globulin ratio. Protein needs may also be estimated based on the patient’s height/weight and overall medical condition defined as baseline metabolic state, minor catabolic state, severe catabolic state, and hepatic or renal failure.
Best Nutrients for Wound Healing Treatment
Protein
Vitamins C and B
Vitamin A
Proper Water Intake
Attention should also be paid to the patient’s hydration status; dehydration should be avoided. Clinical signs of dehydration include dry skin, cracked lips, poor skin turgor (assessed with the skin pinch test), increased confusion, decreased urine output, and increased urine concentration. If additional data is needed, serum electrolytes, osmolality, and blood urea nitrogen (BUN) can be helpful in determining hydration status.
Wound Healing Foods
- Protein – eggs, meats, poultry, fish, and nut products like peanut butter, cottage cheese, yogurt, and milk. Note that several of these high-protein foods are appropriate for soft-texture diets.
- Vitamin C – citrus fruits, cantaloupe, and broccoli, among others.
- Vitamin B – Broccoli, leafy greens vegetables, peas, and chickpeas. Breakfast cereals, while not generally a high-nutrition food, can be a source of B vitamins if fortified with folic acid.
- Vitamin A – leafy green vegetables, tomatoes and bell peppers, cantaloupe, milk, and eggs.
Assessing and Diagnosing Malnutrition
Successful management of malnutrition requires ongoing follow-up and assessment of the impact of nutritional management. Optimization needs will change over time as the patient’s overall condition changes, requiring ongoing changes to the treatment plan. In our case study, the patient would likely have less metabolic demands after her surgical site healed. Additionally, her oral intake should improve with assisted feeding and a mechanical soft diet. Once she experienced deterioration of her wound and clinical condition, however, a reassessment would have been indicated.
There are several types of malnutrition, but the type most typically seen in post-acute wound patients is protein-calorie (or protein-energy) malnutrition. A Body Mass Index (BMI) of <18.5 is classified as underweight and is suggestive of malnutrition, although one may observe malnutrition in obese patients as well. There are a number of validated screening tools available to screen patients for malnutrition, such as the Simple Nutrition Appetite Questionnaire (SNAQ). In general, a patient’s nutritional status should be assessed on admission and with any significant change in condition, including wound failure to progress.
Initial patient assessment should include attention to diminished subcutaneous fat stores, loss of muscle mass, generalized edema, muscle weakness (often assessed with grip strength), and decreased functional status. Malnourished patients may have dull, dry hair, pale or inflamed eyes, oral angular fissures/cheilosis, blotchy pale or irregular skin, easily bruised skin, and fragile or irregular nails.
Certain prescription medications are often linked to anorexia, including amlodipine, ciprofloxacin, cisapride, dignoxin, enalapril, famotidine, furosemide, ipratropium bromide, levothyroxine, opioid analgesics, paroxetine, phenytoin, ranitidine, sertraline, and warfarin. In the case study of Ms. Artemis, her appetite improved after changes in her medication regimen.
Assessment tools should include regular patient weights to identify unintended weight loss, which is often associated with malnutrition. Unintended weight loss is defined as a loss of 5% of body weight in 30 days – as was seen in the case study – or 10% of body weight in 180 days. Assessment should also include the patient’s ability to perform self-feeding, swallowing difficulties, and any psychosocial factors or food preferences that may impact nutrient intake.
Laboratory data can also be useful in assessing or following nutritional status. Serum albumin or prealbumin may be decreased in malnourished patients. Total cholesterol levels are often decreased with malnutrition. Laboratory markers of dehydration like BUN/Cr may be useful as dehydration often coincides with malnutrition.
Who is at risk?
Intervention
The most effective treatment for malnutrition addresses as many contributing factors as possible. In addition to the dietician, the nutrition intervention team may include an occupational and physical therapist, a speech-language pathologist, a psychologist/behavioral health, and the medical treatment team. Family support is also very helpful.
Initial assessment should include an evaluation by a registered dietician. Patient weights are an excellent benchmark for progress, as are assessments by nursing and nursing assistant staff regarding the patient’s meal intake and interest in eating. Calorie counts may be useful to help gauge the extent of the patient’s nutritional deficit.
Supplements should be given appropriately to the patient’s medical condition. Meal intake, usually recorded as a general estimate of the percent of a meal consumed, is an easily documented and helpful marker to follow. If the patient’s intake remains poor, consider dietary preferences; sometimes patients will eat more of their usual food from home. Occupational therapists can help with adaptive devices that may improve the patient’s ability to feed themselves. Physical therapy can also improve upper body strength and help improve self-feeding. Patients who cannot effectively feed themselves should be fed. Involved family members can help encourage their loved ones to eat.
Some patients have psychiatric disorders that contribute to poor dietary intake or non-compliance. Consultation with mental health practitioners is often very helpful in treating these problems and removing these barriers to improvement. Some medications used for treatment may also stimulate appetite.
The patient’s medical team must remain aware of the patient’s progress and consider medication changes that may help with the patient’s appetite if indicated. Appetite stimulants such as anabolic steroids, some psychoactive medications, or cannabis (if legal and deemed appropriate) may be beneficial. Discontinuing medications associated with anorexia may be helpful if this can be done safely.
Drooling, oral food retention or “pocketing”, and frequent coughing during and after meals may indicate dysphagia. If suspected, an evaluation should be undertaken and steps taken to minimize the risk of aspiration.
Pertinent clinical observations should be documented over time. Clinicians should follow any indicated laboratory studies such as albumin and/or prealbumin, liver function tests, and renal function studies. Wound healing progress should be carefully noted as deterioration or failure to progress can be a harbinger of inadequate nutritional support.
Additional consideration: Enteral feeding
If a multidisciplinary intervention fails to improve the patient’s malnutrition, enteral feeding may be an option. Tube feeding allows for the delivery of balanced nutrition; it does not impact malabsorption or catabolic processes related to underlying disease states (such as malignancy).
Not all patients with refractory malnutrition benefit from feeding tubes. Patients whose decreased oral intake is associated with end-stage diseases (such as end-stage dementia or organ failure) or general end-of-life decline usually do not benefit from enteral feeding. In this situation, it simply serves to prolong the dying process rather than correcting a deficiency. The sound clinical judgment that considers the patient’s overall benefit should guide decision-making rather than isolated lab values or clinical measurements.
Conclusion
Malnutrition is a common problem with detrimental effects on wound healing as well as overall patient well-being. Thorough evaluation and multidisciplinary intervention are keys to the successful management of this often chronic issue.
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