Nutrition and Wound Healing

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Nutrition and Wound Healing
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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

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Outline

• Introduction
• What are wounds?
• Mechanisms of healing
• Nutritional therapy in the wounded patient
• Q A

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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

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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.

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What are wounds?

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

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Surgical wound, dehisced
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What are wounds?

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

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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

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Diabetic foot ulcers
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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)

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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

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Pressure ulcer areas

• Coccyx
• Scapula
• Greater trocanter
• Occitiput
• Elbows
• Heals
• knees

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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)

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Stage I
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Stage II
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Stage III
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Stage IV
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Stages and Characteristics

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

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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

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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

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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

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Stages and Characteristics

• Maturation
• Continuous remodeling and organization of
  collagen
• Nutritional deficiencies may produce degeneration
  and weakening of the collagen network

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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

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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

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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

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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

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Specific nutrient effects

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