Nutrition and Wound Healing
Handouts you should have…
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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
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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
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Decubitus ulcers/pressure ulcers
Diabetic foot ulcers
Venous stasis wounds
Arterial stasis wounds
Diabetic foot ulcers
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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
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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
Coccyx
Scapula
Greater trocanter
Occitiput
Elbows
Heals
knees
Staging of Pressure Ulcers
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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
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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
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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
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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
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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