Nutrition in wound care:

To understand the importance of nutrition in wound healing To identify patients with malnutrition and at risk for malnutrition

Important of nutrition:
Nutritional intervention should be reviewed as part of the individuals overall care plan There is a lot of evidence demonstrating the essential role of nutrition in wound healing. Improved nutritional status enables the body to heal wounds such as the accelerated wound healing seen with nutritional supplementation. Without adequate nutrition healing may be impaired and prolonged. Poor nutrition before or during the recovery process may delay healing and impair wound strength, making the wound more prone to breakdown.

Patients who are at risk for malnutrition include:

Patients with chronic wound Patients with non-healing wound Patients with infected wound Uncontrolled DM patients with ulcer Underweight patients Bed bound patients Burn patients Patients with co-morbidities such as uncontrolled diabetes mellitus, dyslipidemia, cancer, kidney

diseases and hypertension are recommended to consult or refer to a dietitian. Effects of wound: A wound causes a number of changes in the body that can affect the healing process, including changes in energy, protein, carbohydrate, fat, vitamin and mineral metabolism. When the body sustains a wound, stress hormones are released in a fight or-flight reaction and the metabolism alters in order to supply the injured area with the nutrients it needs to heal known as the catabolic phase. The body experiences an increased metabolic rate, loss of total body water, and increased collagen and cellular turnover. These effects can be pronounced even with a small wound. If the catabolic phase is prolonged and/or the body is not provided with adequate nutrient supplies, then the body can enter a protein energy malnutrition (PEM) state. Factors causing prolonged catabolism include the severity of the wound and the pre-existing nutritional status of the individual. Poor nutritionoor wound management Protein-energy malnutrition (PEM) is the most serious type of malnutrition when there is an inadequate or impaired absorption of both protein and energy. PEM causes the body to break down protein for energy, reducing the supply of amino acids needed to maintain body proteins and healing, and causing loss of lean body mass. Therefore PEM may be directly linked to wounds that arent healing.

Protein loss via wound exudate needs to be monitored. If dressings are being changed frequently due to the amount of exudate, protein is being lost at a high rate and therefore protein replacement should be considered. PEM can be defined as low Body Mass Index (BMI) or unintentional weight loss (of 5% or more) with loss of subcutaneous fat and/or muscle wasting. As an individual loses more lean body mass (LBM), wound healing is more likely to be delayed. With a 20% or greater loss of LBM wounds compete with muscles for nutrients. If LBM loss reaches 30% or more the body will often prioritise the rebuilding of body over wound healing with available protein. This cascade demonstrates the severely negative impact poor nutrition can have on chronic wound healing. Even in todays society where we are fortunate to have access to a variety of nutritional foods, older people often suffer from malnutrition. In fact it has been estimated that up to 60% of older patients in hospitals are malnourished, or at risk of malnutrition. Of those in nursing homes, between 40 and 85% have malnutrition, and 20 to 60% of home care patients are malnourished.

Patients with pressure ulcers especially larger or multiple ulcers and ulcers on legs in people with diabetes place high demand for nutrients on the body.

Infected wounds also increase nutrient demand as they cause more tissue damage, further strain and a deeper ulcer. Therefore, Nutrition for chronic wounds needs to be assessed on an individual basis

MALNUTRITION UNIVERS S EENING TOOL(MUS AL CR T)

*Adopted from

5-3.

Nutrition Management

Optimal wound healing requires adequate nutrition as well as involvement of wound management team, effective communication and compliance to standard protocol.

Is patient at risk for malnutritio n? Yes Is oral intake possible? No Initiate Nutrition Support*

No

Re-evaluate next visit

Yes

Commence appropriate diet prescription

Ye s Enteral Nutrition (EN)

Is GIT function al?

No Parenteral Nutrition (PN) Re-evaluate GIT function

Adequat e EN? Yes Continue Total EN

No

Consider Combination of EN and PN

* Refer / Consult Dietitian for Nutrition Support

Algorithm for Nutrition Management

Nutrition Prescription 1. Nutrient Recommendation Provision of some specific nutrients has been shown to promote wound healing. Age-appropriate protein and energy needs should be provided. Nutritional supplements with enteral or parenteral support should be considered if target needs are not achieved. Suspected or confirmed micronutrient deficiency should be treated early with provision of 100% RNI (Recommended Nutrient Intake) of micronutrients.

During the healing process, the body needs increased amounts of calories, protein, vitamins A and C, and sometimes, the mineral, zinc.
Vitamin C Vitamin C plays an important role in collagen synthesis and subsequent cross linking, as well as the formation of new blood vessels (angiogenesis). Adequate vitamin C levels help strengthen the healing wound. Vitamin C also has important antioxidant properties that help the immune system, and it increases the absorption of iron. Vitamin C deficiency impairs wound healing and has also been associated with an increased risk of wound infection. Research has shown vitamin C supplementation helps promote pressure ulcer healing. Vitamin C is found mostly in fruit and vegetables, especially oranges, grapefruit, tomatoes, and leafy vegetables. Fruit juices with added vitamin C are also a good source, although often they contain only small amounts of vitamin C.

Vitamin A Vitamin A increases the inflammatory response in wounds, stimulating collagen synthesis. Low vitamin A levels can result in delayed wound healing and susceptibility to infection. It has also been shown that vitamin A can restore wound healing impaired by long term steroid therapy or by diabetes. Serious stress or injury can cause an increase in vitamin A requirements. While the mechanisms of vitamin A in wound healing are still not well understood, it is clear that it plays an important role. Supplementation with vitamin A requires caution, as there is a risk of toxicity. Vitamin A is found in milk, cheese, eggs, fish, dark green vegetables, oranges, red fruits and vegetables. Vitamin E It is possible that vitamin E can reduce injury to the wound by controlling excessive free radicals. Contrary to popular opinion, there is limited evidence for the benefits of vitamin E in decreasing scar formation. There is also some evidence that suggests oral supplementation of vitamin E over 400mg/day has an increased health risk. Zinc Zinc is a trace element, present in small amounts in the body, which has a well established role in wound healing. Zinc plays a key role in protein and collagen synthesis, and in tissue growth and healing. Zinc deficiency has been associated with delayed wound healing, reduced skin cell production and reduced wound strength.

Zinc levels of less than 100g/100mL have been associated with impaired wound healing, but supplementation in people who are not zinc deficient generally has no benefit. Insufficient dietary intake of zinc can be further exacerbated by zinc loss from excess wound drainage. Dietary zinc sources include red meat, fish and shellfish, milk products, poultry and eggs. Iron Iron is part of the system that provides oxygen to the site of the wound, therefore iron (haemoglobin) deficiency can impair healing. Iron deficiency can also result in impaired collagen production and strength of the wound. Iron absorption from non-meat sources can be enhanced with vitamin C. Zinc and iron compete for absorption, therefore if someone is receiving supplements of both, the zinc and iron should be given with meals but not at the same time. The best sources of iron in the diet are red meat, offal, fish, eggs, wholemeal bread, dark green leafy vegetables, dried fruits, nuts and yeast extracts.

Table 5-1: Recommended Nutrient Intake

Nutrient Energy

Recommended Intake Underweight : 35 45 kcal/kg/day Normal : 30 35 kcal/kg/day Overweight : 25 30 kcal/kg/day Burn : 40 kcal/kg/day Trauma : 35 45 kcal/kg/day

Carbohydrate

50 60% of Energy DM: Encourage high fibre complex CHO e.g. wholegrain bread, capati, brown rice according to recommended serving sizes 30 35% of Energy Adult : 0.8 1.5 g/kg/day Dyslipidemia : Limit high saturated fat and fried food Chronic wound : 1.25 1.5 g/kg/day Severely catabolic with more than one wound or Pressure Ulcers Stage III & IV : 1.5 2.0 g/kg/day Vegetarian : consume enough protein from milk, lentils, legumes and beans Omega-3 fatty acid Linoleic acid L-Glutamine 0.2 0.5 g/kg/day Arginine 30 60 g/day Recommended Intake Malnourished patient : 1000 IU Severe burn, poor nutrient store, GI dysfunction, radiation therapy : 10,000 25,000 IU At least 1 serving per day of dark, green &leafy vegetables, orange or yellow vegetables, orange fruit, liver and fortified dairy products

Fat

Protein

Pharmaconutr ients

Nutrient Vitamin A

Vitamin B Complex

B1 (Thiamine) : 10 mg/day B2 (Riboflavine) : 10 mg/day B3 (Niacin) : 200 mg/day B5 (Pantothenic acid) : 100 mg/day B6 (Pyridoxine) : 20 mg/day B7 (Biotin) : 5 mg/day B9 (Folic acid) : 2 mg/day B12 (Cobalamine) : 20 g/day

Vitamin C

Vitamin E Vitamin K Zinc

Small wound eg. Pressure ulcers /elective small to moderate surgery: 0.5 1 g daily in 2 divided dosage Larger injury eg: large BSA burn & Multiple trauma: 1 2 g/day At least 1 serving per day of citrus fruits, guava, tomato, pepper, potatoes, spinach and cruciferous (broccoli, cabbage, cauliflower) Not to exceed 670mg/day 5-10mg (orally or IM 1-3 times weekly in high risk patients) 40 mg/day for 10 days Red meats, seafood and fortified cereals 100 g/day 25 50 mg/day

Selenium Manganese

Copper

2 3 mg/day

Table 5-1: Recommended food intake

Recommend ed Serving Sizes Food Groups Rice, noodle, bread, cereals, cereal products and tubers

1 Serving Size

Daily Serving (Normal Recommenda tion)

Daily Serving (Wound Healing Recommendati on)

1 cup @ 2 scoops rice / noodles / cereals 2 slices bread 1 capati / thosai cup @ 2 table spoons leafy (spinach, kangkung) or starchy (carrots, potato) 1 slice papaya / pineapple / honeydew / watermelon 1 whole apple / orange

4 8 servings

4 8 servings

Vegetables

2 3 servings

4 servings

Fruits

2 servings

3 servings

Fish, poultry, meat and legume

1 fish (eg. kembung, selar) 1 drumstick 2 eggs 2 table spoons beef 1 cup @ 2 scoops

2 3 servings

3 4 servings

cooked dhall 2 tauhu/ tempeh

Milk and milk products Fats, oil, sugar and salt

1 cup milk 1 slice of cheese cup yogurt 1 tsp oil 1 tsp sugar 1 tsp salt Eat less Eat less 1 3 servings 1 3 servings

If patient not eating well;

1.

Suggest five to six small meals a day. Encourage smaller meals and snacks between meals to get enough nutrition. Make nutritious snacks like milk, ice-cream, yogurt, fruits, sandwiches, milkshake, oats with milk, omelettes, roti telur, cream mushroom soup, fruit or fruit juices, cekodok, keropok lekor, pancakes, banana fritters, kerepek, popcorn and corn in cup.

2. Use foods that are "high nutrient-dense" as below: "Low nutrient-dense" foods Clear soup (air rebusan) Plain jelly Carbonated beverages "High nutrient-dense" foods Chicken / beef vegetable soup Jelly with milk / fruits Milk, milkshakes

Popsicles Plain bread / biscuits / pancake Plain porridge

Ice cream floats, smoothie, , ice cream Bread / biscuits / pancake with peanut butter / egg / tuna / sardine Chicken porridge, Fish porridge

3.

Suggest variety of foods if patient experience taste changes to find out what works for the patient. Cold foods and foods with little odor work best. Add spices (e.g. lemongrass, pandan leaves, lime, mint leaves, herbs) in meat, chicken, fish preparations. Take lemon/ orange/ mint flavoured food or drinks to reduce the metallic or bitter taste.

4. Use an oral nutritional supplement if nothing else works. These are available at grocery stores, drug stores, and hypermarkets. Adding milk, cocoa powder, coffee or ice cream may make the supplement tastier. Take a multivitamin if unable to meet the recommended intake.

5.

Ideas to improve nutritional status include: Offer food and fluids in a variety of textures and consistencies Offer assistance and allow sufficient time for meals and enlist family members or volunteers to help Provide encouragement, without pressuring Offer a variety of nutrient dense, high calorie and high protein meals Encourage grazing small frequent meals/snacks Encourage frequent drinking of fluids

 Provide hydration stations for patients to access drinks at any time Provide foods that patients like Position upright when eating Allow time for individuals to eat in a relaxed manner, with time to chew, feed themselves and finish their meal Provide a pleasant mealtime environment If the individual has dentures ensure that these are well fitted Explain that eating well, and eating the right foods, will aid recovery Provide assistance with the opening of containers, lids.
5-5. Food Myth and Truth MYTH Haruan fish and ikan linang are strongly recommended after surgery for wound healing TRUTH Protein is essential for wound healing. Haruan fish and ikan linang / belut are good source of protein similar to any other fish. Consume adequate protein from all type of fish, chicken, meat, lentils and beans to promote wound healing. Do not restrict to haruan fish or ikan linang only.

Eggs will induce itchiness, Eggs are considered a pus and can cause wound complete protein source and breakdown. rich in vitamins and minerals. There is no evidence that consumption of eggs and egg products are related to

itchiness, pus and can cause wound breakdown. Only avoid eggs if you are allergic to it.

Female chicken meat Chicken meat is a good source should not be consumed of protein and there is no after surgery. evidence of contraindication after surgery.

Application of gamat oil on wound and drinking gamat essence can help wound healing.

There is no strong research and evidence for the claim. Usually, any type of essence like essence of chicken, essence of haruan fish and gamat are high in salt and not advisable for regular consumption.

F.

Conclusion

Nutrition is essential for the wound-healing process. The use of a nutritional screening tool highlights those at risk of nutritional deficiency. Regular ongoing monitoring is necessary to evaluate the outcome of nutrition intervention and manage feeding barriers effectively.