Nutrition: The ‘forgotten element’ of wound healing

By Lisa Logan, R.D., CNSC

The role of nutrition in pressure injury (PI) prevention and treatment is a well-recognized factor and an essential component of wound management. Unfortunately, proper nutritional support is often the “forgotten element” that is necessary in maintaining all phases of wound healing. Wounds will not heal without proper nutrition, and malnutrition is a key risk factor in the development of wounds.

Protein Energy Malnutrition will result in a marked increase in the incidence of pressure injuries. According to the National Pressure Advisory Panel (NPUAP), the prevalence of wounds or any chronic, non-healing wound, such as a PI, surgical site wound, trauma, or burn injury is a serious healthcare problem. Therefore, employees that work in the supply and distribution industry need to understand how they can provide solutions for customers to help prevent and treat wounds.

High-risk individuals
Clinicians require evidence-based tools that help identify residents who are at risk, so that prompt attention is directed on the nutritional status of patients. High-risk individuals can be identified by screening for nutritional risk factors, along with understanding pressure injury triggers.

Examples of some PI triggers include the following: unintended weight loss >10 percent in 180 days, BMI (Body Mass Index <18.5 or >30), poor oral intake, dehydration, diagnoses impacting cognition (such as dementia and Alzheimer’s Disease), and/or urinary or fecal incontinence, etc. Advanced wound care programs are now available through various distributors, suppliers and/or manufacturers. These programs provide comprehensive tools and guidelines to help customers develop strategies in areas relating to wound care prevention and treatment.

Medical Nutrition Therapy (MNT) treatment plans are an essential component to wound management. The nursing staff and registered dietitian (RD) are primarily responsible for developing a treatment and prevention plan, as well as documenting nutrition and nursing assessment plans. Routine monitoring and validated assessment tools need to be integrated into a patient’s care plan and an organization’s clinical protocols. The goal is to provide adequate calories, protein, fluid, vitamins and minerals, as well as to understand their role in wound healing. Some important components are as follows:

• Protein is important to help repair damaged tissue and promote healing. (Protein requirements are markedly increased, as collagen – the most abundant protein – is a critical component of collagen synthesis needed for wound healing).
• Fat is an essential component of all cell membranes.
• Other semi-essential amino acids like arginine, the building blocks of protein, are required for tissue repair and to help transport oxygen delivery to the wounds.
• Vitamins and minerals are necessary for all phases of wound healing. A supplement is needed when dietary intake is poor or deficiencies are suspected. (E.g., vitamin C supports formation of new blood vessels and wound strength, and zinc is required for protein synthesis and immunity.)

Oral and tube feeding
Patients benefit from fortified and/or high-calorie foods, as well as high protein oral supplements between meals when nutritional requirements can’t be achieved by dietary intake. This strategy can help combat unintended weight loss, anorexia and malnutrition. These supplements may be delivered orally or through a feeding tube. It is important to consider alternatives like enteral (tube) feeding or parenteral (IV) feeding, when oral consumption remains suboptimal.

Tube feeding is the preferred route, if the gastrointestinal tract is functioning. Depending on the clinical condition, tube feeding necessity will vary in terms of length of need. The Joint Commission and Centers for Medicare and Medicaid Services (CMS) develop, and frequently revise, interpretative guidelines and compliance standards relating to tube feeding administration. This helps surveyors determine if a facility has clinical deficiencies in this area, which need to be remedied.

Enteral nutrition formulas are foods intended for the specific dietary management of a disease or condition. Products vary with respect to macronutrient and micronutrient composition, concentration, fiber, and added nutrients which have been shown to improve immune function and help promote wound healing. These wound-healing formulas contain additional essential nutrients that are required for optimal skin integrity and repair. Often, the resident is offered oral nutritional supplements to provide additional nutrients that are lacking from the diet.  Standard polymeric formulas are widely used and tolerated in patients requiring enteral support. These formulas mimic what is in a typical diet and contain a variety of nutrients consumed by healthy individuals to meet the recommended dietary needs. It is the clinicians’ responsibility to evaluate enteral products for clinical efficacy and to develop formularies to meet the needs of their health care setting.

The primary food ingredients in both oral and tube feeding products include these:

• Carbohydrates, usually in the form of corn syrup solids and maltodextrin.
• Protein, usually in the form of soy protein and casein.
• Fat, typically canola, soybean or safflower oil.
• Fiber – soluble or insoluble.

Quality standards
Considerable evidence exists regarding the seriousness of pressure ulcers and the relationship between pressure ulcers and pain, decreased quality of life, and increased mortality in aging populations. Therefore, state and regulatory agencies like CMS have funded quality measure projects like National Quality Forum (NQF), established in 2008. These quality standards are tightly regulated by federal and state agencies. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires reporting of quality measures – including skin integrity and changes in skin integrity – using standardized patient assessment data across post-acute settings to help improve quality of patient care and outcomes.

Although the development of wounds arises from a complex set of circumstances, proper nutritional supplementation can positively affect the outcome. Therefore, it is important for distributors and sale representatives to understand their product offerings relating to wound care and treatment. Utilizing clinical resources within your company can familiarize customers with guidelines, such as those published by the NPUAP in 2016, as well as by other national organizations that specialize in pressure injury prevention and treatment. The management of pressure injuries requires a collaborative, interdisciplinary team approach that includes not only the individual, family, and/or caregiver, but also the suppliers, manufacturers and distributors that service post-acute-care facilities.

Lisa Logan, Registered Dietitian (R.D.) and Certified Nutrition Support Clinician (CNSC), is enteral program manager/nutrition support clinician for the extended care-clinical resource team, McKesson Medical-Surgical.