1. Nutrition and Wound Healing

2. 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

3. Outline Introduction What are wounds? Mechanisms of healing
Nutritional therapy in the wounded patient
Q & A

4. 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

5. 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.

6. What are wounds? Acute wounds Scrapes and lacerations
Surgical wounds, intact or dehisced
burns

7. Surgical wound, dehisced

8. What are wounds? Chronic wounds Decubitus ulcers/pressure ulcers
Diabetic foot ulcers
Venous stasis wounds
Arterial stasis wounds

9. 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

10. Diabetic foot ulcers

11. 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)

12. 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

13. Pressure ulcer areas Coccyx Scapula Greater trocanter Occitiput Elbows
Heals
knees

14. 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)

15. Stage I

16. Stage II

17. Stage III

18. Stage IV

19. Stages and Characteristics
Inflammation
Within the 1st 72 hours after wound formation
Vascular dilitation
Leukocyte and macrophage migration
Clot formation

20. 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

21. 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

22. 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”

23. Stages and Characteristics
Maturation
Continuous remodeling and organization of collagen
Nutritional deficiencies may produce degeneration and weakening of the collagen network

24. 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

25. 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

26. 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

27. 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

28. 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