Wound Management and Nutrition: An Essential Consideration

Mr. T.Ellis, Director WoundHeal Australia

As a practitioner I focus primarily on care of elderly people with wounds, so malnutrition and its effect on healing is a constant consideration. The consequences of poor nutrition are evident throughout the health care system:

• weight loss
• changes in mental status
• development of pressure ulcers
• reduced immune capacity.

There are many reports demonstrating the extent of malnutrition amongst older western populations. Zulkowski, K (2000) states that in the USA up to 85% of institutionalised elderly are malnourished with more than 55% of hospitalised elderly also similarly affected. In an earlier study Zulkowski (1998) also found that 67% of institutionalised elderly and 74% of acute care elderly patients were hypoalbuminaemic (low serum protein) yet of these only 27.6% were receiving supplementation.

Many other studies and clinical experience confirm this trend and while the actual figures vary in practice, there is no question that poor nutrition is associated with higher rates of wound related morbidity. Given these statistics and through clinical observation of similar rates in Australia, an older person with a wound is at significant additional risk of delayed or complicated healing.

What are the signs to look for?

1. Weight loss:

The loss of body weight is a key indicator of poor nutrition. Generally speaking the loss of lean body mass is the most alarming change. Changes of as little as five percent of body mass over three months can be an indicator that nutrition has changed for the worse. In an obese person this could easily be accounted for as fat loss but in a person of average to smaller size this should be taken very seriously. Regular weighs are a common part of nursing management for elderly in care and need to be observed closely by care managers. If a person already has a wound then they should be weighed at least weekly so even small changes can be observed and dealt with. In the community it is also wise to weigh regularly if people have wounds so that nutrition status changes can be picked up earlier rather than later.

2. Change in mental status:

Confusion, memory loss, aggression or stupor can all be signs of a decrease in nutritional wellbeing. The additional metabolic stress induced by the presence of a wound changes from individual to individual, there will always be an effect. A person who is otherwise able to remember things like days, dates and times may suddenly begin to forget; a confused person who is normally quite placid may suddenly become agitated; a person who is normally alert may quickly become stuporose. If any of these changes are noticeable in people you care for their nutritional status should be checked immediately and seek advice from a dietician.

3. Wound fails to show signs of healing (four weeks):

Wound measurement is important to track wound healing over a defined timeframe; clinicians generally use a four week timeframe as a gauge. If you are unable to observe healing over four weeks then the clinician must reassess for factors influencing healing. One important factor is nutritional status. Weighing, body mass index, mini nutritional assessment and blood values such as Serum Albumin or Pre-Albumin will all contribute information about how nutrition is affecting healing.

4. Exudate leaks from wound:

This can be a sign that nutrition is poor, particularly that protein levels are low, or can be an indicator that nutrition supplementation is necessary due to the potential for excessive protein loss. Wound exudate typically contains a range of proteins normally only found in blood, like Albumin. The loss of these essential nutrients will impact on the rate of healing and metabolic demand. If an elderly person is already in a hypo-nutritional state, then exudate will only make matters worse. If the protein levels are already very low before wounding then it’s possible that exudate levels will be high. In both circumstances it is advisable to seek advice from a dietician to prevent a person from spiralling into Protein Energy Malnutrition.

5. Protein Energy Malnutrition (PEM):

This is very serious, when the body’s demand for nutritional elements exceeds supply then the body uses different energy pathways. When protein, rather than carbohydrates or fat, is used to provide baseline metabolic energy needs then muscle tissue is rapidly lost, resulting in an emaciated patient who often has ribs and spine showing. Once a certain percentage of lean body mass has been lost it may be impossible to restore, and this will lead to death. There are few studies that demonstrate the relationship between chronic wounds and death but clinical experience indicates that the two most common causes of death related to wounds are infection and starvation (PEM).

Managing nutritional needs
If any of these relate to a person in your care who has a wound then seek further advice from a health professional. Talk to your health professional about consulting a dietician to help determine a plan taking into account a range of physiological indicators and outline nutritional needs and dietary requirements.

Supplements
Supplements are often used if someone is unable to take in sufficient nutrients or where specific nutrients are needed. Elderly people often suffer with altered absorption, altered taste, reduced energy levels, reduced ability to chew or swallow or even confusion, leading to reduced dietary intake. In these cases protein and energy dense supplements can be of great value, many clinicians will routinely include a dietary supplement as part of a wound management strategy – particularly where any of the criteria listed above are evident.

The characteristics of an appropriate supplement:

• easy consumption – a variety of presentations, tastes and recipes should be available
• high in protein – many patients will require up to three times their normal daily intake of protein to facilitate healing
• high in energy – high energy drinks reduce the chance for a person to slip into PEM
• contains a wide variety of vitamins and minerals essential for healing – often vitamins A,C,E and B group, minerals such as iron, copper and zinc
• preferably contains high concentrations of L-Arginine – this amino acid has the potential to improve scar strength, reduce healing times and may assist with peripheral blood flow
• readily available – delays in commencing dietary supplements can result in poor healing outcomes.