Practical Nutrition and Wound Care

  During any evaluation of a patient with wounds, many things go through the clinician’s head such as primary cause or etiology, if the patient has diabetes and where their blood sugars are, and is the patient taking any medications that would interfere with overall wound healing. As these things cross our mind, we also consider the nutritional status of the patient. Unfortunately however, many times we don’t feel that this is in the realm of our normal everyday dealings. Oftentimes the clinician will think, or even with a good clinical guess know, that the patient has severe malnutrition, but fails to act to correct any problems, and thus many expensive modalities that we utilize for wound care today do not help the wound overall.

  The body has the amazing ability to correct even minor malnutrition to facilitate wound healing. This is usually done by the body actually breaking down its own tissue, that of muscle tissue, and re-breaking down the proteins and amino acids in this tissue and re-building them back up into the building blocks of standard wound care. This is called reprioritization. We do know from significant research, mainly in the area of pressure ulcers, that mild to moderate malnutrition can affect wound healing, and there is really no difference between mild and moderate malnutrition as far as the overall affect, which means that mild malnutrition can cause the same adverse effects on healing as moderate malnutrition. Of course, severe malnutrition can completely shut down wound healing and multiple other body functions as well, thus leading ultimately to death in many circumstances. The overall problem is that oftentimes mild to moderate malnutrition does not give us the same obvious warning signs that severe malnutrition will give us in a patient and, thus, needs to be investigated. Herein lies the first problem that most wound healers fail to realize, that you can only find something if you are looking for it and, therefore, we must look for malnutrition on a daily basis in every one of our patients. Once we find this, we must act in some way or manner to treat overall malnutrition. Thus, the two main focuses of nutritional support and wound healing are first, the investigation and identification of malnutrition, and ultimately the treatment of malnutrition. Oftentimes, clinicians will say they really don’t understand how to identify malnutrition and actually how to treat malnutrition. Many journal articles, book chapters, and even entire books have been written on the subject of nutrition and wound care. It can be a somewhat daunting and overwhelming field of study which lead, many wound care clinicians to defer any type of treatment of malnutrition and even the investigation of nutrition to the experts – the dietitians or physicians whose practices are geared mainly towards nutrition and malnutrition and the subsequent nutritional abnormalities.

  With the number of patients in the United States that have chronic disease, it has been theorized that up to 65-80% of these patients will have a condition in which the treatment of a chronic malnourished state, whether this be vitamin deficiencies, mineral deficiencies, or some type of building block abnormality such as low protein levels, could actually make a significant difference in their chronic disease state. Many of these patients, as we well know, are wound care patients and ultimately have other medical conditions that can hamper wound healing. Thus, to pass off this problem to other healthcare providers without at least simple investigations, to me, is not treating the whole patient, as we should. Ultimately, we need to understand that nutrition can be very simple because we do understand the basics of nutrition as we eat, or hopefully eat, every day.

  Simple investigatory techniques can be simple observation. Does the patient actually appear to be well nourished? Has the patient lost weight on subsequent visits? Does the patient have new health care diagnoses such as diabetes or new onset cancer, or some other type of abnormality that nutrition affects?

  Many things can be garnered from just the social status of the patient. Does the patient have insurance or some type of payment status? Is the patient afraid to seek medical attention or care of medical problems based on financial needs? Are they actually treating their medical conditions, or do they have to choose between eating and taking their medications? Some of these things can be investigated very easily just from your records of the patient and you can get an idea of whether you think the patient has good nutrition, or maybe borderline, or ultimately have poor nutrition.

  Other social aspects can be is the patient elderly? Do they live alone? Do they live in some type of communal environment or have a good support system so that they can have a reason to fix meals? Do they have hot meals available to them if not? Are they in some type of assistance or can they qualify for some type of assistance? These may be the only simple nutrition intervention that the patient needs. This will also go a long way to improving the psychological aspects of the patient and show that we truly do care about the whole patient as opposed to just their wounds.

  Other more advanced but very simple techniques can be the use of questionnaires to find out the answers to some of these questions. Patients typically tend to be very honest when these questionnaires are worded correctly. There is no one questionnaire that is better than the others. The main thing is simply just administering the questionnaire and, if you have to, actually asking the patient the questions without calling it a formal questionnaire. When a patient can answer some simple questions upon their initial evaluation, it can go a long way toward helping you evaluate their overall nutritional needs.

  The other aspect is simple laboratory guidance. Such as, correcting diabetes, which is obvious to most wound care providers because we know the ravages diabetes causes on many of our patients, or other things, such as albumen, and the more accurate short-term visceral protein, pre-albumen. Several studies have shown that albumen, because of the chronic nature in which it increases or decreases and is affected by hydration, can be a poor marker of overall nutritional status especially in an acute setting where the patient may have developed an illness and not been eating for the last week or two. In these cases, the use of pre-albumen, which is a shorter half-life visceral protein, can actually be somewhat more accurate. Many people complain that these tests are not indicated or they do not make a difference. The only argument that I would have here is that that if we are going to treat simple high blood pressure with a medication, wouldn’t we want to check at least the blood pressure before we started the pill and after we started the pill to see what our intervention had done? Thus, the same goes for nutrition. If we are going to intervene, even simply making sure that our patient is eating three meals a day, wouldn’t we want to know their nutritional status now as opposed to several months from now when we have wasted the patient’s time, our time, and many healthcare dollars, especially in the economic times in which we live.

  In the area of intervening nutrition, simple things, again, may mean to simply ensure that the patient is receiving hot meals or several meals a day. Does the patient have a reason to eat? Is the patient’s appetite normal? Oftentimes, depression, especially in elderly patients if they are living alone, have lost loved ones, or lost support systems which oftentimes causes depression, can lead to poor nutrition, poor sleeping habits, and ultimately have a simply devastating effect on overall wound care for the wounds that they may have. We do oftentimes, especially in the ICU setting or the acute care setting, give complex formulas such as enteral formulas given through feeding tubes or total parenteral nutrition, which are the basic building blocks broken down into IV form that we can give through someone’s vein. These don’t need to be the interventions that we do on many of our patients on an outpatient basis. In this case, I do agree with someone referring these patients to someone who understands their use and can manage these complex patients in that setting. But in the simple outpatient setting or in the new subacute setting, usually just making sure the patient can eat, handle utensils, or actually get out of bed or a wheelchair to help prepare food may be all that is necessary. Therefore, some social support system may be needed and often times nutritional intervention may be as simple as contacting a social worker for home health care needs or for any type of social intervention that may help the patient.

  Other simple nutrition things can be simple discussing food choices with the patient such as high protein from peanut butter or other sources of protein such as beans and legumes if the patient may not be able to handle chewing meat from malpositioned dentures or does not have access to higher quality protein because of economic issues. Peanut butter and other sources of protein can go a long way in helping to improve the overall protein status of our patients. There are many commercially available formulas now that can be used as meal replacements or overall nutritional supplements, but these tend to be expensive and some of the limited paying status of many of our older patients or patients with multiple medical problems can get in the way. In this case, use your imagination. Does the patient have access to eggs, which are a wonderful source of protein, or milk, another wonderful source of protein and fat? One may even consider utilizing something as simple as a ready-made powdered breakfast drink, which contains many vitamins, minerals, protein and carbohydrates along with mixing this with some type of milk for a fairly nutritious and fairly cheap nutritional supplement.

  Overall, nutrition and wound care must first begin with the provider identifying the problem. Very simply choosing to intervene can oftentimes correct any minor or major nutritional abnormality before it becomes a life threatening state. We quite often find ourselves, as a wound care provider, treating the largest organ of the body, that of the skin. We find that so many of the other disease processes and bodily functions affect the skin and ultimately the overall health of our patients.

  In conclusion, nutrition shouldn’t be a scary subject because we deal with it every day and, hopefully, several times a day as we eat and partake in our daily meals. Think of the same thing of any of our patients to ensure the overall health and wound healing of your patients.

  Gregory K. Patterson, MD, FACS, CWS, FASA, FCCWS, FAPWCA, is Medical Director, Archbold Center for Wound Management and Hyperbaric Medicine South Georgia Surgical Associates, division of Archbold Medical Group, located in Thomasville, Georgia. Patterson is also the Clinical Instructor, Department of General Surgery, Medical College of Georgia, Augusta, Georgia Assistant Clinical Professor, Florida State University College of Medicine, Tallahassee, Florida.