Journal of the Dermatology Nurses' Association:
Nutrition and Wound Healing: Implications for Practice
Nicole Barratt, MSN, FNP-BC, University of South Florida, Tampa, FL.
The author declares no conflicts of interest.
Correspondence concerning this article should be addressed to Nicole Barratt, MSN, FNP-BC, University of South Florida, 4202 E. Fowler Ave., Tampa, FL 33620. E-mail: firstname.lastname@example.org
Pressure ulcers are one of the most preventable types of chronic wounds, yet they continue to cause a significant resource burden on the healthcare system. The purpose of this review is to determine if implementing the clinical practice guideline recommendations, according to the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel, of nutritional support is beneficial in treating and preventing pressure ulcers. Review of these studies indicates that there is strong evidence to support the clinical practice guideline recommendation of nutritional support for patients with pressure ulcers. Further research is needed to quantify and specify the particular nutritional support in wound healing to shape future clinical practice guidelines.
With incidence rates ranging from 10% to 18% in the United States, pressure ulcers are one of the most common preventable types of chronic wounds (Lee, Posthauer, Dorner, Redovian, & Maloney, 2006). In the United States alone, more than 8 million people are dealing with acute or chronic wounds (Harsha et al., 2008). Of this national number, pressure ulcers affect an estimated 2.5 million people each year (Berlowtiz, 2009). Healthy People, a United States Health and Human Services program that sets goals for health promotion and disease prevention, has made an objective to decrease the roughly 10% of hospitalizations per 100,000 people over age 65 years related to pressure ulcers by 10% by the year 2020 (U.S. Department of Health and Human Services, 2012).
Chronic disease states are likely to impact an individual’s life experience in some fashion, and pressure ulcers are included among these chronic disease states (Hopkins, Dealey, Bale, Defloor, & Worboys, 2006). As most pressure ulcers are preventable, it is important to understand how to avoid this particular chronic condition. Proper nutrition is important for the body to function properly, which certainly includes wound healing. Vital nutrients play a role at the cellular level and inevitably have some impact on wound healing (Kumar, Abbas, Fausto, & Aster, 2010). This article discusses evidence regarding nutritional assessment and support for the patient dealing with a pressure ulcer.
Numerous studies on both animals and humans have indicated nutritional supplements of various kinds of aid to promote wound healing by a quantifiable extent (Allen, 2012; Anhold et al., 2010; Aprahamian, Dentinger, Stock-Damge, Kowassi, & Grenier, 1985; Bourdel-Marchasson et al., 2000; Cereda, Gini, Pedrolli, & Vanotti, 2009; Collins, Kershaw, & Brockington, 2005; Desneves, Todorovic, Cassar, & Crowe, 2005; Heyman, Looverbosch, Meijer, & Schols, 2008; Karsidag, Asensio, Kabukcuoglu, & Tuzun, 2010; Lee et al., 2006; Lim, Levy, & Bray, 2004; Ohura, Nakajo, Okado, Omura, & Adachi, 2011; Raffoul & Berger, 2006; Theilla et al., 2012; Williams, Abumrad, & Barbul, 2002). Two studies involving humans explored the use of nutritional intervention to decrease the progression of pressure ulcers. One of these studies provided a daily supplement that contained protein, arginine, zinc, and antioxidants as the intervention to prevent pressure ulcers. Under these conditions, patients still developed pressure ulcers, but the intervention may have delayed the onset (Houwing et al., 2003). The other study implemented an enriched diet with the fatty acids and vitamins to promote healing in patients with existing pressure ulcers (Theilla, Singer, Cohen, & DeKeyser, 2007). Both studies found that the intervention resulted in a decrease in the progression and severity of the ulcers (Houwing et al., 2003; Theilla et al., 2007).
In addition to wound measurements, several of the studies used the pressure ulcer scale for healing (PUSH) scores as a wound-healing indicator (Cereda et al., 2009; Lee et al., 2006). A recent prospective, multicenter study was conducted to assess the validity of the PUSH tool and found this to be a valid indicator of wound healing (Hon et al., 2010). The PUSH tool was developed by the National Pressure Ulcer Advisory Panel and can be found at w www.npauap.org.
NUTRIENTS INVOLVED IN HEALING
For the body to break down macronutrients such as proteins, fats, and carbohydrates, adequate amounts of micronutrients, vitamins, and minerals are needed (Fit Day, 2011). Vitamin C and proteins are utilized in the body to produce collagen, which is necessary in skin repair (Kumar et al., 2010; Lexicomp, 2013b). Foods high in the nutrient vitamin C are listed in Table 1.
In addition, the body needs proteins to be utilized in the form appropriate of amino acids for proper wound healing to occur. Several studies used amino acids as either a portion or the entire component of the nutritional intervention that resulted in improved wound healing (Desneves et al., 2005; Karsidag et al., 2010; Williams et al., 2002). Foods high in protein built from these essential amino acids are listed in Table 2.
Zinc is an important mineral believed to help with wound healing. This is particularly true if a person is deficient in this micronutrient (Lexicomp, 2013c). Studies have shown that deficiencies in micronutrients such as zinc can lead to delayed wound healing (Cruse et al., 2000; Lim et al., 2004). People with conditions such as spinal cord injuries often have inadequate intake of albumin or protein, as well as zinc, to meet their metabolic needs. This deficiency increases the likelihood of pressure ulcer development (Cruse et al., 2000). Foods naturally high in zinc are listed in Table 3.
The B vitamins are micronutrients that play a role in cell metabolism, in that the body uses B vitamins to break down macronutrients (Lewis, Heitkemper, & Dirksen, 2004; Lexicomp, 2013a). A study conducted on rabbits is noteworthy in that it showed that using vitamin B5 as a supplement seemed to quicken wound-healing time (Aprahamian et al., 1985). Foods naturally high in B5 are listed in Table 4.
Fatty acids are an important and integral part of the structure of cell membranes. Therefore, fatty acids are a necessary nutrient for tissue repair within all cells of the body (Lewis et al., 2004). Two studies used fatty acids as part of the nutritional intervention and found a decrease in the progression and severity of pressure ulcers (Theilla et al., 2012, 2007). Nuts and seeds are foods that are naturally high in essential fatty acids. These are listed in Table 5.
In addition, many well-known oral nutritional supplements contain nutrients helpful for wound healing, which are compared in Table 6. Each of the supplements compared in the table are marketed for specific patient populations or reasons. Oral nutritional supplements are another way for patients to get adequate nutrient intake to promote wound healing, by providing nutrients such as vitamins C and B5, zinc, and amino acids.
BARRIERS TO ADEQUATE NUTRITION
Unfortunately, barriers to adequate nutrition exist in modern society. Although found in all walks of life, some of these barriers are more prevalent to the elderly population. Such barriers include financial limitations from living on a fixed income, decreased appetite from a disease process such as depression or a medication side effect, transportation limitations, memory impairments, poor dental health, and decreased physical strength (Beattie & Nichols, 2012).
Another barrier to adequate nutrition is environmental, meaning older adults living in a nursing home or patients in the hospital are dependent on the facility to provide adequate nutrition. Using the FoodWorks software program, an Australian hospital found that their menu did not supply enough energy or zinc for proper wound healing (Liang, Thomas, Miller, & Puckridge, 2008). FoodWorks is a software program that can analyze nutrient content of recipes and menus. More information about FoodWorks can be found at http://www.nutrionco.com/FoodWorks.htm.
In addition, financial limitations for a hospital or long-term care facility can be seen as a barrier to providing adequate nutrition to the patients and residents. One noteworthy study was conducted to determine how nutritional support for patients with pressure ulcers impacted wound healing, hospital length of stay, and cost. This study found that there were improved patient outcomes with decreased healing time and shorter length of stay, by assessing baseline nutritional status and then reducing any nutritional deficits with the addition of Proteinex nutritional supplement (Allen, 2012). In addition, this study found that nutritional supplementation use with Proteinex incurred no significant added cost (Allen, 2012).
GAPS IN THE LITERATURE
Most of the reviewed studies that showed improved wound healing with nutritional intervention used a multimodality approach, meaning more than one micronutrients or macronutrients as part of a nutritional supplement (Allen, 2012; Anhold et al., 2010; Bourdel-Marchasson et al., 2000; Collins et al., 2005; Desneves et al., 2005; Heyman et al., 2008; Theilla et al., 2012; Williams et al., 2002). These studies provide some evidence to support beneficial nutritional supplementation for wound healing. However, more research is needed to solidify which nutrients are the most and least effective in the treatment and prevention of pressure ulcers. This article fills a gap in the literature by discussing nutritional support, including micronutrients and macronutrients involved in the healing process, and their role as part of a treatment regimen for patients with pressure ulcers.
RECOMMENDATIONS FOR PRACTICE
Long-term care facilities and inpatient hospital settings may want to consider investigating programs and resources such as FoodWorks to ensure the menu items available at their facilities are providing adequate nutrition for their residents and patients. Exploring the use of such programs and implementing their use would help to adjunct what is already being done with current dietetics at a facility. According to the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel, patients should be screened for nutritional deficiencies, and any deficiencies should be corrected (U.S. Department of Health and Human Services, 2011). In addition, these panels recommend that all individuals with pressure ulcers have a balanced diet providing adequate micronutrients (U.S. Department of Health and Human Services, 2011). Moreover, both of these guidelines specifically mention that proper amounts of protein are needed to maintain the nitrogen balance in the body to promote healing. This further highlights that special consideration or modifications of these diet guidelines are necessary for patients with renal impairment. Such patients exhibit high sensitivity to protein levels (U.S. Department of Health and Human Services, 2011).
Nurses can help to educate patients on a healthy diet that contains adequate amounts of the nutrients known to promote wound healing. Foods high in the nutrients discussed in this article are identified in Tables 1–5. These tables can be used as a resource to help educate patients. Although it is always best to get vital nutrients directly from the foods themselves, sometimes, this is not adequate or not an option, and this would warrant adding an oral nutritional supplement. All of the nutritional supplements compared in Table 6 offer nutritional value with energy and protein. Most also provide additional vitamins and minerals as well.
On the basis of the literature review, there is solid evidence that implementing the clinical practice guideline recommendation of nutritional support with micronutrients and macronutrients involved in the healing process does promote wound healing in patients with pressure ulcers. For clinical practice, providing nutritional support has a positive impact on wound healing, thus suggesting that it would improve a patient’s experience with a pressure ulcer. To better facilitate implementation of the recommendations, healthcare providers should address any outside factors that are negatively affecting the ability to incorporate the clinical practice guidelines for nutritional assessment and support. Such outside factors could include financial resources, provider availability, and patient mobility as well as other issues. Further research is warranted to quantify which nutrients are the most beneficial for promoting wound healing to help shape future practice recommendations.
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Nutrition; Pressure ulcers; Wound healing
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