Nutrition and Wound healing_handout july 2019 (004)

Nutrition and Wound healing- education for patients and families Wounds may include surgical wounds, pressure injury previously referred as decubitus ulcers, pressure ulcers or pressure

Nutrition and Wound healing- education for patients and families

Wounds may include surgical wounds, pressure injury (previously referred as decubitus ulcers, pressure ulcers or pressure sores), diabetic foot ulcers and many more Nutrition and hydration play an important role in preserving skin and in supporting tissue repair for pressure injury or wound healing Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing Associations have been

discovered among old age, malnutrition, and the development of pressure ulcers Proper

nutritional support plays an essential role in preventing pressure ulcers and stimulating wound healing

Eating healthy, balanced meals and snacks that include the right amount of foods from all the MyPlate food groups — protein, fruits, vegetables, dairy and grains will help to promote wound healing and prevent pressure injuries Although the ideal nutrient intake to encourage wound healing is unknown, increased needs for energy, protein, certain amino acids like arginine, zinc, and Vitamins A, C, and E have been documented

Energy/ Kcal

You might benefit from about 14 to 16 kcalories/ lb body weight if you are at risk of developing

a pressure ulcer or at risk of malnutrition Energy intake can be adjusted based on weight change

or level of obesity by your Registered Dietitian Adults who are underweight or who have had significant unintended weight loss may need additional energy intake

For a hospitalized patient – medical professional especially Physicians along with Registered Dietitians may revise and modify/liberalize dietary restrictions when limitations result in

decreased food and fluid intake

Fortified foods and/or high calorie, high protein oral nutritional supplements between meals if nutritional requirements cannot be achieved by dietary intake are beneficial

Your medical team at the hospital may decide about providing you supplemental nutrition via tube feeding or parenteral nutrition when oral intake is inadequate

Protein

Protein is essential for new cell growth It is responsible for the synthesis of enzymes involved in wound healing, cell multiplication, and collagen and connective tissue synthesis All stages of healing require adequate protein, and increased protein levels have been linked to improved healing rates If you have renal disease, your Registered Dietitian might be able to individualize your protein needs for you

An adult with pressure ulcer, at risk of developing pressure ulcer or at risk of malnutrition may benefit from 0.5 to 0.7 grams protein/lb body weight daily

Include adequate protein throughout the day Include a source of protein at each meal or snack Good sources of protein include meats, beans, eggs, milk and yogurt particularly Greek yogurt, tofu, soy, nuts, and soy protein products

One serving of protein provides approximately 7 grams and includes:

 1 ounce meat, including beef, pork, poultry, seafood or wild game

 1 ounce cheese

 ¼ cup cottage cheese

 1 ounce nuts

 2 tablespoons peanut butter

 1 egg

 ½ cup beans

 1 cup milk

 6 ounces regular yogurt

 3 ounces Greek yogurt

Some strategies that might help to optimize your protein intake

 Add extra protein by sprinkling nuts into your cereal, stir-fry or salad

 Drink milk with meals and snacks

 Keep snacks nearby such as cottage cheese, yogurt, pudding, almonds and peanut butter, and crackers

 Add peanut butter or cheese to toast

 Try high calorie, high protein nutritional supplements in addition to the usual diet in between meals

Amino acids:

High protein, arginine enriched nutritional supplement may be beneficial if you have a stage III

or IV Pressure Injury or multiple pressure injuries and when nutritional requirements cannot be met with traditional high calorie and protein supplements Glutamine supplementation has not been proven to have a noticeable effect on wound healing

Hydration:

Adequate fluid intake is necessary to support the blood flow to wounded tissues and to prevent additional breakdown of the skin

30-40 ml/kg of body weight might be beneficial for an otherwise healthy individual Your Registered Dietitian might be able to individualize your fluid needs based on any other

conditions like renal or cardiac diseases

Most nutrient needs can be met through a healthy diet However, individuals with pressure ulcers may not be consuming an adequate diet to meet established nutritional reference standards People who are at risk of developing pressure ulcers should consume good sources of vitamins and minerals such as fruits, vegetables, nuts, whole grains and lean proteins However, if the dietary intake is poor or vitamin and mineral deficiencies are suspected or confirmed, a daily multivitamin with minerals for your age and gender should be consumed

Vitamin C :

In almost all people, the inclusion of fruits and vegetables in the diet can achieve the

recommended daily amount of vitamin C Good sources of Vitamin C include: citrus fruits, orange juice, tropical fruits, such as guava, papaya, and mango, red and green peppers, broccoli, spinach, collard greens, strawberries, tomatoes and peas Mega doses of vitamin C do not

improve wound healing.Only patients with vitamin C deficiency or suspected deficiency should receive supplementation

Regardless of deficiency, the following doses are sometimes recommended:

Stage I or II PU: 100-200 mg/day

Stage III or IV PU: 1000-2000 mg/day

Smokers require an additional 35 mg/day

Patients with renal failure should receive no more than 60-100 mg/day

Zinc: No research has demonstrated an effect of zinc supplementation on improved pressure

ulcer healing When clinical signs of zinc deficiency are present, zinc should be supplemented at

<40 mg elemental zinc/day Doses >40 mg/day can adversely affect copper status and possibly result in anemia Good sources of zinc include: meat, poultry, some seafood, like lobster and crab, liver, eggs, milk, whole grains, nuts, tofu and fortified cereals

Vitamin A: Good food sources of Vitamin A include liver, egg, sweet potato, carrot, peas,

broccoli, kale, spinach, collard greens, pumpkin, winter squash, cantaloupe, apricot, papaya and mango Data does not support the need for regular Vitamin A supplementation for wound

healing People who have documented Vitamin A deficiency may benefit from 10,000-50,000 IU/day orally and 10,000 IU intravenously for moderately to severely malnourished pts for no more than 10 days to avoid toxic levels People on chronic steroids may benefit from 1 week recommended prophylactically to counter act the anti-inflammatory effects of steroid therapy and immune suppression

Manage your blood sugar levels: High blood sugar makes it harder for your wound to heal

Check your blood sugar levels as directed if you have diabetes or if you have a history of high blood sugar levels Speak with your Registered Dietitian for strategies to control your blood glucose levels

How to incorporate protein in your diet if you are on dialysis

It’s important that protein comes from high quality protein sources Some high quality protein sources include eggs, chicken, tuna

Some ideas to increase protein your diet:

1 Eggs: can be incorporated in your diet as an omelet One omelet (1 full egg and 1 egg whites) with ½ ounce cheddar cheese and ½ ounce ham can provide about 17 grams of protein Egg whites are the best quality protein Two egg whites can provide you with 7.2 grams pure protein

A deviled egg snack can contribute about 6 grams of protein

2 Burgers: a three ounce burger made of turkey or lean beef can provide you with 21 grams of good quality protein along with iron to help prevent anemia

3 Chicken: is a good source of high quality protein Protein from fresh chicken products is preferable as processed products often contain large amounts of sodium and phosphorus that should be avoided by patients with kidney disease A 3 ounce cooked chicken breast may provide about 26 grams of protein

4 Cottage Cheese: Cottage Cheese is lower in potassium and phosphorus compared to milk, yogurt and cheese It may have high sodium but you might be able to create a reasonable meal/ snack by combining cottage cheese with low potassium and phosphorus fruits like berries and peaches

5 Fish: A 3-ounce portion of cooked fish has approximately 15-21 grams of protein Some good fish choices may include salmon, mackerel and rainbow trout, and shrimp

6 Greek Yogurt- A cup of Greek yogurt can provide about 22 grams of protein It may be

recommended as a meal replacement

7 High Protein Smoothie- Low potassium milk substitute can be paired with protein powder and your favorite fruit to create a high protein smoothie

8 Nutrition drinks- like Nepro or Novasource Renal are kidney specific nutrition drinks that can

be used

9 Meat substitutes: Veggie burgers, sausage, tofu, veggie crumbles can be a good meat

substitute A half cup tofu can provide about 7- 13 grams of protein However, make sure to check sodium, potassium or phosphorus in these products or consult your renal dietitian

10 Protein Bars: There are several kidney friendly protein bars available Recommended bars may contain more than 15 grams of protein, below 150 mg phosphorus and less than 200 mg potassium and sodium Some examples are: Pure Protein®, Premier Nutrition®, Balance Bars®, Zone Perfect®, EAS Myoplex®, ProMax®, PowerBar® and Atkins Advantage

National Pressure Ulcer Advisory

Prepared by Bhavna Aneja MS, RDN, LDN, CDM of Vidant Medical Center, Greenville, NC and Kathryn M Kolasa PhD, RDN, LDN of Brody School of Medicine at East Carolina University, Greenville NC

July 2019