The role of nutrition in wound healing

MedSurg Nursing, August, 1997 by Vittoria Pontieri-Lewis

Objectives

This independent study offering is designed for nurses and other health care professionals who care for and educate adult patients regarding nutrition and wound healing. The multiple choice examination that follows is designed to test your achievement of the following educational objectives. After studying this offering, you will be able to:

1. Identify three factors that place patients at risk for poor nutritional status and impaired wound healing.

2. Describe how to conduct a patient nutrition history and assessment.

3. Discuss three ways nurses can promote improved nutritional status for patients at risk for impaired wound healing.

Nutrition plays a vital role in wound healing, as it provides the raw materials needed for wound repair and the prevention of infection (Doughty, 1992). Wound healing depends upon the adequate intake and absorption of nutrients such as vitamins, minerals, proteins, and calories. Delayed or impaired wound healing occurs if nutritional supplies are lacking due to intake (malnutrition), abnormal absorption (GI tract disease or surgery), and/or increased metabolic demands (draining wounds). Patients who are mat nourished are at an increased risk for developing complications while undergoing treatment (for example, diagnostic studies, surgery, and/or other therapies). Such complications include sepsis, abscesses, respiratory failure, decreased wound healing, and death.

Malnutrition results from insufficient intake to meet the patient's metabolic needs. Most patients with malnutrition are deficient in both calories and protein. On admission to the hospital, 25% to 50% of all patients are malnourished (Bristrian, Blackburn, Vitale, Cochran, & Naylor, 1976; Coates, Morgan, Bartolucci, & Weinsier, 1993). Unfortunately, 25% to 30% of those patients admitted to a hospital well-nourished will develop malnutrition during their stay. When patients are acutely ill and malnourished they have an increased incidence of concurrent illnesses, as well as a sevenfold increase in mortality. Numerous studies have confirmed the relationship between malnutrition and the risk of complications postoperatively, specifically wound dehiscence, abscesses, and wound infection (Detsky et al., 1987).

Protein calorie malnutrition (PCM), the most common nutritional deficiency in the hospital setting, alters the patient's immune response, inflammatory reaction, and tissue regeneration, all of which are essential for wound repair (Albina, 1994). Therefore, it is apparent that the primary goal of adequate nutritional support should be to maintain body organ function, promote healing, and improve immuno-competence (Dickerson & Lee, 1988). These goals are attained by performing a thorough nutritional assessment, determining the patient's nutritional requirements, implementing a plan of care, and monitoring the outcomes (Barr, 1994).

Nutritional Assessment

An initial assessment of the patient's nutritional status will provide health care professionals with the necessary information to determine the patient's risk or degree of malnutrition. A nutritional assessment is the first step in providing the health care provider with information to develop an individualized nutritional plan. Nutritional assessments should not be left solely for the professional nurse, but should be a multidisciplinary approach consisting of the physician, pharmacist, and dietitian. In addition, the patient and/or significant other should be included in the nutritional plan to accommodate any cultural factors which may affect the patient's dietary habits. A complete nutritional assessment usually consists of a patient history, physical examination, and laboratory data

Patient History

A thorough review of the patient's medical, surgical, and social history provides a foundation for the nurse to gather information about the patient's nutritional status. For example, a prior history of gastrointestinal surgery, especially to the small intestine, may be the cause of malabsorption of vital nutrients. Patients with a wound or enterocutaneous fistula will require more protein in their diet to compensate for the metabolic losses. Other factors that place patients at nutritional risk are burns, infection, and trauma; all increase the patient's metabolic requirements.

During the initial history the nurse should pay particular attention to questions which address the patient's normal eating patterns, any recent changes in dietary intake, how foods are prepared, and any food aversions. The nurse should also question social factors that affect eating habits and place the patient at nutritional risk. For example, a patient may view eating alone as depressing and therefore is more likely to skip a meal or just snack on nonnutritious foods (Grinder Costello, 1996). Inadequate support systems may prevent the patient from grocery shopping. Financial factors such as low income place patients at nutritional risk. These patients have limited cooking facilities and limited access to food and food choices (Nutrition Screening Initiative, 1991). In addition, once many poor elderly patients have purchased their medications, they can have little money left to buy nutritious foods. All of these factors place the patient at nutritional risk and should be identified on admission and appropriate referrals made to assist the patient.