It's Not Just about Protein and Calories:
There are several items to consider when developing a nutritional program to promote wound healing. Dieticians in the industry may be familiar with the acronym PEARLS. We encourange you to use the following information to assist your facility in addressing nutritional needs for patients with wounds.
- P – Protein: The only nutrient that contains nitrogen, protein is responsible for breakdown and use of essential enzymes and collagen required for wound healing. Protein is needed in every part of the healing process.
- How to tell if there is a protein deficiency: Protein energy malnutrition (PEM) is extremely common in the elderly and can be evidenced by something as simple as unintended weight loss. Routine monitoring of weight, Kcal intake and protein levels are key.
- Determining the correct amount of need: Evaluation of renal function and providing adequate fluids are critical pieces. The typical Recommended Dietary Allowances (RDA) for protein intake in a healthy individual is 7 ounces per 140 pounds of body weight. In a patient who is stressed or malnourished, the need increases to 11 – 14 ounces and for critically ill or injured, the daily recommendation is 14 – 18 ounces.
- How to provide necessary protein: Even distribution throughout the entire day yields significantly more success with absorption. When dealing with the elderly, this can be a challenge. When a wound is involved, it becomes even more important. There are a multitude of protein supplements available. For example, liquids and powders are very concentrated, so only a tablespoon may be all that is needed. This can be significant for patients with poor intake. Other things to consider include taste preferences, use in feeding tubes, ease of administration, ease of digestion and cost.
- E – Energy: Unintended weight loss typically means loss of lean body mass. Poor caloric intake leads to weight loss and decreased energy needed to help the body heal.
- Dietary intake to increase energy: Liberalize the diet, provide foods and fluids of preference, consider appetite stimulants, adequate assistance at meals and supplements in the form of medications. There are a multitude of food forms available – puddings, ice cream, shakes, cookies, etc. that contain increased protein. Find and use what best fits the patient’s intake history and lifestyle.
- If there aren’t adequate calories for energy, the body will use protein: Caloric needs must be addressed first.
- A - Amino Acids: There are three types of amino acids that must be reviewed.
- Indispensible – (IAA): Essential amino acids that can only be received via intake. The body does not make them. Examples include Leucine and Tryptophan.
- Dispensable – (DAA): Non-essential amino acids that the body manufactures, but not in sufficient amounts when sick or stressed.
- Conditionally Indispensable – (CIAA): Conditional essential amino acids that the body makes, but not in sufficient amounts when sick or stressed. Examples include Arginine and Glutamine.
Note: A CIAA agent may be needed in order to promote cell growth needed for wound healing.
- R - RDAs/RDIs: Per NPUAP guidelines “Offer vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected”.
- What to provide: Typically, Multivitamins and Vitamin C are clinically appropriate to provide daily. Zinc, if indicated, should be provided in very limited doses to avoid zinc overload, which can interfere with wound healing.
- L - Lab Data: There are a multitude of misconceptions related to what laboratory data holds the most value for the clinician when developing the nutritional Care Plan.
- Serum Albumin: If more reflective of an inflammatory process rather than current nutritional status. Slow to reflect changes due to the long half life.
- Prealbumin: Also can be indicative of an inflammatory process, can be elevated with the use of corticosteroids and in renal disease.
- Hepatic Proteins: Can indicate severity of illness. Identifies risk for malnutrition.
- What to know: All of these laboratory values identify risk rather than if a patient is getting better. Changes in these values should not be used to indicate a change in protein status for patients in an acute or chronic inflammatory state in the wound.
There are three types of weight loss of that dieticians should be familiar with. They include:
- Sarcopenia: The loss of muscle mass and strength with age. Occurs with everyone. Common in Diabetics is Sarcopenic Obesity. In these patients, there is no muscle mass and no metabolism. They have an increased need for protein.
- Cachexia: Involuntary loss of body mass. A result of hypermetabolism.
- Starvation: Involuntary weight loss. Results from inadequate nutrition and poor appetite.
All of these types of weight loss contribute to poor healing. The goal is to prevent atrophy. Ensuring the patient receives enough protein to maintain body mass along with routine exercise, even gentle ROM, is crucial.
If you need help with understanding or interpreting these wound care updates, please click here to contact Harmony Healthcare International or call us at (800) 530-4413.
Collins, N., Sloan, C. Back to Basics: Nutrition as Part of the Overall Wound Treatment Plan.
Ostomy and Wound Management; April 2013