This document discusses nutritional needs and interventions to promote wound healing. It covers increased energy, protein, and micronutrient requirements for wound healing. Carbohydrate intake should be 55-60% of the diet to provide glucose for cellular function. Protein intake should be increased to 20-25% of calories to support new cell growth. Fat intake should be limited to 20-25% of calories or less than 2 grams/kg daily. Several vitamins and minerals like vitamins A, C, zinc, and arginine are important for collagen synthesis and wound healing. Nutrition support through oral or enteral intake can help optimize healing when needed. Non-pharmacological and pharmacological interventions may also be used to further support the nutritional

1. Skin, Wounds and Nutrition
Part 4

2. Assessing Nutritional Needs
 Energy or calorie requirements
 Protein requirements
 Micronutrient requirements

3. Energy Requirements
 May be up to 50% more calories than the
non-stressed individual
 Calculate using Harris Benedict formula,
Mifflin St Jeor, or indirect calorimetry

4. Protein Requirement
 Increased relative to increased demands for
protein synthesis and increased losses of
amino acids
 Needs
 Stage 1-- 1.0 gram/kg
 Stage 2--1-1.2 grams/kg
 Stage 3--1.25-1.5 grams/kg
 Stage 4--1.5-2.0 grams/kg
Note: Protein above 1.5 gm/kg may not help protein syntheses and may
cause dehydration, particularly in the elderly or those with impaired
renal function

5. Micronutrient Requirements
 Increased need for cellular function and
formation

6. Interventions to Promote Healing
 Provide optimum nutrition early
 adequate energy and nutrient profile
 adequate protein
 necessary micronutrients
 Use anabolic agents, if necessary
 Provide exercise stimulus to muscles, to
increase anabolism

7. Basic Principles--CHO
 55-60% of diet
 Provide as complex CHO
 glucose is the prime energy source for the cell
 Leukocytes apparently use glucose to
promote phagocytic activity of lymphocytes
prior to fibroplasia
 Maximum tolerated is 7-8 grams/kg/d for
respiratory patients
 Give insulin for glucose >250 mg/dL and
decrease intake if severe hyperglycemia

8. Basic Principles--Protein
 20-25% of diet from protein
 Increased protein intake decreases the net
nitrogen losses by increasing the amino
acid flow into the protein synthesis channel
 Essential for protein synthesis and new cell
growth
 Protein is the component of collagen and
other structural components

9. Basic Principles--Protein
 Will need increased fluids
 Higher risk for dehydration
 BUN will probably increase
NOTE: Excessive protein does NOT
encourage faster healing as the body does
not store protein but turn it into sugars

10. Basic Principles--Fat
 20-25% of the diet
 No more than 2 grams/kg/day
 Need to monitor triglycerides
 keep triglycerides < 250 mg/dL

11. Fatty Acids/Omega 3
 Synthesize prostanoids
 Normal cell membrane function
 Essential Fatty Acid Deficiency (EFAD) impairs
wound healing
 Often overlooked by RD
 Can obtain in foods and oils
 salmon, mackerel, albacore tuna, sardines, flax
 canola and soybean oil

12. Basic Principles--
Micronutrient Support
 Vitamin A
 Normal inflammatory response
 Allows epithelization, collagen synthesis, and
collagen cross-linking
 Maintains normal humoral defense
mechanism
 Seems to limit complications
 Need a good source (DAILY) in wound
healing

13. Basic Principles--
Micronutrient Support
 Vitamin A Supplements given:
 to counteract catabolic effects of
glucocorticoids
 to corticosteroid dependent patients to
promote healing
 to those with poor nutrient stores or
malabsorption
Note: Too much may exacerbate inflammatory
response

14. Basic Principles--
Micronutrient Support
 Vitamin C
 works with Amino Acids proline and lysine
during collagen synthesis
 needed for carnitine production for fatty acid
metabolism
 Reduces risk of wound reopening
 Body does not store vitamin C

15. Basic Principles--
Micronutrient Support
 Vitamin C deficiency--Scurvy
 Symptoms may develop rapidly but reverse quickly
with treatment
 Interferes with fibroblast function
 Alters healing process of collagen synthesis
 No secretion of procollagen chains
 Impaired polymerization
 Wrong amino acid sequence
 Increased blood cell fragility

16. Basic Principles--
Micronutrient Support
 Thiamine
 necessary for oxidation, reduction reactions
 helps form lysyl oxidase to strengthen collagen
 necessary for adequate collagen formation
 Vitamin K
 Responsible for normal coagulation of blood
 Prolonged bleeding times and hematoma formation
may hinder wound healing

17. Basic Principles--
Micronutrient Support
 Vitamin E
 Responsible for collagen synthesis
 Assists in wound healing
 DOES NOT prevent scar formation

18. Basic Principles--
Micronutrient Support
 Zinc
 Role in cellular proliferation and protein
synthesis
 Excess zinc may interfere with wound
healing via affecting lysyl oxidase, an
enzyme involved in collagen synthesis
 Excess interferes with copper and iron
absorption and metabolism

19. Basic Principles--
Micronutrient Support
 Zinc--cont.
 Needed for ALL enzymatic reactions
 Urinary losses increase with stress and weight
loss
 Body stores are often depleted in patients
with malnutrition, chronic diarrhea and
chronic corticosteroid use

20. Basic Principles--
Micronutrient Support
 Zinc cont.
 In deficiency state, may find low rate of
epithelialization
 Deficiency causes decreased wound and
collagen strength
 Supplementation often done in wound
management but no evidenced based studies
to prove its need

21. Basic Principles--
Micronutrient Support
 Copper
 Cofactor for connective tissue production
 Collagen polymerization
 Formation of cross linkages to enhance scar
strength
 Erythrocyte formation

22. Basic Principles--
Micronutrient Support
 Magnesium
 Necessary for all phases of wound healing
 Translation and synthesis of peptide chains
 Depletion may occur in patients with chronic
diarrhea, fistulas, SBS
 Calcium
 A cofactor for some collagenases during
remodeling
 Necessary for normal blood coagulation

23. Basic Principles--
Micronutrient Support
 Iron
 Enhances enzymatic activity of prolyl
hydroxylase during hydroxylation of proline
and lysine
 Iron stores in the elderly are at their highest
 Make sure check true anemia not anemia of
chronic disease

24. Basic Principles--
Micronutrient Support
 Arginine
 Stimulates collagen synthesis
 Enhances cellular immune mechanisms,
especially T-cell function
 Assists cell growth and replication
 Helps promote wound healing
 Obligatory precursor for wound protein
synthesis

25. Basic Principles--
Micronutrient Support
 Arginine--cont.
 Made in the kidney
 May be consumed in diet
 Breakdown of body protein
 Can be found in enteral formulas with
immune-enhancing nutrients

26. Basic Principles--
Micronutrient Support
 Glutamine
 Precursor for purines and pyrimidines
 Fuels fibroblasts
 Anti-catabolic, anabolic properties
 Preserves LBM
 Stimulates release of Human Growth
Hormone

27. Basic Principles--
Micronutrient Support
 Glutamine--cont
 Levels drop dramatically during stress
 Found in abundance normally
 Enteral formulas or modular forms available
 10-20 grams daily for supplement

28. Basic Principles--
Micronutrient Support
 Dietary Nucleotides
 Building blocks for DNA/RNA
 Improve immune function
 Assist in wound healing
 Found in any animal protein

29. Basic Principles--Water
 30 ml per kg body weight unless
contraindicated
 1 mL/cal for enteral tube feeding
 Additional 10-15 mL/kg/day when air
fluidized beds are used
 Additional for elevated temperatures

30. Basic Principles--Water
 Participates in most metabolic reactions
 Acts as a solvent for minerals, vitamins,
amino acids, glucose, and other small
molecules enabling them to diffuse in and
out of cells
 Transports vital materials to cells and
waste away from cells

31. Intervention Strategies
 Nonpharmacologic strategies
 Counseling and education
 Patients should be told about and become involved
in decisions as should the families
 Optimizing food intake
 Start with foods rather than supplements
 Calorie enhanced/protein enhance
 Supplements
 Immune enhanced formulas
 2 Kcal Med pass

32. Intervention Strategies
 Pharmacologic strategies
 Appetite stimulants
 Megace
 Metabolic nutrients
 Glutamine
 Arginine
 HMB
 Anabolic agents
 Somatotropin—(can be very expensive)
 Oxandrolone

33. Calorie Needs in Wound Healing
 30 kcal/kg body weight generally accepted
 >30 kcal/kg should promote positive
nitrogen balance
 Use indirect calorimetry if available and if
accuracy is critical
 Liberalize diet!!!!

34. Vitamin & Minerals
 Implicated in wound healing
 Remember, they do not hasten healing
once normal stores are present
 No question that information is conflicting
and confusing but with a litigation culture,
we have become a supplement oriented
society

35. Indication for Nutrition Support
 May facilitate wound healing
 Ability to optimize nutrient intake
 Must be monitored
 Must be in accordance with Advanced
Directives

36. AHCPR
The Agency for Health Care Policy and
Research
P.O. Box 8547
Silver Spring MD 20907
1-800-358-9295 (9 am to 5 pm ET)
http://www.ahrq.gov/clinic/cpgonline.htm

37. NPUAP
The National Pressure Ulcer Advisory Panel
1255 Twenty-Third Street NW, Suite 200,
Washington, DC 20037
Phone: (202) 521-6789
Fax: (202) 833-3636
E-mail: npuap@npuap.org