Wound Healing in Patients with Chronic Wounds - Essay Example

Does good nutrition promote wound healing in patients with chronic wounds? Customer Inserts His/Her Name Customer Inserts Grade Course Customer Inserts Tutor’s Name (18, 02, 2009) TABLE OF CONTENTS 1. Introduction……………………………………………………………………………. 2. Study purpose and design.……………………………………………………………... 3. Background……………..……………………………………………………………… a) Importance of nutrition b) Important nutrients 4. Systematic literature search…………………………………………………………….. 5. Critical appraisal……………………………………………………………………….. 6. Review.... …………………...…………………………………………………………. 7. Conclusion……………………………………………………………………………... Does good nutrition promote wound healing in patients with chronic wounds? Introduction Wound management is a major health burden on the society. Any delay in wound healing or/and wound infection puts a great financial load on health care systems. This is due to increase in dependency and hospital admissions. Chronic wounds are a large social, economic and healthcare around the world. Wound care has improved a lot in a few years. With the advances in treatment and the amount of knowledge that we have now has allowed us to evaluate and care for the wounds more accurately. We can also recognize wounds sooner now and intervene to heal it in a better way. Nutrition plays an important role in wound healing. This is due to the fact that it provides the ingredients required for the repair of the wound as well as to prevent infection (Doughty, 1992). In this article we are going to assess the importance of nutrition to wound healing. We will take into account various findings that have been published in this area. Study purpose and design The purpose of this descriptive study was to appraise the hypothesis that good nutrition leads to better healing of chronic wounds. The importance of nutrition for wound prevention as well as healing is deep-rooted (Pinchcofsky-Devin & Kaminski, 1986). Protein is most required in the nutrition that is recommended for wound patients (Lee et al., 2006). Background Importance of nutrition Wound healing depends a lot upon enough intake and proper absorption of the nutrients. Such nutrients include vitamins, minerals, proteins and calories. Lack of nutritional supplies can occur due to intake, which is when malnutrition happens; abnormal absorption, this can be due to GI tract disease; increased metabolic demands, that is draining wounds. Malnourished patients are at a greater risk of developing problems while undertaking cure. Sepsis, respiratory failure, abscesses, decreased wound healing, and death are examples of such problems. Whereas good nutrition assists healing, malnutrition hinders, impedes and complicates the process (Williams & Leaper 2000). According to Johnson (1993) the three main reasons that wounds fail to heal are poor nutrition, infection and impaired organ function. Attending to nutrition in wound care is also cost-effective. Healing can be impaired and would take a longer time if proper nutrition is not provided. Sufficient nutrition allows the body to heal wounds. Wound healing is a complicated process. Basically it is when injured tissue is replaced with new tissue. New tissue is produced by the body and this requires sufficient energy and certain nutrients, especially proteins and calories. Nutrition for chronic wounds has to be assessed on an individual basis. Infected wounds need more nutrition due to the fact that they cause greater tissue damage. Malnutrition happens when the patient does not take in enough nutrients in order to meet his metabolic needs. Usually patients are deficient in calories as well as in proteins. According to Bristrian & Blackburn (1974), 25% to 50% of the patients are malnourished on their admission to the hospital. Another fact is that 25% to 30% of the admitted patients may develop malnutrition during the period they are in the hospital. The combination of being ill and malnourished increases the incidence of concurrent sickness. Also, there is an increase in the risk of death. Many studies have found the link between malnutrition and risk of complications after operations, especially wound dehiscence (Detsky et al., 1987). According to Slachta (2008) there are various factors that can impede wound healing. These include infection, poor tissue perfusion and oxygenation, excessive wound drainage, disease, medications and aging. Another important factor is poor nutrition. Poor nutrition adversely affects the skin, tissue, and healing. Healing requires sufficient quantities of proteins, calories, minerals, vitamins and water. Proper nutrition is also necessary for collagen synthesis, which needs proteins, zinc, vitamin C and iron; collagen fibre cross-linking, which requires B-complex vitamins and copper); and creation of energy for the process of wound healing, requiring calories. Now we know that even mild nutritional deficiencies, which were previously believed to be benign, impair healing (Haydock & Hill, 1986). The commonest nutritional deficiency is PCM, protein calorie malnutrition. This changes the patient’s immune response, inflammatory reaction and tissue regeneration. All these are necessary for wound repair (Albina, 1994). Thus, according to Dickerson & Lee (1988) the main goal of proper nutritional support should be to sustain body organ function, encourage healing and develop immuno-competence. These aims can be achieved by performing a complete nutritional evaluation, deciding on the patient’s nutritional requirements, applying a plan of care and observing the results (Barr, 1994). Important nutrients Nutrients that are most important in the healing process include: Proteins: Reduction in protein can adversely affect the rate as well as the quality of wound healing (Gray & Cooper, 2001). Protein is in great demand when there is a wound. Collagen is the main protein that is made during the healing process. The quality and strength of the wound depends on the collagen made. Carbohydrates: When the body is undergoing the healing process it enters the state of hyper metabolism. In this case there is greater need for carbohydrate. The energy for cellular activity comes from glucose. In case of insufficient carbohydrates, the body starts breaking the protein to get the required energy (Gray & Cooper, 2001). Vitamins: B-complex vitamins speed up the process of wound healing. Vitamin C plays a vital role in collagen synthesis. Vitamin K is necessary for the formation of thrombin and a lack of it in the case of injury may cause haematoma. Minerals: Zinc is necessary for collagen synthesis (Occleston et al., 1995). It also inhibits bacterial growth and is needed in the immune response. Iron is another nutrient required in the synthesis of collagen and absence or lack of iron delays wound healing. Systematic literature search In order to evaluate the importance of nutrition in chronic wound healing we researched into many publications and journal articles. Databases such as MEDLINE were looked into to find the material needed to write this article. Apart from MEDLINE, use of CINAHL was also made. The search history of MEDLINE is included at the end of the article in Appendix A. Likewise, that of CINAHL is given in Appendix B. These are very reliable databases and so there is hardly any chance of there being an error in the findings by these databases. Though we have been able to get much information related to this topic and after evaluating it we can come to a conclusion, there were certain limitations in the production of this article. Firstly, the research was done briefly and in a limited time span. Research was only done using the data available on the internet. Then there was the problem of certain articles not being available due to different factors, one is cost. This may cause differences in the evidences. However, much effort has been undertaken so as not to make this an excuse for incorrect or insufficient data provided in this article. The studies that appeared to be most relevant were included in detail. Other studies that were included were those that contained relevant material. Some of the studies that were looked into and referred to are included in the following table: Author and Year Journal Type of Study Purpose Design Data Collection Key Findings ter Riet et al., 1995 Journal of Tissue Viability Clinical To find link between Vitamin C and wound healing 88 patients receiving 500mg of vitamin C for a period of 12 weeks The individuals did not show any significant improvement in wound healing Supplementation of vitamin C in non-deficient patients is unlikely to improve wound healing Reilly et al., 1988 Journal of Parenteral Nutrition Retrospective To find whether malnourishment affects healing Medical and surgical patients were studied and the probability of getting complications due to malnourishment was investigated. Patients malnourished on admission were 3.4 times more likely to experience a major complication and 3.8 times more likely to die than patients who were nourished Proper nourishment is required for healing of wounds Patricia Abu-Rumman Clinical To find whether proper nourishment helps in wound healing. A diabetic patient was undergoing surgery. The patient was malnourished. His diet was modified to include high protein source, vitamins and minerals. The rate of healing of the wound was monitored regularly. Woundhealing took place quickly which shows the need of nourishment for healing. Greenwald et al. 1990 Journal of Surgical Research Clinical To find the link between Vitamin A and wound healing Inflicted surgical flexor profundus damage and immediate repair on adult chickens They found chickens that ate a diet supplemented with vitamin A (150,000 IU/kg chicken chow) demonstrated wound-breaking strength more than double that of controls fed standard chicken chow Vitamin A may increase both collagen cross-linkage and wound breaking strength Williams et al. 2002 Ann Surg Clinical Importance of proteins to the wound healing process A mixture of arginine (14g/day), glutamine (14 g/day), and beta-hydroxy-betamethylbutyrate (HMB) (3 g/day) was given to 18 (>70 years) individuals who then underwent experimental implantation of sterile polytetrafluoroethylene tubes that could later be studied for fibroblastic migration and collagen deposition Supplementation with this mixture resulted in significantly greater wound collagen deposition than in 17 controls not supplemented Proteins help in collagen productioin which is required for healing of wounds Critical appraisal The process of wound healing is the body’s natural process of curing the injury that has occurred. It requires different nutrients for the process, the main one being proteins. This is due to the fact that healing requires the synthesis of collagen. The body's major structural protein is collagen. It is composed of three protein chains which are wound together in a tight triple helix. During the period the wound is healing, the body should be provided with proper nourishment, especially proteins as it would enhance the rate of recovery. One study conducted in this issue was by Williams et al. (2002). The article is included in the Appendix C of this essay. He performed the study in order to examine how arginine, beta-hydroxy-beta-methylbutyrate (HMB), and glutamine supplementation affected wound collagen accumulation. He supplied a mixture of arginine (14g/day), glutamine (14 g/day), and beta-hydroxy-betamethylbutyrate (HMB) (3 g/day) to 18 elderly (>70 years) individuals who then underwent experimental implantation of sterile polytetrafluoroethylene tubes that could later be studied for fibroblastic migration and collagen deposition. The result of supplementation with this mixture was much greater wound collagen deposition than in the 17 controls that were not supplemented. This study clearly shows that there is a link between nutrition and the rate of wound healing. Proper nutrition, especially enough proteins, is required by the body to heal itself. As the cells are made of proteins, the body mainly requires this nutrient to repair the injuries. However, as is shown by other studies, other different nutrients also enhance healing. As we know, in kwashiorkor, the patient suffers from deficiency in proteins. And thus, even normal skin losses are not made by the regeneration of skin. Thus those regions are subject to abrasions. Restoration of proper amounts of protein to the body can help the patient. New living tissue cannot form without protein; therefore protein is essential for healing of any wound. Review Nutritional status plays a role in wound healing (Whitney, 1999) and so optimising nutrition is important to best care in wound management. Every patient’s plan of care has to be planned on an individual basis as this would help to optimize the relationship between nutrition and wound healing (Arnold & Barbul, 2006). The aim of the healthcare team is to make sure that the patient is in the optimum nutritional state as this would allow the wounds to heal rapidly and properly. This can be achieved by giving the individual with sufficient nutrients and calories. This would promote wound healing. Nutritional intervention has to be evaluated as part of the person’s overall care plan. Success can be measured by results like increase in weight, improved functional ability, better health-related quality of life, reduced occurrence of new wounds and healing of chronic wounds. Regular evaluation is essential particularly because the benefits of nutritional support possibly may take time to turn up in the malnourished patients who have chronic wounds. From common sense and using the so many studies that have been performed, we see that wound healing requires proper nutrition. The rate of healing can be increased by providing the patient with sufficient nourishment and nutrients. The study by Patricia Abu-Rumman was made on a male patient who had undergone surgery. He was put on supplements consisting of proteins and vitamins and other essentials. The patient recovered quickly and this can be attributed to the supplements that he was provided with. The fact that patients can be recovered and healed at a faster rate if they are on a proper diet can be applied here. Though this issue is an important one, and wound care should be given its due attention, the nurses do not pay quite as much notice to it as is required. Nurses need to understand the importance of the roles of certain nutrients in wound healing. The understanding of this issue would enhance their role in the evaluation of nutritional risk. It would also allow them to easily attain the required support for patients in order to promote wound healing. According to different reports, the patients turn out to be more malnourished during their stay at the hospital. This can only be attributed to the fact that they are not well-looked after by the nurses. The nurses have to be assessing their patients properly. They should see their patients’ dietary intake and take their nutritional assessment. The nurses should collaborate with dieticians and together they should complete the report on the patient. The report should include the current nutritional status of the patient as well as what diet the patient should be put to in order to improve his condition, and according to what nutrients are lacking in his body. When nutrients are used to module the inflammatory process it is called immuno-nutrition. This promotes healing and restores the disturbed immune function. Examples of such nutrients include omega-3 polyunsaturated fatty acids along with amino acids, nucleotides, glutamine and arginine. Research has also shown that when a person is wounded his metabolism rate increases he requires more energy and nutrition. More energy is required because of the fact that both inflammation as well as cellular activity take place in the wounds. For this purpose glucose is also required by the body as it is the main source of energy. If the glucose is not available the body may break down proteins to get the required energy. Therefore, it is advisable that the patient takes enough glucose instead of letting his body make use of other nutrients for energy as proteins are more required for the synthesis of collagen and cells. If the patient continues to stay malnourished, or does not increase his daily intake of nutrients, the result may be a decrease in his weight, especially of lean body mass. Therefore, nutritional interventional has to be taken place early enough in order to prevent complications. All nurses should know the process of wound healing, its requirements, and problems and how to tackle them. If this system is followed it can help the patient substantially and improve his recovery to a great extent. This would also reduce costs and the burden on society. Conclusion Nutrition certainly does play a vital role in wound healing but there isn’t yet enough evidence as to whether supplementing the patient’s diet with certain nutrients will improve the results. More research is required to find out the supplements that will prove to be of an advantage to malnourished patients (Gray and & Cooper, 2001). However, in the meantime the patients with wounds should take a healthy and balance diet and they should have nutritional assessment as this would surely be beneficial only, and not prove to harm the person, unless the person takes an excess of the nutrient, for example of Vitamin D. As Shepherd (2003) says, nutrition plays a vital role in the pathology of wound healing. A high metabolic demand is required from patients when they have a wound, therefore it is important for the patients to receive sufficient calories that would prevent malnutrition and promote healing. The quality, and not the quantity, of the food is important. Nurses should carry out regular nutritional assessments of their patients and collaborate with dieticians to ensure that proper action is being taken. This will see to the fact that the patient is provided with a balanced diet that would promote wound healing and better health of the patient. According to Casey (1998) ‘nutritional requirements change in the presence of a wound, whether it is surgical, traumatic or chronic in nature’. Though wounds may heal in their own time, the rate of healing can be increased through identifying the patients early on if they are at any risk of malnutrition and taking the appropriate step. This would make sure that nutritional support is present before these circumstances can impair the healing process which is not what is wanted. Appendix A Arnold M & Barbul A 2006. ‘Nutrition and wound healing’. Plastic & Reconstructive Surgery. 117(7 Suppl):42S-58S. Bistrian BR, Blackburn GL, Hallowell E & Heddle R 1974. ‘Protein status of general surgical patients’. JAMA 230:858-60. Bistrian BR, Blackburn GL, Vitale J, Cochran D & Naylor J 1976. ‘Prevalence of malnutrition in general medical patients’. JAMA 235:15-18. Casey G. 1998. ‘The importance of nutrition in wound healing’. Nursing Standard. 13(3):51-4, 56.  Detsky AS, Baker JP, O'Rourke K, Johnston N, Whitwell J, Mendelson RA & Jeejeebhoy KN 1987. ‘Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery’. JPEN Journal of Parenteral and Enteral Nutrition. 11:440-6. Gray D & Cooper P 2001. ‘Nutrition and wound healing: what is the link?’. Journal of Wound Care 10(3) p86-89. Guillen EO & Barr SI 1994. ‘Nutrition, dieting, and fitness messages in a magazine for adolescent women, 1970-1990’. Journal of Adolescent Health, 15 (6), 464-472. Haydock DA & Hill GL 1986. ‘Impaired wound healing in surgical patients with varying degrees of malnutrition’. J Parenter Enteral Nutr 10:550-4.  Johnson L 1993. ‘Nutrition and wound healing’. Seminars in Perioperative Nursing. 2, 4, 238-242. Reilly J, Hull S, Albert N et al. 1988. ‘Economic impact of malnutrition: a model system for hospitalised patients’. Journal of Parenteral Nutrition. 12, 4, 371-376. Shepherd AA. 2003. ‘Nutrition for optimum wound healing’. Nursing Standard. 18(6):55-8. Whitney JD & Heitkemper MM 1999. ‘Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds’. Heart & Lung. 28(2):123-33. Appendix B DePalma JA 2008, October. ‘Wound healing and nutrition: an evidence update’. Home Health Care Management & Practice, 20(6): 493-4. Edmonds J 2007, December. ‘Nutrition and wound healing: putting theory into practice’. British Journal of Community Nursing, 12(12): Wound Care: S31-4. Fuhrman MP 2003. ‘Wound healing and nutrition’. Topics in Clinical Nutrition, 18(2): 100-10 Gillman B 2008. ‘Fuel for healing’. Nursing in the Community, 9(3): 33-5. Thompson C & Fuhrman MP 2005, June. ‘Nutrients and wound healing: still searching for the magic bullet’. Nutrition in Clinical Practice, 20(3): 331-47, 366. Appendix C Williams JZ, Abumrad N & Barbul A 2002, September. Effect of a specialized amino acid mixture on human collagen deposition. Annals of Surgery. 236(3):369-74; discussion 374-5. Retrieved February 22, 2009, from < http://ovidsp.tx.ovid.com/spa/ovidweb.cgi?&S=FAOOFPIMDODDOFCNNCGLGGCKJCKKAA00&Complete+Reference=S.sh.34%7c1%7c1> OBJECTIVE: To examine the effect of arginine, beta-hydroxy-beta-methylbutyrate (HMB), and glutamine supplementation on wound collagen accumulation in a double-blind, randomized study. SUMMARY BACKGROUND DATA: Control of wound collagen synthesis has been an elusive goal for clinicians and scientists alike. In many clinical instances, it is desired to increase collagen deposition as a means of enhancing wound strength and integrity. Arginine, a semiessential amino acid, has been shown to increase wound collagen accumulation in rodents and humans. HMB, a metabolite of leucine, regulates muscle proteolysis in animals and humans and increases collagen deposition in rodents. METHODS: Thirty-five healthy, nonsmoking human volunteers 70 years or older were enrolled and underwent subcutaneous implantation of two small, sterile polytetrafluoroethylene (PTFE) tubes into the deltoid region under strict aseptic techniques. The tubes were 1 mm in diameter and 6 cm in length with pore size of 90 to 120 microm to allow optimal ingrowth of fibroblasts and the deposition of matrix. Eighteen volunteers (mean age 75.4 years; 2 men, 16 women) were randomized to receive daily supplementation of 14 g arginine, 3 g HMB, and 14 g glutamine (total nitrogen 3.59 g) in two divided doses. The control group (n = 17; mean age 75.3 years; 6 men, 11 women) received an isonitrogenous, isocaloric supplementation of nonessential amino acids. Catheters were removed at 7 and 14 days postimplantation and analyzed for hydroxyproline (OHP, nmol/cm catheter, an index of collagen accumulation) and alpha-amino nitrogen (alpha-AN, mmol/cm, an index of total protein deposition). RESULTS: Supplements were well tolerated, without any reported side effects. Supplementation with the specialized amino acid mixture led to a significant rise in plasma arginine and ornithine levels. The specialized amino acid supplement led to a significant increase in collagen deposition (as reflected by OHP content) in the PTFE tubes without an effect on total protein accumulation. CONCLUSIONS: Collagen synthesis is significantly enhanced in healthy elderly volunteers by the oral administration of a mixture of arginine, HMB, and glutamine. This provides a safe nutritional means for increasing wound repair in patients. Bibliography Albina JE 1994. ‘Nutrition and Wound Healing’ . Journal of Parenteral and Enteral Nutrition, Vol. 18, No. 4, 367-376. Arnold M & Barbul A 2006. ‘Nutrition and wound healing’. Plastic & Reconstructive Surgery. 117(7 Suppl):42S-58S. Bistrian BR, Blackburn GL, Hallowell E & Heddle R 1974. ‘Protein status of general surgical patients’. JAMA 230:858-60. Bistrian BR, Blackburn GL, Vitale J, Cochran D & Naylor J 1976. ‘Prevalence of malnutrition in general medical patients’. JAMA 235:15-18. Casey G. 1998. ‘The importance of nutrition in wound healing’. Nursing Standard. 13(3):51-4, 56.  DePalma JA 2008, October. ‘Wound healing and nutrition: an evidence update’. Home Health Care Management & Practice, 20(6): 493-4. Dickerson J & Lee HA 1988. ‘Nutrition in the Clinical Management of Disease’. Lippincott Williams & Wilkins. Detsky AS, Baker JP, O'Rourke K, Johnston N, Whitwell J, Mendelson RA & Jeejeebhoy KN 1987. ‘Predicting nutrition-associated complications for patients undergoing gastrointestinal surgery’. JPEN Journal of Parenteral and Enteral Nutrition. 11:440-6. Doughty, D 1992. ‘Principles of wound healing and wound management’. Mosby YearBook Inc., St. Louis. Edmonds J 2007, December. ‘Nutrition and wound healing: putting theory into practice’. British Journal of Community Nursing, 12(12): Wound Care: S31-4. Fuhrman MP 2003. ‘Wound healing and nutrition’. Topics in Clinical Nutrition, 18(2): 100-10 Gillman B 2008. ‘Fuel for healing’. Nursing in the Community, 9(3): 33-5. Gray D & Cooper P 2001. ‘Nutrition and wound healing: what is the link?’. Journal of Wound Care 10(3) p86-89. Guillen EO & Barr SI 1994. ‘Nutrition, dieting, and fitness messages in a magazine for adolescent women, 1970-1990’. Journal of Adolescent Health, 15 (6), 464-472. Haydock DA & Hill GL 1986. ‘Impaired wound healing in surgical patients with varying degrees of malnutrition’. J Parenter Enteral Nutr 10:550-4.  Johnson L 1993. ‘Nutrition and wound healing’. Seminars in Perioperative Nursing. 2, 4, 238-242. Lee KS, Posthauer ME, Dorner B, Redovian V & Maloney MJ 2006. ‘Pressure ulcer healing with a concentrated, fortified collagen protein hydro/sate supplement: a randomized controlled trial’. Adv Skin Wound Care 19(2):92,94–96. Occleston N et al. 1995. ‘Matrix metalloproteinases: an essential component of cell mediated collagen contraction’. (Abstract 111). Fifth Annual Meeting Tissue Repair Society. Padova, Italy.  Patricia AS 2008. ‘Caring for chronic wounds: A knowledge update’. American Nurse Today. Volume 3, Number 7. Pinchcofsky-Devin GD & Kaminski MV 1986. ‘Correlation of pressure sores and nutritional status’. J Am Geriatr Soc. 34(6):435–440.  Reilly J, Hull S, Albert N et al. 1988. ‘Economic impact of malnutrition: a model system for hospitalised patients’. Journal of Parenteral Nutrition. 12, 4, 371-376. Shepherd AA. 2003. ‘Nutrition for optimum wound healing’. Nursing Standard. 18(6):55-8. Thompson C & Fuhrman MP 2005, June. ‘Nutrients and wound healing: still searching for the magic bullet’. Nutrition in Clinical Practice, 20(3): 331-47, 366. Whitney, JD & Heitkemper, MM 1999. ‘Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds’. Heart & Lung. 28(2):123-33. Williams L & Leaper D. 2000. Nutrition and wound healing. Clinical Nutrition 5(1), p3-5. Read More