Wounds are up to 32.4% of patients in long term care (LTC). With Malnutrition rampant in LTC, it increases the risk of infection and occurrence. A Registered Dietitian (RD) can implement nutrition wound care strategies! See below for ALL the nutrition interventions you need!
What are Pressure Injuries in Long Term Care?
Pressure injuries (PI’s) are a problem in LTC associated with malnutrition, morbidity and a large cost. PI’s used to be called wounds, so I use the two interchangeably. PI’s are injuries that happen on areas of skin that are under a large amount of pressure.
Frequent Causes: Excessive time in wheelchair, beds, casts.
Frequent Areas: Butt, heels, and shoulders, back of the head, knees, and ankles (1).
Dietitians in Long Term Care: Wounds
RD’s in LTC are an essential part of the wound care team providing wound care nutrition daily. As the RD you should use a Malnutrition Screening Tool to assess if your patient is at increased risk for PI’s. If your patient is at risk, they should be put on your high risk patient tracker.
What Nutrition is Needed for Wound Healing?
Wound healing for nutrition will depend on your patient how much is needed. Nutrition can help heal PI’s if the RD does their best to implement nutrition strategies.
You will assess what stage the PI is at, current nutrition status, and much more! You will perform a full nutrition assessment to determine your patients’ needs.
Why is nutrition important for wound healing?
A patient who is malnourished will not be able to heal their wounds. Wounds need increased protein, carbohydrates and fat in their diet. You want to have high protein as the body has increased protein needs! Malnutrition increases the risk of getting a PI.
How Much Protein is Needed for Wound Healing?
I get this question ALL THE TIME when RD’s start out in LTC.
I tackle this below in the nutrition interventions section exactly how much protein is needed per kilogram of body weight. One factor that will promote wound healing is increased protein!
Fruits for Wound Healing
This area of research isn’t new, the theories are increased vitamins/nutrients in fruits will promote healing. Fruits recommended are those with high antioxidant content such as: grapes, all kinds of berries, and cruciferous vegetables.
Evidence Summary: There just isn’t concrete evidence to support fruit for wound care nutrition. It will promote good health, but won’t speed up wound healing.
Vitamins Needed for Wound Healing
Some RD’s like to trial Zinc, Vitamin A, Arginine, and other vitamins. There have been research trials, but no concrete evidence supporting increasing supplementation.
Without a full CBC, recommending supplementation is not evidence based at this time (2).
Supplements to Promote Wound Healing
Pro-stat for Wound Healing
Pro-Stat is a nutrition supplement drink to promote wound healing in Stage 3 and Stage 4 PI’s (3). It contains an amino acid blend, and is a high protein formulation. It can be a better option than other oral nutrition supplements (ONS) because of the fruit juice flavors available and formulations (4).
Recommended dosage is 1-3 servings/day at 30 mL per serving (individualise).
Role of Collagen in Wound Healing
Collagen is a protein in the body and when a PI happens, the collagen needs to reform the skin (5). Using Juven, nutrition supplement powder, promotes collagen formation. There are clinical studies on the effectiveness of adding this to a nutrition care plan (6). Clinical studies have shown the effectiveness in as little as 2 weeks.
Recommended dosage (individualize) is 2 packets per day mixed with 8 ounces.
Wound Healing Supplement Drink
Another recommendation is ONS drinks. Examples include Resource 2.0, Ensure High Protein, or you can develop a high protein/high calorie smoothie for your facility. The Geriatric Dietitian has some excellent high calorie smoothie recipes available here.
If you’re going the ONS route, these can be administered at MedPass and dosage will depend on intake, weight, and stage of PI.
Establishing Your Role
You need to establish when you should be consulted over PI’s in your facility. You should be on the wound care team. If you don’t have a nutrition referral sheet, find one here. You can use this as a form in your facility, educate staff on how to fill it out and leave it at all nursing desks.
There should be a written out policy or procedure that when a patient has impaired skin integrity, it triggers a referral to the RD. You may not perform a nutrition intervention for a stage 1 or 2, but the patient should be on your high risk tracking sheet.
Nutrition Assessment for High Risk Patients
All high risk patients should be on your spreadsheet.
You will perform a full nutrition assessment on your patient, if you are unsure how to do so, read this case study for a step-by-step process.
You should have an SGA-rating, make sure you determine if you are diagnosing malnutrition!
Nutrition Interventions for Wound Care
Your nutrition intervention will be determined by the stage of the pressure injury.
You need to individualise this for each patient, make sure you take into account the following:
- Physical mobility ability
- Wheelchair, Walker, Independent
- Food and fluid intake
- Weight history (x 6 months)
- Medications
- Diagnosis (current and historical relevant)
- Nutrition related lab values
Stage 1 and Stage 2 Wound Care Nutrition
Nutrition Goal:
1.2-1.5 g/kg BW of protein
30-35 kcal/kg BW
Adjust 5-10 kcal/kg BW for Obese
30 mL/kg BW fluid daily, minimum 1500 mL
Individualise those with Renal and fluid retention issues.
If you cannot meet the requirements through a food first approach, then look at the nutrition supplementation listed above.
Stage 3 and Stage 4 Wound Care Nutrition
1.5-2.0 g/kg BW of protein
30-40 kcal/kg BW
Adjust as necessary
35 mL/kg BW fluid daily, minimum 1500 mL
Individualise those with Renal and fluid retention issues.
If you cannot meet the requirements through a food first approach, then look at the nutrition supplementation listed above.
Nursing Care Plan for Wounds
All care plans fall under nursing, but RD’s in most places will complete nutrition sections.
You’ll fill it in as follows (each system will differ slightly – but the information will be the same):
Intervention:
High Protein, High Calorie Diet, Regular Texture, Regular Fluids.
40 kcal/kg BW protein, 35 kcal/kg BW, 35 mL/kg BW fluid calculated and implemented.
Juven 2 times daily with Medpass.
Fluids 1750 mL.
Reassess wound healing weekly.
Goals:
Promote wound healing through adequate nutrition and high protein nutrition supplement daily.
Body weight maintenance within normal body weight range (based on BMI 23.0-29.9 = 56 kg – 76 kg).
Encourage adequate food and fluid intake at meals and hs/pm snacks.
Outcomes:
Reduce Stage 3 pressure injury to buttocks to Stage 1 pressure injury within 2-4 weeks.
Sample Chart Note for Wounds
“RD received a consult for a stage 3 pressure injury to patients r-buttocks. Full nutrition assessment completed (see RD section for full report). Nutrition Diagnosis: Impaired skin integrity related to inadequate intake as evidenced by intake records 50% average, weight loss 5% in 3/12 and BMI 21.5. RD has calculated patients’ needs and recommends the following: High Protein, High Calorie Diet, Regular Texture, Regular Fluids. 40 kcal/kg BW protein, 35 kcal/kg BW, 35 mL/kg BW fluid calculated and implemented. Juven 2 times daily with Medpass. Fluids 1750 mL. RD will reassess wound healing weekly. RD will be available for consultation sooner as needed.”
Continual Monitoring of High Risk Patients
Based on your patients needs, you will need to determine how often you will follow up. It can be as often as 2-3 times per week to assess intake. Or it can be weekly. I wouldn’t stretch it beyond weekly if it is stage 3 or beyond.
High Risk Nutrition Tracker Form
As discussed throughout, it’s VERY important that you track your high risk patients. Reasons to have a patient on high risk tracking:
Malnutrition
Inadequate intake over 3+ months
Any stage of pressure injury
High risk for pressure injury
Swallowing and Chewing Issues, Dysphagia
Weight loss (significant or not)
Keep your high risk spreadsheet available for both your tracking as well as audits!
Let me know how you deal with wounds, do you follow the process that I have laid out?
