Nutritional Interventions to Promote Wound Healing

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Introduction   

The medical field is an ever-evolving and constantly changing arena. Advances in technology and an increased understanding of how the body works have produced newer and better procedures and techniques in healing. These initiatives, as innovative as they may be, still depend on the body’s ability to heal itself as the foundation of the recovery process.  

In turn, the body needs proper nutrition to support the healing process within itself. Nutrition is often overlooked by nurses even though it is arguably the most critical aspect of physical healing. 

Factors That Impact Wound Healing 

Wound healing is a complex process. There are a myriad of factors that impact the body’s ability to heal and recover from an injury. Comorbidities, genetic disorders, medications, and, in some cases, disease treatments (chemotherapy, radiation, steroids, etc.) can all have the potential to slow, change, or interfere with normal wound healing (2). For this course, we will discuss a few of the more common factors that nurses will undoubtedly come across during their practice. 

Diabetes 

It is estimated that this growing, global disease will impact forty million people by the year 2030. It has been proven that diabetes is responsible for more than one hundred changes in wound healing.  

These alterations have been seen across all four phases of wound healing. Platelet activation, epithelialization, collagen deposition, and granulation tissue formation are among the alterations that take place with diabetes. Worsening renal function/failure and peripheral vascular disease as a result of diabetes also affect the wound-healing process (2). 

Renal Failure 

Though most patients who have chronic kidney disease or renal failure also have multiple comorbidities that cause the renal problem, renal failure does, independently, bring a risk of diminished wound healing. Tissue edema, delayed granulation, chronic inflammation, and decreased vessel formation are all ways that renal failure impacts wound healing.  

Hemodialysis, a life-sustaining treatment of chronic renal failure, adds fuel to the fire when it comes to risks of diminished wound healing. Protein and water-soluble vitamins and nutrients are lost through the dialysis process. This includes zinc and iron and will lead to deficiencies in these needed nutrients. Further, patients on hemodialysis and patients who receive a kidney transplant as treatment for renal failure are both at higher risk for developing infections (2).  

Smoking 

Smoking causes multiple alterations within the body at the molecular level that affect normal wound healing. Vasoconstriction caused by smoking worsens wound ischemia. The highly documented negative impact that smoking has on wound healing has led physicians to decline some elective surgeries due to the risk of poor wound healing (2). 

Infection 

It is not fully understood how infection alters wound healing. It is believed to be a multifactorial process that has a range of properties that can be progressive in nature; infection-necrosis-sepsis-death. The bacteria create an environment where the collagen that repairs the injured tissue is destroyed (2). 

Obesity 

Obesity complicates virtually every disease process including normal wound healing. Wound healing complications due to obesity include increased rates of infection, hematomas, and dehiscence. Local hypoxia is also a complication that impacts wound healing (2). 

Age 

Aging also has an impact on wound healing. During the aging process, the skin loses elasticity, thickness, and water content. There is also a decrease in the skin’s blood vessels as it ages, reducing the capacity for oxygenation and nutrients. Wound closure becomes slower with aging; by age forty, the amount of time for an identical wound to heal doubles from age twenty. After the age of fifty, dermal collagen decreases by one percent per year (2). 

Malnutrition 

Malnutrition or undernutrition has a variety of effects on wound healing. Good nutrition is essential for proper wound healing and the overall recovery of the body after an injury.  

Malnutrition can lead to the loss of immune function which will affect the body’s response to infection. With malnutrition, the skin becomes thin and frail thus more apt to develop wounds. Pressure wounds are also more likely as fat deposits over pressure points become depleted. The lack of energy during malnutrition leads to immobility, increasing the possibility of wounds. Collagen synthesis is also decreased (5).

Phases of Wound Healing 

Once again, wound healing is a complex process. From a simple pin prick to a stage-four decubitus ulcer, the wound healing process itself remains the same. The body will go through the four phases of wound healing to repair the damage.  

Hemostasis 

The first phase of wound healing is hemostasis. Whether by surgery or trauma, the body attempts to achieve hemostasis at the time of the injury. The intrinsic and extrinsic coagulation cascades are activated by the body.  

Vasoconstriction takes place while platelet aggregation occurs to form a fibrin clot. This is all in an effort of the body to stop the bleeding to bring about hemostasis. As the platelets arrive at the site of injury, cytokines and growth factors are released by the platelets to initiate the inflammation process (3) (4) (5). 

Inflammation 

Inflammation is the second phase of wound healing. It starts once hemostasis has been re-established. During this phase, the previous vasoconstriction reverses and the vessels dilate.  

This brings blood to the injury site along with neutrophils, macrophages, monocytes, and other inflammatory cells. Phagocytosis is initiated and the wound is cleansed by the removal of bacteria. The wound site will swell and there may be some restrictions in mobility to the affected area (3) (5). 

Proliferation 

Phase three is proliferation. In this phase, rebuilding of the wounded tissue begins. The number of fibroblasts increases and begins to build a collagen network and prepare the wound base for new granulation tissue.  

At the same time, new blood vessels are created; a highway for oxygen and nutrients to be supplied to the site. By the end of this phase, the foundation will have been laid for full epithelialization (3) (5). 

Remodeling 

The final phase of wound healing is remodeling. Epithelialization is in full swing once granulation tissue has filled the wound. This process stimulates skin integrity restoration.  

Scar tissue is formed as proteins such as collagen and elastin along with keratinocytes are produced. The wound closes and begins to strengthen and appear “normal”; it may take a couple of years for the site to return to its fully functional pre-injured status (3). 

How Does Nutrition Impact Healing? 

Nutrition is, perhaps, the most important underlying aspect of wound healing. The mechanism of wound healing and the role nutrition plays in that process is very complex.  

Adding nutritional interventions to the wound healing care plan is generally low cost and will increase the probability of a full recovery. Nutrition is essential for all phases of the healing process. It is the foundation of wound healing.  

The malnourished patient will have difficulty progressing through the wound healing phases. Proper nutrition will also help prevent wounds such as pressure ulcers from developing in the first place.  

Understanding which nutrients are needed through the phases of wound healing will help to devise a nutritional plan of care. Energy is required in all the phases of wound healing and is only made possible through proper nutrition (3). 

Common Deficiencies 

Nutrients and proteins are the building blocks of life. They are needed for growth, maintenance, and healing of the body. Many types of nutrient deficiencies greatly impact the healing process. Here, we will discuss some of the more common nutrient deficiencies. 

Iron 

Iron plays a key role in the synthesis of hemoglobin. Hemoglobin delivers oxygen throughout the body; oxygen is required through all phases of wound healing. Iron deficiencies can lead to anemia and decreased tissue perfusion. An iron deficiency will also affect protein synthesis, macrophage function, and overall wound strength (3) (6). 

Vitamin A 

When it comes to wound healing, vitamin A quickens collagen synthesis and the overall inflammatory phase. A deficiency in vitamin A decreases collagen production, epithelization, and tissue granulation (9). 

Vitamin B 

There are eight vitamins included in the vitamin B complex. Each of the eight vitamins has its own daily recommended intake. Vitamin B promotes cell proliferation and promotes normal metabolism. In the presence of a wound, some dietitians promote doubling the daily recommended intake of the B vitamins (3). 

Vitamin C 

Vitamin C (ascorbic acid) assists with iron absorption. It is also essential in the process of collagen formation. Without vitamin C, the immune response cannot take place as needed. There are many sources of vitamin C readily available for everyday consumption (6). 

Zinc 

Zinc is used through all phases of the wound-healing process. It is used to initiate and modulate enzyme function throughout the wound healing phases. It affects immunity and assists in fibroblast proliferation and collagen production. It is also needed for granulation tissue formation (5) (6). 

Amino Acids 

Protein and amino acids are another set of nutrients that are highly essential in wound healing. The blood’s most abundant amino acid, glutamine, provides the body’s preferred energy source, glucose. Increased levels of glutamine have been shown to help with wound strength and increase the levels of mature collagen.  

Generally, the body is able to produce enough glutamine for regular function. In times of stress on the body, such as a wound, glutamine is sought out in the diet. Arginine assists in modulating the collagen deposits, increases new vessel formation, and aids in wound contraction (3). 

Special Considerations 

Tube Feedings 

Patients who use tube feedings or enteral feedings are in a unique situation when it comes to wound healing and nutrition. Once a proper nutrition assessment has been performed, a tailor-made nutrition-rich diet can be formulated and administered directly into the gut.  

Studies have shown that different formulas with supplemental nutrients have increased the ability of the body to heal faster than those without supplements. With tube feedings, patients don’t need to prefer the taste of one formula over another as it is delivered through the tube.  

The amount of formula can also be adjusted as the patient’s needs change. Though some formulas may have side effects such as diarrhea, the overall benefits usually outweigh such side effects (8). 

Chronic and Terminal Illness 

Autoimmune, inflammatory, and cancers are among the chronic and terminal diseases that are under special consideration when it comes to wound healing. These types of diseases can interrupt the immune/inflammatory response of the body thus prolonging the phases of wound healing.  

When a wound develops on a patient who is immunocompromised, there is a higher incidence of wound infection which will delay wound healing. In many of these diseases, there may be circulatory issues that decrease the body’s ability to provide the affected area with nutrient-rich blood.  

Chronic illnesses often decrease the patient’s energy levels. This can lead to immobility and increases the risk of wounds developing.  

Further, for many of these types of issues, the treatment itself can have adverse effects on wound healing. Chemotherapy, radiation therapy, and immunosuppressants all decrease the body’s ability to heal and increase the rates of infection in wounds (2). 

Supplements 

Nutritional supplements have been shown to improve wound healing and recovery outcomes. It is important that the supplements are given under the supervision of a provider as too much of some nutrients can have a detrimental effect on wound healing.  

A proper nutrition screening should be performed on all patients with wounds so that the nutrition plan can be tailored to the individual patient. These improvements to wound healing with nutritional supplementation differ based on the type of wound and the overall health of the patient.  

The patient should be monitored and reassessed regularly by a dietitian. Again, there is no cookie-cutter supplement regimen.  

Another factor to consider with supplements is the ease of following the supplement regimen. Hard to swallow pills or foul-tasting food/liquids may have a negative impact on the patient’s ability to adhere to the supplement regimen.  

Allowing the patient to choose (with the input of the provider) the method of supplement delivery along with a choice of flavors will help increase compliance with the prescribed regimen (1). 

Patient Education 

Throughout the entire wound healing process, patient education is a must. Not only is it important so that the patient can make an informed decision about their care, but the patient should understand what is going on with their bodies.  

Education fuels compliance. A comprehensive nutrition assessment will not only provide a baseline of the patient’s nutritional status but will also help identify gaps in the patient’s understanding.  

This is where the education can be focused to best help the patient meet their wound healing goals. Education must include which foods contain which nutrients, the amount of these foods to eat, and which foods will interact with the absorption processes of the nutrients.  

Discussing normal daily requirements and the requirements needed during wound healing is also needed (1). 

Conclusion

Nutrition plays a key role in wound healing. There are many factors that affect the body’s ability to acquire and use the needed nutrients. One of the most important considerations that we as healthcare providers need to put into practice is determining a patient’s nutritional status.  

A nutritional assessment should be done on patients with wounds so that a proper plan of care can be developed. Often, nutrition is an afterthought when in reality it is the foundation on which other treatments should be built upon.  

Once this has been established, the patient’s plan of care can be implemented and must include nutritional education. Needed supplements to increase the patient’s ability to heal can be added or removed as necessary when the reassessments have been completed. 

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