malnutrition universal screening tool (must) flow chart
TRANSCRIPT
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Nutrition in wound care: To understand the importance of nutrition in wound
healing
To identify patients with malnutrition and at risk for
malnutrition
Important of nutrition: Nutritional intervention should be reviewed as part
ofthe individuals overall care plan
There is a lot of evidence demonstrating the
essential role of nutrition inwound healing.
Improved nutritional status enables the body to heal
wounds such as the accelerated wound healing
seen with nutritional supplementation.
Without adequate nutrition healing may be impaired
and prolonged.
Poor nutrition before or during the recovery process
may delay healing and impair wound strength,
making the wound more prone to breakdown.
Patients who are at risk for malnutrition
include: Patients with chronic wound
Patients with non-healing wound
Patients with infected wound
Uncontrolled DM patients with ulcer
Underweight patients
Bed bound patients
Burn patients
Patients with co-morbidities such as uncontrolled
diabetes mellitus, dyslipidemia, cancer, kidney
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diseases and hypertension are recommended to
consult or refer to a dietitian.
Effects of wound: A wound causes a number of changes in the body
that can affect the healing process, includingchanges in energy, protein, carbohydrate, fat,vitamin and mineralmetabolism.
When the body sustains a wound, stress hormonesare released in a fight or-flight reaction and themetabolism alters in order to supply the injured
area with the nutrients it needs to heal known asthe catabolic phase.
The body experiences an increased metabolic rate,loss of total body water, and increased collagen andcellular turnover. These effects can be pronouncedeven with a small wound.
If the catabolic phase is prolonged and/or the bodyis not provided with adequate nutrient supplies,
then the body can enter a protein energymalnutrition (PEM) state.
Factors causing prolonged catabolism include theseverity of the wound and the pre-existingnutritional status of the individual.
Poor nutritionoor wound management Protein-energy malnutrition (PEM) is the most
serious type of malnutrition when there is aninadequate or impaired absorption of both proteinand energy.
PEM causes the body to break down protein forenergy, reducing the supply of amino acids neededto maintain body proteins and healing, and causingloss of lean body mass.
Therefore PEM may be directly linked to woundsthat arent healing.
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Protein loss via wound exudate needs to bemonitored. If dressings are being changedfrequently due to the amount of exudate,protein is being lost at a high rate andtherefore protein replacement should beconsidered.
PEM can be defined as low Body Mass Index (BMI) orunintentional weight loss (of 5% or more) with lossofsubcutaneous fat and/or muscle wasting.
As an individual loses more lean body mass (LBM),wound healing is more likely to be delayed.
With a 20% or greater loss of LBM wounds competewith muscles for nutrients.
If LBM loss reaches 30% or more the body will oftenprioritise the rebuilding of body over wound healingwith available protein.
This cascade demonstrates the severely negativeimpact poor nutrition can have on chronic woundhealing.
Even in todays society where we are fortunate tohave access to a variety of nutritional foods, olderpeople often suffer from malnutrition.
In fact it has been estimated that up to 60% of olderpatients in hospitals are malnourished, or at risk ofmalnutrition.
Of those in nursing homes, between 40 and 85%have malnutrition, and 20 to 60% of home carepatients are malnourished.
Patients with pressure ulcers especially larger or
multiple ulcers and ulcers on legs in people withdiabetes place high demand for nutrients on the body.
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Infected wounds also increase nutrient demand as theycause more tissue damage, further strain and a deeperulcer.
Therefore, Nutrition for chronic wounds needs tobe assessed on an individual basis
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MALNUTRITION UNIVERSAL SCREENING TOOL (MUST)
*Adopted from
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5-3. Nutrition Management
Optimal wound healing requires adequate nutrition as well as
involvement of wound management team, effective
communication and compliance to standard protocol.
Is patient
at risk for
malnutrition?
YesIs oral
intake
possible?
Commence
appropriate
diet
prescription
Re-evaluate
next visit
Yes
No
InitiateNutrition
Support*
Is GIT
function
al?
Enteral
Nutrition (EN)
Parenteral
Nutrition (PN)
Adequat
e EN?
Continue TotalEN
Consider
Combination of EN
and PN
No
Ye
sNo
Yes
No
Re-evaluate
GIT function
* Refer / Consult Dietitian for Nutrition Support
Algorithm for Nutrition
Management
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Nutrition Prescription
1. Nutrient Recommendation
Provision of some specific nutrients has been shown to promote
wound healing. Age-appropriate protein and energy needs
should be provided. Nutritional supplements with enteral or
parenteral support should be considered if target needs are not
achieved. Suspected or confirmed micronutrient deficiency
should be treated early with provision of 100% RNI
(Recommended Nutrient Intake) of micronutrients.
During the healing process, the body
needs increased amounts of calories,
protein, vitamins A and C, and
sometimes, the mineral, zinc.
Vitamin C
Vitamin C plays an important role in collagen synthesisand subsequent cross linking, as well as the formation ofnew blood vessels (angiogenesis).Adequate vitamin C levels help strengthen the healingwound.Vitamin C also has important antioxidant properties thathelp the immune system, and it increases the absorptionof iron.
Vitamin C deficiency impairs wound healing and has alsobeen associated with an increased risk of woundinfection. Research has shown vitamin Csupplementation helps promote pressure ulcer healing.Vitamin C is found mostly in fruit and vegetables,especially oranges, grapefruit, tomatoes, and leafyvegetables.Fruit juices with added vitamin C are also a good source,
although often they contain only small amounts ofvitamin C.
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Vitamin AVitamin A increases the inflammatory response in
wounds, stimulating collagen synthesis.Low vitamin A levels can result in delayed wound healingand susceptibility to infection.It has also been shown that vitamin A can restore woundhealing impaired by long term steroid therapy or bydiabetes.Serious stress or injury can cause an increase in vitaminA requirements.
While the mechanisms of vitamin A in wound healing arestill not well understood, it is clear that it plays animportant role.Supplementation with vitamin A requires caution, asthere is a risk of toxicity. Vitamin A is found in milk, cheese, eggs, fish, darkgreen vegetables, oranges, red fruits and vegetables.
Vitamin EIt is possible that vitamin E can reduce injury to thewound by controlling excessive free radicals.Contrary to popular opinion, there is limited evidence forthe benefits of vitamin E in decreasing scar formation.
There is also some evidence that suggests oralsupplementation of vitamin E over 400mg/day has anincreased health risk.
ZincZinc is a trace element, present in small amounts in thebody, which has a well established role in woundhealing.Zinc plays a key role in protein and collagen synthesis,and in tissue growth and healing.Zinc deficiency has been associated with delayed woundhealing, reduced skin cell production and reduced woundstrength.
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Zinc levels of less than 100 g/100mL have been associated with impaired wound healing, butsupplementation in people who are not zinc deficientgenerally has no benefit.Insufficient dietary intake of zinc can be furtherexacerbated by zinc loss from excess wound drainage.Dietary zinc sources include red meat, fish and shellfish,milk products, poultry and eggs.
IronIron is part of the system that provides oxygen to thesite of the wound, therefore iron (haemoglobin)
deficiency can impair healing.Iron deficiency can also result in impaired collagenproduction and strength of the wound.Iron absorption from non-meat sources can be enhancedwith vitamin C.Zinc and iron compete for absorption, therefore ifsomeone is receiving supplements of both, the zinc andiron should be given with meals but not at the same
time.The best sources of iron in the diet are red meat, offal,fish, eggs, wholemeal bread, dark green leafyvegetables, dried fruits, nuts and yeast extracts.
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Table 5-1: Recommended Nutrient Intake
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Nutrient Recommended Intake
Energy Underweight : 35 45 kcal/kg/day
Normal : 30 35 kcal/kg/day
Overweight : 25 30 kcal/kg/day Burn : 40 kcal/kg/day
Trauma : 35 45 kcal/kg/day
Carbohydrate 50 60% of Energy
DM: Encourage high fibre complex CHO e.g.
wholegrain bread, capati, brown rice according to
recommended serving sizes
Fat 30 35% of Energy
Adult : 0.8 1.5 g/kg/day
Dyslipidemia : Limit high saturated fat and fried food
Protein Chronic wound : 1.25 1.5 g/kg/day
Severely catabolic with more than one wound or
Pressure Ulcers Stage III & IV : 1.5 2.0 g/kg/day Vegetarian : consume enough protein from milk,
lentils, legumes and beans
Pharmaconutr
ients
Omega-3 fatty acid
Linoleic acid
L-Glutamine 0.2 0.5 g/kg/day
Arginine 30 60 g/day
Nutrient Recommended Intake
Vitamin A Malnourished patient : 1000 IU
Severe burn, poor nutrient store, GI dysfunction,
radiation therapy : 10,000 25,000 IU
At least 1 serving per day of dark, green &leafy
vegetables, orange or yellow vegetables, orange
fruit, liver and fortified dairy products
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Vitamin B
Complex
B1 (Thiamine) : 10 mg/day
B2 (Riboflavine) : 10 mg/day
B3 (Niacin) : 200 mg/day
B5 (Pantothenic acid) : 100 mg/day
B6 (Pyridoxine) : 20 mg/day
B7 (Biotin) : 5 mg/day
B9 (Folic acid) : 2 mg/day
B12 (Cobalamine) : 20 g/day
Vitamin C Small wound eg. Pressure ulcers /elective small to
moderate surgery:
0.5 1 g daily in 2 divided dosage
Larger injury eg: large BSA burn & Multiple trauma:
1 2 g/day
At least 1 serving per day of citrus fruits, guava,
tomato, pepper, potatoes, spinach and cruciferous
(broccoli, cabbage, cauliflower)
Vitamin E Not to exceed 670mg/day
Vitamin K 5-10mg (orally or IM 1-3 times weekly in high riskpatients)
Zinc 40 mg/day for 10 days
Red meats, seafood and fortified cereals
Selenium 100 g/day
Manganese 25 50 mg/day
Copper 2 3 mg/day
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Table 5-1: Recommended food intake
Recommend
ed ServingSizes
Food Groups
1 Serving Size
Daily Serving
(Normal
Recommenda
tion)
Daily Serving
(WoundHealing
Recommendati
on)
Rice,
noodle,
bread,
cereals,
cereal
products
and tubers
1 cup @ 2 scoops
rice / noodles /
cereals
2 slices bread
1 capati / thosai
4 8 servings 4 8 servings
Vegetables
cup @ 2 table
spoons leafy
(spinach, kangkung)
or starchy (carrots,
potato)
2 3 servings 4 servings
Fruits
1 slice papaya /
pineapple /
honeydew /
watermelon
1 whole apple /
orange
2 servings 3 servings
Fish,
poultry,
meat and
legume
1 fish (eg. kembung,
selar)
1 drumstick
2 eggs
2 table spoons beef
1 cup @ 2 scoops
2 3 servings 3 4 servings
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cooked dhall
2 tauhu/ tempeh
Milk and
milk
products
1 cup milk
1 slice of cheese
cup yogurt
1 3 servings 1 3 servings
Fats, oil,
sugar and
salt
1 tsp oil
1 tsp sugar
1 tsp salt
Eat less Eat less
If patient not eating well;
1. Suggest five to six small meals a day. Encourage smaller
meals and snacks between meals to get enough nutrition.
Make nutritious snacks like milk, ice-cream, yogurt, fruits,
sandwiches, milkshake, oats with milk, omelettes, roti
telur, cream mushroom soup, fruit or fruit juices,
cekodok, keropok lekor, pancakes, banana fritters,
kerepek, popcorn and corn in cup.
2. Use foods that are "high nutrient-dense" as below:
"Low nutrient-dense"
foods
"High nutrient-dense"
foods
Clear soup (air rebusan) Chicken / beef vegetable soup
Plain jelly Jelly with milk / fruits
Carbonated beverages Milk, milkshakes
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PopsiclesIce cream floats, smoothie, ,
ice cream
Plain bread / biscuits /
pancake
Bread / biscuits / pancake with
peanut butter / egg / tuna /
sardine
Plain porridge Chicken porridge, Fish porridge
3. Suggest variety of foods if patient experience taste
changes to find out what works for the patient. Cold foodsand foods with little odor work best. Add spices (e.g.lemongrass, pandan leaves, lime, mint leaves, herbs) inmeat, chicken, fish preparations. Take lemon/ orange/mint flavoured food or drinks to reduce the metallic orbitter taste.
4. Use an oral nutritional supplement if nothing else works.
These are available at grocery stores, drug stores, andhypermarkets. Adding milk, cocoa powder, coffee or icecream may make the supplement tastier.
5. Take a multivitamin if unable to meet the recommendedintake.
Ideas to improve nutritional status include:
Offer food and fluids in a variety of textures andconsistencies Offer assistance and allow sufficient time for mealsand enlist family members or volunteers to help Provide encouragement, without pressuring Offer a variety of nutrient dense, high calorie and highprotein meals Encourage grazing small frequent meals/snacks
Encourage frequent drinking of fluids
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Provide hydration stations for patients to access drinksat any time Provide foods that patients like Position upright when eating Allow time for individuals to eat in a relaxed manner,with time to chew, feed themselves and finish their meal Provide a pleasant mealtime environment If the individual has dentures ensure that these arewell fitted Explain that eating well, and eating the right foods, willaid recovery Provide assistance with the opening of containers, lids.
5-5. Food Myth and Truth
MYTH TRUTH
Haruan fish and ikan
linang are strongly
recommended aftersurgery for wound healing
Protein is essential for wound
healing. Haruan fish and ikan
linang / belut are good sourceof protein similar to any other
fish. Consume adequate
protein from all type of fish,
chicken, meat, lentils and
beans to promote wound
healing. Do not restrict to
haruan fish or ikan linang
only.
Eggs will induce itchiness,
pus and can cause wound
breakdown.
Eggs are considered a
complete protein source and
rich in vitamins and minerals.
There is no evidence that
consumption of eggs and egg
products are related to
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itchiness, pus and can cause
wound breakdown. Only avoid
eggs if you are allergic to it.
Female chicken meat
should not be consumed
after surgery.
Chicken meat is a good source
of protein and there is no
evidence of contraindication
after surgery.
Application ofgamat oilon
wound and drinking gamat
essence can help wound
healing.
There is no strong research
and evidence for the claim.
Usually, any type of essence
like essence of chicken,
essence of haruan fish and
gamatare high in salt and not
advisable for regular
consumption.
F. Conclusion
Nutrition is essential for the wound-healing process. The use of
a nutritional screening tool highlights those at risk of nutritional
deficiency. Regular ongoing monitoring is necessary to
evaluate the outcome of nutrition intervention and manage
feeding barriers effectively.