January 2025 Issue
LTC Concerns: Aiding Wound Healing Success
By Michelle Saari, MSc, RD
Today’s Dietitian
Vol. 27 No. 1 P. 46
How Dietitians Play a Central Role on the Care Team
Long term care (LTC) is a unique work environment for dietitians and wound care is one area where dietitians may contribute significantly to the care team. In the LTC setting, wound care requires the collaboration of various health care professionals, with nutrition playing a central role. Although dietitians haven’t always been extensively involved in wound care teams, nutrition is widely recognized as a primary player in wound healing.1
As a new dietitian, it can be challenging to feel comfortable voicing opinions on the wound care team. Yet, with extensive research, education, and training, confidence grows, and it becomes clear just how important dietitians are in wound care. Their expertise in nutrition is vital for promoting healing, optimizing patient outcomes, and serving as a pivotal part of the wound care team. Recognizing this value is essential for dietitians to fully contribute to patient care.
Nutrition in Wound Healing
Wound healing requires increased energy and nutrient intake, particularly in LTC residents who often have multiple comorbidities, complex medical histories, and ongoing health issues.2 Adequate calorie and protein intake along with specific nutrients, such as arginine and zinc, are necessary to support tissue repair and immune function.3
Protein and Calorie Recommendations
Protein aids in collagen synthesis, which forms the structural framework of the skin, and research indicates that individuals with wounds have significantly increased protein needs.4
The National Pressure Injury Advisory Panel recommends a protein intake of 1.25 to 1.5 g per kg of body weight per day for patients with pressure injuries.5 To meet these protein needs, dietitians can incorporate a variety of high-protein foods and supplements into residents’ meal plans. Oral nutrition supplements (ONS) such as protein shakes and fortified drinks are convenient options that provide a concentrated source of protein.
Fortified foods, including protein-enriched puddings, cereals, and yogurts, can also help increase protein intake without significantly increasing food volume, which is particularly beneficial for residents with poor appetite.
Calories are just as important, as the body requires energy to support the processes involved in wound repair. In LTC this can be difficult as residents may struggle with decreased intake, which can make meeting daily calorie needs tough. Caloric needs for individuals with wounds generally range from 30 to 35 kcal/kg/day, depending on the stage of the wound.5
RDNs should always use their clinical judgment to determine the exact needs of each individual. Ensuring sufficient calorie intake helps preserve protein for its role in tissue repair rather than being used as an energy source.6
Arginine
Arginine, an amino acid, supports wound healing by serving as a precursor to nitric oxide, which is important for blood flow and immune function. Arginine also aids in collagen synthesis and other proteins involved in tissue repair.7 The recommended dosage for arginine supplementation typically ranges from 4.5 to 9 g per day.2 Supplementing arginine through a premade ONS designed for wound healing is ideal because it ensures precise dosing, delivers a balanced mix of essential nutrients and is backed by clinical research, all of which promote better healing outcomes. This method is also convenient and improves patient compliance, making it an effective choice in wound care management.
Micronutrients
Micronutrients play an important role in wound healing, with the mineral zinc and vitamins A, C, and B complex being particularly beneficial.8 Vitamin A supports cellular growth and immune function, helping maintain the integrity of the skin and mucous membranes. Vitamin C is necessary for collagen synthesis, a key player in wound healing, and acts as an antioxidant, protecting cells from damage. B vitamins, including B6, B12, and folate, aid in energy metabolism and the production of new cells, both essential during the wound healing process. Together, these micronutrients contribute to faster healing, reduce the risk of infection, and improve overall tissue repair.
Spotlight on Zinc
Zinc is involved in various cellular processes essential for wound healing, including DNA synthesis, protein production, and cell division.9 Zinc deficiency can impair wound healing by reducing collagen synthesis and weakening the immune response. Residents in LTC may be at higher risk for zinc deficiency due to poor dietary intake or malabsorption, making it challenging to meet their needs through diet alone. Supplementation with zinc has been shown to support healing, particularly in chronic wounds. The recommended zinc dosage for wound healing is typically 15 to 30 mg per day.10
While best practices in dietetics typically recommend a “food first” approach, the prevalence of poor intake in this population often necessitates the use of ONS that include zinc. These supplements provide a reliable and convenient way to ensure adequate zinc intake, especially in cases where dietary improvements alone may not suffice. It’s important to monitor zinc supplementation closely, as excessive intake—more common with supplements than with whole foods—can lead to immune impairment and other health risks. Therefore, while ONS can be beneficial, they should be used with caution and tailored to individual needs.
Practical Tips for the LTC Dietitian
LTC dietitians typically join many care teams,4 but perhaps where they see some of the biggest impact of their expertise is on the wound care team. If a patient has a wound and their nutrition care isn’t addressed or their nutrition is inadequate, it will be difficult if not impossible to have any success in healing.
One of the primary tasks on the team is making sure the resident gets an individualized nutrition care plan to meet their increased needs for wound healing. This includes addressing barriers to meeting those needs, such as poor appetite, difficulty swallowing, or even food preferences and aversions.
Adapt Plans for the Individual
Working in LTC, RDNs have the unique ability to tailor nutrition care plans to meet individual needs, including aligning with residents’ preferences. To ensure residents receive and consume the nutrients necessary for wound healing, dietitians should work closely with residents and caregivers to identify preferred high protein, high calorie foods. Tailoring nutrition care plans to include these preferences can help improve food acceptance, overall intake, and health outcomes.
The dietitian should meet with the resident and perform individualized nutrition assessments to determine what will work best for them. This may include collaborating with a speech language pathologist to address swallowing issues, providing high protein snacks they enjoy, or increasing the frequency of meals throughout the day. In addition to adapting plans for the individual, dietitians should regularly participate in wound care rounds. This helps them to stay informed about the progress of residents with wounds, contribute nutritional insights, and make real-time adjustments to care plans based on current wound healing status.
Create Follow-Up Plans
For residents with significant wounds, such as stage 3 and 4 pressure injuries, dietitians should create follow-up plans that include weekly assessments of nutritional status and wound healing progress.5 Regular follow-ups ensure that any changes in nutritional needs are promptly addressed. Even a five-minute daily check-in can make all the difference in correcting potential issues that arise.
Develop Educational Materials
Dietitians can amplify their impact by developing educational materials for staff, residents, and families about the importance of nutrition in wound healing. The education could look like handouts for families related to how wounds heal, holding five-minute rounds with staff about the importance of nutrition for wound healing, or hanging up posters explaining how wounds heal faster with the nutrients mentioned in this article. This education can help increase awareness, encourage adherence to nutritional interventions, and support advocating for the leading role dietitians play on the care team.
Wound Care Challenges
Wound healing in LTC is often complicated by a variety of factors. Many residents have multiple comorbidities such as diabetes, CVD, and renal disease, which can lower the body’s ability to heal. In addition, these conditions can affect circulation, immune function, and overall metabolic health and further complicate the healing journey.11
Elderly patients may also experience decreased appetite, which often leads to inadequate intake, slowing the wound healing process. As residents age, their basal caloric needs may decrease, but other nutritional needs, particularly for protein and calories during wound healing, may remain high.
Difficulty with chewing and swallowing (dysphagia) is another common symptom among elderly residents, potentially limiting their ability to consume protein-rich foods. This can result in difficulty meeting protein needs, directly impacting the body’s ability to repair tissues and heal wounds.
Decreased intake, whether due to cognitive decline, medication side effects, or gastrointestinal issues, is a significant barrier to providing the necessary nutrition for wound healing. When residents are unable to consume enough calories, protein, and micronutrients, their wounds are less likely to heal effectively, leading to prolonged recovery times and increased risk of infection or other complications.5
Recommendations for RDNs
Dietitians are an integral part of the wound care team in LTC. Their expertise in nutrition directly impacts the healing process, helping residents recover more effectively. By providing personalized nutrition care and working closely with the interdisciplinary team, dietitians ensure that the needs of residents are met, which is essential for wound healing. The following are some key points to keep in mind when working within LTC:
• Build strong, trusting relationships with residents and their families. These relationships enable the dietitian to tailor nutritional interventions more effectively, and better consider the individual preferences and needs of each patient.
• For residents with poor appetite, aiming for small, frequent meals and snacks that are calorie and protein-dense can feel more manageable.
• Wound healing-specific supplements, such as protein shakes or fortified drinks, can be an effective method for meeting nutrition goals. Some brands available include Juven, Expedite, and ArgiMent AT by Medtrition.
• LTC typically allows flexibility in menu planning and availability, making it easier to incorporate soft, high-protein foods that can help those with dysphagia who struggle with typical protein sources. Foods that may work well include scrambled eggs, cottage cheese, yogurt, and pureed beans. In-house smoothie recipes can also be made and tailored to individual homes. However, these options aren’t typically available in large hospitals.
• Adjust care plans in collaboration with the entire care team. This regular team communication ensures that nutritional interventions are continuously optimized based on the resident’s progress.
Dietitians not only support physical recovery but also enhance the overall quality of life for residents. As wound care continues to evolve, the contributions of dietitians will remain key in promoting better outcomes for those in LTC.
— Michelle Saari, MSc, RD, has been working for over a decade in long term care and health care management. She currently runs the website LongTermCareRD.com, supporting clinical dietitians working with older adults and developing a membership platform to provide readily available evidence-based resources.
References
1. van Anholt RD, Sobotka L, Meijer EP, Heyman H, Groen HW, Topinková E. Optimal wound healing requires adequate protein intake: a prospective randomized placebo-controlled trial. Am J Clin Nutr. 2010;91(3):838-845.
2. Oostingh EC, van der Schans CP, De Vries H, et al. Nutritional status and its relationship with frailty in older adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2022;70(4):1180-1191.
3. Ellinger S. Micronutrients, arginine, and glutamine: does supplementation provide an efficient tool for prevention and treatment of different kinds of wounds? Adv Wound Care (New Rochelle). 2014;3(11):691-707.
4. Wang X, Yu Z, Zhou S, Shen S, Chen W. The effect of a compound protein on wound healing and nutritional status. Evid Based Complement Alternat Med. 2022;2022:4231516.
5. National Pressure Injury Advisory Panel website. https://npiap.com. Accessed September 2, 2024.
6. Ghaly P, Iliopoulos J, Ahmad M. The role of nutrition in wound healing: an overview. Br J Nurs. 2021;30(5).
7. Barbul A. Arginine therapy for wounds: benefits and limitations. J Nutr. 2006;136(6 Suppl):1681S-1685S.
8. Hoffman H, Omar E, Eldin AM, et al. The role of nutritional support in wound healing: a systematic review and meta-analysis. Adv Wound Care (New Rochelle). 2023;12(3):121-133.
9. Zhao G, Usui ML, Lippman SI, et al. Biofilms and inflammation in chronic wounds. Nutrients. 2018;10(1):16.
10. Saper RB, Rash R. Zinc: an essential micronutrient. Am Fam Physician. 2009;79(9):768.
11. Beyene RT, Derryberry SL Jr, Barbul A. The effect of comorbidities on wound healing. Surg Clin North Am. 2020;100(4):695-705.