are oxidized and excreted instead of incorporated into new tissues. Tus, protein and energy requirements increase, yet intake remains insufficient. Eventually, the body obtains the necessary substrates to fuel the healing and inflammatory processes through body protein catabolism with loss of lean body mass and unplanned weight loss.24

Nutrient requirements for healing Energy requirement. Energy consumption at rest is called resting

metabolic rate or basal metabolic rate. Inflammatory stress due to acute or chronic illness, intentional wounds (e.g., surgery) or unintentional wounds (e.g., pressure ulcers) increase RMR. Energy is required during each phase of wound healing.25 Energy expenditure is measured by direct or indirect calorim-

etry or estimated using predictive equations. Direct calorimetry measures the body’s heat output. Indirect calorimetry determines energy expenditure by measuring the body’s oxygen consumption and carbon dioxide production. In many high-acuity clinical settings, a computerized metabolic cart is used. Mathematical equations to estimate RMR or BMR include the

Mifflin-St. Jeor, Ireton-Jones or Harris-Benedict equations. Energy requirements for patients with wounds can be estimated using any of the methods described above. Te Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline recommends 30 to 35 kcal/kg actual body weight.26

Moreover, the energy estimation

is individualized based on underlying medical condition, level of physical activity and current body weight. Energy intake of 30 to 35 kcal/kg of body weight is recommended for patients at risk for developing a pressure ulcer, those who are assessed as being at risk for malnutrition and those who currently have a pressure ulcer.26 Protein requirement. Dietary proteins are composed of amino

acids linked together in a polypeptide chain. Amino acids are categorized by origin. Indispensable or essential amino acids are obtained exclusively from dietary sources and cannot be synthesized by the body. Dispensable or nonessential amino acids are synthesized by the body. Small quantities of DAAs are found in food, but often destroyed by cooking. Conditionally indispensable or conditionally essential amino acids are syn- thesized by the body, but may become indispensable under certain conditions such as physiological stress and nonhealing wounds.27 Recommendations for total protein requirements are based

on meeting two criteria:28 1. Minimum requirements for each IAA 2. Sufficient nitrogen to meet the “nonspecific” nitrogen requirement

Te Institute of Medicine, Food and Nutrition Board Recommend-

ed Dietary Allowance for protein for healthy adults is 0.8 g protein/ kg of body weight.27

Tese recommendations assume that the person

is consuming high-quality protein and adequate energy. Numerous studies of protein requirements for older adults have concluded that the RDA is not sufficient. One study concluded that adults 65 years and older needed between 1 and 1.2 g/kg of body weight.29 Stressed and injured patients/residents have greater needs for

energy and protein because of the increased requirements for protein synthesis and increased losses of amino acids. Urinary nitrogen losses increase after injury. Researchers concluded that adults 65 years and older with acute or chronic diseases may require 1.2 to 1.5 g/kg of body weight to regain or maintain lean body mass.29

Two amino acids have been identified which are of particular

importance to the healing process: glutamine and arginine. Both proteins show a significant decline following wounds and trauma. Appropriate supplementation can positively influence both rates of infection and successful healing following burns or trauma. Both proteins also appear to lessen urinary nitrogen losses.25 Of particular importance is attention to glutamine, as it is the rate-limiting substrate for protein synthesis. Additionally, gluta- mine plays many roles throughout the healing process, initially as an energy resource following the insult, then as an antioxidant and finally through its expression of properties that stimulate the immune system and release human growth hormone. Release of human growth hormone can stimulate anabolic processes, an important component to a successful healing process.25 High-quality protein is required for each phase of wound healing.25

Collaboration between physicians, the nursing staff and the RDN is vital to identify patients with slow-healing wounds and to initiate an effective plan to meet total protein requirements. Some patients may benefit from selected oral amino acid therapies if intake of IAAs is insufficient. Moreover, nursing staff may have greater insight into acceptability of selected protein supplements or timing the delivery of dietary sources of protein. Te nurse is in daily contact with patients and can initiate a formal consult or informally pass information to the dietitian — information that impacts the treatment plan. Te interprofessional team can better meet the care needs of the patient when all parties are committed to a holistic approach to wound care. Researchers have demonstrated that an even distribution of

protein throughout the day is most helpful in promoting tissue synthesis in healthy adults and elders. Consider the meals served in your healthcare unit. Te typical healthcare menu consists of relatively lower amounts of dietary protein served at breakfast compared to the midday or evening meals. Unlike fat and carbo- hydrate, the body does not store surplus protein from one meal to use for tissue synthesis at a later time. Studies have demonstrated that a modest portion of approximately 30 g of high-quality protein per meal is required to optimize tissue accretion. More than 30 grams per meal is not necessarily beneficial. Researchers found that consuming up to 90 g high-quality dietary protein in a single serving did not stimulate further protein synthesis.30-31 Although two different healthcare menus may provide about

the same grams of protein, they may not be equivalent in terms of tissue synthesis. Nursing plays a pivotal role in promoting wound healing by encouraging patients to eat sufficient protein at each meal and discouraging the practice of one “good meal” per day. Because it is a concern if patients do not like menu choices or the total volume of food, talk with the RDN about alternate food choices, protein-fortified foods and oral nutrition supplements that may be incorporated into the menus. Vitamin and mineral requirements. Tere are no evi-

denced-based guidelines for individual vitamin or mineral re- quirements for wound healing. Te Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline does not recommend multivitamin and mineral supplements for patients assessed to be at risk of pressure ulcers or who have a pressure ulcer unless dietary intake is poor or nutrient deficiencies are suspected or confirmed. Te guidelines recommend a balanced diet that pro- vides sufficient sources of vitamins and minerals.26

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