Contributed by Nestlé Health Science

Skin is the largest organ of the human body. It is tough and resilient; it renews and repairs itself from the inside while losing 30,000 to 40,000 dead skin cells from the outside every minute. Despite its significant strength, skin is vulnerable to pressure injuries. While the number of pressure injuries and venous leg ulcers rises, healing rates have not improved over the past decade. The fundamental components of wound management are:

  1. Pressure Relief and Nursing Care
  2. Dressings
  3. Nutrition: Adequate protein, calories, key vitamins and minerals, specific amino acids, and fluids are essential for healing.
    Protein depletion delays wound healing by prolonging the inflammatory and proliferation phases and impairing the wound
    remodeling phase of healing. Wounds must be treated aggressively with high-protein, calorically-adequate foods, oral
    nutritional supplements (ONS), or tube feeding formulas (TF).

Think of the key components of healing as a three-legged stool. Each of the three legs must be equal or the stool will topple over. If one leg is too short to meet its clinical goal, it can’t be fixed by adding more length to another leg; all three legs of the stool must be addressed equally to achieve a balanced treatment plan that helps accomplish healing.

In many environments, the tendency of health care professionals is to focus on one or two of the fundamentals of wound management, but not on all three equally. Nutrition is the area that is most often overlooked, which causes the care plan to become lopsided. It is unfortunate, but many clinicians do not consider malnutrition to be an issue in the home care and long-term care setting, yet nutritional status and risk for pressure injury formation have been well documented and correlated for decades. Today, medical advances allow the aging population to survive illnesses and medical events that were previously catastrophic, only to face pressure injuries.

Malnutrition, often used synonymously with under nutrition, is defined as a nutrition imbalance that can affect both overweight and underweight patients. Lack of adequate calories, protein, or other nutrients needed for tissue maintenance and repair can result in malnutrition. In 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition issued a consensus statement, recommending a standardized set of characteristics to be used to identify and document adult malnutrition status, specifically, the identification of two or more of the following characteristics was recommended for a malnutrition diagnosis:

  1. Insufficient energy (calorie) intake
  2. Unintentional weight loss
  3. Loss of muscle mass
  4. Loss of subcutaneous fat
  5. Localized or generalized fluid accumulation that may mask weight loss
  6. Diminished functional status

It is common to see a decrease in appetite and involuntary weight loss in sick patients or in those recently discharged from the
hospital. Patients with non-healing wounds are likely the ones with malnutrition and malnutrition is in direct opposition to healing.
Since wounds heal from the inside out, deficiencies in nutrients needed for wound healing may occur based on dietary intake,
malabsorption, or stress factors that increase protein requirements.
Routine nutritional screening, assessment, and intervention for malnutrition are critical for homecare patients. This can be as simple
as utilizing a validated nutrition screening tool, such as the Mini Nutritional Assessment (MNA®), which is easily completed by a
healthcare professional (or incorporated into an EHR), or the Self-MNA®, which can be completed by the home care patient or

MNA® and Self MNA®—Validated Nutrition Screening Tools

In the acute care setting, registered dietitians nutritionists perform a nutrition-focused physical exam (NFPE) on patients who are at
risk for malnutrition. NFPE incorporates techniques of a physical assessment with a concentration on evaluation of nutrient
deficiencies to establish and document a diagnosis of malnutrition. Many clues about nutritional status are found by evaluating the
hair, eye, teeth, gums, tongue, skin, nails, abdomen and extremities. In the homecare setting, a basic version of a NFPE can be
accomplished with these simple observations:

“Simplified” Nutrition-Focused Physical Exam

  • Touch shoulder gently to assess muscle wasting
  • Notice if patient’s clothing fits
  • Look closely at face and eyes to assess fat loss
  • Assess dental issues (loose fitting dentures, poor dentition)
  • Check for edema/fluid collection during wound dressing changes
  • Check weight regularly – increasing too quickly may indicate edema
  • Discuss GI issues – diarrhea and/or constipation

Providing a high-calorie high-protein diet does not require complicated mathematical calculations. Many tools are available to help
health care professionals help patients enhance the nutritional content of their diet.


Without proper nutrition, one leg of the three-legged stool becomes too short, and the process of wound healing will be compromised. A nutritious diet plays a critical role in how fast a pressure injuries heals, how strong the wound tissue becomes, and how well the body fights off infection. A poor diet may turn a small pressure injury into a chronic wound that may never seem to heal. Nestlé Health Science offers a comprehensive range of specialized products to meet the unique nutritional needs of patients with pressure injuries and other non-healing wounds. For more information on Nestlé Health Science, please page XX of this newsletter. If you have additional questions, please contact your representative, or call 1-800-422-2752 Monday-Friday from 8 am to 8 pm EST, or visit