NUTRITIONAL SCREENING

Nutritional screening is defined as “the process of identifying patients, clients, or groups who may have a nutrition diagnosis and benefit from nutrition assessment and intervention by a registered dietitian/nutritionist”.[2][16] 

• Indication: nutritional screening is indicated for all individuals who come in contact with healthcare services.[17]
• Method: any member of the healthcare team can conduct a nutritional screening. Guidelines recommend that nutritional screenings be performed using a validated tool.[17] 
• Frequency: the first screening is usually performed within the first 24-48 hours after first contact. Subsequent screenings are conducted at regular intervals, according to the care setting.[17]
• • In acute care facilities, the first nutritional screening is conducted within 24 hours of admission.[2]
  • In long term post acute care facilities, nutrition screening is completed upon admission and at regular intervals based on the Minimum Data Set regulations.[2]
  • In the outpatient care setting and in home health care, the first nutritional screening is completed during the first consultation.
• For all subjects identified as being malnourished or “at risk” for malnutrition, guidelines recommend a full nutritional assessment by a registered dietitian/nutritionist.[17]

Nutritional risk screening tools

Several validated nutritional screening tools exist. Those tools often include parameters such as height and weight, unintentional weight changes, changes in intake/appetite, lifestyle habits (physical activity, tobacco use), gastrointestinal disorders, and medical history.[2] Table 1 lists some commonly used nutritional screening tools and the care settings for which each tool has been validated.[2][18]

Table 1. Care settings and validated nutrition screening instruments [18]

When to refer patients to a registered dietitian/nutritionist 

To help maintain/improve skin integrity, a referral/consult to a registered dietitian/nutritionist is recommended or suggested when:

• A member of the healthcare team identifies a patient who is malnourished or at risk for malnutrition using a validated nutritional screening tool.[2][18]
• A patient presents with pressure ulcers/injuries (PU/PI). [11]
• A patient is at risk of a PU/PI and at risk of malnutrition. [11]
• A patient has other underlying conditions that require specific nutrition interventions (e.g. liver disease, kidney disease, high output enteroatmospheric fistula, etc)
• A patient presents with full thickness surgical wounds healing by tertiary intention
• A patient at risk for developing non-healing wounds is being prepared for a major elective surgical procedure
• Patient discharge is being planned. Although not always possible, guidance from a clinical dietitian and an individualized nutrition plan that the patient can follow at home may help prevent a “nutrition gap” after discharge, in which the patient does not receive enough nutrition to ensure an optimal recovery.[19]

NUTRITION CARE PROCESS (NCP)

When assessing and planning nutrition interventions for patients, registered dietitians/nutritionists usually follow a systematic approach such as the Nutrition Care Process (NCP). Developed by the Academy of Nutrition and Dietetics and adopted by countries around the world, this process includes four basic steps: nutrition assessment, diagnosis, interventions, and plan monitoring and evaluation. [16] The steps are briefly described in the following sections. 

Nutrition Assessment

Nutrition assessment consists of [2][16]:

• Client History and Food/Nutrition-Related History
• Anthropometric Measurements
• Nutrition-Focused Physical Exam
• Biochemical Data, Medical Tests, and Procedures

Client History and Food/Nutrition-Related History

History is one of the key elements in nutrition assessment and should include: food and nutrient intake, food and nutrient administration, medication, complementary/alternative medicine use, knowledge/beliefs, food and supplies availability, physical activity, nutrition quality of life.[16]

Obtaining accurate information may be challenging. Patients need to recall and be willing to share information about their eating patterns. Several tools may be utilized when obtaining food/nutrition-related history; a common method is the food record/diary:

• Food Record/Diary: self-reported account of all foods and beverages (and possibly, dietary supplements) consumed by a respondent over one or more days.[20] 
• 3-day-food record: see sample template for adults and for kids

Table 2 shows tips for dietary assessment.

Table 2. Tips to Capture Food/Nutrition-Related History

Anthropometric Measurements

Anthropometric measurements are an important component of the nutrition assessment. Frequently assessed parameters include: height, weight, body mass index (BMI), growth pattern indices/percentile ranks for children, weight history, mid-arm circumference, triceps skinfold thickness.[16][20]

Nutrition-Focused Physical Exam

Nutrition-focused physical exam includes assessment of the physical appearance, muscle and fat wasting, swallow function, appetite, and affect.[16] Rapidly regenerating tissues, such as hair, skin, lips, eyes and tongue are more likely to reflect nutritional deficiencies compared to other tissues. Table 3 below summarizes physical signs that may indicate nutrient deficiencies.

Table 3. Nutrition-Focused Physical Findings and Signs of Nutrient Deficiencies [22]

Biochemical Data, Medical Tests, and Procedures

Recent nutrition guidelines have moved away from including previously used biomarkers such as protein, albumin, prealbumin, as their sensitivity in assessing nutritional status can be altered by inflammation, hydration or other disease states.[18] For a summary of the impact of inflammation, hydration or other disease states on selected biomarkers, see Table 4. Considerations on specific tests are provided below.

Acute-phase proteins (e.g. serum albumin and prealbumin)

For screening and diagnosis of malnutrition, the ASPEN and ESPEN guidelines do not support use of acute-phase proteins such as serum albumin and prealbumin.[23]

• Rationale: it has been shown that changes in acute phase proteins such as serum albumin and prealbumin are not associated with weight loss, calorie restriction, or increased protein intake. [24] These laboratory tests appear to better reflect severity of the inflammatory response rather than poor nutritional status.[23] While probable indicators of inflammation, these biomarkers do not specifically indicate malnutrition and do not typically respond to feeding interventions in the setting of active inflammatory response.[25] Thus, relevance of these laboratory tests as indicators of malnutrition, is limited.[23]

Other laboratory indicators of inflammation

The following tests may aid in investigating the cause of malnutrition:

• Elevated C-reactive protein (CRP), white blood cell count, and blood glucose levels.[17]
• Negative nitrogen balance and elevated resting energy expenditure.[17]

Laboratory assessment of micronutrient abnormalities

• Clinical guidelines suggest that clinicians do not order laboratory testing of micronutrient status routinely, unless there is a specific acute concern, use of restrictive dietary regimes, prolonged history of undernutrition or during supplementation.[17]
• • Rationale: laboratory assessment of micronutrient abnormalities (e.g. deficiency of iron, folate or vitamin D) may not be accurate during certain disease states such as acute inflammation.[17]

• Vitamin D (serum 25-hydroxyvitamin D (25-OH-D) test): the American Society for Clinical Pathology recommends against screening for vitamin D deficiency in the general population.[26][27] Indications for screening of vitamin D deficiency include metabolic bone disease, abnormal blood calcium levels, malabsorption syndromes, chronic renal disease, chronic liver disease.[26] For patients with non-healing wounds, clinicians might opt to assess for conditions that result in vitamin D deficiency.
• Vitamin D deficiency supplementation is indicated when serum 25-hydroxyvitamin D (25-OH-D) is less than 20 ng/mL.[28]

Table 4. Impact of inflammation, hydration or other disease states on selected biomarkers

Nutrition Diagnosis

The purpose of a nutrition diagnosis is to identify and describe a specific nutrition problem that can be resolved or improved through treatment/nutrition intervention by a food and nutrition professional. A nutrition diagnosis (e.g., inconsistent carbohydrate intake) is different from a medical diagnosis (e.g., diabetes).[16]

Nutrition diagnoses considers 3 domains or categories: intake, clinical and behavioral-environmental.[16] Examples in each domain are provided below:

• Intake-related diagnosis: inadequate energy intake, inadequate oral food/beverage intake
• Clinical diagnosis: swallowing difficulty, altered gastro-intestinal function, altered nutrition-related laboratory values, underweight, overweight
• Behavioral-environmental diagnosis: food and nutrition-related knowledge deficit

Nutrition Interventions

Once nutrition assessment is completed and the gap between the nutrients needed and the nutrients consumed/absorbed is identified, efforts to meet the nutrient gap should be part of the plan of care. Oral nutritional supplements (ONS), enhanced and fortified foods can be used to prevent or manage unintended weight loss and malnutrition in individuals who are unable to meet their estimated nutritional requirements through a regular diet.

• For all patients with chronic wounds, clinical guidelines and CMS recommend that an individualized nutrition care plan be developed and implemented.[11][14][29]

Nutritional needs: patients with chronic wounds

For wounds to heal, nutrients need to be available in correct proportions throughout the wound healing phases. The wound healing process requires higher amounts of calories, protein, vitamins A, C, D3, zinc, copper and iron.[8][18][30] For suggested nutritional optimization plan for individuals with or at risk of PU/PI, see section 'Nutrition' in topic "Pressure Ulcers/Injuries - Introduction and Assessment". A summary is provided below. Macronutrient and micronutrient needs are detailed in the topic “Nutrition in Wound Healing”.

DIETARY INTAKE RECOMMENDATIONS FOR CHRONIC WONDS

General dietary intake recommendations for chronic wounds are listed in Table 5.[11][30]

Table 5. Nutrients for adults with chronic wounds [18][30][31][32][33][34] DRI: Dietary Reference Intake, RAE: Retinol Activity Equivalent  

Proteins 

It is estimated that up to 40% of healthy adults over 50 years of age do not consume the protein they need.[36] Patients with chronic wounds need even more protein, as proteins are the “building blocks” used to create new tissue.[37] However, older adults may struggle to meet protein requirements with diet alone due to motor difficulties such as chewing or swallowing.[36] In those cases, many types of food can help increase oral protein intake, and protein supplementation may be indicated. 

Protein supplementation with arginine, glutamine and beta-hydroxy-beta-methylbutyrate (HMB)

In recent years, studies have focused on protein supplementation with specific amino acids:

• Arginine and glutamine: usually, arginine and glutamine are dispensable amino acids, that is, they are naturally produced by our body. However, in the presence of stress, such as with a wound or sepsis, the body’s demand for these amino acids outweighs supply, and these amino acids become essential and indispensable in our diet.[18][31] These amino acids support several cells that participate in wound healing.[18][31] Arginine supplementation has been shown to be effective in increasing collagen deposition and promoting wound healing.[33] Supplemental glutamine has demonstrated some possible wound healing benefits that warrant further evaluation.[33][38][39]
• B-hydroxy B-methylbutyrate (HMB): HMB is a metabolite of leucine, an essential amino acid which must be obtained through diet. HMB is used in the biosynthesis of proteins and may help attenuate muscle breakdown and enhance muscle protein synthesis.[30]

Evidence and recommendations

• 2AFor patients with a Stage 2 or greater PU/PI who are malnourished or at risk of malnutrition, guidelines recommend supplemental arginine, along with high-calorie, high-protein, zinc and antioxidant oral nutritional supplements or enteral formula for adults (Grade 2A).[11][30][40] 
• For patients with chronic wounds, supplemental arginine is recommended to promote wound healing. Clinicians might opt to add supplemental glutamine and HMB in addition to arginine, if resources are available. 
• Rationale: Despite increased interest in supplemental arginine, glutamine and HMB for wound healing, only supplemental arginine has been supported by higher certainty evidence for wound healing so far.[29][30][40] To date, research on the use of supplemental glutamine and HMB with or without arginine to promote wound healing has demonstrated conflicting results.[33][41][42][43] Studies show considerable variation in supplementation methods and wound outcomes. Among the studies with favorable results, a randomized controlled trial (RCT) showed that compared to control, daily supplementation of 14 g arginine, 3 g HMB, and 14 g glutamine increased  collagen deposition in small polytetrafluoroethylene tubes that were surgically implanted in the arms of older adults.[44] However, those were healthy subjects and the blend was not tested on patients with chronic wounds. High quality randomized clinical trials are still needed to determine with confidence whether or not glutamine or HMB is effective in promoting wound healing, either alone or in combination with other amino acids.[33]
• For patients with diabetic foot ulcers, a Cochrane systematic review and meta-analysis concluded that there is not enough evidence to support arginine, glutamine and β-hydroxy-β-methylbutyrate supplementation to promote healing of diabetic foot ulcers.[1]
• • It is uncertain whether arginine, glutamine and β-hydroxy-β-methylbutyrate supplement increases the proportion of ulcers healed at 16 weeks compared with placebo (RR 1.09, 95% CI 0.85 to 1.40).[1]
• For patients with acute burn injuries, trauma, sepsis or inflammatory bowel diseases, guidelines recommend glutamine supplementation to reduce gram-negative bacteremia and decrease mortality.[34][45] Glutamine, which is severely depleted in this population, offers gut protection via maintenance of the gut barrier and gut immune function.[34]

Selection of nutritional interventions for patients with chronic wounds

Successful selection of nutritional interventions often involves some trial and error, and requires solid collaboration with the patient regarding food preferences. The patient’s support system and the bedside care team may assist with this selection as well, due to their important role in promoting adherence to the care plan.

In general:

• Real foods are preferred for optimal absorption of nutrients. However, ONS can and should be utilized when estimated needs are not met with meals and snacks. Another consideration for optimal digestion and absorption (and blood sugar control) is timing of meals, snacks and ONS, which ideally should be evenly ingested throughout the day.
• Enteral nutrition would be indicated for any patient with a viable gut who is unable to take adequate nutrients per os (PO) due to swallowing difficulty, etc. Specialized formulas with high protein content and micronutrients for wound healing may be used.
• Parenteral nutrition would be indicated for patients who are unable to absorb nutrients through their gut for more than 5-7 days.

Oral nutrition

For patients with chronic wounds who are malnourished or at risk of malnutrition, clinical guidelines recommend offering high-calorie, high-protein fortified foods and/or nutritional supplements in addition to the usual diet, if nutritional requirements cannot be achieved by normal dietary intake.[11][17]

Table 6 provides examples of foods that may help promote wound healing.[21] Table 7 shows common protein food choices that equal 1 serving. Table 8 displays the suggested amount of daily protein servings for older adults based on their weight and health status.

Table 6. Nutrients to promote wound healing

Proteins

Table 7. Estimating protein needs  (1 protein serving = 1 ounce of cooked meat = 7 grams of protein). Consider evaluating renal function and providing enough fluids. [29][46][47]

TABLE 8. Amount of protein servings per type of food [48]

Oral nutrition therapy/supplements

Patients with chronic wounds have increased nutritional needs and require specific nutrients for their wounds to heal. To meet their increased and specialized needs, patients with wounds may benefit from additional oral nutrition therapy/supplements.[36]

Oral nutrition therapy/supplements is mainly given as ONS. ONS are developed to provide energy and nutrient-dense solutions that are provided as ready to drink liquids, creams or powder supplements that can be prepared as drinks or added to drinks and foods.[17] While many ONS will increase calorie and protein intake, a specialized ONS includes certain types and amounts of specific nutrients (e.g. arginine, zinc, antioxidants) to meet the complex needs of patients with chronic wounds.[36] 

• For malnourished patients with PU/PI, it has been shown that 8 weeks of supplementation with an oral nutritional formula enriched with arginine, zinc, and antioxidants improves PU/PI healing. [40]
• • Rationale: The addition of arginine (6g/day), zinc (15mg/day) and vitamin C (500mg/day) with a high-protein formula supplement given twice daily accelerates PU/PI healing compared with the same high-protein formula supplement alone.[40] 

For a list of different brands and respective protein and calories values see topic "Nutritional Supplements Quick Reference".

Specific populations

• For patients with PU/PI: see nutrition recommendations in section ‘Nutrition’ in topic “Pressure Ulcer/Injury Treatment”
• For patients with diabetic foot ulcers, see section ‘Nutrition’ in topic “Diabetic Foot Ulcer - Treatment”
• For patients with liver disease:
• • Patients with chronic wounds may present with liver disease such as liver cirrhosis and steato-hepatitis. Wound healing in the presence of liver cirrhosis is known to be delayed, possibly due to liver insufficiency and subsequent malnutrition status.[49]
  • • Cirrhosis is a late-stage liver disease in which the liver is permanently damaged. Hepatitis and chronic alcohol abuse are frequent causes.
    • Steato-hepatitis is a type of fatty liver disease, characterized by inflammation of the liver and fat accumulation in liver.
  • For this population, involvement of a registered dietitian/nutritionist is highly recommended for specific nutritional counseling.[50]
  • Liver disease patients should be screened for malnutrition using a validated tool. [50]
  • In patients with liver cirrhosis, there is a high prevalence of malnutrition, protein depletion and trace element deficiency.[50]
  • • For patients with liver cirrhosis with malnutrition and muscle depletion, oral diet should provide 30-35 kcal/kg/day and 1.5 g protein/kg/day.[50]
• For patients with kidney disease:
• • Abnormal kidney function (also known as AKI/AKD or CKD) is highly prevalent among hospitalized patients across different clinical settings. As it relates to nutrition, the approach to these patients when hospitalized is highly complex since they represent a very heterogeneous group of subjects, with variable and widely differing metabolic characteristics and nutritional needs. [51] Thus, nutrition guidance from a registered dietitian/nutritionist is essential.
  • Patients with kidney disease should be screened for malnutrition, as it is highly prevalent in this population as well. [51]

Plan monitoring

Once nutrition interventions are implemented, plan monitoring by the registered dietitian/nutritionist in collaboration with the interprofessional team is of utmost importance. Nursing and caregivers play a major role in ensuring the interventions are carried out and outcomes are monitored (e.g. patient’s clinical course, wound healing).

Any change in conditions or failure to achieve desired goals should trigger reassessment of the nutrition plan.[2] Trends, rather than single measurements or point estimates, should be monitored.

Parameters used to evaluate the clinical course include:

• Food/Nutrition-Related History outcomes:
• • Food and nutrient intake
• Anthropometric Measurement outcomes
• • Changes in body weight/mass
  • • Total body weight
    • Lean body mass
• Nutrition-Focused Physical Finding outcomes
• • Physical appearance, muscle and fat wasting, swallow function, appetite,
  • Adequate wound healing
• Biochemical Data, Medical Tests, and Procedure Outcomes
• • Relevant laboratory tests
  • Nitrogen balance
  • Indirect calorimetry

PRACTICE TIPS

To increase protein intake:

• First try doubling up portions of protein at meal times, and offer protein rich snacks.
• ONS (e.g Boost, Ensure) are much more affordable than specialized supplements (e.g. Juven).
• Specialized supplements (e.g. Juven) contain a blend of nutrients that may include arginine and glutamine, HMB (a metabolite of the amino acid leucine), collagen protein, antioxidants (vitamins C & E), vitamin B12, and zinc. Check how many grams of protein (usually from collagen) the specialized supplement has. If not enough protein to meet daily needs, consider offering the specialized supplement together with another high protein ONS, in addition to protein rich meals and snacks. 
• For patients who cannot manage volume well, consider concentrated specialized supplements (e.g. Pro-Stat Sugar Free Advanced Wound Care - each serving size of 1 fl oz/30ml has 3.3g arginine, 17g collagen protein, citrulline, cystine, vitamin C and zinc).
• Many patients prefer unflavored ONS (versus sweet, flavored versions), which can be added to water or food.
• For a list of different brands of ONS and respective protein and calories values see topic "Nutritional Supplements Quick Reference".
  

To increase micronutrients intake:

• Add a multivitamin with minerals, per facility formulary

To narrow the nutrition gap post facility discharge:

• Patients may connect with registered dietitians/nutritionists of other members of the nutrition healthcare team via telemedicine, and receive counseling.

PATIENT EDUCATION

Education

To increase patient adherence to the care plan, education is essential. For instance, when introducing ONS, instead of just ordering it, it is important to explain the rationale to the patient (e.g. wounds require more nutrients in order to heal, the importance of nutrition in wound healing). Refer to Table 9 and the topics below for patient education materials related to nutrition in wound healing.

Table 9. Tips for people who are not eating well [21]

Patient Education Materials:

• Patient Education - Nutrition for Wound Healing : Understanding the Basics
• Patient Education - Nutrition for wound healing : What if I have other health conditions?
• Patient Education - Nutrition for wound healing in action - Step 1: Map out your meals
• Patient Education - Nutrition for wound healing in action - Step 2: Leverage supplements
• Patient Education - Nutrition for wound healing in action - Step 3: Shop smartly
• Patient Education - Nutrition for wound healing in action - Step 4: What if I don’t cook?

Support

Caregivers, family members, and the multi professional healthcare team should provide a supportive environment that encourages adherence to the care plan.

DOCUMENTATION

The registered dietitian/nutritionist and healthcare team should document all steps described above in the patient medical record. Those include:

• Nutrition screening and re-screening
• Nutrition Care Process: assessment, diagnosis, care plan and nutrition interventions, plan monitoring, including outcomes and plan reassessment
• Food intake by nursing staff

In addition, CMS states that:

“A basic assessment of the patient’s metabolic stability and adequacy of nutritional support should be included in the Plan of Care (treatment plan). Some expected parameters indicating this metabolic stability might be recently documented CBC, BUN/Creatinine (serum), albumin/prealbumin (serum), glucose and hemoglobin A1C (serum). Patients who are not following the expected progression of wound healing should have a formal nutritional assessment, using a standardized assessment such as the ASPEN criteria.”[14]