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A review of the use and benefits of nutritional supplements in the wound healing of orthopaedic patients
A review of the use and benefits of nutritional
supplements in the wound healing of orthopaedic patients Caroline Handel N u t r i t i o n a l health is a crucial requirement of every patient, to help fight infection and to aid recovery from illness or surgery. N u t r i t i o n plays an i m p o r t a n t part in recovery, and in particular the ability of a wound to heal may be determined by the nutritional status of the individual. Orthopaedic patients may have traumatic, surgically-made or chronic open wounds that require energy and nutrients to heal. By neglecting the nutritional health of the individual, the programme of wound management may be compromised. The importance of nutrients and the effects of u n d e r n o u r i s h m e n t will be reviewed. The potential beneficial effect of prescribing vitamins and zinc supplements will be explored. A variety of orthopaedic patients' nursing care will be examined within the review, illustrating the nurses' role in the holistic care of the patient. Editor's c o m m e n t For more than a century studies and surveys have shown that hospital patients are malnourished. McWhirter and Pennington (I 994) state that malnutrition remains an unrecognized problem in many hospitals?Elderly patients are particularly vulnerable to the adverse consequences of undernourishment', Tierney (I 996, p228). The majority of orthopaedic patients are elderly, therefore, their nutrition while in hospital requires specific and extensive attention to ensure a prompt and uneventful rehabilitation. Supplements to diet in the form of vitamins and zinc are being increasingly used to promote recovery from surgery and to aid wound and tissue repair. McWhirter J P, Pennington C R 1994 Incidence and recognition of malnutrition in hospital. BMJ 308:945-948 Tierney A J 1996 Undernutrition and elderly hospital patients: a review. Journal of Advanced Nursing 23:228-236 PD
NUTRITIONAL Caroline Handel RN ENB 219; Sister, Orthopaedic Unit at Wellington Hospital, Pinehurst,Woodhill Road, Sandon,Chelmesford,Essex CM2 7SE,UIK.TeI:01245 225337 This article wm completed while the author was a student on the orthopaedic nursing course at the Royal National Orthopaedic Hospital
ASSESSMENT
A mixed diet containing a wide variety of foods is essential to obtain all the nutrients required for normal metabolic function, and includes those needed to enhance wound heating. The primary aims of nutritional support are summarized by Seltzer et al (1982) as being to maintain body mass and organ function, to promote healing and therefore reduce the mortality associated with surgery. Following orthopaedic surgery, cells require nutrients for growth, repair, rebuilding and regulation of
Journal of OrthopaedicNursing (1997) I, 179-1829 1997HarcourtBrace& Co Ltd
their function. Wilmore (1986) carried out a study showing that a large wound can impose a considerable nutritional burden on the body, and concluded that the wound becomes a parasite in effect, altering the metabolism of the whole body in an attempt to feed itself. Therefore, it is an essential role of the orthopaedic nurse to assess the nutritional status of the patient prior to surgery and to ensure the referral to a dietician if alternatives are required. This early initial assessment will aid the plan of care for the patient.
180
Journalof OrthopaedicNursing
Case report
Case report
A 26-year-old girl, with a history of bulimia nervosa, was admitted for an anterior cruciate ligament repair, following a skiing accident. During the nursing admission it was noted she had a 'poor appetite with altered eating pattern'. Unfortunately, this was not acted upon. Three days postoperatively, she was referred to the dietician for a high protein, high calorie diet, as wound healing was slow. Full assessment of the nutritional state of this lady preoperatively, and early referral to the dietician, may have helped encourage better wound healing. Winsor et al (1988) describes how an inadequate food intake during the weeks before surgery impairs wound healing. It may even have proven cost-effective to postpone surgery for a few weeks to allow the metabolism to revert to an anabolic state, thus preventing impairment of the wound healing response. Wallace (1994) emphasizes the need to assess nutritional status outlining six reasons:
An 83-year-old man developed a pressure sore on his heel following a total hip replacement. He was commenced on a high-protein diet and a course of multi-vitamins to aid wound healing. Subsequently the wound healed quickly and effectively producing good quality tissue. Babel (1987) describes how open wounds such as pressure sores and fasciotomy sites discharge significant amounts of protein through exudate, thus reducing levels further. Delaney et al (1990) found that early postoperative feeding with proteins produced improved healing to knee replacement wounds. He concluded that wound healing is sensitive to postoperative protein intake and even small deviations can adversely affect it. Bastow et al (1983) showed the benefits of tube feeding after surgery for fractured neck of femur. Delmi et al (1990), in a similar study, found oral supplementation following meals produced earlier discharge, fewer postoperative complications and lower death rates. Fats are essential nutrients responsible for the normal functioning of all tissues. They help transport nutrients across the cell membrane and are a reserve form of energy. The role of fatty acids in wound repair is still uncertain but it appears that a deficiency could affect the repair process (Rubery 1984). Minerals help build body tissue and regulate body processes like bone formation. Zinc deficiency, particularly, results in loss of taste, reducing appetite and also crucially impairing granulation of wounds. Vitamins are organic substances needed for growth and maintenance of cells. Vitamins cannot be manufactured, but must be obtained in the diet. Specifically, Vitamin C plays a vital role in collagen formation. Collagen provides support to tissues of the skin and bone. Vitamins are the major components of the scar tissue formed during healing of skin and fractures, and a deficiency can crucially affect any wound healing.
9 The nutritional health of the individual can determine the outcome of wound management 9 Frequent nutritional assessments must be prepared, in order to detect patients with malnutrition or at risk of malnutrition 9 Energy requirements must be calculated for those deemed to be malnourished, or at risk of malnourishment 9 Early intervention is paramount to ensure that wound healing occurs unimpeded 9 The use of supplements enhances womld healing 9 Nutritional care is cost effective.
N U T R I E N T S A N D T H E EFFECTS O F DEFICIENCY The function of nutrients can be divided into three main areas: 9 To build and maintain body tissue; the body requires nutrients to constantly renew itself 9 To furnish energy; carbohydrates, fats and proteins are all classified as fuels required for body activity 9 To regulate body processes by controlling all chemical reactions in the body through what is ingested. Nutrients have vital roles to play, yet they cannot function independently. Therefore, any adverse change of one nutrient will alter the balance, thus potentially affecting wound and bone healing after trauma or surgery. Proteins, in particular, provide the foundation in every body cell for growth and maintenance. Protein deficiency delays healing and also results in healed wounds with diminished tensile strength (Steiger 1993).
VITAMIN AND ZINC SUPPLEMENTS There is now increasing evidence that vitamin and zinc supplements may be beneficial in wound healing. The following is only a fraction of the evidence that has become available. Sanapati and Thompson (1985) suggested that the demand for zinc increases in the process of wound healing, and it was found that to increase the levels in the diet could aid this process. Zinc supplements, if given immediately following a surgical or trauma wound can aid in this healing process. Arden (1990) carried out a study concluding that the presence of pressure sores is associated with increased requirements for specific nutrients, notably zinc. Prescribing zinc sulphate 220 mg TDS helped prevent pressure sore development and repair wounds already formed.
Nutritional supplements in wound healing Stress, from any source including orthopaedic surgery, can cause re-distribution of body zinc and excretion of zinc for a few days. Therefore the importance of monitoring zinc sulphate levels and the possibility of prescribing oral supplements can be beneficial. Lehman (1989) and Thompson (1991) found that reduced zinc levels from malnutrition contributed not ouly to difficulty with wound repair, but also to an increased risk of infection. Use of supplemental zinc may prevent these complications developing following orthopaedic surgery or trauma. If vitamin deficiency, particularly Vitamin C, prevents healing of skin and fractures, then it seems reasonable to suggest that prescribing supplements will stimulate healing. Certain groups of patients are at risk from vitamin deficiency, probably of dietary origin. Dickerson and Williams (1990) carried out a study that found that 82% of elderly women admitted to a District General Hospital with femoral fractures had significantly low levels of ascorbic acid. The Department of Health (1996) recommended daily allowance of Vitamin C for healthy adults is 60 mg. It can be assumed that individuals in hospital following orthopaedic surgery, who have had surgical excisions or who have developed pressure sores, will require considerably higher levels of vitamins to counteract this. Vitamin C will not be the only vitamin depleted, and multi-vitamin supplements (one tablet once or twice a day) are recommended, if diet cannot fulfil requirements. Vitamins and zinc, therefore, play an essential role in wound healing. The requirement for each may be increased following injury or surgery. Supplements may accelerate the healing process and are recommended for patients likely to be deficient or in high-risk categories, particularly the elderly or chronically sick. The orthopaedic nurse's role is to identify and assess these patients; and become involved in the education of other members of the surgical team in emphasizing the importance of nutrition as an essential factor influencing wound healing. Based on increasing amounts of evidence as to their benefits, prescription of supplements is increasingly considered cost-effective. For example, an orthopaedic patient's discharge can be delayed due to many reasons, but if it is due to poor wound healing as the patient is malnourished, then it is a very costly and unnecessary complication of surgery.
T H E A G E I N G PROCESS As we age, there are a whole host of our parameters that decline in function, such as stamina, skin condition, immune system and digestion. The rate at which these parameters decline varies between individuals, and is strongly influenced by lifestyle and nutritional factors. For example, reduced
181
metabolic rate decreases calorie requirements. The elderly require less calories so their need for food reduces, yet the body still needs the same levels of nutrients to function. Therefore, the elderly become potentially the worst-nourished group, and small amounts of low calorie food, enriched in nutrients, become vital. This is also the group who are most likely to be in hospital, and due to osteoporotic changes leading to fractures, the ageing population are most likely to be admitted to orthopaedic units.
Case report An 87-year-old gentleman fell at home and sustained a fractured acetabulum. He lived alone and had refused meals-on-wheels or Home Help to prepare food, as he wished to remain independent. On admission, he was underweight and complained of lethargy. The following day he had an operation to replace the fractured acetabulum. Surgically, the operation was a success, but the wound failed to heal. He was referred to a dietician but could only tolerate small meals. After 4 weeks the wound eventually began to heal and he was finally discharged 6 weeks later. It had therefore taken the patient 10 weeks as an in-patient to recover from a routine operation. It is clear that malnutrition, prior to admission and during hospitalization, was evident, an important factor which delayed his recovery. He was unable to tolerate the hospital food. A review of his diet and the prescription of vitamin and zinc sulphate supplements at an earlier stage could have aided his recovery as he was unable to tolerate the recommended diet. Ahmed (1992) identified factors that are responsible for malnutrition in the elderly. Taste, smell and thirst sensations decrease with age. He found that the amount of taste buds in children is approximately 245. In a comparison group of adults aged 74-85 years this level had reduced to a mere 88, which might explain the loss of appetite commonly found in this age group. Following orthopaedic surgery, where there is an increased demand by the body for nutrients, nurses should encourage an increased dietary intake. This is often not possible, and therefore supplements should be considered for this age group, so that malnutrition does not affect healing.
Case report A 92-year-old gentleman was admitted to the orthopaedic unit for release of bilateral Dupuytren contracture. He lived in a bungalow with his wife who was 90 years old and suffered with Alzheimer's disease. She needed her meals prepared and assistance with washing. The man had diabetes mellitus, otherwise he was active and capable of looking after himself and his wife, with the aid of a Home Help for washing.
182
Journal of Orthopaedic Nursing
O n admission it was noted that he was 7 stone in weight, which was underweight for his build. His skin was dry and thin, suggesting dehydration. He had a pressure sore on his sacrum that he said had been there for approximately 2 weeks. During the initial assessment, a dietary history was taken. Information was obtained about eating patterns, the presence of weight loss, any nausea, taste changes, difficulty buying and preparing food and financial restrictions. The patient was unable to maintain his nutritional status w h e n well, so it was anticipated that following surgery the problem would increase. This would affect wound healing and could delay his rehabilitation. Ill fitting dentures prevented him chewing effectively, so a soft diet was ordered. He disliked milk, so milk supplement drinks were not an option. Rehydration with intravenous fluids was c o m m e n c e d preoperatively to regain adequate hydration prior to surgery. He was c o m m e n c e d on multi-vitamins once daily and zinc sulphate tablets 200 m g three times daily pre- and postoperatively. Food charts were c o m m e n c e d to monitor nutritional intake after surgery. Due t o t h e history of diabetes, the wounds were observed closely. Surgery was successful, and both wounds healed within the optimum time. On discharge, a H o m e Help was arranged to buy and deliver shopping, helping him to choose a balanced diet rich in vitamins and high in protein. He was assessed by the occupational therapist and was given adaptations to help him prepare and eat food. He was prescribed multi-vitamins and zinc sulphate tablets as the pressure sore on his sacrum was still healing. It can be concluded that by effectively assessing nutritional status, a plan of care can be delivered which aids recovery and reduces the risk of the complications of delayed wound healing.
CONCLUSION Nutritional support is essential for the holistic care of the orthopaedic patient. If not considered, it may have a detrimental effect on the individual, decreasing wound tensile strength, prolonging rehabilitation and increasing the complications of delayed healing. Early assessment of nutritional status is essential, and the correct levels of nutrients required for wound healing following orthopaedic surgery are
vital, particularly vitamins and zinc. If these levels of nutrients cannot be obtained from diet, then the introduction of supplements can be beneficial. Wounds heal most successfully in well-nourished individuals, and as orthopaedic nurses we must ensure patients with wounds receive the best nutrition possible. 'By improving eating habits and nutritional status, this in turn may provide a better internal environment for heating' (Lewis 1993).
REFERENCES Ahmed F 1992 Effect of nutrition on health of the elderly. Journal of American Dieticians Association 92: 1102-1104 Argen M 1990 Zinc in wound healing. Linkoping University, Sweden Bastow M D, Rawlings J, Allison S P 1983 Benefits of supplementary tube feeding after fractured neck of femur. BMJ 287:1589-1592 Bobel L 1987 Nutritional implications in the patient with pressure sores. Clinical Nursing 22:379-390 Delaney H, Demetrov A, The E 1990 Effect of early post operative support on skin wound healing. Parenteral and Enteral Nutrition 14:357-360 Delmi M, Rapin C H, Bengoa J M, Delmas P D, Vasey H, Bonjour J P 1990 Dietary supplementation in elderly patients with fractured neck of femur. Lancet 1013-1016 Department of Health 1996 Dietary reference values for food energy and nutrients for the UK. HMSO, London Dickerson T, Williams C 1990 Vitamin related disorders. In: The Metabolic and Molecular basis of acquired Diseases. Tindall, London Lehman A B 1989 Review: undernutrition in elderly people. Age & Ageing 18:339-353 Lewis B 1993 Nutritional intake and wound healing in elderly people. Journal of Wound Care 2(4): 227-229 Rubery R 1984 Role of nutrition in wound healing. Surgical Clinics of North America 64(4): 703-714 Seltzer M, Slocum H, Belcher E I982 Instant nutritional assessment: Weight loss and surgical mortality. Parenteral and Enteral Nutrition 6:218-221 Senapati A, Thompson R 1985 Zinc deficiency and the prolonged accumulation of zinc in wounds. British Journal of Surgery 2:561 Steiger T 1993 Post operative intravenous nutrition: Effects of body weight, protein regeneration, wound healing and liver morphology. Surgery 73(5): 681--691 Thompson R 1991 Assessment of zinc status. Proceedings of Nutrition Society 150:19-28 Wallace E 1994 Feeding the wound. Nutrition and wound care. British Journal of Nursing 3(13): 662-667 Wilmore D 1986 Influence of wounds on local and systemic responses to injury. A M Surgery: 444-458 Winsor J, Knight G, Hill G 1988 Wound healing response in surgical patients: recent food intake is more important than nutritional status. British Journal of Surgery 75: 135-137
supplements in the wound healing of orthopaedic patients Caroline Handel N u t r i t i o n a l health is a crucial requirement of every patient, to help fight infection and to aid recovery from illness or surgery. N u t r i t i o n plays an i m p o r t a n t part in recovery, and in particular the ability of a wound to heal may be determined by the nutritional status of the individual. Orthopaedic patients may have traumatic, surgically-made or chronic open wounds that require energy and nutrients to heal. By neglecting the nutritional health of the individual, the programme of wound management may be compromised. The importance of nutrients and the effects of u n d e r n o u r i s h m e n t will be reviewed. The potential beneficial effect of prescribing vitamins and zinc supplements will be explored. A variety of orthopaedic patients' nursing care will be examined within the review, illustrating the nurses' role in the holistic care of the patient. Editor's c o m m e n t For more than a century studies and surveys have shown that hospital patients are malnourished. McWhirter and Pennington (I 994) state that malnutrition remains an unrecognized problem in many hospitals?Elderly patients are particularly vulnerable to the adverse consequences of undernourishment', Tierney (I 996, p228). The majority of orthopaedic patients are elderly, therefore, their nutrition while in hospital requires specific and extensive attention to ensure a prompt and uneventful rehabilitation. Supplements to diet in the form of vitamins and zinc are being increasingly used to promote recovery from surgery and to aid wound and tissue repair. McWhirter J P, Pennington C R 1994 Incidence and recognition of malnutrition in hospital. BMJ 308:945-948 Tierney A J 1996 Undernutrition and elderly hospital patients: a review. Journal of Advanced Nursing 23:228-236 PD
NUTRITIONAL Caroline Handel RN ENB 219; Sister, Orthopaedic Unit at Wellington Hospital, Pinehurst,Woodhill Road, Sandon,Chelmesford,Essex CM2 7SE,UIK.TeI:01245 225337 This article wm completed while the author was a student on the orthopaedic nursing course at the Royal National Orthopaedic Hospital
ASSESSMENT
A mixed diet containing a wide variety of foods is essential to obtain all the nutrients required for normal metabolic function, and includes those needed to enhance wound heating. The primary aims of nutritional support are summarized by Seltzer et al (1982) as being to maintain body mass and organ function, to promote healing and therefore reduce the mortality associated with surgery. Following orthopaedic surgery, cells require nutrients for growth, repair, rebuilding and regulation of
Journal of OrthopaedicNursing (1997) I, 179-1829 1997HarcourtBrace& Co Ltd
their function. Wilmore (1986) carried out a study showing that a large wound can impose a considerable nutritional burden on the body, and concluded that the wound becomes a parasite in effect, altering the metabolism of the whole body in an attempt to feed itself. Therefore, it is an essential role of the orthopaedic nurse to assess the nutritional status of the patient prior to surgery and to ensure the referral to a dietician if alternatives are required. This early initial assessment will aid the plan of care for the patient.
180
Journalof OrthopaedicNursing
Case report
Case report
A 26-year-old girl, with a history of bulimia nervosa, was admitted for an anterior cruciate ligament repair, following a skiing accident. During the nursing admission it was noted she had a 'poor appetite with altered eating pattern'. Unfortunately, this was not acted upon. Three days postoperatively, she was referred to the dietician for a high protein, high calorie diet, as wound healing was slow. Full assessment of the nutritional state of this lady preoperatively, and early referral to the dietician, may have helped encourage better wound healing. Winsor et al (1988) describes how an inadequate food intake during the weeks before surgery impairs wound healing. It may even have proven cost-effective to postpone surgery for a few weeks to allow the metabolism to revert to an anabolic state, thus preventing impairment of the wound healing response. Wallace (1994) emphasizes the need to assess nutritional status outlining six reasons:
An 83-year-old man developed a pressure sore on his heel following a total hip replacement. He was commenced on a high-protein diet and a course of multi-vitamins to aid wound healing. Subsequently the wound healed quickly and effectively producing good quality tissue. Babel (1987) describes how open wounds such as pressure sores and fasciotomy sites discharge significant amounts of protein through exudate, thus reducing levels further. Delaney et al (1990) found that early postoperative feeding with proteins produced improved healing to knee replacement wounds. He concluded that wound healing is sensitive to postoperative protein intake and even small deviations can adversely affect it. Bastow et al (1983) showed the benefits of tube feeding after surgery for fractured neck of femur. Delmi et al (1990), in a similar study, found oral supplementation following meals produced earlier discharge, fewer postoperative complications and lower death rates. Fats are essential nutrients responsible for the normal functioning of all tissues. They help transport nutrients across the cell membrane and are a reserve form of energy. The role of fatty acids in wound repair is still uncertain but it appears that a deficiency could affect the repair process (Rubery 1984). Minerals help build body tissue and regulate body processes like bone formation. Zinc deficiency, particularly, results in loss of taste, reducing appetite and also crucially impairing granulation of wounds. Vitamins are organic substances needed for growth and maintenance of cells. Vitamins cannot be manufactured, but must be obtained in the diet. Specifically, Vitamin C plays a vital role in collagen formation. Collagen provides support to tissues of the skin and bone. Vitamins are the major components of the scar tissue formed during healing of skin and fractures, and a deficiency can crucially affect any wound healing.
9 The nutritional health of the individual can determine the outcome of wound management 9 Frequent nutritional assessments must be prepared, in order to detect patients with malnutrition or at risk of malnutrition 9 Energy requirements must be calculated for those deemed to be malnourished, or at risk of malnourishment 9 Early intervention is paramount to ensure that wound healing occurs unimpeded 9 The use of supplements enhances womld healing 9 Nutritional care is cost effective.
N U T R I E N T S A N D T H E EFFECTS O F DEFICIENCY The function of nutrients can be divided into three main areas: 9 To build and maintain body tissue; the body requires nutrients to constantly renew itself 9 To furnish energy; carbohydrates, fats and proteins are all classified as fuels required for body activity 9 To regulate body processes by controlling all chemical reactions in the body through what is ingested. Nutrients have vital roles to play, yet they cannot function independently. Therefore, any adverse change of one nutrient will alter the balance, thus potentially affecting wound and bone healing after trauma or surgery. Proteins, in particular, provide the foundation in every body cell for growth and maintenance. Protein deficiency delays healing and also results in healed wounds with diminished tensile strength (Steiger 1993).
VITAMIN AND ZINC SUPPLEMENTS There is now increasing evidence that vitamin and zinc supplements may be beneficial in wound healing. The following is only a fraction of the evidence that has become available. Sanapati and Thompson (1985) suggested that the demand for zinc increases in the process of wound healing, and it was found that to increase the levels in the diet could aid this process. Zinc supplements, if given immediately following a surgical or trauma wound can aid in this healing process. Arden (1990) carried out a study concluding that the presence of pressure sores is associated with increased requirements for specific nutrients, notably zinc. Prescribing zinc sulphate 220 mg TDS helped prevent pressure sore development and repair wounds already formed.
Nutritional supplements in wound healing Stress, from any source including orthopaedic surgery, can cause re-distribution of body zinc and excretion of zinc for a few days. Therefore the importance of monitoring zinc sulphate levels and the possibility of prescribing oral supplements can be beneficial. Lehman (1989) and Thompson (1991) found that reduced zinc levels from malnutrition contributed not ouly to difficulty with wound repair, but also to an increased risk of infection. Use of supplemental zinc may prevent these complications developing following orthopaedic surgery or trauma. If vitamin deficiency, particularly Vitamin C, prevents healing of skin and fractures, then it seems reasonable to suggest that prescribing supplements will stimulate healing. Certain groups of patients are at risk from vitamin deficiency, probably of dietary origin. Dickerson and Williams (1990) carried out a study that found that 82% of elderly women admitted to a District General Hospital with femoral fractures had significantly low levels of ascorbic acid. The Department of Health (1996) recommended daily allowance of Vitamin C for healthy adults is 60 mg. It can be assumed that individuals in hospital following orthopaedic surgery, who have had surgical excisions or who have developed pressure sores, will require considerably higher levels of vitamins to counteract this. Vitamin C will not be the only vitamin depleted, and multi-vitamin supplements (one tablet once or twice a day) are recommended, if diet cannot fulfil requirements. Vitamins and zinc, therefore, play an essential role in wound healing. The requirement for each may be increased following injury or surgery. Supplements may accelerate the healing process and are recommended for patients likely to be deficient or in high-risk categories, particularly the elderly or chronically sick. The orthopaedic nurse's role is to identify and assess these patients; and become involved in the education of other members of the surgical team in emphasizing the importance of nutrition as an essential factor influencing wound healing. Based on increasing amounts of evidence as to their benefits, prescription of supplements is increasingly considered cost-effective. For example, an orthopaedic patient's discharge can be delayed due to many reasons, but if it is due to poor wound healing as the patient is malnourished, then it is a very costly and unnecessary complication of surgery.
T H E A G E I N G PROCESS As we age, there are a whole host of our parameters that decline in function, such as stamina, skin condition, immune system and digestion. The rate at which these parameters decline varies between individuals, and is strongly influenced by lifestyle and nutritional factors. For example, reduced
181
metabolic rate decreases calorie requirements. The elderly require less calories so their need for food reduces, yet the body still needs the same levels of nutrients to function. Therefore, the elderly become potentially the worst-nourished group, and small amounts of low calorie food, enriched in nutrients, become vital. This is also the group who are most likely to be in hospital, and due to osteoporotic changes leading to fractures, the ageing population are most likely to be admitted to orthopaedic units.
Case report An 87-year-old gentleman fell at home and sustained a fractured acetabulum. He lived alone and had refused meals-on-wheels or Home Help to prepare food, as he wished to remain independent. On admission, he was underweight and complained of lethargy. The following day he had an operation to replace the fractured acetabulum. Surgically, the operation was a success, but the wound failed to heal. He was referred to a dietician but could only tolerate small meals. After 4 weeks the wound eventually began to heal and he was finally discharged 6 weeks later. It had therefore taken the patient 10 weeks as an in-patient to recover from a routine operation. It is clear that malnutrition, prior to admission and during hospitalization, was evident, an important factor which delayed his recovery. He was unable to tolerate the hospital food. A review of his diet and the prescription of vitamin and zinc sulphate supplements at an earlier stage could have aided his recovery as he was unable to tolerate the recommended diet. Ahmed (1992) identified factors that are responsible for malnutrition in the elderly. Taste, smell and thirst sensations decrease with age. He found that the amount of taste buds in children is approximately 245. In a comparison group of adults aged 74-85 years this level had reduced to a mere 88, which might explain the loss of appetite commonly found in this age group. Following orthopaedic surgery, where there is an increased demand by the body for nutrients, nurses should encourage an increased dietary intake. This is often not possible, and therefore supplements should be considered for this age group, so that malnutrition does not affect healing.
Case report A 92-year-old gentleman was admitted to the orthopaedic unit for release of bilateral Dupuytren contracture. He lived in a bungalow with his wife who was 90 years old and suffered with Alzheimer's disease. She needed her meals prepared and assistance with washing. The man had diabetes mellitus, otherwise he was active and capable of looking after himself and his wife, with the aid of a Home Help for washing.
182
Journal of Orthopaedic Nursing
O n admission it was noted that he was 7 stone in weight, which was underweight for his build. His skin was dry and thin, suggesting dehydration. He had a pressure sore on his sacrum that he said had been there for approximately 2 weeks. During the initial assessment, a dietary history was taken. Information was obtained about eating patterns, the presence of weight loss, any nausea, taste changes, difficulty buying and preparing food and financial restrictions. The patient was unable to maintain his nutritional status w h e n well, so it was anticipated that following surgery the problem would increase. This would affect wound healing and could delay his rehabilitation. Ill fitting dentures prevented him chewing effectively, so a soft diet was ordered. He disliked milk, so milk supplement drinks were not an option. Rehydration with intravenous fluids was c o m m e n c e d preoperatively to regain adequate hydration prior to surgery. He was c o m m e n c e d on multi-vitamins once daily and zinc sulphate tablets 200 m g three times daily pre- and postoperatively. Food charts were c o m m e n c e d to monitor nutritional intake after surgery. Due t o t h e history of diabetes, the wounds were observed closely. Surgery was successful, and both wounds healed within the optimum time. On discharge, a H o m e Help was arranged to buy and deliver shopping, helping him to choose a balanced diet rich in vitamins and high in protein. He was assessed by the occupational therapist and was given adaptations to help him prepare and eat food. He was prescribed multi-vitamins and zinc sulphate tablets as the pressure sore on his sacrum was still healing. It can be concluded that by effectively assessing nutritional status, a plan of care can be delivered which aids recovery and reduces the risk of the complications of delayed wound healing.
CONCLUSION Nutritional support is essential for the holistic care of the orthopaedic patient. If not considered, it may have a detrimental effect on the individual, decreasing wound tensile strength, prolonging rehabilitation and increasing the complications of delayed healing. Early assessment of nutritional status is essential, and the correct levels of nutrients required for wound healing following orthopaedic surgery are
vital, particularly vitamins and zinc. If these levels of nutrients cannot be obtained from diet, then the introduction of supplements can be beneficial. Wounds heal most successfully in well-nourished individuals, and as orthopaedic nurses we must ensure patients with wounds receive the best nutrition possible. 'By improving eating habits and nutritional status, this in turn may provide a better internal environment for heating' (Lewis 1993).
REFERENCES Ahmed F 1992 Effect of nutrition on health of the elderly. Journal of American Dieticians Association 92: 1102-1104 Argen M 1990 Zinc in wound healing. Linkoping University, Sweden Bastow M D, Rawlings J, Allison S P 1983 Benefits of supplementary tube feeding after fractured neck of femur. BMJ 287:1589-1592 Bobel L 1987 Nutritional implications in the patient with pressure sores. Clinical Nursing 22:379-390 Delaney H, Demetrov A, The E 1990 Effect of early post operative support on skin wound healing. Parenteral and Enteral Nutrition 14:357-360 Delmi M, Rapin C H, Bengoa J M, Delmas P D, Vasey H, Bonjour J P 1990 Dietary supplementation in elderly patients with fractured neck of femur. Lancet 1013-1016 Department of Health 1996 Dietary reference values for food energy and nutrients for the UK. HMSO, London Dickerson T, Williams C 1990 Vitamin related disorders. In: The Metabolic and Molecular basis of acquired Diseases. Tindall, London Lehman A B 1989 Review: undernutrition in elderly people. Age & Ageing 18:339-353 Lewis B 1993 Nutritional intake and wound healing in elderly people. Journal of Wound Care 2(4): 227-229 Rubery R 1984 Role of nutrition in wound healing. Surgical Clinics of North America 64(4): 703-714 Seltzer M, Slocum H, Belcher E I982 Instant nutritional assessment: Weight loss and surgical mortality. Parenteral and Enteral Nutrition 6:218-221 Senapati A, Thompson R 1985 Zinc deficiency and the prolonged accumulation of zinc in wounds. British Journal of Surgery 2:561 Steiger T 1993 Post operative intravenous nutrition: Effects of body weight, protein regeneration, wound healing and liver morphology. Surgery 73(5): 681--691 Thompson R 1991 Assessment of zinc status. Proceedings of Nutrition Society 150:19-28 Wallace E 1994 Feeding the wound. Nutrition and wound care. British Journal of Nursing 3(13): 662-667 Wilmore D 1986 Influence of wounds on local and systemic responses to injury. A M Surgery: 444-458 Winsor J, Knight G, Hill G 1988 Wound healing response in surgical patients: recent food intake is more important than nutritional status. British Journal of Surgery 75: 135-137