malnutrition universal screening tool (must) flow chart

7/31/2019 Malnutrition Universal Screening Tool (MUST) FLOW CHART

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Nutrition in wound care: To understand the importance of nutrition in wound

healing

To identify patients with malnutrition and at risk for

malnutrition

Important of nutrition: Nutritional intervention should be reviewed as part

ofthe individuals overall care plan

There is a lot of evidence demonstrating the

essential role of nutrition inwound healing.

Improved nutritional status enables the body to heal

wounds such as the accelerated wound healing

seen with nutritional supplementation.

Without adequate nutrition healing may be impaired

and prolonged.

Poor nutrition before or during the recovery process

may delay healing and impair wound strength,

making the wound more prone to breakdown.

Patients who are at risk for malnutrition

include: Patients with chronic wound

Patients with non-healing wound

Patients with infected wound

Uncontrolled DM patients with ulcer

Underweight patients

Bed bound patients

Burn patients

Patients with co-morbidities such as uncontrolled

diabetes mellitus, dyslipidemia, cancer, kidney


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diseases and hypertension are recommended to

consult or refer to a dietitian.

Effects of wound: A wound causes a number of changes in the body

that can affect the healing process, includingchanges in energy, protein, carbohydrate, fat,vitamin and mineralmetabolism.

When the body sustains a wound, stress hormonesare released in a fight or-flight reaction and themetabolism alters in order to supply the injured

area with the nutrients it needs to heal known asthe catabolic phase.

The body experiences an increased metabolic rate,loss of total body water, and increased collagen andcellular turnover. These effects can be pronouncedeven with a small wound.

If the catabolic phase is prolonged and/or the bodyis not provided with adequate nutrient supplies,

then the body can enter a protein energymalnutrition (PEM) state.

Factors causing prolonged catabolism include theseverity of the wound and the pre-existingnutritional status of the individual.

Poor nutritionoor wound management Protein-energy malnutrition (PEM) is the most

serious type of malnutrition when there is aninadequate or impaired absorption of both proteinand energy.

PEM causes the body to break down protein forenergy, reducing the supply of amino acids neededto maintain body proteins and healing, and causingloss of lean body mass.

Therefore PEM may be directly linked to woundsthat arent healing.


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Protein loss via wound exudate needs to bemonitored. If dressings are being changedfrequently due to the amount of exudate,protein is being lost at a high rate andtherefore protein replacement should beconsidered.

PEM can be defined as low Body Mass Index (BMI) orunintentional weight loss (of 5% or more) with lossofsubcutaneous fat and/or muscle wasting.

As an individual loses more lean body mass (LBM),wound healing is more likely to be delayed.

With a 20% or greater loss of LBM wounds competewith muscles for nutrients.

If LBM loss reaches 30% or more the body will oftenprioritise the rebuilding of body over wound healingwith available protein.

This cascade demonstrates the severely negativeimpact poor nutrition can have on chronic woundhealing.

Even in todays society where we are fortunate tohave access to a variety of nutritional foods, olderpeople often suffer from malnutrition.

In fact it has been estimated that up to 60% of olderpatients in hospitals are malnourished, or at risk ofmalnutrition.

Of those in nursing homes, between 40 and 85%have malnutrition, and 20 to 60% of home carepatients are malnourished.

Patients with pressure ulcers especially larger or

multiple ulcers and ulcers on legs in people withdiabetes place high demand for nutrients on the body.


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Infected wounds also increase nutrient demand as theycause more tissue damage, further strain and a deeperulcer.

Therefore, Nutrition for chronic wounds needs tobe assessed on an individual basis


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MALNUTRITION UNIVERSAL SCREENING TOOL (MUST)

*Adopted from


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5-3. Nutrition Management

Optimal wound healing requires adequate nutrition as well as

involvement of wound management team, effective

communication and compliance to standard protocol.

Is patient

at risk for

malnutrition?

YesIs oral

intake

possible?

Commence

appropriate

diet

prescription

Re-evaluate

next visit

Yes

No

InitiateNutrition

Support*

Is GIT

function

al?

Enteral

Nutrition (EN)

Parenteral

Nutrition (PN)

Adequat

e EN?

Continue TotalEN

Consider

Combination of EN

and PN

No

Ye

sNo

Yes

No

Re-evaluate

GIT function

* Refer / Consult Dietitian for Nutrition Support

Algorithm for Nutrition

Management


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Nutrition Prescription

1. Nutrient Recommendation

Provision of some specific nutrients has been shown to promote

wound healing. Age-appropriate protein and energy needs

should be provided. Nutritional supplements with enteral or

parenteral support should be considered if target needs are not

achieved. Suspected or confirmed micronutrient deficiency

should be treated early with provision of 100% RNI

(Recommended Nutrient Intake) of micronutrients.

During the healing process, the body

needs increased amounts of calories,

protein, vitamins A and C, and

sometimes, the mineral, zinc.

Vitamin C

Vitamin C plays an important role in collagen synthesisand subsequent cross linking, as well as the formation ofnew blood vessels (angiogenesis).Adequate vitamin C levels help strengthen the healingwound.Vitamin C also has important antioxidant properties thathelp the immune system, and it increases the absorptionof iron.

Vitamin C deficiency impairs wound healing and has alsobeen associated with an increased risk of woundinfection. Research has shown vitamin Csupplementation helps promote pressure ulcer healing.Vitamin C is found mostly in fruit and vegetables,especially oranges, grapefruit, tomatoes, and leafyvegetables.Fruit juices with added vitamin C are also a good source,

although often they contain only small amounts ofvitamin C.


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Vitamin AVitamin A increases the inflammatory response in

wounds, stimulating collagen synthesis.Low vitamin A levels can result in delayed wound healingand susceptibility to infection.It has also been shown that vitamin A can restore woundhealing impaired by long term steroid therapy or bydiabetes.Serious stress or injury can cause an increase in vitaminA requirements.

While the mechanisms of vitamin A in wound healing arestill not well understood, it is clear that it plays animportant role.Supplementation with vitamin A requires caution, asthere is a risk of toxicity. Vitamin A is found in milk, cheese, eggs, fish, darkgreen vegetables, oranges, red fruits and vegetables.

Vitamin EIt is possible that vitamin E can reduce injury to thewound by controlling excessive free radicals.Contrary to popular opinion, there is limited evidence forthe benefits of vitamin E in decreasing scar formation.

There is also some evidence that suggests oralsupplementation of vitamin E over 400mg/day has anincreased health risk.

ZincZinc is a trace element, present in small amounts in thebody, which has a well established role in woundhealing.Zinc plays a key role in protein and collagen synthesis,and in tissue growth and healing.Zinc deficiency has been associated with delayed woundhealing, reduced skin cell production and reduced woundstrength.


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Zinc levels of less than 100 g/100mL have been associated with impaired wound healing, butsupplementation in people who are not zinc deficientgenerally has no benefit.Insufficient dietary intake of zinc can be furtherexacerbated by zinc loss from excess wound drainage.Dietary zinc sources include red meat, fish and shellfish,milk products, poultry and eggs.

IronIron is part of the system that provides oxygen to thesite of the wound, therefore iron (haemoglobin)

deficiency can impair healing.Iron deficiency can also result in impaired collagenproduction and strength of the wound.Iron absorption from non-meat sources can be enhancedwith vitamin C.Zinc and iron compete for absorption, therefore ifsomeone is receiving supplements of both, the zinc andiron should be given with meals but not at the same

time.The best sources of iron in the diet are red meat, offal,fish, eggs, wholemeal bread, dark green leafyvegetables, dried fruits, nuts and yeast extracts.


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Table 5-1: Recommended Nutrient Intake


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Nutrient Recommended Intake

Energy Underweight : 35 45 kcal/kg/day

Normal : 30 35 kcal/kg/day

Overweight : 25 30 kcal/kg/day Burn : 40 kcal/kg/day

Trauma : 35 45 kcal/kg/day

Carbohydrate 50 60% of Energy

DM: Encourage high fibre complex CHO e.g.

wholegrain bread, capati, brown rice according to

recommended serving sizes

Fat 30 35% of Energy

Adult : 0.8 1.5 g/kg/day

Dyslipidemia : Limit high saturated fat and fried food

Protein Chronic wound : 1.25 1.5 g/kg/day

Severely catabolic with more than one wound or

Pressure Ulcers Stage III & IV : 1.5 2.0 g/kg/day Vegetarian : consume enough protein from milk,

lentils, legumes and beans

Pharmaconutr

ients

Omega-3 fatty acid

Linoleic acid

L-Glutamine 0.2 0.5 g/kg/day

Arginine 30 60 g/day

Nutrient Recommended Intake

Vitamin A Malnourished patient : 1000 IU

Severe burn, poor nutrient store, GI dysfunction,

radiation therapy : 10,000 25,000 IU

At least 1 serving per day of dark, green &leafy

vegetables, orange or yellow vegetables, orange

fruit, liver and fortified dairy products


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Vitamin B

Complex

B1 (Thiamine) : 10 mg/day

B2 (Riboflavine) : 10 mg/day

B3 (Niacin) : 200 mg/day

B5 (Pantothenic acid) : 100 mg/day

B6 (Pyridoxine) : 20 mg/day

B7 (Biotin) : 5 mg/day

B9 (Folic acid) : 2 mg/day

B12 (Cobalamine) : 20 g/day

Vitamin C Small wound eg. Pressure ulcers /elective small to

moderate surgery:

0.5 1 g daily in 2 divided dosage

Larger injury eg: large BSA burn & Multiple trauma:

1 2 g/day

At least 1 serving per day of citrus fruits, guava,

tomato, pepper, potatoes, spinach and cruciferous

(broccoli, cabbage, cauliflower)

Vitamin E Not to exceed 670mg/day

Vitamin K 5-10mg (orally or IM 1-3 times weekly in high riskpatients)

Zinc 40 mg/day for 10 days

Red meats, seafood and fortified cereals

Selenium 100 g/day

Manganese 25 50 mg/day

Copper 2 3 mg/day


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Table 5-1: Recommended food intake

Recommend

ed ServingSizes

Food Groups

1 Serving Size

Daily Serving

(Normal

Recommenda

tion)

Daily Serving

(WoundHealing

Recommendati

on)

Rice,

noodle,

bread,

cereals,

cereal

products

and tubers

1 cup @ 2 scoops

rice / noodles /

cereals

2 slices bread

1 capati / thosai

4 8 servings 4 8 servings

Vegetables

cup @ 2 table

spoons leafy

(spinach, kangkung)

or starchy (carrots,

potato)

2 3 servings 4 servings

Fruits

1 slice papaya /

pineapple /

honeydew /

watermelon

1 whole apple /

orange

2 servings 3 servings

Fish,

poultry,

meat and

legume

1 fish (eg. kembung,

selar)

1 drumstick

2 eggs

2 table spoons beef

1 cup @ 2 scoops



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cooked dhall

2 tauhu/ tempeh

Milk and

milk

products

1 cup milk

1 slice of cheese

cup yogurt


Fats, oil,

sugar and

salt

1 tsp oil

1 tsp sugar

1 tsp salt

Eat less Eat less

If patient not eating well;

1. Suggest five to six small meals a day. Encourage smaller

meals and snacks between meals to get enough nutrition.

Make nutritious snacks like milk, ice-cream, yogurt, fruits,

sandwiches, milkshake, oats with milk, omelettes, roti

telur, cream mushroom soup, fruit or fruit juices,

cekodok, keropok lekor, pancakes, banana fritters,

kerepek, popcorn and corn in cup.

2. Use foods that are "high nutrient-dense" as below:

"Low nutrient-dense"

foods

"High nutrient-dense"

foods

Clear soup (air rebusan) Chicken / beef vegetable soup

Plain jelly Jelly with milk / fruits

Carbonated beverages Milk, milkshakes


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PopsiclesIce cream floats, smoothie, ,

ice cream

Plain bread / biscuits /

pancake

Bread / biscuits / pancake with

peanut butter / egg / tuna /

sardine

Plain porridge Chicken porridge, Fish porridge

3. Suggest variety of foods if patient experience taste

changes to find out what works for the patient. Cold foodsand foods with little odor work best. Add spices (e.g.lemongrass, pandan leaves, lime, mint leaves, herbs) inmeat, chicken, fish preparations. Take lemon/ orange/mint flavoured food or drinks to reduce the metallic orbitter taste.

4. Use an oral nutritional supplement if nothing else works.

These are available at grocery stores, drug stores, andhypermarkets. Adding milk, cocoa powder, coffee or icecream may make the supplement tastier.

5. Take a multivitamin if unable to meet the recommendedintake.

Ideas to improve nutritional status include:

Offer food and fluids in a variety of textures andconsistencies Offer assistance and allow sufficient time for mealsand enlist family members or volunteers to help Provide encouragement, without pressuring Offer a variety of nutrient dense, high calorie and highprotein meals Encourage grazing small frequent meals/snacks

Encourage frequent drinking of fluids


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Provide hydration stations for patients to access drinksat any time Provide foods that patients like Position upright when eating Allow time for individuals to eat in a relaxed manner,with time to chew, feed themselves and finish their meal Provide a pleasant mealtime environment If the individual has dentures ensure that these arewell fitted Explain that eating well, and eating the right foods, willaid recovery Provide assistance with the opening of containers, lids.

5-5. Food Myth and Truth

MYTH TRUTH

Haruan fish and ikan

linang are strongly

recommended aftersurgery for wound healing

Protein is essential for wound

healing. Haruan fish and ikan

linang / belut are good sourceof protein similar to any other

fish. Consume adequate

protein from all type of fish,

chicken, meat, lentils and

beans to promote wound

healing. Do not restrict to

haruan fish or ikan linang

only.

Eggs will induce itchiness,

pus and can cause wound

breakdown.

Eggs are considered a

complete protein source and

rich in vitamins and minerals.

There is no evidence that

consumption of eggs and egg

products are related to


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itchiness, pus and can cause

wound breakdown. Only avoid

eggs if you are allergic to it.

Female chicken meat

should not be consumed

after surgery.

Chicken meat is a good source

of protein and there is no

evidence of contraindication

after surgery.

Application ofgamat oilon

wound and drinking gamat

essence can help wound

healing.

There is no strong research

and evidence for the claim.

Usually, any type of essence

like essence of chicken,

essence of haruan fish and

gamatare high in salt and not

advisable for regular

consumption.

F. Conclusion

Nutrition is essential for the wound-healing process. The use of

a nutritional screening tool highlights those at risk of nutritional

deficiency. Regular ongoing monitoring is necessary to

evaluate the outcome of nutrition intervention and manage

feeding barriers effectively.

malnutrition universal screening tool (must) flow chart

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