The Importance of Nutrition in Wound Healing - Research Proposal Example

An Exploration of Nurses' Attitudes to the Importance of Nutrition in Wound Healing in Irish Hospitals Introduction In recent years, the amount of knowledge surrounding the processes of wound healing has significantly increased, resulting in a vast array of therapeutic options. The assortment of options to treat wounds currently available may become somewhat perplexing to physicians and medical personnel including nurses. There is considerable body of knowledge on difficulty involved in selecting the most appropriate therapy for a specific type of wound. Very many different branches of Medicine come across different types of wounds, both acute and chronic wounds that have typical, specific, and sometimes unique features; however, any wound needs care to heal, which is nursing care. The maintenance care to the wounds is provided in the clinical practice by the nurses, and sometimes, especially in the case of chronic wounds, the nursing care can be extremely painstaking. Therefore, what matters in those cases is attitude of the nurses, and it is a well known fact that attitude is governed by knowledge. Thus, it could be a great idea to explore the attitudes of the nurses to wound care apart from their technical skills in wound management. Healing a wound is a high priority to the body. The complex system of wound healing presents an adaptive advantage that ensures the survival of the organism despite the decreased defense against microbial invasion. When injured, the wound is an effective parasite removing from the body what it needs. Despite the fact that most wounds heal well without special nutritional supplementation, the clinician must be aware of those circumstances where nutritional intervention is necessary. It is apparent that proper nutritional support of the patient with a wound requires attention to not only provide enough nutrition but also to avoid nutrient excess to avoid the "toxic" effects of the nutrient. Therefore, pharmacologic nutritional manipulation has a role in healing of the wounds. In the holistic approach to wound healing, nutrition has been regarded to be crucial, and to have an appropriate attitude, the nurses need to understand the roles that specific nutrients play in wound healing. Development of such an attitude based on knowledge may help better understanding and may enhance their role in the assessment of nutritional risk and enable them to obtain more easily the necessary support for patients to promote optimal healing of the wounds. Although several studies have offered supports to this evidence, this concept is often neglected in clinical practice. Literature demonstrates that nutrition plays a key role in the pathology of wound healing, and further research is warranted into this area (Edmonds, 2007, S31-34). Basic Definitions Nutrition is crucial in a holistic approach to wound healing. Nurses need to understand the roles of specific nutrients in wound healing. Such an understanding would enhance their role in the assessment of nutritional risk and enable them to obtain more easily the necessary support for patients to promote optimal wound healing. This concept is often neglected. The literature shows that nutrition plays a key role in the pathology of wound healing. More research is needed into the effects of different food types on aspects of wound healing. The term 'wound', as found in dictionaries and in the commonly accepted terminology, usually relates to an acute injury or an acute mechanical trauma, such as a gunshot wound, a stab wound, etc. The accepted definition of 'chronic wound' relates to any wound that fails to heal within a reasonable period. There is no clear-cut definition that points to the chronicity of a wound. However, most would agree that a wound that fails to heal within 3-4 months may be regarded as chronic. The estimated time for healing is not arbitrary but depends on factors such as the size of the wound, its cause, and the patient's general clinical status. Wound healing is a complex alignment of various dynamic processes which are not yet fully understood. The natural processes that occur during normal wound healing include the various aspects of molecular and cellular events (Thompson and Fuhrman, 2005, 331-347). In its usual schematic presentation, the course of normal wound healing is divided into three phases, phase of inflammation, proliferative phase, and tissue remodelling phase. This traditional division is somewhat arbitrary and these phases partially overlap. For example, processes of tissue formation begin while active events of the inflammation phase are still occurring. Wound healing is regulated and synchronized by a unique group of cytokines, known as growth factors, secreted from thrombocytes, macrophages, neutrophils, lymphocytes, endothelial cells, and fibroblasts. Many cytokines have been identified as having a certain role in the processes of wound healing, such as platelet-derived growth factor (PDGF), fibroblast-derived growth factor (FGF), epidermal growth factor (EGF), tumor necrosis factor (TNF), granulocyte-macrophage colony-stimulating factor (GM-CSF), insulin-like growth factor (IGF), and transforming growth factors (TGF) ' and ' (Bates and Jones, 2003, 107-120). Growth factors induce proliferation of certain cell lines, including fibroblasts, endothelial cells, and epithelial cells with subsequent tissue formation. Growth factors also induce processes such as chemotaxis of white cells, wound contraction, and extracellular matrix deposition. The initial events of the inflammation phase begin immediately after the wounding: The injured blood and lymphatic vessels undergo rapid vasoconstriction that lasts a few minutes. The tissue formation phase includes the most prominent events of wound healing. It begins about 4-5 days after wounding and lasts for a few weeks thereafter in the case of a normal, 'healthy' healing process. The main processes that take place during this phase are angiogenesis and granulation tissue formation, re-epithelialization, and extracellular matrix formation. Release of growth factors induces migration and proliferation of endothelial cells. Endothelial proliferation results in angiogenesis, i.e., the formation of new blood vessels. The new capillaries that are formed branch out and invade the fibrin matrix within the wound site, thereby forming a complex and branched vascular network. This vascular alignment is clinically manifested as the new granulation tissue covering the ulcer surface area during the normal healing process. Granulation tissue consists of immature collagen (type III) and ground substance, in which white blood cells, fibroblasts, and young endothelial cells are embedded. In contrast to the normal, natural course of wound repair described above, chronic cutaneous ulcers are considered to be arrested and 'trapped' in an ongoing inflammatory phase. A protracted inflammatory process develops in ulcers where normal mechanisms of wound healing are not sufficient to enable the wound to heal completely. The level of growth factors is not necessarily lower in chronic ulcers than in acute lesions. Numerous studies of growth factor levels in chronic ulcers have reported a wide range of results. Nevertheless, the general impression is that the growth factors of chronic ulcers are subjected to ongoing degradation due to increased protease activity, as described above. Accumulating evidence suggests that in chronic ulcers there may be reduced expression of growth factor receptors. It seems that these pathophysiologic changes are, at least in part, an expression of cell senescence that occurs in the chronic ulcer bed (Kiritsy and Lynch, 1993, 729-760). In most cases, malnutrition is not a direct cause of delays in wound healing. However, malnutrition does interfere with wound healing and has a detrimental effect on the general condition of the patient. Research has demonstrated that various nutritional deficiency states can have a profound impact on the mechanisms of wound healing. It is important for the nurses to remember that the presence of a skin wound or a cutaneous ulcer can be associated with a state of stress, that is., severe trauma that has caused the wounding. At times, skin ulceration is secondary to a systemic disease which, in itself, may also result in physiological stress. During physiological stress, energy requirements are significantly increased as is the demand for components such as protein, vitamins, and trace elements. Research has demonstrated earlier that the body's capacity for repair is impaired in cases of widespread burns, sepsis, or multi-organ trauma. Many chronic wounds develop slowly. In these cases, appropriate nutrition is also of importance. The repair process requires energy and nutritional elements for tissue repair and replacement (Russell, 2001, S42-S49). Awareness of a possible nutritional deficiency associated with chronic wounds can become the mainstay of wound management, since without this perception this important parameter of wound healing will be missed. This happens due to the fact that the states of nutritional deficiency are not always obvious. Some of these states may develop unnoticed if the diet is inadequate, or due to the administration of anti-neoplastic drugs. It is still not clear whether interference with wound repair can occur even before certain types of nutritional deficiency have manifested themselves clinically. Studies have shown that malnutrition is clinically associated with a high incidence of skin ulcers, impaired healing, and wound complications. Apart from adversely affecting mechanisms of wound healing, malnutrition also damages basic functions such as cell-mediated immunity, phagocytosis, and the bactericidal effect of macrophages. Malnourished patients usually present with combined protein/energy deficiency states. Several studies have examined the significance of each component separately; most have documented the clinical consequences of protein depletion (Mechanick, 2004, 52-56). Relationship between Nutrition and Wound Healing Studies have demonstrated that it is unusual for patients to present with an isolated protein or essential-fatty-acid deficiency. Malnutrition usually involves a combination of these as well as caloric deficiency. These isolated states of deficiency are seen only rarely, in patients treated with total parenteral nutrition, in which a specific component has been accidentally omitted. If the nurses are planning a wound care regimen, to formulate a nursing diagnosis, they must include nutritional assessment as an important component of the overall assessment of the patient. A basic assessment of nutritional status is required in patients with chronic non-healing wounds of the skin. This is especially significant in populations which are prone to inadequate nutrition, such as, nursing-home residents with pressure ulcers. In nutritional evaluation, the nurses must evaluate the general parameters of nutrition. The very basic indicators of nutritional status are weight and height. Patients at high risk for involuntary weight loss should be weighed once or twice weekly. It must be taken into account that the presence of edema may lead to false conclusions as to nutritional status. Additional parameters for more thorough nutritional assessment may be measured, such as the triceps skin-fold thickness and uppermid-arm circumference. These should be assessed with respect to standard values, according to age and gender. In laboratory assessments, the albumin level can serve as an indicator of nutritional status. However, it is not a fully accurate parameter, since certain conditions may rapidly affect its plasma concentration. Dehydration leads to an increase in the concentration of various plasma components, thereby masking the presence of low albumin. Shifts of fluids from intravascular to extravascular spaces may also alter albumin levels in the plasma. On the other hand, neither the synthesis nor the catabolism of albumin is subject to sudden changes, since its half-life is approximately 20 days. Measurement of proteins with a shorter half-life, such as, pre-albumin [transthyretin] and transferrin may provide a better estimation as to the protein status. The half-life of pre-albumin is only 2 days and it responds quickly to deficient protein states and re-feeding, which makes it a more sensitive indicator for this purpose. On the basis of this discussion it is clear that nutrition has immense role to play in wound healing process, and it is just not empiric and has distinct pathophysiologic correlation to the mechanism of wound healing. This leads to the hypothesis that any wound management programme must have a nutritional assessment and nutritional supplementation incorporated into it aside from other modalities of therapy. Since most of the wound care is the responsibility of the nurses, nurses must have knowledge and must show appropriate attitude towards the importance of nutrition in wound healing. A screening method was suggested for detecting malnourishment in patients with chronic obstructive pulmonary disease, in which the nutritional evaluation included measurement of weight and height, serum albumin and prealbumin, total lymphocyte count, triceps skin-fold thickness, mid-arm muscle circumference, and information on unintentional weight loss. It would be advisable to implement similar screening methods for the identification of malnutrition in high-risk patients with cutaneous wounds as well (Campos, Groth, and Branco, 2008, 281-288). Research Question Do the nurses have appropriate attitude towards the importance of nutrition in wound healing' Aim To examine the nurses' attitude towards importance of nutrition in wound healing through questionnaire survey across Irish hospitals. Objective Survey questionnaire would incorporate the existing knowledge on wound care, specifically related to the role and importance of nutrition in the nursing management of wounds, and through this the perspectives and attitudes of the nurses will be explored. To this end, a literature review will be conducted, and a methodology of this study will be developed to understand the attitude of these wound care hospital nurses. Strategy for Literature Review To build a scientific basis of evidence, a comprehensive literature search was undertaken and then evaluated critically. For the purpose of the review of literature to support the rationale, need, and probable continuation of the project, this author conducted a literature search across databases. Those accessed for information included: CINHAL, Medline and Pubmed along with the Google Scholar internet search engine. Moreover MEDLINE, EMBASE, CINAHL, Swetswise, British Nursing Index, and Cochrane databases were searched to identify relevant literature on nurse administered wound management programmes in different clinical settings. HighWire Press was also searched. The key words in the search included "wound care nursing", "wound care nurses", "role", "attitude", "nutritional supplement", "nutritional deficiency", "nursing," "clinical trials", "wound healing", "wound healing process", "nutritional deficiency", "chronic wounds," "nurse-administered wound care", "nurses knowledge", and "wound management" published in the last 10 years. Inclusion criteria for each article reviewed were answers to the following questions: 1. Was the article a valid research article' 2. Did the article's study include role of nursing in area of wound care practice and applied to nursing practice in that area' 3. Was the article published within the past 10 years' 4. Did the article have some identification with nursing practice and healthcare delivery related to wound care' 5. Did the article deals with the role of nutritional elements in wound healing' 6. Did the article deals with the attitude of the nurses towards the importance of nutritional elements in the wound management protocol' 7. Was the article written in English language and preferable British in origin' Each article must answer "yes" to all of these questions. Based on these criteria, out of about 250 initial articles, only 17 latest research articles that fit the criteria described above were selected to be critically reviewed to synthesize evidence relevant to this nursing practice. Those which were review, conversation, editorial, poster presentation, or letters to the editor were excluded. To further narrow the search, a combination of search words were used with an aim to narrow the search so specific areas of wound care nursing and role of nutrition in wound healing are reflected in the research. Although this would miss the literatures that involve combinatorial wound care nursing roles, this would generate articles that focus on nursing care in specific practice settings with reference to the role of nutritional supplementation in wound care nursing management. Only 7 articles could fit this narrowed search that encompasses almost all possible areas of nursing care related to wound care and its management and nurses' attitude towards the roles of nutritional elements in wound care management. For this assignment, these seven articles will be critically reviewed, and the findings have been presented in the following section. Review of Literature The findings from this literature review will be presented in two sections. The first section will deal with recent evidence from literature as to the utility of different nutritional elements in different stages of wound healing. This evidence has been gleaned to update nursing knowledge, since it is believed that knowledge ultimately develops attitude. If the attitude of the nurses towards nutritional supplementation in wound care and management is negative, it would be due to deficiency of knowledge in this area. The second section will examine the literatures that pertain to investigation on nurses' attitude. Section 1 It has been studied that protein depletion can prolong the inflammatory phase of chronic cutaneous wounds. It affects a variety of basic wound healing functions such as proliferation of fibroblasts, collagen synthesis, angiogenesis, and wound remodeling. Several studies have demonstrated that hospitalized patients with pressure ulcers are prone to suffer from malnutrition with protein depletion. The serum albumin concentration may reflect nutritional status; a level less than 3.3 g/dl is associated with increased risk for the formation of pressure ulcer. It has also been reported that there exists a correlation between impaired nutritional status with intake of less than 50 g protein per day and the formation of cutaneous ulcers within six weeks. Researchers have shown that high protein diets may improve the healing of pressure ulcers in malnourished nursing-home patients (Casey, 2003, 55-58). Several studies have been conducted to identify specific amino acids that have a significant effect on wound repair mechanisms. However, since amino acids produce a complex alignment of interactive mechanisms, they should all be regarded as significant to the healing process. The provision of essential amino acids according to the recommended daily allowance (RDA) to patients with chronic wounds is mandatory. The addition of methionine and cysteine has been shown to enhance collagen formation and fibroblast proliferation. Arginine deficiency may impair wound healing by its effect on T-cells and macrophages. Moreover, recent evidence has been accumulating as to the various effects of nitric oxide (NO) on wound healing. Current data suggest that a certain increase in NO production may be beneficial to normal healing (Stefanski, and Smith, 2006, 293-299). The provision of adequate energy is required for the basic functions of healing, such as cellular proliferation and tissue regeneration. The results other studies showed that daily supplements of 200 kcal to a regular diet of 1880 kcal/day significantly reduced the incidence of pressure ulcers. Total parenteral nutrition (TPN) with inadequate provision of lipids may result in the depletion of essential fatty acids. This condition has been seen to cause impaired wound healing in infants during prolonged fat-free parenteral alimentation. Nursing-home residents with pressure ulcers, who are prone to inadequate nutritional status, are also at increased risk of suffering from inadequate hydration. It is important to maintain proper hydration in these patients. Vitamins A, C, and E function as anti-oxidants and are generally associated with wound healing. Improved wound repair can be expected if vitamin A deficiency is corrected. Vitamin C deficiency is associated with a higher incidence of wound infection. Vitamin C deficiency impedes the normal course of wound repair mainly by interfering with collagen synthesis and its cross-linking. Zinc deficiency interferes with normal processes of wound healing, including delayed epithelialization, reduced proliferation of fibroblasts, and reduced collagen synthesis. Iron plays a major role in cellular respiration, cellular proliferation, and differentiation, as well as in gene expression. Impairment of host defense mechanisms may be a result of the effect of iron deficiency on lymphocyte proliferation. In addition, iron is a cofactor in the hydroxylation of proline and lysine in the process of collagen synthesis, so it may affect wound repair processes in this way as well (Pollack, 1979, 615-619). Section 2 Todorovic (2002) in his article on nutritional factors in wound formation and healing states that to holistically treat and help the wounds, including pressure ulcers or leg ulcers, heal a good nutritional status of the patients is necessary. Poor nutritional status and support can delay the wound healing process leading to inadequate healing. This demands an assessment and correction of nutritional deficiencies included in the care protocol of all wounds. For the nurses, hence, nutritional screening is an important part. Wound care is a very common nursing practice in the hospitals and community, and these nurses have a key role to play while delivering wound care to these patients. This responsibility mainly pertains to identification and monitoring of the patients who may be at risk nutritionally, and these are the patients who will require nutritional support to hasten the process of wound healing. Therefore, nurses' attitude towards the need for nutritional supplementation as a wound care measure becomes very important (Todorovic, 2002, 43-44). Anderson (2005) highlights the necessity of appropriate assessment in nutrition and wound healing in his article published in the British Journal of Nursing. Since wound healing is an intricate affair related to a fine tuned nutritional status of the patient. As has been highlighted earlier, nutrients play vital roles in the constitution of a well-balanced diet and any depletion of the nutritional intake of any person who has suffered a wound. Depletion of nutrients, especially proteins-energy malnutrition has important impact on the wound healing process. Therefore, a holistic nutritional assessment in all patients needing wound care is of paramount importance for early detection of nutritional deficiency through the use of recognised nutritional assessment tools. These may indeed increase the nurses' awareness in this undertaking. The nurses play central role in the management of patients who nutritionally at risk, and hence their attitude to the roles of nutritional supplementation in wound management is very important (Anderson, 2005, S30-S34). Mathus-Vliegen (2004) explores the ill-fated alliance between old age, malnutrition, and pressure sores. There has been definite role of nutrition in wound healing. Since there is a consistent relationship between poor nutritional status and risk of complications from pressure ulcers of the skin. Most of the present knowledge in relation to nutrition and wound healing suggest that within the prospects of an ageing community, there is a very high prevalence of pressure sores in the hospitals and nursing homes. The respective values in prevalence of nutritional deficiencies in these groups of patients are 30 to 50% and 19 to 59% respectively. It has also been found that elderly people are at nutritional risk when they have a body mass index below 24 kg/m2. In this population, it is hard to meet daily requirements (Mathus-Vliegen, 2004, M355-M360). The role of protein energy malnutrition has been highlighted Azad et al in their study. Protein-energy malnutrition has been associated with poor wound healing. Since this is associated with lean tissue depletion, this would lead to poor wound healing. The protein wasting in such cases has been believed to represent the metabolic cost of rapidly mobilizing amino acids for wound healing. This is also important for synthesis of immune proteins and cells. In wound care nutritional support has been recognised to be an important part of the therapy and care, but this clinically provided with the expectation of limiting the progression of the wound rather than to reverse the protein losses from the body. Drawing upon this, the article of Azad et al (1999) can be referred to find evidence as to why malnutrition in the elderly patients in hospitals is a matter of concern. Routine nutritional assessment is important current emphasis (Azad et al., 1999, 511). Higgins et al., (2006) discusses the assessment of nutritional status in chronic critically ill adult patients and highlights the importance of two factors in these patients. These two factors are the role of nutritional status and the role of nutritional supplementation. Since these patients are hypermetabolic, they have increased nutritional needs. Since studies have produced mixed results about these two factors, researchers and clinical professionals including nurses generally agree that nutritional status is important in these patients, but the type and amount of supplemental feeding can actually vary considerably depending on the underlying disease processes. This becomes particularly important in wound healing, where nurses strive to produce results. In such cases, the nurses and the care team must incorporate nutritional assessment and interventions as one of the assessment strategies (Higgins et al., 2006, 166-176). It is evident from this literature review that wound care is principally a nursing role. Nutritional deficiencies may impact healing of the wounds especially the chronic wounds, which are difficult to heal. Nurses' awareness about the roles of nutritional supplementation may shape their attitudes towards nutritional assessments in all patients suffering from wounds, and hence evidence may raise their awareness and hence change practice. In this way, the patients with wounds may receive more effective care through appropriate nutritional intervention (Hoffer, 2001, 1345). Methodology 300 hospital nurses selected at random from the Irish Hospitals will receive a specially prepared detailed health and nutrition attitude survey, which they will be requested to complete and return anonymously. Appropriate ethical approval will be sought from the ethical committee and the relevant scientific advisory board. The survey will consist of two parts. 1. Demographic Survey: Respondents will be asked about their age, sex, whether they attend Irish Hospitals as nurses, whether their work roles include wound care, year of graduation, years in service, and whether they had a course in wound care and nutrition during their nursing training. 2. An Attitude Survey: All respondents will be asked to indicate the degree of agreement with each of the 36 statements on the use of nutrition in their wound care nursing practice on a 5-point Likert scale that ranged from strongly agree to strongly disagree. This attitude survey will comprise of 17 positive statements and 19 negative statements. The positive statements comprised of Diet has an important role in effective wound care management. Diet has an important role in prevention in progression of wound. Medical schools should place greater emphasis on nutritional education. Continuing medical education courses should devote time to nutrition-related issues. It is important to have an understanding of food composition and preparation to provide reliable nutritional counseling. Diet has an important role in the prevention of chronicity of the wounds. While doing wound management, medication could be reduced or eliminated if patients followed a recommended diet. Nutrition will have an increasingly important role in the prevention and management of wounds. There is an increasing need to support nutrition-related research. Diet has an important role in the prevention of pressure ulcers. Nurses should spend more time exploring dietary habits during patient assessment. Negative Attitude Statements Most nurses are very knowledgeable about nutrition. Nurses are well prepared to provide nutrition assessment and counseling. Nutrition education is not the responsibility of the nurses. Nutrition is important only in certain medical specialties, not in wound care. Diet has no effect on wound healing. Diet sheets are a sufficient source of dietary information for the patient. Patients ask too many questions about diet. There is not enough time to assess the nutritional status of the patient. The pleasures of eating are more important than the potential health benefits of balanced nutrition in a patient with wounds. Nutritional assessment is a waste of time because there is not enough evidence that it helps wound healing. Data Collection and Analysis This data from these survey forms will be collated and collected. The scores of the positive and negative attitude responses will be computed by summing up the responses for the 17 positive and 19 negative attitude items. The associations between means and medians of these attitude scores and the categorical variables will be assessed with the Student's t-test and Mann-Whitney test respectively. The results will be considered significant at P less than 0.05 level. Linear association among continuous variables will be assessed by the standard Pearson product-moment correlation coefficient. Results The results will be computed and the findings will be presented. Conclusion With this study, the real picture of the attitudes of the nurses in Irish hospitals who cater wound care services to the people will be available. It has been stated that the ultimate use of a good nutrition programme is an effective application in the patients. It has been already highlighted that knowledge builds attitude. Therefore this study can point out the knowledge gaps that these nurses might have had, which can be targeted for a professional development programme directed to development of attitude of these nurses, to ultimately provide the most efficient wound nursing care at least in these Irish hospitals. Reference List Anderson, B., (2005). Nutrition and wound healing: the necessity of assessment. Br J Nurs; 14(19): S30, S32, S34. Azad, N., Murphy, J., Amos, SS., and Toppan, J., (1999). Nutrition survey in an elderly population following admission to a tertiary care hospital. Can. Med. Assoc. J.; 161: 511. Bates, DO and Jones, ROP., (2003) The Role of Vascular Endothelial Growth Factor in Wound Healing. International Journal of Lower Extremity Wounds; 2: 107 - 120. Campos, AC., Groth, AK., and Branco, AB., (2008). Assessment and nutritional aspects of wound healing. Curr Opin Clin Nutr Metab Care; 11(3): 281-8. Casey, G., (2003). Nutritional support in wound healing. Nurs Stand; 17(23): 55-8. Edmonds, J., (2007). Nutrition and wound healing: putting theory into practice. Br J Community Nurs; 12(12): S31-4. Higgins, PA., Daly, BJ., Lipson, AR., and Guo, S., (2006). Assessing Nutritional Status in Chronically Critically Ill Adult Patients. Am. J. Crit. Care., Mar 2006; 15: 166 - 176. Kiritsy, CP and Lynch, SE., (1993). Role of Growth Factors in Cutaneous Wound Healing: A Review. Critical Reviews in Oral Biology & Medicine; 4: 729 - 760. Levine, BS., Wigren, MM., Chapman, DS., Bergman, RL., and Rivlin, RS., (1993). A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutrition in medical practice. Am J Clin Nutr:57:115-9. Mechanick, JI., (2004). Practical aspects of nutritional support for wound-healing patients. Am J Surg; 188(1A Suppl): 52-6. Pollack, SV., (1979). Wound healing: a review. III. Nutritional factors affecting wound healing. J Dermatol Surg Oncol; 5(8): 615-9. Russell, L., (2001). The importance of patients' nutritional status in wound healing. Br J Nurs; 10(6 Suppl): S42, S44-9. Stefanski, JL: and Smith, KJ., (2006). The Role of Nutrition Intervention in Wound Healing. Home Health Care Management Practice; 18: 293 - 299. Thompson, C. and Fuhrman, MP., (2005). Nutrients and Wound Healing: Still Searching for the Magic Bullet. Nutr Clin Pract, ; 20: 331 - 347. Todorovic, V., (2002). Food and wounds: nutritional factors in wound formation and healing. Br J Community Nurs; 43-4. Mathus-Vliegen, EMH., (2004). Old Age, Malnutrition, and Pressure Sores: An Ill-Fated Alliance. J. Gerontol. A Biol. Sci. Med. Sci.; 59: M355 - M360. Hoffer, LJ., (2001). Clinical nutrition: 1. Protein-energy malnutrition in the inpatient. Can. Med. Assoc. J.; 165: 1345. Read More