If you have a client with a Grade 3 or Grade 4 pressure injury — or a wound that simply will not heal — one key question is often missed:

Has this client had a comprehensive nutritional assessment by a dietitian?

Both the 2019 International Guidelines on the Prevention and Treatment of Pressure Ulcers/Injuries and the 2025 Nutrition in Pressure Injury Prevention Guidelines clearly state that all individuals with, or at risk of, a pressure injury should be screened for malnutrition.  If someone scores at high risk, then they should receive a full nutrition assessment by a dietitian.1

Clients with a brain injury, spinal cord injury or complex orthopaedic trauma are frequently at high risk of malnutrition, but this doesn’t always get identified until problems start to appear.  Case managers should therefore be screening all clients for malnutrition as a core part of their initial and ongoing assessment processes (alongside questions about mobility, skin integrity and equipment). Validated screening tools that can be used include:

• Malnutrition Universal Screening Tool
• Mini Nutritional Assessment Tool (full edition)

You can’t build skin out of thin air.  The food that you eat provides the nutrient “building blocks” necessary to form new, healthy skin.  In fact, malnutrition is a massive contributing factor to wounds developing in the first place.2

Dressings, repositioning and pressure relief are only part of the wound healing equation.  Wounds cannot heal if they don’t have the appropriate amounts of protein and other nutritional “building blocks” onboard.  This is why a comprehensive assessment by a dietitian is so important.

How can a dietitian help with wound healing?

Dietitians can help clients with wound healing in five main ways.

1. Blood tests

The main blood tests which need to be done any time a wound is slow to heal include:

• HbA1C (to check for diabetes/pre-diabetes);
• full blood count (to check for iron deficiency anaemia and infection);
• ferritin (a secondary marker for iron deficiency anaemia);
• C-reactive protein (to help interpret the ferritin readings); and
• Urea & electrolytes (to check hydration and renal function).

Elevated blood glucose levels can make a wound much slower to heal and much more prone to infection.  Insufficient iron in the body can lead to reduced ferritin levels and ultimately, low haemoglobin levels.  Low haemoglobin levels will reduce the amount of oxygen that the red blood cells can deliver to the wound and this can slow wound healing.

Note that albumin, a protein in the blood, is no longer considered a reliable indicator of nutritional status.

2.  Protein intake & weight monitoring

Wound healing requires extra protein. This is because the body is effectively trying to rebuild tissue while under stress, and this significantly increases protein requirements.  While some clients are aware they need to eat “more” protein, many are unclear as to exactly how much protein they need to eat.  Protein requirements are based on body weight and someone with a pressure injury or wound typically needs about 1.2 – 2.0 grams protein per kg body weight (1) (using ideal body weight if the client is obese).  High-calorie, high-protein nutrition supplements are one option for increasing the protein intake in underweight clients.  However, the situation is trickier in overweight or obese clients, where they often have extremely high protein requirements but extremely low calorie needs.  Some clients hear the “eat more protein” message and are happy to load up on more meat/chicken/fish, only to realise that they have gained significant amounts of weight because they didn’t reduce their intake of other foods to offset this.

Weight monitoring is critical during the wound healing period to prevent unwanted weight gain and unintentional weight loss, as both can slow wound healing.  Weight loss needs to be avoided (or very, very slow, even in obese clients), otherwise some of the dietary protein will get burned as energy instead of being used to build new tissue.

3.  Micronutrients (vitamins & minerals)

Certain vitamins and minerals are absolutely critical for wound healing and skin repair, such as vitamin A, vitamin C, vitamin E, zinc, copper, selenium and magnesium.2, 3  Wound healing increases the body’s need for certain nutrients and additional supplements are often required to ensure that these higher needs are being met.  When clinically indicated, dietitians may recommend either a nutritionally complete multivitamin and mineral supplement or if a client is underweight, an oral nutrition supplement. Supplementation should always be targeted to the individual to avoid nutrient imbalances.  This is because excessive or inappropriate supplementation (for example, high-dose zinc) can interfere with the absorption of other key nutrients.

4. Arginine

While consuming enough protein is important for wound healing (as outlined above), higher levels of the amino acid arginine (in particular) can speed up and support wound healing even more.4, 5, 6  The 2019 International Guidelines on the Prevention and Treatment of Pressure Ulcers/Injuries specify that adults with a Stage II or greater pressure injury should consume a high-calorie, high-protein oral nutrition supplement containing arginine, zinc and antioxidants.  Other research suggests that combining the arginine with glutamine, omega-3 fatty acids and/or nucleotides, may provide an additive or synergistic effect for even better wound healing.4, 7

5.  Hydration and other lifestyle factors

Dehydration causes the skin to lose elasticity and makes it more fragile.2  It also slows the transport of oxygen and nutrients to the wound.8  A dietitian can work with clients to increase their fluid intake if required.

Smoking and/or consuming high amounts of alcohol are other lifestyle factors which can contribute to slow wound healing.3  A dietitian can direct clients to resources and support on how to reduce both behaviours, if needed.

Wounds may take significantly longer to heal if underlying nutritional issues are not addressed.   Chronic wounds can also result in a higher risk of infection, longer hospital stays and long-term complications.  Early dietetic input is therefore needed for rapid wound healing.

If you are managing a client with a pressure injury or a wound that is slow to heal, make sure you have screened the client for malnutrition and if at high risk, refer on to a dietitian for further assessment.

For a more detailed explanation of how nutrition impacts wound healing, check out: Nutrition….healing wounds from the inside out.

To refer a client with a pressure injury or slow healing wound, contact Specialist Nutrition Rehab at info@specialistnutritionrehab.co.uk or 0121 384 7087.

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References:

1. Pressure Ulcer Guideline (2025) European Pressure Ulcer Advisory Panel.
2. Acton, C. (2013). The importance of nutrition in wound healing. Wounds UK, 9(3).
3. Guo, S. A., & DiPietro, L. A. (2010). Factors affecting wound healing. Journal of dental research, 89(3), 219-229.
4. Kurmis, R., Woodward, M., Ryan, H., & Rice, J. (2021). The importance of nutrition in wound management: new evidence from the past decade. Wound Practice & Research: Journal of the Australian Wound Management Association, 29(1), 18-40.
5. Neyens, J. C. L., Cereda, E., Meijer, E. P., Lindholm, C., & Schols, J. M. G. A. (2017). Arginine-enriched oral nutritional supplementation in the treatment of pressure ulcers: a literature review. Wound Medicine, 16, 46-51.
6. Cheshmeh, S., Hojati, N., Mohammadi, A., Rahmani, N., Moradi, S., Pasdar, Y., & Elahi, N. (2022). The use of oral and enteral tube‐fed arginine supplementation in pressure injury care: A systematic review and meta‐analysis. Nursing open, 9(6), 2552-2561.
7. Ellinger, S. (2014). Micronutrients, arginine, and glutamine: does supplementation provide an efficient tool for prevention and treatment of different kinds of wounds?. Advances in wound care, 3(11), 691-707.
8. Quain, A. M., & Khardori, N. M. (2015). Nutrition in wound care management: a comprehensive overview. Wounds: a compendium of clinical research and practice, 27(12), 327-335.