A Fresh Take on Comprehensive Patient Care in Wound Healing

“Before you heal someone, ask him if he’s willing to give up the things that make him sick.” — Hippocrates

As caregivers, where should we begin when we look at comprehensive patient care? We begin with the whole patient, the whole person. We must develop a robust personal mission statement around patient care, which helps determine one's direction and focus on future goals. It aligns strategies and can give a person/team a way to reflect, evaluate, and improve outcomes in practice, such as, “I believe every patient needs a physician who will be an advocate to help them regain their health.” Strong mission statements can produce profound changes and benefits for your patients, but to do so involves viewing the patient as a whole person, not perseverating on the wound care dynamics in disunion.

The impact of conventional medicine's "sick-care" focus on our medical systems have repercussions. Is conventional medicine the best in care? It is the practice of acute treatment targeting pathogens, traumatic events, or the long-term practice for controlling disease and/or it's risk factors that reduce or degrade long-term primary and secondary outcomes. It remains a disease-focused approach with patients as recipients of “sick-care.” Patients need only comply with treatment and are not required to make significant changes or commitments to their health. The providers are responsible for the care and outcomes, while the patient is a passive receiver of services.

The "patient-centric" approach can be achieved with the use of a lifestyle medicine approach to treat, reverse, and prevent all too prevalent lifestyle-related chronic disease AND improve health literacy. Lifestyle medicine involves the use of evidence-based lifestyle therapeutic approaches, such as a predominantly whole food plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use, and other non-drug modalities to treat, reverse, and prevent all too prevalent lifestyle-related chronic disease. Most wound care patients do not experience discreetly limited events.

Acute and impaired wound healing impact our population differently. In the United States, chronic wounds affect approximately 6.5 million patients, with the majority of the chronic wounds beginning as minor traumatic injuries [see reference 1]. When wound healing is impaired, it is usually not because a single factor failed, but rather, numerously neglected and ignored comorbidities lead to an impaired healing process. A literature review of common wound care treatment options underscores to lack of whole-person care when clear evidence-based options are available and provide improved wound healing. There are several areas a provider and team can influence change. Build a referral base, create action plans, or write prescriptions that address nutritional assessments, increase exercise, improve sleep, and influence positive emotions. Below are a few ways to implement well-care with patients.

  1. Talk to patients about their diet. Nutrition is a complex field that wound care has taken a pro-active approach over the last decade. However, recently, new studies have evaluated the impact of dietary protein in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Shockingly, in the 2018 United States Renal Data System report, only 10% of individuals who were classified by laboratory measurements as having Stage 1-3 CKD, were aware of their kidney disease. CKD patients include poorly controlled diabetes mellitus, peripheral vascular disease, chronic venous insufficiency, and aging.

    Wound care providers should address the co-morbidity of kidney disease, protein intake, and chronic wound regimens with dietary intervention. Providers unfamiliar with the complexity of nutrition can refer patients to a skilled practitioner, such as a registered dietician, to monitor protein levels, and help address problems that arise when providers increase dietary proteins to promote wound healing. The problem emerges when an increase in protein intake increases both glomerular filtration and renal tubular acid excretion; therefore, intensifying renal injury in patients. Dietary protein intake varies for adult dialysis patients is ∼1.2 g/kg body weight of proteins per day, as opposed to non-dialysis patients, the daily protein is 0.6-0.75 g/kg.

    Lower protein intake, as reported by Klahr et al in the study, The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group, slows the progression of CKD. Another study by Kamper and Strandgaard, Long-Term Effects of High-Protein Diets on Renal Function, noted,  "daily red meat consumption over years may increase CKD risk, whereas white meat and dairy proteins appear to have no such effect, and fruit and vegetable proteins may be renal protective."

    Finally, increasing protein intake in older patients during critical illness may lead to azotemia due to decreased renal functional reserve and possibly augment the propensity towards worsened renal function and worsened clinical outcomes reported Dickerson in Nitrogen Balance and Protein Requirements for Critically Ill Older Patients.

  2. Vascular disease wound patients benefit from decreasing free fats and increasing fruit and vegetables that are rich in flavonoids to improve vascular health; reduce endothelial dysfunction, inflammation, and oxidative stress, according to Macready et al in the study Flavonoid-rich fruit and vegetables improve microvascular reactivity and inflammatory status in men at risk of cardiovascular disease--FLAVURS: a randomized controlled trial.

    Sustained dietary nitrate ingestion, via the nitric oxide (NO) cascade, improves vascular function in hypercholesterolemic patients: a randomized, double-blind, placebo-controlled study by Velmurugan et al. titled Dietary nitrate improves vascular function in patients with hypercholesterolemia: a randomized, double-blind, placebo-controlled study. These changes are associated with alterations in the oral microbiome and, in particular, nitrate-reducing organisms, which give rise in circulating levels of nitrite derived from dietary nitrate. Acute dietary nitrate load causes a marked reduction in BP, reduces platelet activation, and protects against endothelial injury. There is emergent evidence supporting the idea that CVD risk can be reduced by a dietary pattern that provides more plant sources of protein compared to animal-based dietary protein. It is a multifaceted reason that links the amino acid content of particular foods with the gut microbiome to the overall wellness of a patient. And yet, there remains a little emphasis on patient nutrition or even physical activity.

  3. Physical inactivity is a leading cause of preventable death in the USA. Exercise is commonly overlooked and never addressed as a vital sign in most physician offices and wound care clinics. However, low-intensity exercise accelerated wound healing rates in diabetic mice in Low-intensity Exercise Accelerates Wound Healing in Diabetic Mice, a study by Keylock. They further noted, future studies should investigate the mechanisms behind this effect and evaluate different intensities of exercise on wound healing in humans with type 2 diabetes. The current recommendation is for exercise involves 30minutes of moderate-intensity 5 days per week. The findings are robust that insurance reimbursement is available to patients.

  4. Today, structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs. A supervised exercise therapy (SET) program with up to 36 sessions, over a 12 week period, is considered medically necessary to help prevent wounds from becoming chronic, significantly reduce pain and immobility. Three months in a moderate-intensity aerobic activity healed standard wounds compared to the sedentary controls. The possible mechanism of action is the enhanced neuroendocrine response, pro-inflammatory cytokines in the wound bed, enhanced re-epithelialization, and collagen turnover in connective tissue structures such as tendons, ligaments, bone, and muscle in patients with PAD, according to Emery et al. Therefore, building a foundation in patient-focused lifestyle changes that can promote wound healing and rejuvenation.
  1. Stress and wound healing in acute and chronic wounds have been thoroughly investigated and its adverse effects are well established. Cytokines play a crucial role in healing. If a dysregulation of the specific cytokines occurs as a breach in wound healing, this leads to delayed healing. The overproduction of cortisol, during stress or abnormal sleep patterns, can hinder wound healing due to the suppression of cytokines. Social interactions buffer against stress and promote wound healing through a mechanism that involves oxytocin-induced suppression of cortisol reports Social facilitation of wound healing.

    Both the qualitative and quantitative studies illustrate that disturbances in sleep significantly increase the risk of developing diabetes, which is supported by numerous community-based and hospital-based epidemiological studies discussed in a review by Chattu VK in The Interlinked Rising Epidemic of Insufficient Sleep and Diabetes Mellitus. Sleep fragmentation (SF) delays wound healing in diabetic mice models in a study by McLain et al. This delayed wound healing in obese, diabetic mice caused by SF is homologous to delayed wound healing in some patients with type 2 diabetes. 

    Poor habitual sleep efficiency elevates cortisol, and thus, reduces the migratory rates of keratinocytes and suppression of cytokines. Therefore, sleep therapy may be a low-cost method in combating the rising epidemic of Type 2 Diabetes and wound care costs. Providers can refer patients for Cognitive Behavioral Therapy (CBT) as the primary treatment for a patient with sleep disturbances, which is usually inclusive of stress reduction techniques and reinforcement of positive emotions – overall improving wound healing and the whole patient.

     6. Additional practitioner tools are to incorporate SMART and FITT prescriptions in their wound care treatment plans.


The acronym used to guide goal setting:

  • SPECIFIC: Examples
  • MEASURABLE: Size, Amount
  • ACHIEVABLE: Agreed, Attainable
  • RELEVANT: Reasonable, Realistic
  • TIME BOUND: Time-limited, Time frame

Wound care treatment plan: RX: DIET:

  • ½ Cup blanched collard greens
  • ½ Cup well-cooked beans
  • As a replacement for ½ portion of a meat
  • Once-daily for one month


The acronym for cardiovascular aerobic exercise guidelines:  

  • FREQUENCY: How often
  • INTENSITY: How hard
  • TIME: Length of time
  • TYPE: What kind of exercise

Wound care treatment plan: RX: EXERCISE

  • Walk for 30+ minutes, three times per week (Tuesday/Thursday/Sunday) at moderate intensity
  • When walking you can talk *but not sing
  • Longevity: 3 months

Above all, remember that, before you heal someone, ask if they are willing to make a change and support them because patients need providers who will be an advocate to help them regain their health. 

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