WHEN YOU DEVELOP a care plan for a patient with a pressure ulcer (PU), your focus is usually on wound care, dressings, and support surfaces. But don't forget that nutrition is also an important component of treatment. Nutrition is the fuel that supplies calories, protein, vitamins, minerals, and fluids vital to both wound prevention and healing.
Nutritional support should be integrated into your interdisciplinary individualized wound care plan. As a key member of your wound care team, the registered dietitian nutritionist (RDN) can assess the patient's nutritional status, establish an intervention plan, and monitor the patient's progress toward achieving goals. This article will review the proper nutrition needed for healing PU and the RDN's role in patient care.
Feeding the wound
Risk factors for PU development include unintended weight loss (UWL), suboptimal energy and protein intake, and eating problems, such as dysphagia or issues with chewing.1,2 UWL is defined as weight loss that's not planned or desired; a loss of 5% in 30 days and 10% in 180 days is a predictor of mortality, places the patient at risk for PU development, and slows the healing process.1,3,4 The patient who consistently consumes an inadequate amount of food and fluid is at risk for UWL and malnutrition. Unless the patient has a terminal illness, undernutrition is a reversible risk factor for PU development. Early identification and treatment is critical. An Australian study noted that factors such as weight loss, poor food intake, and decline in eating were associated with one-and-a-half to two times the risk of PU development.5
Your healthcare organization should have a policy on nutrition screening, including its frequency. The policy should mandate early referral to the RDN when risk is identified or a PU is present. Screening tools should be quick, easy to use, validated, and reliable for the patient population served.
The Mini Nutritional Assessment (MNA) has been validated for adults over age 65 and identifies individuals who are malnourished or at risk for malnutrition.6,7 It consists of six questions addressing decline in food intake due to loss of appetite, digestive problems, or swallowing/chewing difficulties; involuntary weight loss during the last 3 months; mobility; psychological stress or acute disease in the past 3 months; neuropsychological problems such as dementia or depression; and body mass index (BMI) or calf circumference if BMI is unavailable. The maximum screening score is 14 (normal nutritional status is 12 to 14). A score of 0 to 7 indicates the patient is malnourished; a score of 8 to 11 indicates the patient is at risk for malnutrition.
Assessing nutrition needs
Nutrition is one of the six subscales on the Braden Scale for Predicting Pressure Ulcer Risk.8 When completing the nutrition subscale, don't guess how the patient is eating; instead, check documented intake records or question the patient or family. A nutrition subscale score of one (very poor) or two (probably inadequate) should trigger a more in-depth assessment by the RDN. A score of three (adequate) may indicate the need for further assessment and intervention, particularly for patients who have comorbidities that increase metabolic needs. Because protein is responsible for tissue repair and synthesis of enzymes involved in wound healing, cell multiplication, and collagen and connective tissue synthesis, low dietary protein intake must be addressed immediately.9 (See More protein, please.)
Several organizations have published PU prevention and treatment guidelines that follow rigorous methodology and are supported by research. The following nutrition recommendations are from the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance's 2014 Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline.10
The body's first priority is for adequate energy (kilocalories or kcalories) provided from carbohydrates, protein, and fat. Carbohydrates and fats are the preferred energy source, thus sparing protein for cell structure and maintenance.11 Wounds, such as PU, may increase the body's metabolic demands and nutritional requirements. Severe illness, trauma, sepsis, wounds, or major surgery trigger hyper-metabolism and increase caloric needs.12 The 2014 guideline recommendation for energy is 30 to 35 kcalories/kg body weight for adults at risk of a PU who are assessed as at risk for malnutrition. This formula may be adjusted up for a person with UWL or down based on the level of obesity.10 If a patient eats poorly or refuses a therapeutic diet, consult with the RDN and healthcare provider and suggest modifying or liberalizing the diet.10,13
Protein is essential to promote positive nitrogen balance; adequate protein intake can improve healing rates.14 Aging is associated with a decrease in energy and protein intake and a loss of lean body mass. This places older adults at risk for malnutrition and declining immune function, which can impair wound healing.
Research supports increasing protein requirements for older adults with acute and chronic diseases.15,16 The current recommendation is 1.25 to 1.5 g of protein/kg body weight for an adult with a PU who's at risk for malnutrition.10
Dehydration also increases the risk of PU development and impedes healing. Older adults in particular have a decreased thirst mechanism and often don't drink enough fluids during the day.17 The current minimum recommendation for fluids for older residents in nursing homes is 1,500 mL per day, including fluids in foods such as soup and gelatin.18 The 2014 guideline recommends monitoring for signs and symptoms of dehydration and providing additional fluid when a patient has an elevated temperature, profuse diaphoresis, diarrhea, or heavily draining wounds.10
Food before supplements
When a PU is identified, some clinicians' initial reaction is to order a supplement. While evidence supports the role of supplements for wound healing, first consult with the RDN to determine if the nutritional requirements can be met with the meals served.14 The 2014 guideline recommendation is to offer fortified foods and/or high-calorie, high-protein oral nutritional supplements between meals if nutritional requirements can't be achieved by dietary intake.10
Therapeutic diets should be individualized if the patient isn't eating well. As a team, ask these questions:
- Are we serving food the patient enjoys?
- Does the patient need assistance with eating?
- Does he or she have any chewing or swallowing difficulties?
- Is the diet too restrictive and/or bland to appeal to the patient?
- Would the patient eat a sandwich and drink a glass of milk at bedtime?
- Would the patient eat Greek yogurt (level of protein, 20 to 28 g) or a high-protein bar as a snack?
- Does the patient drink enough fluid (6 to 7 cups a day)?
- Can the patient reach and lift his or her water pitcher?
- Are fluids offered during therapy or after wound care?
If the team determines that nutritional supplements are indicated, it's best to offer them between meals, not at mealtime.
Enriched commercial supplements formulated for wound healing have additional protein, vitamin C, zinc, and other vitamins and minerals. Several studies of these supplements demonstrate promising results.19-21 The 2014 guideline recommends supplementing the diet with high protein, arginine, and micronutrients for adults with a PU category/stage III or IV or multiple PUs when nutritional requirements can't be met with traditional high-calorie and protein supplements.10
Vitamins and minerals
Does your wound care protocol include mega doses of ascorbic acid (vitamin C) and zinc? For patients with PUs who don't consume an adequate diet or who may have a deficiency, the recommendation is to provide a multivitamin with minerals.10,22
Vitamin C is a water-soluble vitamin essential for collagen formation; a deficiency could prolong the healing time and reduce resistance to infection. The Dietary Reference Intake of 70 to 90 mg/day of vitamin C can easily be met by consuming citrus fruits and vegetables such as broccoli and potatoes. However, research doesn't support giving mega doses of vitamin C to accelerate healing time.23 Check the label of the nutritional supplements you offer because they usually contain ascorbic acid plus other vitamins and minerals including zinc.
Zinc has many functions, including being a cofactor for collagen formation and supporting immune function.24 Those with excessive gastrointestinal fluid losses, large draining wounds, or very poor dietary protein intake over an extended time may be zinc deficient. Plasma or serum zinc levels are commonly used tests for evaluating zinc deficiency, but these levels don't necessarily reflect cellular zinc status due to the distribution of zinc throughout the body as a component of protein.24
No research supports giving mega doses of zinc, such as zinc sulfate 200 to 250 mg daily, over the upper tolerable limit of elemental zinc of 40 mg/day. High serum zinc levels may inhibit healing and interfere with copper metabolism.25,26 Zinc requirements can be met by eating two servings a day of meat, milk, eggs, or liver.24
Fueling the healing process
Assess the nutritional status of all patients who have a PU or are at risk for a PU. Because early nutrition interventions can prevent and/or delay undernutrition, the interdisciplinary team should refer these patients to the RDN as soon as possible. (See the Nursing2014 iPad app for additional content.) The team should focus the care plan on improving each patient's nutritional status through accepted, evidence-based nutrition interventions to ensure that nutritional deficits are corrected.
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