The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) have collaborated to develop international guidelines for pressure ulcer treatment. The guidelines include everything from pressure relief to dressings to palliative care. I had the wonderful experience of developing the nutrition guidelines with a team of experts in the field: Mary Ellen Posthauer, RD, CD; David Thomas, MD, CMD, FACP; and Steven Black, MD. Our work included a systematic, comprehensive evaluation of peer-reviewed journal articles of research on pressure ulcer treatment from 1998 through January 2008, with supplemental reviews of previous guidelines' evidence tables to identify relevant studies published prior to 1998.
All studies that met inclusion criteria were reviewed for quality, summarized into evidence tables, and classified according to the Sackett Level of Evidence Rating System for Individual Studies (1989). Recommendations were developed based on available scientific evidence, rated for strength of evidence, and then reviewed by NPUAP directors, EPUAP guidelines development group, and stakeholders from many countries.
We also published a detailed nutrition white paper in May 2009, which includes a comprehensive review of the literature, international guidelines for nutrition, and detailed suggestions for best practice.
Medical nutrition therapy
There is limited evidence-based research related to nutrition treatment of pressure ulcers. However, known risk factors for pressure ulcer development include compromised nutritional status (unintentional weight loss, undernutrition, protein energy malnutrition, and dehydration), as well as low body mass index, reduced food intake, and impaired ability to eat independently. In addition, undernutrition and protein energy malnutrition can negatively impact pressure ulcer healing, all of which makes early identification and treatment of nutritional problems critical. Each clinician must use expert clinical judgment based on a thorough medical and nutritional assessment to make appropriate individualized recommendations.
Recommendations in brief
All individuals should be screened for nutrition problems upon admission and with each change in condition. Individuals with nutrition issues and those with pressure ulcers should be referred to the registered dietitian (RD), who conducts a thorough nutritional assessment including review of weight status, ability to eat independently, and adequacy of total food/fluid intake.
Sufficient calories must be provided for individuals under stress with a pressure ulcer: 30-35 kcalories/kg body weight; adjust as needed based on weight loss/gain or level of obesity. Dietary restrictions should be liberalized if they decrease the individual's food/fluid intake. For example, we had a resident with a pressure ulcer who was on a low fat/low cholesterol, 2 gram sodium diet. Food had become unpalatable and unappealing and he was not eating enough to meet his nutritional needs. In this case, we liberalized to a regular diet with no added salt until the pressure ulcer was healed, and then gradually added back a few restrictions as needed. Enhanced foods and/or oral nutritional supplements should be provided and nutrition support should be considered (as consistent with goals of care) when oral intake is inadequate.
Protein must be provided at a level that creates a positive nitrogen balance: 1.25-1.5 grams protein/kg body weight is recommended if compatible with goals of care. This should be individualized and reassessed with condition changes. Renal function must be assessed to ensure that higher levels of protein are appropriate and tolerated.
Fluids should be encouraged to promote adequate hydration. Since evidence specific to fluid requirements and pressure ulcers is lacking, general formulas are used to determine individual needs (i.e., 30 mL/kg body weight or 1 mL fluid/calorie consumed). Monitoring of fluid balance is essential. Additional fluids may be needed for those with insensible fluid losses such as vomiting, diarrhea, fever, and draining wounds.
A healthy, well-balanced diet that includes good sources of vitamins and minerals should be encouraged. If nutritional intake is poor or deficiencies are confirmed or suspected, additional vitamin/mineral supplements should be offered. However, there is no research to justify supplementation above the U.S. Recommended Dietary Intake (RDI) for any vitamin or mineral.
There is not enough evidence to support recommendation of specialized amino acid supplements such as arginine or glutamine for pressure ulcer healing. Additional research is needed in this area.
There were no studies to address the nutritional needs of the obese individual (BMI >30) with pressure ulcers. Research is needed to define appropriate caloric ranges for these individuals. Dietary restrictions aimed at weight loss may need to be modified or postponed until the pressure ulcer has healed. Additional research is also needed to develop recommendations for pediatric patients and neonates.