Nutrition therapy and pressure ulcer prevention: new NPUAP-EPUAP guidelines, nutrition white paper cast new light on wound care.
At a glance ...
Becky Dorner, RD, LD, coauthor of the NPUAP-EPUAP International Guidelines for Pressure Ulcer Pressure ulcer
Also known as a decubitus ulcer, pressure ulcers are open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body. Patients who are bedridden are at risk of developing pressure ulcers. Treatment, discusses the nutritional findings on preventing and treating pressure ulcers.
The National Pressure Ulcer Advisory Panel (NPUAP NPUAP National Pressure Ulcer Advisory Panel ) and the European Pressure Ulcer Advisory Panel (EPUAP EPUAP European Pressure Ulcer Advisory Panel ) have collaborated to develop international guidelines for pressure ulcer treatment. The guidelines include everything from pressure relief to dressings to palliative care palliative care (paˑ·lē·ā·tiv kerˑ),
n an approach to health care that is concerned primarily with attending to physical and emotional comfort rather . 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 CMD cerebromacular degeneration. , FACP FACP Fellow of the American College of Physicians.
1. Fellow of the American College of Physicians
2. Fellow of the American College of Prosthodontists ; and Steven Black, MD. Our work included a systematic, comprehensive evaluation of peer-reviewed journal peer-reviewed journal Refereed journal Academia A professional journal that only publishes articles subjected to a rigorous peer validity review process. Cf Throwaway 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 nutritional status,
n the assessment of the state of nourishment of a patient or subject. (unintentional weight loss, undernutrition Undernutrition
A type of malnutrition caused by inadequate food intake or the body's inability to make use of needed nutrients.
Mentioned in: Appetite-Enhancing Drugs
see malnutrition, starvation. , 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 un-palatable 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 hydration /hy·dra·tion/ (hi-dra´shun) the absorption of or combination with water.
1. The addition of water to a chemical molecule without hydrolysis.
2. . 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 in-sensible 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 RDI - Receiver Data Interface ) for any vitamin or mineral.
There is not enough evidence to support recommendation of specialized amino acid supplements such as arginine arginine (är`jənĭn), organic compound, one of the 20 amino acids commonly found in animal proteins. Only the l-stereoisomer participates in the biosynthesis of proteins. or glutamine glutamine (gl`təmēn), organic compound, one of the 20 amino acids commonly found in animal proteins. 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 BMI body mass index.
body mass index
Body mass index (BMI)
A measurement that has replaced weight as the preferred determinant of obesity. > 30) with pressure ulcers. Research is needed to define appropriate caloric caloric /ca·lo·ric/ (kah-lor´ik) pertaining to heat or to calories.
1. Of or relating to calories.
2. Of or relating to heat. 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.
Access the Guidelines
The complete set of guidelines and a full list of references are available in the publication, The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel (NPUAP) White Paper available on the NPUAP Web site at www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf.
Note: Check the NPUAP Web site at www.npuap.org for final details on the full set of the NPUAP-EPUAP Pressure Ulcer Treatment Guidelines.
by Becky Dorner, RD, LD
Becky Dorner, RD, LD, is a speaker and author who has provided publications, presentations, and consulting services to enhance the quality of care for our nation's older adults since 1983. For her free e-mail magazine, free articles, publications, CEU CEU Continuing Education Unit
CEU Central European University
CEU College of Eastern Utah (Price, UT)
CEU Centro Escolar University (Manila, Philippines)
CEU Centro Escolar University programs, and teleseminars, visit her Web site (www.BeckyDorner.com). To send your comments to the editor, e-mail email@example.com.