Nutrition Connection: Role of Nutrition in Pressure Ulcer Prevention and Treatment

(reprinted from Dietary Manager, May 2010)

Have you ever considered that the skin is the largest organ of the body? The skin contributes about 10 percent of the total body weight. For example, if a resident weights 300 pounds, his skin alone weights 30 pounds! The skin is a vital organ that is constantly exposed to a changing environment as it protects the body from a variety of assaults.

The skin has two layers. The epidermis is the thin outer layer and the dermis is the thick inner layer. Each layer is made up of different types of tissue with different functions. The dermis contains two important proteins- collagen and elastin. Collagen is the major structural protein. Elastin fibers form coil-like structures that allow the protein to be stretched and when released will spring back to the original shape.
The skin is a vital organ that is often ignored until it is injured. The skin provides five major functions:

• Protection
• Thermoregulation
• Metabolism
• Sensation
• Communication

The skin acts as a physical barrier from all environmental attacks including water, chemicals, ultraviolet radiation, bacteria and viral pathogens. It prevents loss of fluids and electrolytes to maintain a healthy balance in the body. The skin provides a barrier between the inside of the body and the environment to maintain body temperature. The body regulates core body temperature through blood circulation and sweating. It is the site of synthesis of vitamin D from UVB rays. If the skin senses too much sunlight, the nerve receptors in the skin are stimulated. The skin is sensitive to touch, pain, pressure heat and cold. Finally the skin plays cosmetic, identification and communication roles. The skin over the face is especially important in identification of a person.

Skin & Aging
Skin changes over time with age, exposure to the sun, hydration, medications and nutrition. In older adults the dermis has decreased in thickness and the rate of cell turnover increases with each decade. The practical implications of these facts are that the skin becomes more fragile with disability and aging. In addition, skin tears and wounds take much longer to heal.

Skin breakdown is a common problem in adults with limited mobility such a spinal cord injury or neurological disease. Pressure ulcers are the most commonly reported type of skin failure. It is estimated that 1 to 3 million people living in the USA develop pressure ulcers each year. According to Joint Commission, more than 2.5 million hospitalized patients in the USA will have pressure ulcers and about 60,000 will die from pressure ulcer complications each year. It is estimated that the prevalence (proportion of persons who have a pressure ulcer at a specific point in time) of pressure ulcers in the USA is between 10-18 percent in acute care, 2 to 28 percent in long term care and up to 29 percent in home care. Even more alarming is the report from the Agency for Healthcare Research and Quality (AHRQ) that indicates that pressure ulcer-related hospitalizations increased by 80 percent from 1993 to 2006.

The Centers for Medicare and Medicaid Services (CMS) announced that they will no longer reimburse hospitals for treatment of hospital acquired pressure sores in Medicare patients as of October 2008. Pressure ulcer development following admission is considered a ‘reasonably preventable’ hospital-acquired condition. This new payment regulation has dramatically changed the focus of skin care.

The focus in both acute and long term care is to prevent skin breakdown. The NPUAP (National Pressure Ulcer Advisory Panel) and the EPUAP(European Pressure Ulcer Advisory Panel) have worked together to develop guidelines for both the prevention and treatment of pressure ulcers.

Prevention
The NPUAP and EPUAP have published the following nutrition guidelines for the prevention of pressure ulcers. CDMs must work collaboratively with RDs and health care team members to implement these guidelines while complying with state licensure laws for dietitians. The general and specific recommendations are summarized below. The complete report can be access at http://www.npuap.org/Final_Quick_Prevention_for_web_2010.pdf

General Nutrition Recommendations for Prevention of Pressure Ulcers:
1. Screen and assess the nutritional status of every individual at risk of pressure ulcers in each health care setting.
Since undernutrition is a reversible risk factor for pressure ulcer development, early identification and management of undernutrition is very important. Individuals at risk of pressure ulcer development may also be at risk of undernutrition, and so should be screened for nutritional status.

1.1 Use a valid, reliable and practical tool for nutritional screening that is quick and easy to use and acceptable to both the individual and health care worker.

1.2 Have a nutritional screening policy in place in all health care settings, along with recommended frequency of screening for implementation.

Refer each individual with nutritional risk and pressure ulcer risk to a registered dietitian and also, if needed, to a multidisciplinary nutritional team that includes a registered dietitian, a nurse specializing in nutrition, a physician, a speech and language therapist, an occupational therapist, and when necessary a dentist.

If the nutritional screening identifies individuals as being prone to develop pressure ulcers or to be malnourished or at nutritional risk, then a more comprehensive nutritional assessment should be undertaken by a registered dietitian or a multidisciplinary nutritional team. Nutritional support should be offered to each individual with nutritional risk and pressure ulcer risk.

2.1. Provide nutritional support to each individual with nutritional risk and pressure ulcer risk, following the nutritional cycle. This should include:

• Nutritional assessment
• Estimation of nutritional requirements
• Comparison of nutrient intake with estimated requirements
• Provide appropriate nutrition intervention, based on appropriate feeding route
• Monitoring and evaluation of nutritional outcome, with reassessment of nutritional status at frequent intervals while an individual is at risk. Individuals may need different forms of nutritional management during the course of their illness.

2.2. Follow relevant and evidence based guidelines on enteral nutrition and hydration for individuals at risk of pressure ulcers, who show nutritional risks or nutritional problems.

2.3. Offer each individual with nutritional risk and pressure ulcer risk a minimum of 30-35 kcal per kg body weight per day, with 1.25-1.5 g/kg/day protein and 1 ml of fluid intake per kcal per day.

Specific Nutrition Recommendations for Prevention of Pressure Ulcers:
1. Offer high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet to individuals with nutritional risk and pressure ulcer risk because of acute or chronic diseases, or following a surgical intervention. Oral nutrition (via normal feeding and/or with additional sip feeding) is the preferred route for nutrition, and should be supported whenever possible.

Oral nutritional supplements are of value because many pressure-ulcer-prone patients often cannot meet their nutritional requirements via normal oral food intake. Moreover, oral nutritional supplementation seems to be associated with a significant reduction in pressure ulcer development, compared to routine care. Enteral (tube feeding) and parenteral (delivered outside the alimentary tract) nutrition may be necessary when oral nutrition is inadequate or not possible, based on the individual’s condition and goals.

1.1. Administer oral nutritional supplements (ONS) and/or tube feeding (TF) in between the regular meals to avoid reduction of normal food and fluid intake during regular mealtimes.

Treatment Guidelines
The NPUAP and EPUAP have published the following nutrition guidelines for the treatment of pressure ulcers. CDMs must work collaboratively with RDs and health care team members to implement these guidelines while complying with state licensure laws for dietitians. The treatment recommendations are summarized below. The complete report can be access at:
http://www.npuap.org/Final_Quick_Treatment_for_web_2010.pdf

Nutrition Recommendations for Treatment of Pressure Ulcers:
1. Screen and assess nutritional status for each individual with a pressure ulcer at admission and with each condition change — and/or when progress toward pressure ulcer closure is not observed.
1.1. Refer all individuals with a pressure ulcer to the dietitian for early assessment of and intervention for nutritional problems.
1.2. Assess weight status for each individual to determine weight history and significant weight loss from usual body weight (> 5% change in 30 days or > 10% in 180 days).
1.3. Assess the individual’s ability to eat independently.
1.4. Assess the adequacy of total nutrient intake (food, fluid, oral supplements, enteral/parenteral feedings).
2. Provide sufficient calories.
2.1. Provide 30-35 kcalories/kg body weight for individuals under stress with a pressure ulcer. Adjust formula based on weight loss, weight gain, or level of obesity. Individuals who are underweight or who have had significant unintentional weight loss may need additional kcalories to cease weight loss and/or regain lost weight.
2.2. Revise and modify (liberalize) dietary restrictions when limitations result in decreased food and fluid intake. These adjustments are to be managed by a dietitian or medical professional.
2.3. Provide enhanced foods and/or oral supplements between meals if needed.
2.4. Consider nutritional support (enteral or parenteral nutrition) when oral intake is inadequate. This must be consistent with the individual’s goals.
3. Provide adequate protein for positive nitrogen balance for an individual with a pressure ulcer.
3.1. Offer 1.25 to 1.5 grams protein/kg body weight daily for an individual with a pressure ulcer when compatible with goals of care, and reassess as condition changes.
3.2. Assess renal function to ensure that high levels of protein are appropriate for the individual.
4. Provide and encourage adequate daily fluid intake for hydration.
4.1. Monitor individuals for signs and symptoms of dehydration: changes in weight, skin turgor, urine output, elevated serum sodium, or calculated serum osmolality.
4.2. Provide additional fluid for individuals with dehydration, elevated temperature, vomiting, profuse sweating, diarrhea, or heavily draining wounds.
5. Provide adequate vitamins and minerals.
5.1. Encourage consumption of a balanced diet that includes good sources of vitamins and minerals.
5.2. Offer vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected.

Non-healing wounds
CMS differentiates between avoidable and unavoidable declines in nutritional status. Under F325 CMS defines an unavoidable decline in nutritional status as one that develops even though the facility does the following:

• Evaluates the resident’s clinical condition and nutritional risk factors.
• Develops a plan of care and implements intervention consistent with resident’s needs, goals and recognized standards of practice.
• Monitors and evaluates interventions.
• Modifies approaches as necessary.

Not all skin breakdown is preventable. Individuals with cachexia, metastatic cancer, multiple organ failure, sarcopenia, severe vascular disease and terminal illness may develop skin breakdown despite competent nursing care and optimal nutrition. Under F-tag 314, Comprehensive Assessment, CMS defines an unavoidable pressure ulcer as one that develops even though the facility does the following:

• Evaluates the resident’s clinical condition and identifies risk factors for skin breakdown.
• Develops a plan of care and implements intervention consistent with resident’s needs, goals and recognized standards of practice.
• Monitors and evaluates interventions.
• Modifies approaches as necessary (AMDA, 2008).

One other source of unavoidable pressure ulcers is in the resident who is not willing to comply with the nursing, nutrition and rehabilitation interventions recommended to prevent or treat skin breakdown. In 2010, the NPUAP consensus conference panelists have agreed that ‘patients who chose not to participate in their own pressure ulcer prevention could develop unavoidable pressure ulcers.’ They also agreed that ‘there are clinical situations in which the development of pressure ulcers can be unavoidable.’ They have proposed to CMS a revised definition of unavoidable pressure ulcer to encompass these issues.

Implications for Practice
The newest NPUAP/EPUAP Guidelines for Prevention and Guidelines for Treatment of Pressure Ulcers need to be considered as you update your facility skin care policies and procedures. Work with the RD to develop inservice education programs to update healthcare staff on new guidelines.

References:
American Medical Directors Association (2008) Pressure ulcers in the long-term care setting. AMDA.
National Pressure Ulcer Advisory Panel and European Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel, 2009.
Litchford, MD (2010) Advanced Practitioner’s Guide to Nutrition & Wounds. Greensboro, NC: CASE Software & Books.

By Mary D. Litchford, PhD, RD, LDN

Mary D. Litchford, PhD, RD, LDN is a nationally-recognized speaker and the author of various articles and books, including Common Denominators of Declining Nutritional Status.