Recommendations for Nutrition of Patients at Risk of or with Pressure Ulcers

A substantial amount of prognostic data demonstrates the impact of nutrition on the risk and healing of pressure ulcers. Therefore, nutritional measures should be included in clinical care for patients at high risk of developing pressure ulcers or already with their presence.

Identification of Patients at Risk of Pressure Ulcers

The risk of developing pressure ulcers is high in the case of:

• a positive result when using a pressure ulcer risk assessment tool;
• a positive result when using a malnutrition assessment tool;
• unintended weight loss of ≥ 5% in 30 days or ≥ 10% in 180 days;
• BMI ≤ 18.5 or ≥ 30 kg/m²;
• sarcopenia;
• reduced ability or capacity to consume food per os, problems with chewing and swallowing;
• enteral or parenteral nutrition;
• immobility;
• malnutrition/dehydration;
• certain comorbidities: end-stage renal failure, chronic heart failure, diabetes;
• cognitive impairment;
• history of pressure ulcers.

Assessment of Nutritional Status in Patients at High Risk or with Existing Pressure Ulcers

Patients and their family, the attending physician, and a nutrition specialist should be informed about the risk or presence of pressure ulcers. Care for such patients should be managed by an interdisciplinary team. The nutrition specialist will perform a nutritional assessment including:

• diagnosis, comorbidities, medication;
• weight history, BMI calculation;
• physical examination focused on nutrition (subcutaneous fat, muscle atrophy);
• determination of required caloric and protein intake;
• assessment of current nutritional and fluid intake;
• assessment of patient preferences and food intolerances;
• evaluation of the patient's ability to chew, swallow, and eat independently;
• assessment of dehydration risk;
• laboratory values related to nutrition (HbA_1c, urea);
• assessment of renal function concerning protein intake;
• monitoring hydration in patients with fever, vomiting, excessive sweating, and significant wound exudation.

Recommended Nutritional Intake

The daily caloric intake should correspond to 30–35 kcal/kg body weight, protein intake 1.2–1.5 g/kg (both considering the clinical condition), and fluid intake 1 ml per 1 kcal of consumed food. Hydration status should be monitored. Preferred foods should be offered to the patient. Consideration may be given to serving fortified foods and beverages. If medically possible, it is advisable to reduce the severity of restrictive diets. In cases of vitamin and mineral deficiencies or low intake, oral supplements should be administered. The patient should be weighed weekly.

For patients with malnutrition and at risk of pressure ulcers, caloric and protein intake should be adjusted. Patients with stage 2–4 pressure ulcers, multiple pressure ulcers, or chronic wounds and malnutrition should receive high-calorie, high-protein oral nutrition and food supplements containing arginine, zinc, and antioxidants.

Regular Monitoring

For patients at risk of or already with pressure ulcers, it is essential to check the condition of the skin or wound at least once a week, tolerability of food supplements, intake of calories, proteins, and fluids compared to recommended values, oral intake ability (consider enteral or parenteral nutrition if necessary), body weight, laboratory parameters, effectiveness of intervention within the multidisciplinary team, and healing of the pressure ulcer using a validated tool.

Nutritional interventions should be repeatedly reassessed until the pressure ulcer is healed.

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Source: Munoz N., Posthauer M. E., Cereda E. et al. The role of nutrition for pressure injury prevention and healing: the 2019 international clinical practice guideline recommendations. Adv Skin Wound Care 2020 Mar; 33 (3): 123–136, doi: 10.1097/01.ASW.0000653144.90739.ad.