The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper
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The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
Authors: Becky Dorner, RD, LD, Mary Ellen Posthauer, RD, CD,
and David Thomas, MD, CMD, FACP
National Pressure Ulcer Advisory Panel
Introduction
The purpose of this white paper is to review the Pressure ulcers can reduce overall quality of life
currently available scientific evidence related to due to pain, treatments, and increased length of
nutrition and hydration for pressure ulcer institutional stay, and may also contribute to
prevention and treatment in adults; introduce the premature mortality in some patients (6,7).
nutrition recommendations from the new Therefore, any intervention that may help to
National Pressure Ulcer Advisory Panel prevent pressure ulcers or to treat them once
(NPUAP)-European Pressure Ulcer Advisory they occur is important to reduce the cost of
Panel (EPUAP) Guidelines for Pressure Ulcer pressure ulcer care and improve quality of life
Treatment; and review research needs for the for affected individuals.
future.
The burden of having a pressure ulcer is high, in
Overview of Pressure Ulcers: Prevalence, physical, emotional and financial terms. Data
Incidence, Cost and Nutrition from 1999 indicates that the cost of treating
Estimates indicate that 1 to 3 million people in pressure ulcers may range from $5 to 8.5 billion
the US develop pressure ulcers each year (1). annually (8). Factor in 7% per year for health
According to the Joint Commission, more than care inflation, and this equates to approximately
2.5 million patients in United States (US) acute- $9.2 to 15.6 billion dollars in 2008. AHRQ
care facilities suffer from pressure ulcers, and reported that pressure ulcer-related
60,000 die from pressure ulcer complications hospitalizations ranged from 13 to 14 days and
each year (2). cost $16, 755 to $20,430 compared to the
average stay of 5 days and costs approximately
The NPUAP defines prevalence as “a proportion $10,000 (5). The Centers for Medicare/Medicaid
of persons who have a pressure ulcer at a Services (CMS) reports the cost of treating a
specific point in time” (3). Prevalence of pressure ulcer in acute care (as a secondary
pressure ulcers in the US is widespread in all diagnosis) is $43,180.00 per hospital stay (9,10).
settings with estimates of 10% to 18% in acute Contributing cost factors include increased
care, 2.3% to 28% in long-term care, and 0% to length of stay due to pressure ulcer
29% in home care (3). The NPUAP defines complications such as pain, infection, high tech
incidence as “the number of new cases of support surfaces, and decreased functional
pressure ulcers appearing in a pressure ulcer - ability (11).
free population over a period of time” (3).
Incidence of pressure ulcers ranges from 2.3% In addition to the financial cost of pressure
to 23.9% in long-term care, 0.4% to 38% in ulcers, mortality rates are disturbing. A recent
acute care, 0% to 17% in home care and 0% to AHRQ document (5) reports 503,300 pressure
6% in rehabilitative care (3,4). In addition, new ulcer-related hospitalizations in 2006 which
information from Agency for Healthcare included 45,500 hospital admissions in which
Research and Quality (AHRQ) (5) indicates that patients had pressure ulcers as the primary
pressure ulcer-related hospitalizations increased diagnosis. Of these admissions, one in 25
by an alarming 80 percent from 1993 to 2006. admissions ended in death. Another 457,800
Please note that the interpretation of incidence pressure ulcer-related hospital admissions noted
and prevalence numbers require caution as pressure ulcer as the secondary diagnosis. Of
numbers are influenced by multiple factors these admissions, the death rate was one in
including definition and method of calculation eight.
(3).
©2009 NPUAP Nutrition White Paper 1The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
Litigation adds to the burden of health care of detailed resident characteristics, treatments,
costs. This is especially true in long-term care, and outcomes using a convenience sample of
where nearly 87% of verdicts and out of court nursing home residents. Participants included
settlements against facilities are awarded to the 2,420 adult residents of nursing facilities, with a
plaintiffs (12). One report reviewed 54 nursing length of stay of 14 days or longer, who were at
home law suit cases from September 1999 to risk of developing a pressure ulcer. More than
April 2002 involving pressure ulcers. The 50% of residents in the study experienced
average monetary recovery was more than weight loss of at least 5% during the 12 week
$13.5 million and included awards of up to $312 study, and 45.6% of residents were considered
million in one case, when determined by a underweight (defined as a BMI of 22 or less).
verdict or settlement (13). In litigation cases The highest percentage of weight loss occurred
related to pressure ulcers, jury awards are in the residents with a recent pressure ulcer. In
highest for multiple causation factors. When addition, residents with the lowest BMIs also had
awards were related to single causes, the existing pressure ulcers (20). Thomas (21) noted
highest awards were for those where inadequate that recent weight loss in older adults was a key
nutrition was alleged to be the cause of pressure factor in mortality risk, and Murden and Ainslie
ulcers (12). However, it is important to note that (22) indicated that a 10% decline in weight over
in the past few years a few states have passed a 6 month period was a strong predictor of
legislation limiting malpractice awards which mortality in this population. Two studies
may help to control these cost burdens in the supported the theory that individuals in long-
future. term care whose body weight declined by 5% in
30 days were at increased risk for death (23,24).
Nutrition and Pressure Ulcers Thomas (25) described the “anorexia of aging”
Although limited evidence-based research is including appetite decline, weight loss and,
available, general consensus indicates that decreased metabolic rate placing the elderly
nutrition is an important aspect of a person at risk for undernutrition.
comprehensive care plan for prevention and
treatment of pressure ulcers (7,14,15), and it is Undernutrition has been defined as pure protein
essential to address nutrition in every individual and energy deficiency which is reversed solely
with pressure ulcers. Adequate calories, protein, by the administration of nutrients (26). This
fluids, vitamins and minerals are required by the definition ultimately defines undernutrition by the
body for maintaining tissue integrity and ability to improve nutritional status and reverse
preventing tissue breakdown. A large cohort the consequences of undernutrition.
study of 1524 residents in 95 nursing facilities
documented that pressure ulcer incidence may Poor outcomes are associated with
be higher with increased age, frailty or severity undernutrition including the risk of morbidity and
of illness, pressure ulcer history or significant mortality, hence the need to quickly identify and
weight loss and eating difficulties (16,17). treat undernutrition when pressure ulcers are
present. Undernutrition may also negatively
Compromised nutritional status such as impact pressure ulcer healing. Conditions that
unintentional weight loss, undernutrition, protein may lead to undernutrition include: increased
energy malnutrition (PEM), and dehydration dependence on others for eating, chewing and
deficits are known risk factors for pressure ulcer swallowing problems, decreased oral intake of
development (1,18). Other nutrition-related risk food and fluid, unintentional weight loss and
factors associated with increased risk of advanced age. Undernutrition may decrease the
pressure ulcers include low body mass index body’s ability to fight infections and have a
(BMI), reduced food intake, and impaired ability negative impact on pressure ulcer healing.
to eat independently (16,18,19).
Several other medical conditions may affect
The National Pressure Ulcer Long Term Care pressure ulcer healing. PEM has been defined
Study (NPULS) was a retrospective cohort study as a wasting and excessive loss of lean body
©2009 NPUAP Nutrition White Paper 2The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
mass resulting from “too little energy being physical, functional and psychosocial factors
supplied to the body tissue that can be reversed that can contribute to inadequate intake,
solely by the administration of nutrients” (27). unintentional weight loss, undernutrition and/or
Cachexia is another medical malady which may PEM, including cognitive deficits, dysphagia,
affect pressure ulcer healing. “Cachexia is a depression, food-medication interactions,
complex metabolic syndrome associated with gastrointestinal (GI) disorders and impaired
underlying illness and characterized by loss of ability to eat independently. No clear method
muscle with or without loss of fat mass. The exists to determine when nutritional status
prominent clinical feature of cachexia is weight decline begins, especially in older people. In
loss in adults (corrected for fluid retention)… spite of aggressive nutritional interventions,
Anorexia, inflammation, insulin resistance, and some individuals are simply unable to absorb
increased muscle protein breakdown are adequate nutrients for good health.
frequently associated with wasting disease.
Wasting disease is distinct from starvation, age Nutrition Screening and Assessment
related loss of muscle mass, primary The nutrition screening process can identify
depression, malabsorption and hyperthyroidism individuals at nutritional risk and assist in making
and is associated with increased morbidity” (28). referrals to the appropriate health care
professionals for further assessment. Initial
Yet another concern is hypermetabolism, a screening is completed on admission by a
responsive increase in metabolic rate, which is qualified health care professional.
triggered by trauma, severe illness, infection,
pressure ulcers and other factors. The body Several tools may be utilized in the nutrition
utilizes calories at a rapid rate, first pulling from screening process. Langkamp-Henken and
available glycogen stores, then from visceral colleagues (30) concluded from a cross-
protein stores in order to provide energy needed sectional study that the Mini-Nutritional
to keep the major organs functioning. At the Assessment (MNA) and MNA Screening Form
same time, cytokines, the proteins that are provided an advantage over using visceral
liberated in tissue injury and that mediate the protein in screening and assessing nutritional
body’s immune and inflammatory response, status (31). The Malnutrition Universal
contribute to metabolic and gastrointestinal Screening Tool (MUST) is another potential
changes such as anorexia and malaise. The screening tool which helps practitioners identify
effect of increased cytokines and Interleukin 1-6 risk of undernutrition (32). However, these tools
(pro-inflammatory cytokines) on nutritional status are not widely used in all practice areas.
results in anorexia, muscle wasting, decreased
nitrogen retention, and impaired albumin The Braden Risk Assessment Scale: Predicting
synthesis (29). Together, the above maladies pressure ulcer risk (33) includes a nutrition
may contribute to unintended weight loss, subscale which yields additional data that can
undernutrition and/or PEM which in turn are risk be used in the nutrition screening and
factors for pressure ulcer development. assessment process. Individuals should be
reassessed following a change in condition, e.g.,
Recommendations for Practice surgery, NPO status, intravenous fluid therapy
Nutritional Considerations in Pressure only, etc.
Ulcer Prevention
Little specific evidence exists related to medical Based on the results of the nutrition screening, a
nutrition therapy (MNT) for preventing pressure referral is made for a formal assessment by a
ulcers. However, early nutrition screening and registered dietitian (RD), who then completes a
assessment is essential to identify risk of thorough nutritional assessment on each
undernutrition, PEM and unintentional weight individual and makes appropriate
loss which may precipitate pressure ulcer recommendations for interventions and
development and delay healing. There are many management. The American Dietetic
Association (ADA) Nutrition Care Process
©2009 NPUAP Nutrition White Paper 3The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
includes four basic steps: Nutrition Assessment, with fortified foods at each meal and a 6 ounce
Nutrition Diagnosis, Nutrition Intervention and nutritional supplement at 2:00 PM and HS” (34).
Nutrition Monitoring and Evaluation (34).
Nutrition assessment is a systematic and Biochemical Data
continual process of obtaining, verifying, and Biochemical data analysis is one component of
interpreting data upon which the decisions about the total nutrition assessment process. Although
the impact and cause of nutrition-related laboratory tests may help clinicians evaluate
problems are made. The process includes nutrition issues in patients at risk for a pressure
review and analysis of medical, nutritional, ulcer or for those who already have a pressure
laboratory data and food-medication ulcer, no laboratory test can specifically
interactions; obtaining anthropometric determine an individual’s nutritional status.
measurements; and reviewing physical Serum albumin, prealbumin and other lab values
examination results (assessment of visual signs may be useful to help establish overall
of malnutrition, oral status, chewing/swallowing prognosis; however, they may not correlate well
ability, and/or diminished ability to eat with clinical observation of nutritional status
independently, etc.). (38,39).
A German study conducted by Hengstermann et Serum albumin levels have historically been
al. (35) concluded that the Mini Nutritional used widely in practice, however they are a poor
Assessment, a validated nutrition assessment indicator of visceral protein status. This is due to
tool, was “easy to use to determine the nutrition albumin’s long half-life (12 to 21 days) and
status in multi-morbid geriatric patients with multiple factors which decrease albumin levels
pressure ulcers.” The American Dietetic even when protein intake is adequate (e.g.,
Association (ADA) Nutrition Risk Assessment is infection, acute stress, surgery, cortisone
commonly utilized in long-term care, and was excess, hydration status). Decreases in serum
recently validated in a small study conducted by albumin may reflect the presence of
ADA (36,37). Further research is planned to inflammatory cytokine production or other
complete the validation process. comorbidities rather than nutritional status (40).
Cytokine production may result in albumin being
Following the assessment, the registered pulled from the intravascular spaces into the
dietitian (RD) identifies and determines a extravascular spaces and circulating back to the
specific nutrition diagnosis or problem that the liver until the inflammatory process is resolved.
dietetics professional is responsible for treating. Recent studies show the hepatic proteins
The intervention is specific to the nutrition (albumin, transthyretin and transferrin) correlate
diagnosis or problem. The monitoring and with the severity of an underlying disease rather
evaluation steps determne the progress made than nutritional status (41). Conversely,
by the individual to meet the specific goals dehydration may falsely elevate albumin levels.
established. An example of the nutrition
diagnosis for an individual with a pressure ulcer Due to its short half-life (2 to 3 days), prealbumin
is: “Inadequate food and fluid intake related to (or transthyretin and thyroxine-binding albumin)
less than 50% intake of meals as evidenced by has historically been used by practitioners with
non-healing Stage IV pressure ulcer and five the assumption that it may be a better indicator
pound weight loss in two weeks.” The nutrition of the effectiveness of interventions used to
intervention is related to the specific nutrition improve clinical condition (including nutrition
diagnosis. The client/individual and the other status). However, prealbumin is subject to the
members of the healthcare team would work same influences that make albumin problematic
together to develop appropriate and when used as a nutritional indicator. Metabolic
individualized interventions, and then monitor stress and inflammation may decrease levels;
and evalutate for needed changes to nutrition and converse to what practitioners may assume,
interventions. In this case, an example of a prealbumin levels may be maintained during
nutrition intervention is: “Provide a regular diet
©2009 NPUAP Nutrition White Paper 4The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
states of malnutrition (42). For these reasons, it energy and protein due to hypermetabolism
is not recommended as a marker for nutritional which occurs in malnourished patients (14)
status (41,43-49).
Carbohydrate in the form of glucose is the major
One study of critically ill patients receiving total fuel source for collagen synthesis, which is the
parenteral nutrition (TPN) failed to demonstrate building block of tissue. Providing sufficient
that an increase in the prealbumin level carbohydrate as the primary fuel source is much
indicated a better prognosis for this population more efficient than synthesis of glucose from
(45). However, monitoring of low levels of serum protein and fat.
hepatic proteins indicate that a person is very ill
and therefore at high risk for undernutrition, Provision of sufficient caloric requirements
PEM and unintended weight loss. In these should be based on achieving individualized
cases, the individual would benefit from nutritional goals. Energy needs are currently
aggressive and frequent monitoring of weight assessed using several methods. The methods
and oral intake and appropriateness of nutrition used for predictive formulas or energy needs
interventions. measurement must be defined for individual
populations (e.g., critically ill, obese). Recent
Current laboratory values are not always readily research indicates that the Harris-Benedict
available, and waiting for test results may further equation is inaccurate for calculating energy
delay nutritional intervention. Evaluation of lab requirements (51). The Mifflin-St. Jeor Equation
values is only one aspect of the nutritional may be more accurate and have a smaller
assessment process and should be considered margin of error when used to calculate resting
along with other factors such as daily food/fluid metabolic rate for healthy obese individuals (52).
intake, changes in weight status, diagnosis and Measured energy requirements (i.e. indirect
medications. calorimetry), if available, is a more accurate
measure of energy expenditure but cost may be
Nutritional Considerations in Pressure prohibitive in most settings. The National
Ulcer Treatment Academy of Sciences, Institute of Medicine, and
Nutritional recommendations are primarily based Food and Nutrition Board in partnership with
on expert opinion, best practice guidelines and Health Canada (53) defined estimated energy
smaller studies. Each clinician must use expert requirements needed to maintain energy
clinical judgment based on a thorough medical balance in a healthy individual. The
and nutritional assessment to make appropriate requirements are defined by age, gender,
individualized recommendations. The weight, height and activity; and form the basis
individualized care plan should focus on for determining baseline caloric requirements.
improving and/or maintaining the patient’s
overall nutritional status, acceptance of nutrition Calories may be adjusted upwards or
interventions, and clinical outcomes. downwards based on individual nutritional
assessment. Individuals in a hypermetabolic
Macronutrients and Micronutrients state have caloric requirements above the
Related to Pressure Ulcer Treatment baseline caloric requirements.
Macronutrients
Energy Caloric needs are ideally met by a healthy diet;
Energy, or kilocalories, are provided through the however some individuals are unable or
macronutrients: carbohydrates, fats and unwilling to consume an adequate diet. Overly
proteins. Energy is essential for pressure ulcer restricted diets may make food unpalatable and
healing. Providing adequate kilocalories unappealing and therefore reduce intake. The
promotes anabolism, nitrogen and collagen ADA’s position statement indicates that quality
synthesis and healing (50). Increased calories of life and nutritional status are enhanced by the
are needed to overcome accelerated loss of liberalization of the diet ordered by the physician
(54). For example, an individual may not find a
©2009 NPUAP Nutrition White Paper 5The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
sodium restricted diet appealing and therefore contains nitrogen. Protein is responsible for the
intake may be poor, leading to undernutrition synthesis of enzymes involved in pressure ulcer
and slowing the pressure ulcer healing process. healing, cell multiplication, and collagen and
The type and amount of food/fluid ingested daily connective tissue synthesis. All stages of
should be reviewed periodically to ensure the healing require adequate protein. Caloric
individual actually ingests enough calories (energy) needs must be met first in order to
based on estimated needs. It is also important to spare protein from being utilized as an energy
examine the reasons for the intake being source.
decreased. Oral nutritional supplements,
enhanced foods, and food fortifiers can be used Protein is essential to promote positive nitrogen
to combat unintended weight loss and balance. Increased protein levels have been
undernutrition. linked to improved healing rates (57-61). Dietary
protein is especially important in the older adult
In a retrospective uncontrolled cohort study of due to body composition changes that occur
1524 residents in long-term care facilities, the with aging and reduced activity levels. These
prescription of an oral supplement was a changes may include sarcopenia and decreased
predictor of pressure ulcer healing (16,17). immune function, which can lead to impaired
Desneves et al. conducted a randomized wound healing and the inability to adequately
controlled clinical trial (RCT) to measure fight infection. Sarcopenia, normal age-related
pressure ulcer healing using the Pressure Ulcer loss of muscle, can be accelerated due to hyper-
Scale for Healing (PUSH) scores for three catabolic disease states and production of
different groups of subjects (55). Group A inflammatory cytokines which are liberated in
received a standard hospital diet. Group B tissue injury. Recent studies indicate the basic
received a standard diet plus two high calorie requirement for exogenous protein in older
supplements totaling 500 Kcalories, 18 grams of adults is a minimum of 1.0 gram per kilogram
protein, 72 mg of vitamin C and 7.5 mg of zinc. body weight, rather than 0.8 gram per kilogram
Group C received a standard diet plus two high of body weight for healthy adults (62).
calorie supplements which provided 500
Kcalories, 21 grams of protein, 9 grams of The recommended range of protein associated
additional arginine, 500 mg of vitamin C and 50 with healing currently is between 1.2 to 1.5
mg of zinc. Of the three groups, group C noted a grams per kilogram of body weight per day (63).
2.5 fold greater improvement in healing as Past studies have indicated that protein levels
measured by a lower PUSH score. However, as high as 2.0 grams per kilogram body weight
this was a small three week intervention study of may not increase protein synthesis and may
only 16 subjects and pressure ulcers were not contribute to dehydration in the elderly (64).
described by stage. Therefore it is not possible
to determine the impact of the diet by stage of Wolfe and Miller (65) noted that a protein level
pressure ulcer. A study conducted by Wilson above the recommended 0.8 per kilogram of
and colleagues indicated that individuals who body weight for healthy adults is appropriate
consumed oral nutritional supplements between under conditions such as wound healing.
meals experienced better absorption of nutrients Campbell, Trapp, Wolfe, et al. suggest a protein
with the least interference to meal intake (56). allowance of at least 1.0 to 1.2 grams per
Nutritional supplements include products that kilogram of body weight per day for healthy
supply nutrients such protein, calories, fat, elderly individuals (66). The Agency for Health
vitamins, minerals and/or amino acids. Care Policy and Research (AHCPR, which has
been renamed Agency for Healthcare Research
Protein and Quality, or AHRQ) pressure ulcer treatment
Protein is the basis of the human body structure. guidelines recommend 1.25 to 1.5 grams per
Proteins are uniquely different from kilogram of body weight per day for patients with
carbohydrates and fats (lipids) as only protein pressure ulcers (67). The European Pressure
Ulcer Advisory Panel (EPUAP) guideline
©2009 NPUAP Nutrition White Paper 6The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
recommends 1.0 to 1.5 grams per kilogram of controlled clinical trial in elderly nursing
body weight per day (50). home residents with pressure ulcers
reported that arginine supplementation
Some recent studies have focused on increasing was well tolerated but did not enhance
the amount of protein provided for wound mitogen-induced lymphocyte proliferation
healing. In one study, 89 nursing home or healing (69). In a small 3 week
residents with Stage II, III and IV pressure ulcers interventional RCT, Desneves et al.
were randomized into a treatment group which noted a reduction in PUSH scores for
received standard care plus a concentrated, individuals with pressure ulcers who
fortified, collagen protein hydrolysate consumed high calorie supplements
supplement three times a day (providing an containing arginine (55). Maximum safe
additional 45 grams protein per day), and a dosages of arginine supplementation in
control group which received standard care plus humans have not been established.
a placebo three times a day. PUSH scores were Additional research is needed to
used to analyze wound healing. In the eight recommend the use of arginine alone or
week study period, those in the treatment group combined with other nutrients for
had a fifty percent reduction in the PUSH scores pressure ulcer healing (70).
compared to those in the control group (58).
Additional studies are needed to determine Glutamine
whether higher amounts of protein are safe and Glutamine’s role in pressure ulcer
effective in promoting pressure ulcer healing. healing may be its function as a fuel
source for fibroblasts and epithelial cells
It is also important to note that nitrogen losses needed for healing. The safe maximum
may occur from exudating pressure ulcers, dose for glutamine supplementation has
possibly increasing protein needs. Clinical been established as 0.57 grams per
judgment is required to determine the kilogram of body weight per day (71).
appropriate level of protein for each individual, Supplemental glutamine has not been
based on the number of pressure ulcers, overall shown to improve wound healing (72).
nutritional status, comorbidities, and tolerance to More studies are needed to determine
nutritional interventions. For example, glutamine’s impact on pressure ulcer
individuals with chronic kidney disease may be healing.
inappropriate candidates for high levels of
protein (68). Fluids
Fluids serve as the solvent for vitamins,
Amino Acids minerals, glucose and other nutrients and the
Amino acids are the building blocks of protein. transport medium for nutrients and waste
Certain amino acids such as arginine and products though the body. Preliminary data from
glutamine become conditionally essential amino Stotts and Harriet (73) indicate that fluid
acids during periods of severe stress such as administration may increase low tissue oxygen.
trauma, sepsis, and/or pressure ulcers. Tissue oxygenation is needed for proper
healing.
Arginine
Arginine stimulates insulin secretion, The RD calculates individual fluid requirements
promotes the transport of amino acids and determines nutritional interventions. Various
into tissue cells and supports the formulas have been used to calculate adequate
formation of protein in the cells. Studies daily fluid intake. One general formula utilizes 1
related to wound healing appear to be mL per kcalorie consumed (50) initially.
controversial and there is no definitive Practitioners must assess for tolerance and
research study specifically related to reassess as condition changes.
arginine’s impact on pressure ulcer
healing in humans. A randomized
©2009 NPUAP Nutrition White Paper 7The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
Health care practitioners should monitor patients with pressure ulcers who were
individuals’ hydration status, checking for signs randomized to receive 10 mg or 500 mg of
and symptoms of dehydration such as: changes vitamin C twice daily. The study did not result in
in weight, skin turgor, urine output, elevated improved healing in either of the two groups
serum sodium or calculated serum osmolality (79). The inclusion of fruits and vegetables such
(74). as citrus fruits in the diet can achieve the
Individuals consuming high levels of protein may desired recommended daily amount. However,
require additional fluid. Elevated temperature, vitamin C at physiological doses should be
vomiting, profuse sweating, diarrhea and heavily considered when dietary deficiency is
draining wounds contribute to fluid loss which diagnosed.
must be replaced (74).
Zinc and Copper
In generally healthy individuals who are Zinc is a mineral that functions as an antioxidant
adequately hydrated, food accounts for any and is associated with collagen formation,
where from 19 to 28% of total fluid intake (75). synthesis of protein, DNA and RNA, and cell
Total fluid needs include the water content of the proliferation. Inflammatory cells, epithelial cells
food consumed (75). Nutritional supplements and fibroblasts are proliferating cells (80). Zinc is
and enteral feedings are generally 75% water. transported through the body primarily by
For specific amount of free fluids refer to the albumin, therefore, zinc absorption declines
individual product nutrition labeling. when plasma albumin declines, such as in PEM,
trauma, sepsis or infection (81).
Micronutrients
The Institute of Medicine (IOM), National Deficiency of zinc may be the result of wounds
Academy of Sciences (NAS) Dietary Reference with increased drainage, poor dietary intake over
Intakes indicate the level of each micronutrient a long period of time, or excessive
needed at each stage of life for healthy gastrointestinal losses. Zinc deficiency may
individuals (53,76). Most nutrient needs can be cause loss of appetite, abnormal taste, impaired
met through a healthy diet. However, individuals immune function and impaired wound healing.
with pressure ulcers may not be consuming an Good sources of zinc include high protein foods
adequate diet to meet established nutritional such as meat, liver, and shellfish.
reference standards.
No research has demonstrated an effect of zinc
Micronutrients that are “hypothesized” to be supplementation on improved pressure ulcer
related to pressure ulcer healing include vitamin healing. When clinical signs of zinc deficiency
C, zinc and copper. are present, zinc should be supplemented at no
more than 40 mg of elemental zinc per day
Ascorbic Acid which is the Daily Reference Intakes (DRI)
Ascorbic acid (vitamin C), a water soluble upper limit (82). Zinc supplementation should be
vitamin, is a cofactor with iron during the stopped once the deficiency is corrected. High-
hydroxylation of proline and lysine in the dose zinc supplementation (above 40 mg per
production of collagen. Thus ascorbic acid is day) is not recommended (76) because it can
important for tissue repair and regeneration (77). adversely affect copper status possibly resulting
Deficiency can be associated with impaired in anemia. High serum zinc levels may inhibit
fibroblastic function and decreased collagen healing, impair phagocytosis, interfere with
synthesis, which can result in delayed healing copper metabolism, and induce a copper
and capillary fragility. Ascorbic acid deficiency is deficiency since both minerals compete for
also associated with impaired immune function binding sites on the albumin molecule (15,83,
which can decrease the ability to fight infection 84). Copper deficiency may be harmful as
(77). However, mega doses of vitamin C have copper is essential for collagen cross-linking.
not been shown to accelerate wound healing
(78). One blinded, multicenter trial included 88
©2009 NPUAP Nutrition White Paper 8The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
To determine if additional supplementation is A – Recommendation supported by direct
necessary and before recommending additional scientific evidence from properly designed and
supplementation, practitioners should review implemented controlled trials on pressure ulcer
any comprehensive vitamin/mineral in humans providing statistical results that
supplements, enteral formulas, oral nutritional consistently support the recommendation
supplements or fortified foods which contain (Sackett Level I studies).
additional micronutrients.
B – Recommendation supported by direct
Current Recommendations for Medical scientific evidence from properly designed and
Nutrition Therapy for Pressure Ulcer implemented clinical series on pressure ulcers in
Treatment humans providing statistical results that
The following recommendations are taken from consistently support the recommendation
the NPUAP-EPUAP Pressure Ulcer Treatment (Sackett Level II, III, IV, V studies).
Guideline, published in 2009. The Treatment
Guideline was developed following a systematic, C – The recommendation is supported by expert
comprehensive review of the peer-reviewed, opinion or indirect evidence (e.g. studies in
published research on pressure ulcer treatment animal models and/or other types of chronic
from 1998 through January 2008. Supplemental wounds).
searches were conducted on related nutrition
issues. Evidence tables from previous guidelines A complete description of the NPUAP-EPUAP
were reviewed to identify relevant studies guideline development methodology has been
published prior to 1998. All studies meeting previously published (86).
inclusion criteria were reviewed for quality,
summarized in evidence tables and classified Additional research is needed to determine the
according to their level of evidence using a effects of various medical nutrition therapy
schema developed by Sackett (85). (MNT) interventions on pressure ulcer healing.
The goals of MNT must also be based on the
individual’s prognosis and goals of treatment.
Sackett Level of Evidence Rating System
For some, aggressive intervention is
for Individual Studies appropriate. However, for others, such as those
Level at end of life, the goal may simply be to maintain
Large randomized trial with clear-cut comfort to the extent possible based on the
I
results (and low risk of error) patient’s wishes.
Small randomized trial with uncertain
II results (and moderate to high risk of For individuals who have a pressure ulcer,
error) the NPUAP-EPUAP guidelines are:
Non randomized trial with concurrent or
III All individuals should have a nutritional
contemporaneous controls
Non randomized trial with historical assessment upon admission and with each
IV condition change. This is particularly true
controls
Case Series with no controls. Specify for individuals with pressure ulcers.
V
number of subjects. 1. Screen and assess nutritional status for
Adapted from Sackett DL/ Evidence based
medicine. What it is and what it isn't. Br Med J each individual with a pressure ulcer at
1996;312:71-72. admission and with each condition
change and/or when progress toward
Strength of Evidence Supporting Each pressure ulcer closure is not observed.
Recommendation (Strength of Evidence = C.)
Next the cumulative strength of evidence
1.1. Refer all individuals with a
supporting each recommendation was rated
pressure ulcer to the dietitian for
according to the following criteria:
©2009 NPUAP Nutrition White Paper 9The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
early assessment and intervention 2.4. Consider nutritional support
of nutritional problems. (Strength (enteral or parenteral nutrition)
of Evidence = C.) when oral intake is inadequate.
This must be consistent with
1.2. Assess weight status for each individual goals. (Strength of
individual to determine weight Evidence = C.)
history and significant weight loss
from usual body weight (> 5% 3. Provide adequate protein for positive
change in 30 days or > 10% in 180 nitrogen balance for an individual with a
days). (Strength of Evidence = C.) pressure ulcer. (Strength of Evidence =
B.)
1.3. Assess ability to eat
independently. (Strength of 3.1. Offer 1.25 - 1.5 grams protein/kg
Evidence = C.) body weight for an individual with
a pressure ulcer when compatible
1.4. Assess adequacy of total nutrient with goals of care, and reassess
intake (food, fluid, oral as condition changes. (Strength of
supplements, enteral/parenteral Evidence = C.)
feedings). (Strength of Evidence =
C.) 3.2. Assess renal function to ensure
high levels of protein are
2. Provide sufficient calories. (Strength of appropriate for the individual.
Evidence = B.) (Strength of Evidence = C.)
2.1. Provide 30-35 Kcalories/kg body 4. Provide and encourage adequate daily
weight for individuals under stress fluid intake for hydration. (Strength of
with a pressure ulcer. Adjust Evidence = C.)
formula based on weight loss,
weight gain or level of obesity. 4.1. Monitor individuals for signs and
Individuals who are underweight symptoms of dehydration:
or who have had significant changes in weight, skin turgor,
unintentional weight loss may urine output, elevated serum
need additional Kcalories to cease sodium or calculated serum
weight loss and/or regain lost osmolality. (Strength of Evidence
weight. (Strength of Evidence = C.) = C.)
2.2. Revise and modify (liberalize) 4.2. Provide additional fluid for
dietary restrictions when individuals with dehydration,
limitations result in decreased elevated temperature, vomiting,
food and fluid intake. This is to be profuse sweating, diarrhea or
done by a dietitian or medical heavily draining wounds. (Strength
professional. (Strength of of Evidence = C.)
Evidence = C.)
5. Provide adequate vitamins and minerals.
2.3. Provide enhanced foods and/or (Strength of Evidence = B.)
oral supplements between meals if
needed. (Strength of Evidence = 5.1. Encourage consumption of a
B.) balanced diet which includes good
sources of vitamins and minerals.
(Strength of Evidence = B.)
©2009 NPUAP Nutrition White Paper 10The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
5.2. Offer vitamin and mineral nutrition assessment and intervention. Nutrition
supplements when dietary intake and hydration can have a positive impact on the
is poor or deficiencies are quality of life. Poor health outcomes may be
confirmed or suspected. (Strength associated with even small amounts of
of Evidence = B.) unintended weight loss. Early nutrition
interventions can help to prevent and/or delay
Research Needs undernutrition, PEM and hydration deficits and
Undernutrition is associated with increased their impact on risk of pressure ulcer
morbidity and mortality. Early identification and development and delayed healing. Refer the
treatment of nutritional problems is critical. patient to the RD as soon as risk is identified or
There were no studies specifically addressing upon identification of a pressure ulcer. If
the obese individual with pressure ulcers. medically possible, early aggressive nutrition
Additional research is also needed for pediatric interventions should be implemented to prevent
patients and neonates. Appetite stimulants and or correct nutrition deficits. For individuals at the
anabolic steroids may have a role in improving end of life, however, nutrition interventions must
body weight; however, more research is needed be weighed against the burdens versus benefits
to determine effectiveness in promoting and patient preferences.
pressure ulcer healing.
If oral intake is inadequate, the registered
Research is needed to better define appropriate dietitian may recommend consideration of
caloric range for obese individuals (those with enteral or parenteral nutrition consistent with the
BMI >30) with pressure ulcers. Although weight patient’s wishes. Enteral (tube) feeding is the
loss is usually recommended for obese preferred route if the gastrointestinal tract (GI) is
individuals, weight loss efforts may need to be functioning. The risks and benefits of nutrition
modified or postponed temporarily to provide support should be discussed with the individual
sufficient nutrients for pressure ulcer healing. and caregivers early on, and should reflect the
individual’s preferences and goals for care.
It is essential to meet minimal recommended Studies that have reviewed enteral nutrition for
dietary intake (RDI). Protein levels for patients improved outcomes for pressure ulcers have
with wounds should be 1.25-1.5 grams of been disappointing (60,87,88). If enteral feeding
protein. Randomized clinical trials indicate is provided, health practitioners should routinely
increased protein levels promote pressure ulcer monitor feedings to ensure individuals are
healing. The research to date does not actually receiving the amount of tube feeding
demonstrate the effectiveness of branched chain solution prescribed.
or individual amino acids, such as arginine and
glutamine, in the treatment of pressure ulcers. Acknowledgements
Further study is needed. Becky Dorner, RD, LD, is President, Becky
Dorner & Associates, Inc, and Nutrition
Recommendations are based on good clinical Consulting Services, Akron, Ohio; Mary Ellen
practice as the evidence specific to fluid Posthauer, RD, CD, is a Consultant Dietitian and
requirements and pressure ulcers is lacking. Chief Executive Officer of MEP Healthcare
Services, Evansville, Indiana; David Thomas,
There is no research to justify administration of MD, CMD, FACP, is Professor of Medicine,
vitamin/mineral supplements that are above the Saint Louis University, Saint Louis, Missouri.
US RDI or comparable European or international
standards. The authors thank the National Pressure Ulcer
Advisory Panel board for its approval of this
Ethical and Clinical Implications for document on December 22, 2008: Joyce Black,
Practice PhD, RN; Mona M. Baharestani, PhD, ANP,
Clinicians need evidence-based research results CWON, CWS; Evan Call, MS; Janet Cuddigan,
to develop appropriate clinical guidelines for PhD, RN, CWCN, CCCN; Teresa Conner-Kerr,
©2009 NPUAP Nutrition White Paper 11The Role of Nutrition in Pressure Ulcer Prevention and Treatment:
National Pressure Ulcer Advisory Panel White Paper
PhD, PT, CWS, CLT; Becky Dorner, RD, LD; Care Hospitals. Available at
Laura Edsberg, PhD; Aimee´ Garcia, MD; Susan http://www.cms.hhs.gov/apps/media/press/factsh
Garber, MA, OTR, FAOTA, FACRM; Diane eet.asp?Counter=3045&intNumPerPage=10&ch
Langemo, PhD, RN, FAAN; Laurie McNichol, eckDate=&checkKey=&srchType=1&numDays=3
500&srchOpt=0&srchData=&keywordType=All&c
MSN, RN, GNP, CWOCN; Barbara Pieper, PhD,
hkNewsType=6&intPage=&showAll=&pYear=&y
RN, CS, CWOCN, FAAN; Catherine Ratliff, PhD, ear=&desc=&cboOrder=date. Accessed
APRN-BC, CWOCN; Steven Reger, PhD, CP; December 3, 2008.
and Greg Schultz, PhD. 10. Centers for Medicare & Medicaid Services.
Medicare Program; Proposed Changes to the
The authors also thank the reviewers of the Hospital Inpatient Prospective Payment Systems
document: Diane Langemo, PhD, RN, FAAN; and Fiscal Year 2009 Rates; Proposed Changes
Janet Cuddigan, PhD, RN, CWCN, CCCN; to Disclosure of Physician Ownership in
Steven Black, MD; and Lynn Moore, RD, LD. Hospitals and Physician Self-Referral Rules;
Proposed Collection of Information Regarding
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