The Role of Nutrition for Pressure Injury Prevention and Healing: … · 2020. 3. 5. · 4.12 Discussthe benefits andharmsof enteral or parenteral feeding tosupport pressure injurytreatment

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The Role of Nutrition for Pressure Injury Preventionand Healing The 2019 International ClinicalPractice Guideline RecommendationsNancy Munoz DNC MHA RDN FAND Lecturer University of Massachusetts Amherst Amherst Massachusetts Assistant Chief Nutrition and FoodService VA Southern Nevada Healthcare System Las Vegas Nevada Director National Pressure Injury Advisory PanelMary Ellen Posthauer RDN LD FAND President MEP Healthcare Dietary Services Inc Evansville Indiana Past President National Pressure Injury Advisory PanelEmanuele Cereda MD PhD Physician and Research Scientist Clinical Nutrition and Dietetics Unit Fondazione IRCCS Policlinico San Matteo Pavia ItalyJos M G A Schols MD PhD Professor of Old Age Medicine Department of Family Medicine Maastricht University Limburg the NetherlandsEmily Haesler PhD BN P Grad Dip Adv Nurs Associate Professor School of Nursing Midwifery and Paramedicine Curtin University Perth Australia

C M E1 AMA PRA

Category 1 CreditTM

ANCC20 Contact Hours

GENERAL PURPOSE To review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory PanelNational Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure UlcersInjuriesClinical Practice Guideline with further discussion of nutrition for pressure injury management in the context of the recommendationsTARGET AUDIENCE This continuing education activity is intended for physicians physician assistants nurse practitioners and nurseswith an interest in skin and wound careLEARNING OBJECTIVESOUTCOMES After participating in this educational activity the participant should be better able to1 Distinguish nutrition and malnutrition especially as they relate to the development and healing of pressure injuries2 Differentiate the tools and techniques that help clinicians assess nutrition status as well as the causes of pressure injuries in specific populations3 Identify interventions for improving nutrition status and promoting pressure injury healing

ABSTRACTMacro- and micronutrients are required by each organsystem in specific amounts to promote the growthdevelopment maintenance and repair of body tissuesSpecifically nutrition plays an important role in the preventionand treatment of pressure injuries The purpose ofthis manuscript is to review the nutrition-relatedrecommendations presented in the 2019 European PressureUlcer Advisory Panel National Pressure Injury AdvisoryPanel and Pan Pacific Pressure Injury Alliance Prevention andTreatment of Pressure UlcersInjuries Clinical PracticeGuideline Nutrition for pressure injury management isdiscussed in the context of the recommendationsKEYWORDS assessment clinical practice guidelinesevidence malnutrition nutrition pressure injury screening

ADV SKIN WOUND CARE 202033123ndash36

DOI 10109701ASW000065314490739ad

INTRODUCTIONNutrition plays an important role in the prevention andtreatment of pressure injuries (PIs) Macro- and micro-nutrients are required by each organ system in specificamounts to promote growth development maintenanceand repair of body tissues The 2019 European Pressure Ul-cerAdvisoryPanel (EPUAP)National Pressure InjuryAdvi-sory Panel (NPIAP) andPan Pacific Pressure InjuryAlliance(PPPIA) Prevention and Treatment of Pressure UlcersInjuriesClinical Practice Guideline (EPUAPNPIAPPPPIACPG)provides guidance on the prevention andmanagement ofPIs1 This guidelinewas a collaborationbetween theEPUAPNPIAP andPPPIAwith the assistance of 14 associate orga-nizations The goal of this international collaborationwas to provide an updated comprehensive review ofthe research literature and develop recommendationsreflecting recent evidence The intent is for health profes-sionals around the world to use the recommendationsgenerated to prevent and treat PI

Acknowledgments DrMunoz has disclosed that she is a member of the Board of Directors for the National Pressure Injury Advisory Panel and the cochair of the small work groupthat developed the nutrition recommendations for the clinical practice guideline Dr Haesler has disclosed that she is the consultant methodologist for the guideline on which thisarticle reports The authors thank the other members of the nutrition work group Merrilyn Banks Angela Liew and Siriluck Sirlpanyawat The authors faculty staff and plannersincluding spousespartners (if any) in any position to control the content of this CMECNE activity have disclosed that they have no financial relationships with or financial interestsin any commercial companies relevant to this educational activity

To earn CME credit you must read the CME article and complete the quiz online answering at least 14 of the 20 questions correctly This continuing educational activity will expirefor physicians on February 28 2022 and for nursesMarch 4 2022 All tests are now online only take the test at httpcmelwwcom for physicians and wwwnursingcentercom fornurses Complete CECME information is on the last page of this article

Clinical Management Extra

WWWASWCJOURNALCOM 123 ADVANCES IN SKIN amp WOUND CARE bull MARCH 2020

Copyright copy 2020 Wolters Kluwer Health Inc All rights reserved

Thepurpose of this article is to review the nutrition-relatedrecommendations presented in the EPUAPNPIAPPPPIACPG and to discuss nutrition for PImanagement in the con-text of the recommendations The recommendations weredeveloped using a rigorous methodology outlined inthe guideline in print and online (internationalguidelinecom) Each recommendation includes a list of implemen-tation considerations Table 1 presents the nutrition-relatedrecommendations from the EPUAPNPIAPPPPIACPG including the strengths of evidence and assigned

recommendations With the recommendations presentedin Table 1 in mind this article will discuss the underpin-ning research and the context in which the recommenda-tions are implemented in the nutritional management ofindividuals with or at risk of PIs

NUTRITION AS A RISK FACTOR FOR PRESSURE INJURIESA large body of prognostic research has reported on theinfluence of impaired nutrition on the risk of PI in adultsAs reported in the EPUAPNPIAPPPPIA CPG of 50

Table 1 2019 INTERNATIONAL GUIDELINE NUTRITION RECOMMENDATIONSThe strength of evidence (SoE) ratings used in this table are defined as follows B1 level 1 studies of moderate or low quality providing direct evidence level 2 studies ofhigh or moderate quality providing direct evidence andor most studies have consistent outcomes and inconsistencies can be explained B2 level 2 studies of low qualityproviding direct evidence level 3 or 4 studies (regardless of quality) providing direct evidence andor most studies have consistent outcomes and inconsistencies can beexplained C level 5 studies (indirect evidence) andor body of evidence with inconsistencies that cannot be explained reflecting genuine uncertainty and Good PracticeStatements (GPSs statements that are not supported by a body of evidence but considered by the Guideline Governance Group to be significant for clinical practice) Thestrength of recommendation (SoR) ratings are as follows uarruarr strong positive recommendation definitely do it uarr weak positive recommendation probably do it

Noa Recommendation SoE SoR or GPSb

110 Consider the impact of impaired nutritional status on the risk of pressure injuries SoE = C SoR =uarr41 Conduct nutritional screening for individuals at risk of a pressure injury SoE = B1 SoR =uarruarr42 Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of

malnutrition and for all adults with a pressure injurySoE = B2 SoR =uarruarr

43 Develop and implement an individualized nutrition care plan for individuals with or at risk of a pressure injury who aremalnourished or who are at risk of malnutrition

SoE = B2 SoR = uarruarr

44 Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition SoE = B2 SoR = uarr45 Adjust protein intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition GPS46 Provide 30 to 35 kcalorieskg body weightday for adults with a pressure injury who are malnourished or at risk of

malnutritionSoE = B1 SoR = uarr

47 Provide 125 to 15 g proteinkg body weightday for adults with a pressure injury who are malnourished or at risk ofmalnutrition

SoE = B1 SoR =uarruarr

48 Offer high-calorie high-protein fortified foods andor nutritional supplements in addition to the usual diet for adults who areat risk of developing a pressure injury and who are also malnourished or at risk of malnutrition if nutritional requirementscannot be achieved by normal dietary intake

SoE = C SoR = uarr

49 Offer high calorie high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who aremalnourished or at risk of malnutrition if nutritional requirements cannot be achieved by normal dietary intake


410 Provide high-calorie high-protein arginine zinc and antioxidant oral nutritional supplements or enteral formula for adultswith a CategoryStage II or greater pressure injury who are malnourished or at risk of malnutrition

SoE = B1 SoR = uarr

411 Discuss the benefits and harms of enteral or parenteral feeding to support overall health in light of preferences and goals ofcare with individuals at risk of pressure injuries who cannot meet their nutritional requirements through oral intake despitenutritional interventions

GPS

412 Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferencesand goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intakedespite nutritional interventions

SoE = B1 SoR = uarr

413 Provide and encourage adequate waterfluid intake for hydration for an individual injury when compatible with goals of careand clinical conditions

GPS

414 Conduct age appropriate nutritional screening and assessment for neonates and children at risk of pressure injuries GPS415 For neonates and children with or at risk of pressure injuries who have inadequate oral intake consider fortified foods age

appropriate nutritional supplements or enteral or parenteral nutritional supportGPS

222 Provide pressure injury education skills training and psychosocial support to individuals with or at risk of pressure injuries SoE = C SoR = uarraFor ease of reference the recommendation number published in the Clinical Practice Guideline has been usedbAs published in the Clinical Practice GuidelineAdapted with permission from the European Pressure Ulcer Advisory Panel National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance

ADVANCES IN SKIN amp WOUND CARE bull MARCH 2020 124 WWWASWCJOURNALCOM


prognostic studies reportingmultivariable analyses that in-cluded at least onemeasure of nutrition status 40 identi-fied ameasure of nutrition as a significant predictor of PIsThis suggests there is a moderate statistical association be-tween nutrition status and developing a PI The EPUAPNPIAPPPPIA CPG recommends providers consider theimpact of impaired nutrition status on the risk of PI(Table 1)1 Impaired nutrition has not been included in pe-diatric PI risk factor studies to date however it is reason-able to assume that this guideline recommendation isalso relevant to neonates and childrenThe research on PI risk factors reports a wide selection of

measures that can be used to identify impaired nutrition in-cluding food intake a medical diagnosis of malnutritionskin fold thickness arm circumference weight body massindex (BMI) nutrition assessment scales and so on Someof these measures are included in nutrition screeningtools and have been validated as predictors of impairednutrition2ndash4 However there is low consistency regard-ing the significance of these outcome measures as posi-tive predictors for PI For example ldquofood intakerdquo wasreported as significant in only 467of studies that includedthat measure in a multivariate analysis5ndash19 There are nu-merous contextual considerations and limitations to thisprognostic research The variability in research qualitychoice of other outcomes and the number of participantsall influence the results Few studies had anadequate num-ber of participants with extremely low or high weightsBMIs in the sampleTranslating research into clinical practice requires clin-

ical judgment informed by knowledge of the literature1

When undertaking a PI risk assessment the use of clini-cal judgment that considers the individualrsquos overall pre-sentation and the significance of that individualrsquosnutrition status is required For example if an individualpresents with other risk factors considered highly pre-dictive of PI risk (eg immobility) and the individualrsquosclinical condition is vulnerable nutrition should be con-sidered when assessing that individualrsquos PI risk12021

Nutrition status is included on most of the commonlyused PI risk assessment tools including those for specificpopulations such as pediatric or critically ill patients2022ndash26

In prognostic studies nutrition assessment scales werenot significantly predictive of PIs Only one of 16 (63)reported a nutrition assessment scale as a significantfactor in amultivariate analysis18 In that study data from170 participants recruited prospectively in a private hos-pital were analyzed From 16 factors included in the pre-dictivemodel five were statistically significant includingscores on the Subjective Global Nutrition Assessment(P lt 001)18 However when used as a part of an overallstructured PI risk assessment in conjunction with clinicaljudgment findings from a PI risk scale can guide nutri-tion (and other) care planning

MalnutritionMalnutrition involves several disorders that include under-nutrition obesity and abnormal micronutrient levels Othernutrition-relateddisorders that impact an individualrsquos nutri-tion status include frailty sarcopenia and cachexia whichhavemultifaceted pathogenic origins27 The European Soci-ety for Parenteral and Enteral Nutrition (ESPEN) definesmalnutrition as ldquoa state resulting from lack of intake oruptake of nutrition that leads to altered body composition(decreased fat free mass) and body cell mass leading todiminished physical and mental function and impairedclinical outcome from diseaserdquo2728

Several organizations have defined criteria to diagnosemalnutrition Most recently the Global Leadership Initia-tive on Malnutrition developed criteria to help identifymalnutrition in adults in healthcare settings consistingof three phenotype characteristics (weight loss lowBMIde-creased muscle mass) and two etiologic characteristics (de-creased food intake or assimilation and disease burdeninflammation) The presence of one phenotype and oneetiologic characteristic is required29 Table 2 outlinesthe malnutrition criteria used by different organizationsMalnutrition and PIs Meeting the bodyrsquos nutrition

requirements is essential to promote health and well-being Although the point at which inadequate nutrientintake affects skin integrity has not been defined it isknown that decreased acceptance of food and fluidswater and weight loss are associated with PIs Also in-sufficient nutrient intake and low body weight are bothassociated with impaired wound healing530ndash35

International research suggests there is a relationship be-tween nutrition and PI prevalence In the US a study of2425 patients concluded that 76 of participants were mal-nourished36 An Australian study conducted in acute andlong-term care settings found that for adults with malnutri-tion the odds ratio of developing a PI was 26 (95 confi-dence interval [CI] 18-35) in acute care settings and 20(95 CI 15-27) in long-term care37 In Japan a study byIizaka et al32 examined the impact of nutrition on the devel-opment and severity of PIs in home care The sampleconsisted of 290 patients with PIs and 456 patients withoutResearchers reported the prevalence of malnutrition washigher in older adults with a PI32 Similarly a Belgian studyfound that the odds ratio of an older adult with a PI beingmalnourished was 502 (95 CI 169-1492 P lt 01)33

Malnutrition is a major health concern in community-dwelling older adults A meta-analysis analyzing datafrom 111 studies conducted in 38 countries (n = 69702)reported thatmalnutrition ranges from 08 inNorthernEurope to 246 in Southeast Asia In this systematic re-view older adults receiving home care had the highestprevalence of malnutrition (146) It was also moreprevalent in rural versus urban communities (99 and57 respectively)38



Undernutrition Decreased intake of calories proteinvitamins and minerals is commonly seen in individualswith malnutrition which is often associated with under-nutrition This results in unplanned and undesired weightloss protein-calorie malnutrition decreased BMI reducedmuscle mass and dehydration all of which are linked toPIs3940 Unplanned or involuntary weight loss is consid-ered a major risk factor for both malnutrition andPI development41

OvernutritionObesity Overnutrition is a form of mal-nutrition in which the amount of nutrients consumed ex-ceeds the amount of nutrients needed to support growth

development and metabolism Overnutrition can result inindividuals becoming overweight and obese In 2013 theAmerican Medical Association acknowledged obesity as adisease that should be medically treated42

In the US the rate of obesity has reached epidemic pro-portions The CDC reported its prevalence was 398 in2015 and 201643 Obesity has been linked to health condi-tions such as cardiovasculardisease diabetes cancer hyper-tension dyslipidemia respiratory problems and impairedwound healing43

Comorbidities such as skin infection dehiscence PIs andvenous ulcers are common in obese individuals These con-ditions occur because of hypoperfusion and ischemia insubcutaneous adipose tissue Hypovascularity also contrib-utes to theprevalence of PIs in patientswho are obese44 Thedecreased mobility and difficulty with self-repositioning of-ten associated with individuals who are obese or extremelyobese further increase the risk of PI development Microor-ganisms that are attracted to themoist environment createdby skin folds contribute to infections and tissue injuries44

NUTRITION SCREENINGThis is defined as ldquothe process of identifying patients cli-ents or groups who may have a nutrition diagnosis andbenefit from nutrition assessment and intervention by aregistered dietitian nutritionistrdquo45 Recognizing that nu-trition screening helps to identify and treat malnutritionin patients with or at risk for a PI the EPUAPNPUAPPPPIACPG recommends it for all individuals at risk of aPI (Table 1) Any member of the interdisciplinary teamwho has been educated on screening tools can use themand screening can be conducted in any practice setting46

A validated screening tool can determine nutrition riskin all types of patients including those with fluid shiftsand for whom weight and height cannot be easily ob-tained4748 Validated tools should be quick and easy touse reliable and valid economical of low risk to the in-dividual being screened and appropriate for the popu-lation and care settingNutrition screening and rescreening should be con-

ducted in accordance with the mandates outlined byaccrediting bodies and a healthcare facilityrsquos internalpolicies In acute care facilities in the nutrition screeningis conducted within 24 hours of admission Informationcollected through the screen is used by a registereddietitian nutritionist (RDN) to identify patients whosenutrition concerns warrant further assessment In long-term postacute care nutrition screening is completed atregular intervals based on the MinimumData Set regula-tions In all care settings communicationwith the RDN isessential to determine appropriate intervention(s) anddiscuss opportunities to improve patient outcomesMany nutrition risk screening parameters are common in

assigning risk level These include height and weight

Table 2 DIAGNOSTIC CHARACTERISTICS FORMALNUTRITION

Characteristic

ASPENAcademyof Nutrition andDietetics ESPEN GLIM

Unintendedweight loss

X X

Low body massindex

X X

Loss of musclemass

X X

Loss ofsubcutaneousfat

X X

Localized orgeneralized fluidaccumulation

X

Decreasedfunctional status

X

Reduced foodintake orassimilation

X X

Disease burdeninflammation

X

At risk pervalidatedscreening tool

X

Two of the sixcharacteristicsmust be present

Once theperson isdeemed at riskby a validatedscreening toolone of the othertwo items mustbe present

One phenotypeand one etiologiccharacteristicmust be present

Abbreviations ASPEN American Society for Parenteral and Enteral Nutrition ESPEN EuropeanSociety for Parenteral and Enteral Nutrition GLIM Global Leadership Initiative on MalnutritionSources White JV Guenter P Jensen G et al Consensus statement Academy of Nutritionand Dietetics and American Society for Parenteral and Enteral Nutrition characteristicsrecommended for the identification and documentation of adult malnutrition (undernutrition)J Parenter Enteral Nutr 201236(3)275-83Cederholm T Jensen GL Correia MITD et al29



unintentional weight changes changes in intakeappetitelifestyle habits (physical activity tobacco use) gastrointesti-nal disorders and medical history Laboratory data are notused in traditional nutrition screens and serum proteinssuch as albumin and prealbumin are not endorsed fornutrition screening49 There is no association between in-creased or decreased protein intake and changes in thesemarkers As a result nutrition screening or assessmentbased on serum protein levels is not recommended46

Nutrition Screening ToolsCommon nutrition screening instruments include the MiniNutritional Assessment (MNA) Malnutrition UniversalScreeningToolNutritionRisk Screening 2002 and the ShortNutritional Assessment Questionnaire3474850ndash55 All ofthese screening tools have been validated for identifyingnutrition riskFor example Grattagliano and colleagues50 used the

MNA to screen 274 patients 75 years or older in four townsin Southern Italy They concluded that the easy-to-usescreen allowed the four general practitioners involved inthe study to quantify the risk for major events Early identi-fication of impaired nutrition status allowed for the timelydevelopment and implementation of interventions50 Fur-ther a prospective cohort study of 471 patients admittedto amedical center inHelsinki concluded that decreasednu-trition status as measured by the Malnutrition UniversalScreening Tool score (OR 3825 95 CI 1730-8455 P =001) is one of the best predictors for the development ofPIs in older adults56 Finally research data collected from422 patients (average age 850 plusmn 76 years) at a rural inter-mediate and acute care hospital in Japan imply that theMNA screen assisted in forecasting the development ofPIs and that a score of less than 8 on the MNA is a betterpredictor for PIs than the Subjective Global Assessmentthe Braden Scale and plasma arginine levels The resultsof these studies reinforce the need to conduct nutritionscreens and assessments57

NEONATES AND CHILDRENAs indicated in several studies neonates and pediatricpatients are also at risk of developing PIs Multicenterstudies report PI prevalence estimates from 047 to35 with the highest rates occurring in ICUs5859 Schluumlerand colleagues59 estimated a 43 PI incidence in their neo-natal ICU Most pediatric PIs are facility acquired60 andmedical devices account for the highest number of PIsin neonates and young children5861

Pediatric PIs are also expensive A study by Goudieet al62 reported the average cost for patients aged 1 to4 years was $20000 per PI This increased to $85803when multiplied by the available prevalence andincidence data62

Pediatric malnutrition leads to complex hospital staysbecause of the complications from underlying diseasesand conditions such as slowwound healing In these pa-tients this contributes to increased hospital costs andlength of stay63 The ASPEN defines pediatric malnutri-tion (undernutrition) as ldquoan imbalance between nutrientrequirement and intake resulting in cumulative deficitsof energy protein or micronutrients that may negativelyaffect growth development and other relevant out-comesrdquo64 Many factors are involved in defining pediat-ric malnutrition including illness injury and adverseenvironmental or behavioral conditions The Academyof Nutrition and Dietetics and ASPENrsquos consensus state-ment on the indicators of pediatric malnutrition (undernu-trition) for ages 1 month to 18 years recommends that astandardized set of diagnostic indicators be used to iden-tify and document undernutrition in routine pediatricpractice The recommended indicators include z scoresfor weight for heightlength BMI for age lengthheightfor age ormid-upper arm circumferencewhen a single da-tum is available65When twoormore data points are avail-able indicators may also include weight gain velocity (lt2years of age) weight loss (2-20 years of age) decelerationin weight for lengthheight z score and inadequate foodnutrient intake65

Neonates and pediatric patients are at risk of compro-mised nutrient intake because of an increased nutritionrequirement per unit weight to meet their normal growthneeds along with smaller appetites Children at risk ofand with PIs usually have other comorbidities that com-promise their ability to consume adequate nutrients topromote and maintain wound healing66 Early nutritionscreening and assessment are important to identify mal-nutrition risk and implement a care plan The EPUAPNPIAPPPPIA CPG recommends providers conduct anage-appropriate nutritional screen and assessment for neo-nates and children at risk of PIs (Table 1)1 There are vari-ous screening tools used for this population includingthe SubjectiveGlobalNutritional Assessment forChildrenthe Pediatric Nutritional Risk Score the Screening Toolfor theAssessment ofMalnutrition in Pediatrics PediatricYorkhill Malnutrition Score and the Screening Tool forthe Risk of Impaired Nutritional Status and GrowthGrowth assessment is the strongest gauge of nutrition

status in pediatric patients and neonates Anthropomet-ric data including weight height growth scores headcircumference and Z scores are used to determine if aneonate or child is developing according to estab-lished parameters Z scores are the preferred nutritionassessment tool because they are more descriptivethan growth charts6667

As part of the nutrition assessment the RDNmay conductanutrition-focusedphysical examination todeterminemicro-nutrient deficiencies and signs of malnutrition They should



conduct weekly nutrition assessments for critically ill chil-dren68ndash70 The healthcare team including the RDNand pe-diatrician should devise an individualized nutrition planfor the pediatric patients and it should include the modeof feeding frequent monitoring of intake and growth sta-tus oral supplements nutrition support and feeding strat-egies for parents and caregivers6771

NUTRITION ASSESSMENTThe EPUAPNPIAPPPPIA CPG recommends the com-pletion of a comprehensive nutrition assessment for adultsat risk of PIs andmalnutrition as well as for all adults witha PI (Table 1)1 A prepost quasi-experimental design studyconducted in Florida examined the use of an interprofes-sional nutrition protocol on 100 patients 60 years or olderwith Stage 2 andor 3 PIs This study concluded thatconducting a nutritional assessment is linked to increasedPI healing rates72 Completing a nutrition assessment is acomponent of the Nutrition Care Process Developed bythe Academy of Nutrition and Dietetics and adopted bycountries around theworld this process includes four ba-sic steps nutrition assessment diagnosis interventionsand plan monitoring and evaluationThe nutrition assessment should be completed by an

RDN in collaboration with the interprofessional nutri-tion team72 The assessment includes the interpretationof anthropometric biochemical clinical and dietary data73

Information obtained and analyzed should include foodnutrition-related history biochemical data medical testsand procedures anthropometric measurements nutrition-focused physical findings and patient history73 The foodnutrition-related history domain includes assessmentparameters such as food and nutrient intake medicationand complementaryalternative medication use factorsaffecting food and nutrition supplies and physicalactivity Anthropometric measurements include heightweight body frame weight change body mass growthpattern indices and body compartment estimatesNutrition-focused physical findings include muscleand subcutaneous fat atrophy oral health swallow-ing function and appetite Patient history includes apersonal medical social and health history73

Body composition is an independent risk factor formalnutrition sarcopenia and associated comorbiditiesVery often patients who are overweight or obese are de-scribed in the medical records as ldquowell nourishedrdquo Tak-ing a closer look at the body composition of theseindividuals over time can show decreased body massuncovering an increased risk for sarcopenic obesity Inaddition sarcopenia is also often present in (immobile)individuals with undernutritionAgain although they support the use of laboratory

data such as albumin and prealbumin to establish theoverall prognosis of the patient these values are not

sensitive indicators of nutrition status Serum proteinlevels can be affected by inflammation renal functionhydration and other factors4974ndash77

NUTRITION CONSIDERATIONS FOR PREVENTIONAND HEALINGThe EPUAPNPIAPPPPIA CPG recommendation is toprovide 30 to 35 kcalkg of body weight per day foradultswith a PIwho aremalnourished or at risk ofmalnu-trition The recommendation for protein is 125 to 15 gkgof body weight per day1

Providing and consuming adequate kilocalories sup-port collagen and nitrogen synthesis thus promotinganabolism by sparing protein from being used as an en-ergy source Fat is the most concentrated source of calo-ries providing a reserve source of energy in the form ofstored triglycerides in adipose tissue It cushions bonyprominences provides insulation and transports thefat-soluble vitamins A D E and K which are stored inthe liverIf the energy from carbohydrates and fat fails to meet

the individualrsquos needs the liver and kidneys synthesizeglucose from noncarbohydrate sources such as proteinThe body uses this released energy as fuel for anabolismwhich increases the bodyrsquos metabolic rate and caloric re-quirements Wound healing is compromised if the bodyis forced to produce glucose by degrading protein anddepleting lean body mass (LBM) The decline in LBMcan lead to muscle wasting decline in subcutaneousfat and poor PI healing Demlingrsquos78 research noted thatany loss of LBM is detrimental but with a 20 loss thecompetition between using protein to rebuild LBM andwound healing is equal therefore slowing the healingprocess This study recommended increasing energy in-take 50 above the normal level and increasing proteinto 15 gkg of body weight78

Because there is no specific research on optimal caloricrequirement to prevent PIs the EPUAPNPIAPPPPIACPG suggests that energy and protein intake be opti-mized for the individual This should be done withinthe context of the individualrsquos nutrition status (eg cur-rent usual and goal weights) and clinical conditionThe EPUAPNPIAPPPPIA CPG also provides spe-

cific guidance on the energy needs of patients with PIs(Table 1) In a meta-analysis of observational studiesCereda et al79 reported that the use of indirect calorimetryto measure resting energy expenditure using a correctionfactor of 13 for physical activity (for individuals confinedto bed) and a 11 PI correction factor adds to a total dailyenergy requirement of about 30 kcalkg per day79 Ohuraet al80 reported that in hospitalized older adults receivingtube feeding (n = 60) 12weeks of nutrition support calcu-lated using resting energy expenditure activity factor11 stress factor 13 to 15 (mean intake 379 plusmn 65 kcalkg



per day) was associated with reduced PI size (P lt 001)and depth (P lt 05) compared with standard care (meanintake 291 plusmn 49 kcalkg per day)The energy and protein needs of pediatric patients are

also increasedwhen they experience the metabolic stressof healing wounds Their caloric and protein require-ments should be assessed frequently to avoid over or un-der feeding The RDNs and clinicians assessing andestimating nutrition needs for the pediatric populationcan refer to theAcademy of Nutrition andDietetics PediatricNutrition Care Manual and the Pediatric Pocket Guide toNutrition Assessment for guidance

ProteinProtein is vital for the growth and maintenance of cellsfluid balance and blood clotting its functions include im-mune function preservation wound healing enzyme re-pair and synthesis cell multiplication and collagen andconnective tissue synthesis Additional protein is also re-quired to compensate for the nitrogen losses that occurwith PI exudateResearch supports the theory that increased protein

levels are linked to improved PI healing As early as1993 Breslow et al81 demonstrated that individuals re-ceiving higher-proteinhigher-calorie diets had a statis-tically greater reduction in PI surface area comparedwith baseline than the individuals receiving a standarddiet (P lt 02) A change in PI surface area was correlatedwith both dietary protein (r = 050 P lt 01) and energyintake (r = minus041 P lt 03)81 A randomized controlledtrial (RCT) by Ohura et al80 stated that a high intake ofprotein can result in reducted PI size and depth com-pared with a low protein intake An RCT by Lee et al82

reported that providing a standard diet with a concen-trated protein supplement equaling 45 g daily resultedin a 60 reduction in Pressure Ulcer Scale for Healingscores after 8 weeks of treatment whereas standard careand a placebo resulted in a 48 reduction (P lt 05)Yamamoto et al35 demonstrated improvement in PI heal-ingwhen adults consumedmore than 30 kcalkg of bodyweight per day whereas individuals consuming le20kcalkg of body weight per day experienced deteriora-tion or no improvement in healing Finally in a trial byOhura et al80 comparing the efficacy of two different nu-trition regimens high-calorie (379 plusmn 65 vs 291 plusmn 49kcalkg per day) and high-protein intake (intake 162 plusmn030 vs 124 plusmn 022 gkg per day) resulted in im-proved PI healing (higher reduction in area and depth)A secondary analysis of the same trial data demonstratedthat high-calorie high-protein support in patients withPIs is a cost-effective intervention83

The recommended dietary allowance for protein forall adults including older adults is 08 gkg of bodyweight Evidence supports that LBM is maintained

when an older adult consumes higher levels of proteinin the range of 10 to 12 gkg per day84ndash86 Evidence alsosupports increasing energy and protein intake for adultsand children with PIs who are malnourished or at riskof malnutrition84ndash86

FluidWaterAn adultrsquos body is 60water which is distributed in theintracellular interstitial and intravascular compartmentsIt serves as the transport medium for moving nutrients tothe cells and removing waste products Water is the sol-vent for minerals vitamins amino acids glucose andother small molecules allowing them to diffuse intoand out of cellsThe EPUAPNPIAPPPPIA CPG recommends pro-

viders encourage adequate fluid intake Although cur-rent research has not determined the optional formulafor calculating a daily fluid requirement for individualswith PIs 1 mL fluidkcal consumed is commonlyused625487 Adequate daily fluidswater should be of-fered to and encouraged for all individuals with PIsThose with draining wounds emesis diarrhea elevatedtemperature or increased perspiration require addi-tional fluidswater to replace lost fluid88 Cliniciansshould monitor individuals for any signs or symptomsof dehydration changes in weight skin turgor urineoutput or elevated serum sodium Older adults usuallyhave increased body fat and decreased LBM thus de-creasing the percentage of water their bodies can storeThis combined with a decreased sense of thirst in-creases their risk of dehydration88 Fluid requirementsaremetwith liquids including thewater content of foodwhich accounts for 19 to 27 of the total fluid intake ofhealthy adults

MicronutrientsAs explained in Table 3 micronutrients play a role in the PIhealing process and are key components of a healthy dietPreviouslymegadoses of supplements such as ascorbic acidand zinc have beenprescribed for patientswith PIs Becauseof the lack of evidence-based research on the validity of thispractice the 2019 Guideline committee did not study this is-sueManyof the oral supplements enteral formulas and for-tified foods recommended for individuals with PIs containadditional micronutrients and should be considered beforerecommending additional supplementation

THE ROLE OF SUPPLEMENTSEvidence-based guidelines particularly those focusingon nutrition in older populations have highlighted thatdespite many trials the most effective treatment optionsfor malnutrition still need to be identified Therefore ap-proaches should be comprehensive relying first on im-proving oral intake8990 Prior to or in addition to offering



oral nutrition supplements clinicians should considercomprehensive approaches for improving oral intakebull nutrition counselingbull modifying food such as with fortified foodsbull revisingmodifying or liberalizing diet restrictions thatresult in decreased intake91

bull offering assistance with eatingbull honoring culturalreligious food preferencesbull providing a pleasant eating environmentAs reported above a positive energy and protein bal-

ance to sustain anabolism plays a crucial role in skin vi-ability and wound healing However patients withchronic diseases or at risk ofwith a PI frequently cannotmeet protein and calorie needs Aside from increasing theenergy expenditure of the patient PIs are responsible fora further worsening the energy balance79 When oral feed-ing is safe the use of oral nutritional supplements (ONSs)can be an effective strategy to help fulfill protein andcalorie requirementsThe EPUAPNPIAPPPPIA CPG recognizes the role of

supplements and recommends ONSs with micronutrientsfor individuals with a PI who are malnourished (or atrisk Table 1) According to a systematic review of RCTsONSs are usually well tolerated and result in both a pos-itive energy balance and clinical benefits especiallywhen higher-energy-density ONSs (15-24 kcalmL)are consumed between meals92 Because ONSs includeproducts that supply macro- and micronutrients pro-viders must weigh their value for the treatment planHealth professionals are advised to review the nutritionlabeling to determine nutrient adequacyStudies investigating the role of ONSs in preventing

PIs have mixed findings with uncertainty surroundingtheir efficacy All of the investigations included in theguideline review were conducted in older populationsinwhich PIs are clearly ofmultifactorial origin and the con-tribution of ONSs is more difficult to establish because it isonly one part of the overall patientrsquos care which is orientedtoward treating all underlying conditions Further theheterogeneity in study designs contributed to the risk ofbias5693ndash96 However a meta-analysis of trials in this areafound that the provision of high-calorie (250-500 kcal)high-protein ONSs is associated with a 25 lower inci-dence of PIs in individuals at risk comparedwith routinecare (OR 075 95 CI 062-089)97

On the other hand evidence on the efficacy of ONSsin increasing the rate of healing is consistent and sub-stantiated by different trials which also suggest thatthe duration of intervention should be at least 4 weeksand reasonably up to complete healing These studiessupport not only the importance of extra energy andprotein but also the positive effect adding arginine andmicronutrients (zinc and antioxidants)5818298ndash101 A re-cent large double-blind RCT (the Oligo Element Sore

Trial) has elucidated the independent role of these addi-tional nutrients in PI healing100102 In this study high-energy high-protein ONSs (two bottles per day 500 kcaland 40 g protein) enriched with arginine zinc and anti-oxidants were compared with isocaloric isonitrogenouscontrol ONSs in malnourished adults with Stages 2through 4 (70 Stage 3 or 4) PIs After 8 weeks a greaterreduction in wound surface area was achieved in the in-tervention group (adjustedmean change 187 95CI57-318) Interestingly a reduced intensity of care (fewerdressings and less time spent changing them) has beenreported with the use of this formula103

Last but not least using data from available RCTsAustralian researchers have demonstrated that nutritionsupport is a cost-effective intervention in preventing PIsin the hospital setting Specifically ONSs are likely re-sponsible for a reduction in length of hospital stay whencompared with usual care (standard diet)104ndash106 Analy-sis of the Oligo Element Sore Trial data also showed thatthe studied ONS is a cost-effective treatment associatedwith substantial savings when compared with the con-trol formula99 With this background the use of ONSsin preventing and treating PIs could be recommended

NUTRITION SUPPORTDespite limited evidence supporting artificial nutritionand hydration for PI intervention and treatment the inter-professional team should discuss the risks and benefits ofenteral nutrition (EN tube feeding) or parenteral nutrition(PN) with individuals who cannot meet their nutritionrequirements through oral intake despite previous inter-vention The interdisciplinary team should consider ifthe patient has the desire andor capacity to tolerate nu-trition support Nutrition goals should not take priorityover the patient-centered goals of the individualOne low-quality level 1 study and three low-quality level

3 studies indicate that the provision of EN and PN has lim-ited impact on preventing PI for those at risk9495107108 Thehigh-acuity level of patients in acute or long-term care in-creases the incidence of PIs and can lead to the decision totrial EN or PN The long-term care patients in Arinzon andcolleaguesrsquo107 study receiving ENwere at greater risk of de-veloping PI and had lower BMIs than those who were notConsidering the length of the trials (from 2 to 12weeks) lackof reported comorbidities and quality of the trials it remainsunclearwhether offering artificial nutrition and hydration forthose at risk of PIs would reduce prevalenceThe goal for artificial nutrition support for individuals

with PIs is to improve their nutrition status promotehealing and restore their immune function109110 WhenPI healing has stalled and oral intake is inadequate tosupport healing EN should be considered if it is consis-tent with the individualrsquos goals of care The RDN andinterprofessional team should evaluate the patientrsquos



medical condition to determine whether EN is a long- orshort-term solution Prior to initiating EN the risks andbenefits of nutrition support must be discussed with thepatient andor caregivers Although artificial nutritionand hydration aremedical treatments an individualrsquos cul-tural andor religious values may dictate their decision toaccept or decline EN

If the gastrointestinal tract is functioning EN is the pre-ferred route Parenteral nutrition should be considered forpatients whose nutrition requirements cannot be met withEN Prior to the initiation of EN the RDN should assessthe patientrsquos calorie protein and hydration needs and tailorthe feeding regimen tomeet their needs There are pediatricenteral formulas designed for children from 1 to 13 years of

Table 3 NUTRIENTS AND THEIR THERAPEUTIC PROPERTIES

Nutrient Functions Notes SourcesRelated CPGRecommendation

Calories Supply energy prevent weight losspreserve lean body mass

Carbohydrate protein and fatcarbohydrate and fat are preferred

46 48 49 410

Carbohydrates Glucose supports cell growthfibroblasts and leukocytes

Delivers energy energy needs must bemet to spare protein from being used forenergy

Grains fruits and vegetablescomplex carbohydrates arepreferred

Protein Immune support binding of skincartilage and muscle

Contains nitrogen which is essential forwound healing Arginine becomes aconditionally indispensable amino acidduring times of physiologic stress

Meats fish poultry eggslegumes milk and dairy productsfavor lean meat and reduced- orlow-fat dairy products

45-410

Fat Carries fat-soluble vitamins providesinsulation under the skin and padding ofbony prominences helps modulateinflammation and the immune response

Most concentrated energy source Meats eggs dairy products andvegetable oils

Fluidswater Solvent for minerals and vitaminsamino acids and glucose helpsmaintain body temperature transportsmaterials to cells and waste productsfrom cells maintains skin integrity

Water juices beverages fruitsand vegetables containapproximately 95 water Mostsupplements are 75 water

413

Vitamin A Protein synthesis collagen formationmaintenance of epithelium immunefunction

May delay healing in older adults oncorticosteroidsUL is 3000 μg DRI females aged gt70 yis 700 μg males aged gt70 y is 900 μg

Beef liver milk dark green andyellow vegetables (carrots sweetpotatoes broccoli spinachapricots)

Vitamin C Collagen formation enhances activationof leukocytes and macrophages towounds improves tensile strength aidsin iron absorption

Water-soluble noncaloric organicnutrient

Citrus fruits and juices tomatoespotatoes broccoli

Vitamin E Fat metabolism collagen synthesis cellmembrane stabilization

Antioxidant Vegetable oils sweet potatoes

Copper Red blood cell formation responsiblefor collagen cross-linking anderythropoiesis

Inorganic noncaloric nutrientUL is 10000 μg DRI females and malesaged ge70 y is 900 μg

Nuts dried fruit organ meatsdried beans whole-grain cereal

Iron Transports oxygen to the cells as acomponent of hemoglobin importantin collagen formation creates energyfrom cells

Heme iron meats poultry and fishNonheme iron vegetables grainseggs meat fish

Zinc Cofactor for collagen formationmetabolizes protein assists in immunefunction liberates vitamin A from theliver interacts with platelets in bloodclotting

Inorganic noncaloric nutrientMega doses of zinc may inhibit healingand cause copper deficiencyUL is 40 mgDRI females aged ge70 y is 8 mg malesaged ge70 y is 11 mg

Meats liver eggs and seafood

Abbreviations CPG EPUAPNPIAPPPPIA Clinical Practice Guideline DRI dietary reference intake UL tolerable upper intake levelAdapted with permission from Bernstein M Munoz N Nutrition for the Older Adult 3rd ed Burlington MA Jones and Bartlett Learning 2020



age These formulas meet the recommended dietary refer-ence intakes for children aged 1 to 8 years in 1000 mLdand 1500 mLd for children aged 9 to 14 years111

After artificial nutrition support is initiated the interpro-fessional team should frequently evaluate the patientrsquos toler-ance to EN and note any adverse reactions such as nauseadiarrhea or vomitingClinicians should also routinely checkand confirm that the patient is receiving the correct formulain the prescribed amount The RDN and interprofessionalteam should document the benefit from the feedings in re-lation to the desired outcome of healing and stabilizing nu-trition status in the medical record They should alsomonitor and evaluate the individualrsquos tolerance and prog-ress toward achieving the desired outcome and recom-mended changes as neededResearch reviewing EN for improved outcomes for PI

healing is limited Two high-level studies one with 60 indi-viduals and anotherwith 28 noted improvement in healingrates when the nutrition support used was a high-proteindisease-specific formula80102 Arinzon and colleaguesrsquo107

study of residents with dementia residing in long-term carereported more complications such as pneumonia weightloss and death in the intervention group receiving EN thanthose receiving an oral diet (61 vs 34 P lt 01) Anotherstudy reported no change in mortality with PN over ENin critically ill individuals112

Palliative CareHospicePatients receivingpalliative careareathigh riskofdevelopingPIs because they have a serious illness are immobile or areapproaching end of life The EPUAPNPIAPPPPIA CPGhighlights the importance of discussing benefits and harmsof ENorPNwith individuals in palliative care and their fam-ilies andor caregivers (Table 1)The guiding principles of palliative care for PI man-

agement focus on relieving pain and providing comfortfor the individual Nutrition interventions should be com-patible with patient goals and desired outcomes For exam-ple serving the individualrsquos favorite food or beveragewhenrequested improves his or her quality of lifeIt is the position of the Academy of Nutrition and Di-

etetics that ldquoindividuals have the right to request or re-fuse nutrition and hydration as medical treatmentrdquo113

and ESPEN states that a ldquocompetent patient has the rightto refuse a treatment after adequate information even whenthis refusal would lead to his or her deathrdquo114 Hospice PItreatment goals should be individualized respecting eachpersons unique values and personal decisions115

CARE PLANNING PATIENT MONITORINGAND EVALUATIONRegardless of the setting the EPUAPNPIAPPPPIACPGrecommends that an individualizednutrition careplanbe developed The interdisciplinary team is responsible for

nutrition care that addresses thedesiredoutcomes for the in-dividual Allenrsquos72 study demonstrated that individualizednutrition assessment and planning for older adults withCategoryStage 2 or 3 PIs (n = 100) are associated with im-proved wound healing compared with standardized nutri-tion plans (37 vs 234 P lt 05) The care plan processshould encompass the policies andor regulations of the or-ganization The RDN builds the nutrition care plan basedon the information gathered in the nutrition assessment in-cluding data generated by the physician nurses and phys-ical occupational and speech language therapists Thepatient-centered care plan shouldbull be individualizedbull involve the individual and all disciplinesbull reflect the patientrsquos choicespreferencesbull offer a variety of interventions to meet the stated goalbull identify specific interventionsbull educatethe individualcaregiveronthebenefitsof thesuggestedinterventionbull include a time frame for completion or reviewbull be documented in the medical recordThe interprofessional team should counsel individuals

and suggest a variety of other options for patients residingin the community who cannot prepare meals or affordONSs and vitaminmineral supplements Suggestions in-clude eating small frequent meals and snacks such ashigh-calorie bars sandwiches Greek yogurt homemademilk shakes instant breakfasts and other nutrient-richitems46 Referral to an RDN for individualized counselingwould be advantageous for community-dwelling pa-tients with literacy or language difficulties Some UShospitals host a Food Pharmacy including ONSs for in-dividuals who have limited access to affordable and nu-tritious foods Wound care clinics and rehabilitationdepartments acute care hospitals and post-acute carefacilities are encouraged to provide hot and cold bever-ages as part of their hydration protocols andor tomakestrategic connections with a Food Pharmacy programRoutine or periodic monitoring of the care plan is the

most important component of the nutrition care processInterventions must be adjusted with any change in con-ditions and when progress toward the desired outcomeis not achieved The RDN may need to reassess the pa-tient or refer them to another discipline for further eval-uation or treatment (Figure 1)

PATIENT EDUCATION AND ENGAGEMENTPatient education and engagement are an importantcomponent of nutrition assessment and treatment forall individuals including those with or at risk of PIs1

Evidence on the effectiveness of education in reducingPI incidence and promoting healing has shown mixedresults however there was sufficient evidence for theEPUAPNPIAPPPPIA CPG to recommend providing



individuals with or at risk of PIs access to educationskills training and psychosocial support The evidenceindicates that for individuals with ongoing PI risk (egthose with spinal cord injury) multifaceted lifestyleskills programs or telephone-based education and sup-port programs can produce short-term positive impactson knowledge education and quality of life116ndash119 Pa-tients themselves have noted the importance of engag-ing in nutrition education Haesler et al120121 reportedthat 718 (275383) of respondents to an internationalsurvey identified that knowing more about what to eatanddrink toprevent PI and tomaintain healthy skinwas im-portant or very important in caring for themselves Furtherthe survey respondents identified that nutrition educa-tion was also important for their family and caregiversGiven the complexities of nutrition for individuals

with and at risk of PIs education and nutrition-relatedlifestyle coaching (eg guidance on weight managementmenu planning food selection and preparation) are animportant component to include in patient and familyeducation and engagement programs120121 Written in-formation on nutrition should be presented in a concisemanner to reinforce person-to-person education Hartiganet al122 noted that providing a simple pamphlet withevidence-based PI-related messages including ldquoEatplenty of protein (eg meat fish eggs)rdquo to a sample ofcommunity-based older adults at risk of PI (n = 75)

was associated with improvements in knowledge of PIrisk factors A similar concise written resource was usedby Chaboyer et al123 as a part of a comprehensive PI pre-vention bundle delivered in eight Australian hospitalsThe simple nutrition message provided to patients wasldquoEat a healthy dietrdquo The hazard ratio (048 95 CI 020-121) indicated a 52 reduction in hospital-acquired PIsassociated with the intervention In this acutely ill popu-lation the researchers noted that the willingness of indi-viduals to engage in education interventions is limitedby their clinical condition123 This suggests that appropri-ate timingis an important consideration for nutrition-related education

RESEARCH PRIORITIESNutrition plays a vital role in human growth and devel-opment the maintenance of good health and functional-ity prevention and treatment of infectious acute andchronic diseases and PI development and treatmentTo effectively and efficiently advance the role of nutri-tion in improving and sustaining health and tissue via-bility to prevent or treat PI efforts must be made toadvance nutrition researchImprovednutrition couldbe one of themost cost-effective

approaches to address many of the societal environmentaland economic challenges facing nations around the worldtoday124 Adequate nutrition promotes positive outcomes

Figure 1 GUIDE FOR THE NUTRITION MANAGEMENT OF PRESSURE INJURIES (PIS) FOR ADULTS IN ACUTE ORLONG-TERM CARE



among patients at risk of orwith PIs in all care settings Keyresearch priorities on nutrition and PI prevention and treat-ment include the impact of malnutrition frailty andsarcopenia onpatient recoveryMethods to estimate caloriesand protein requirements for individuals classified as obeseneed to bedefined Patient history includingpersonalmed-ical social and health history also influences PI develop-ment Research on the use of high-calorie high-proteinONSs as an intervention to reduce the incidence of PI isneeded along with studies on key nutrients such as aminoacids zinc and antioxidants as adjunct therapy The valueand benefits of EN and PN either supplemental or totalshould also be clarified Finally the cost-effectiveness of nu-trition interventions in patients with PIs must always beconsidered among the outcomes of interest

CONCLUSIONSNutrition is an important consideration when treatingpatients at risk of or with PIs Early nutrition screeningusing a validated tool and assessment is a key elementin diagnosing malnutrition which can impede healingThe interdisciplinary team including the RDN shouldapply the CPG recommendations to reduce process var-iation and achieve positive outcomes

PRACTICE PEARLS

bull Use a validated nutrition screening tool to identifythe nutrition status of individuals at risk of or with PIsbull Refer individuals at risk of or with PIs to an RDN orother qualified professional for a nutrition assessmentand collaborate with the interprofessional team andpatient to determine a patient-centered nutrition planbull Encourage consumption of a balanceddiet based on in-dividualized requirements Supplement betweenmeals ifneeded to achieve assessed requirementsbull Offer nutrition support to individuals who cannotconsume adequate intake assuming this is compatiblewith individualrsquos goals and wishesbull

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Pressure Injury Alliance Prevention and Treatment of Pressure UlcersInjuries Clinical PracticeGuideline The International Guideline 3rd ed Haesler E ed 2019 httpinternationalguidelinecomLast accessed December 27 2019

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3 Neelemant F Kruizenga HM de Vet HC Seidell JC Butterman M van Bokhorst-de van derSchueren MA Screening malnutrition in hospital outpatients Can the SNAQ malnutrition-screeningtool also be applied to this population Clin Nutr 200827(3)439-46

4 Nestle Nutrition Institute Mini Nutritional Assessment MNAreg 1994 wwwmna-elderlycomformsminimna_mini_englishpdf Last accessed December 27 2019

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7 Berlowitz DR Wilking SV Risk factors for pressure sores A comparison of cross-sectional andcohort-derived data J Am Geriatr Soc 198937(11)1043-50

8 Brandeis G Ooi W Hossain M Morris J Lipsitz L A longitudinal study of risk factors associatedwith the formation of pressure ulcers in nursing homes J Am Geriatr Soc 199442388-93

9 Dhandapani M Dhandapani S Agarwal M Mahapatra AK Pressure ulcer in patients with severetraumatic brain injury significant factors and association with neurological outcome J Clin Nurs201423(7-8)1114-9

10 Ham HW Schoonhoven LL Schuurmans MM Leenen LL Pressure ulcer development in traumapatients with suspected spinal injury the influence of risk factors present in the emergencydepartment Int Emerg Nurs 20173013-9

11 Bergstrom N Braden B A prospective study of pressure sore risk among institutionalized elderlyJ Am Geriatr Soc 199240(8)747-58

12 Bergquist S Frantz R Pressure ulcers in community-based older adults receiving home health carePrevalence incidence and associated risk factors Adv Wound Care 199912(7)339

13 Compton F Hoffmann F Hortig T et al Pressure ulcer predictors in ICU patients nursing skinassessment versus objective parameters J Wound Care 200817(10)417

14 De Laat E Pickkers P Schoonhoven L Verbeek A Feuth T van Achterberg T Guidelineimplementation results in a decrease of pressure ulcer incidence in critically ill patients Crit CareMed 200735(3)815-20

15 Defloor T Grypdonck M Pressure ulcers validation of two risk assessment scales J Clin Nurs200514(3)373-82

16 Kwong EW-y Pang SM-c Aboo GH Law SS-m Pressure ulcer development in older residents innursing homes influencing factors J Adv Nurs 200965(12)2608-20

17 Roca-Biosca A Velasco-Guillen M Rubio-Rico L Garciacutea-Grau NA Anguera-Saperas L Pressureulcers in the critical patient detection of risk factors Enferm Intensiva 201223(4)155-63

18 Serpa L Santos V Assessment of the nutritional risk for pressure ulcer development throughBraden Scale JWOCN 200734(3S)S4-S6

19 Watts D Abrahams E MacMillan C et al Insult after injury pressure ulcers in trauma patientsOrthop Nurs 199817(4)84-91

20 Coleman S Smith IL McGinnis E et al Clinical evaluation of a new pressure ulcer risk assessmentinstrument the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T) J Adv Nurs20172323

21 National Institute for Health and Clinical Excellence Pressure ulcers prevention and managementclinical guideline [CG179] wwwniceorgukguidancecg179 2014 Last accessed December 272019

22 Norton D Exton-Smith AN McLaren R An Investigation of Geriatric Nursing Problems in HospitalLondon UK National Corporation for the Care of Old People 1962

23 Waterlow J A risk assessment card Nurs Times 19858124-724 Bergstrom N Braden BJ Laguzza A Holman V The Braden Scale for predicting pressure sore risk

Nurs Res 198736(4)205-1025 Cubbin B Jackson C Trial of a pressure area risk calculator for intensive therapy patients

Intensive Care Nurs 1991740-426 Vocci MC Toso LAR Fontes CMB Application of the Braden Q Scale at a pediatric intensive care

unit Rev Enferm UFPE 201711(1)165-7227 Cederholm T Barazzoni R Austin P et al ESPEN guidelines on definitions and terminology of

clinical nutrition Clin Nutr 20173649-6428 Basics in Clinical Nutrition 4th ed Sobotka Led Czech Republic Galen 201229 Cederholm T Jensen GL Correia MITD et al GLIM criteria for the diagnosis of malnutritionmdasha

consensus report from the global clinical nutrition community Clin Nutr 201938(1)1-930 Fry DE Pine M Jones BL Meimban RJ Patient characteristics and the occurrence of never events

Arch Surg 2010145(2)148-5131 Green CJ Existence causes and consequences of disease-related malnutrition in the hospital and

the community and clinical and financial benefits of nutritional intervention Clin Nutr 199918(suppl 2)3-28

32 Iizaka S Okuwa M Sugama J Sanada H The impact of malnutrition and nutrition-related factorson the development and severity of pressure ulcers in older patients receiving home care Clin Nutr201029(1)47-53

33 Verbrugghe M Beeckman D van Hecke A et al Malnutrition and associated factors in nursinghome residents a cross-sectional multi-centre study Clin Nutr 201332(3)438-43

34 Wojcik A Atkins M Mager DR Dietary intake in clients with chronic wounds J Can Diet Assoc201172(2)77-82

35 Yamamoto T Fujioka Kitamura R et al Evaluation of nutrition in the healing of pressure ulcers arethe EPUAP nutritional guidelines sufficient to heal wounds Wounds 200921(6)153-7

36 Lyder CH Preston J Grady JN et al Quality of care for hospitalized Medicare patients at risk forpressure ulcers Arch Intern Med 2001161(12)1549-54

37 Banks M Bauer J Graves N Ash S Malnutrition and pressure ulcer risk in adults in Australianhealth care facilities Nutr Clin Pract 201026(9)896-901

38 Crichton M Craven D Mackay H Marx W de van der Schueren M Marshall S A systematicreview meta-analysis and meta-regression of the prevalence of protein-energy malnutritionassociations with geographical region and sex Age Ageing 201948(1)38-48

39 Guenter P Malyszek R Bliss DZ et al Survey of nutritional status in newly hospitalized patientswith Stage III or Stage IV pressure ulcers Adv Skin Wound Care 200013(4 Pt 1)164-8

40 Mathus-Vliegen E Nutritional status nutrition and pressure ulcers Nutr Clin Pract 200116286-91

41 Saghaleini SH Dehghan K Shadvar K Sanaie S Mahmoodpoor A Ostadi Z Pressure ulcer andnutrition Indian J Crit Care Med 201822(4)283-9

42 AMA House of Delegates Adapts Policy to Recognize Obesity as a Disease 2013 httpsobesitymedicineorgama-adopts-policy-recognize-obesity-disease Last accessed December 272019

43 Centers for Disease Control and Prevention Adult obesity facts 2018 wwwcdcgovobesitydataadulthtml Last accessed December 27 2019



44 Greco JA 3rd Castaldo ET Nanney LB et al The effect of weight loss surgery and body massindex on wound complications after abdominal contouring operations Ann Plast Surg 200861235-42

45 Academy of Nutrition and Dietetics Definition of Terms List Definition of Terms WorkgroupQuality Management Committee 2019 wwweatrightproorg-mediaeatrightpro-filespracticescope-standards-of-practice20190910-academy-definition-of-terms-listpdf Last accessedDecember 27 2019

46 Academy of Nutrition and Dietetics Nutrition Care Manual 2019 wwwnutritioncaremanualorgLast accessed December 27 2019

47 Kondrup J Rasmussen HH Hamberg I Stanga Z Nutritional risk screening (NRS 2002) a newmethod based on an analysis of controlled clinical trials Clin Nutr 20033321-36

48 Elia M Zellipour L Stratton RJ To screen or not to screen for adult malnutrition Clin Nutr 200524(6)867-84

49 White J Consensus Statement AND and ASPEN characteristics recommended for theidentification and documentation of adult malnutrition (undernutrition) J Acad Nutr Diet 2012112(5)730-8

50 Grattagliano I Marasciulo L Paci C Montanaro N Portincasa P Mastronuzzi T The assessment ofthe nutritional status predicts the long term risk of major events in older individuals Eur Geriatr Med20178(3)273-4

51 Hengstermann S Fischer A Steinhagen-Thiessen E Schulz RJ Nutrition status and pressure ulcerwhat we need for nutrition screening JPEN 200731(4)288

52 Langkamp-Henken B Hudgens J Stechmiller JK Herrlinger-Garcia KA Mini nutritional assessmentand screening scores are associated with nutritional indicators in elderly people with pressureulcers J Am Diet Assoc 2005105(10)1590-6

53 Poulia KA Yannakoulia M Karageorgou D et al Evaluation of the efficacy of six nutritionalscreening tools to predict malnutrition in the elderly Clin Nutr 201231(3)378-85

54 Trans Tasman Dietetic Wound Care Group Evidence based practice guidelines for the nutritionalmanagement of adults with pressure injuries 2011 wwwacihealthnswgovau__dataassetspdf_file000438823713-Trans-Tasman-Dietetic-Wound-Care-Group-Pressure-Injury-Guidelines-2011pdf Last accessed December 27 2019

55 Tsai AC Chang TL Wang YC Liao CY Population-specific short-form mini nutritional assessmentwith body mass index or calf circumference can predict risk of malnutrition in community-living orinstitutionalized a people in Taiwan J Am Diet Assoc 2010110(9)1328-34

56 Tsaousi G Stavrou G Ioannidis A Salonikidis S Kotzampassi K Pressure ulcers and malnutritionresults from a snapshot sampling in a university hospital Med Princ Pract 201524(1)11-6

57 Yatabe MS Taguchi F Ishida I et al Mini nutritional assessment as a useful method of predictingthe development of pressure ulcers in elderly inpatients J Am Geriatr Soc 201361(10)1698-704

58 Schluumler AB Schols JMGA Halfens RUG Risk associated factors of pressure ulcers in hospitalizedchildren over one year of age J Spec Pediatr Nurs 2014180-9

59 Schluumler AB Halfens RJ Schols JGA Pediatric pressure ulcer prevalence a multicentercross-sectional point-prevalence study in Switzerland Ostomy Wound Manage 201258(7)18-31

60 McLane KM Boolout K McCord S McCann Jefferson LS The 2003 national pressure ulcerprevalence study and skin breakdown study a multisite study J Wound Ostomy Continence Nurs200431(4)168-78

61 Curley MAO Hasbari NR Quigley SM et al Predicting pressure injury risk in pediatric patients theBraden QD Scale J Pediatr 2018192168-95

62 Goudie A Dynan L Brady PW Fieldston E Brilli RJ Walsh KE Costs of venous thromboembolismcatheter-associated urinary tract infection and pressure ulcers Pediatrics 2015136(3)432-9

63 Hecht C Weber M Grote et al Disease associated malnutrition correlates with length of hospitalstay in children Clin Nutr 201534(1)53-9

64 Mehta N Corkins M Lyman B et al Defining pediatric malnutrition a paradigm shift towardsetiology-related definitions JPEN 201337(4)460-81

65 Becker R Carney LN Corkins MR et al Consensus statement of the Academy of Nutrition andDieteticsAmerican Society for Parenteral and Enteral Nutrition indicators recommend for theidentification and documentation of pediatric malnutrition (undernutrition) Nutr Clin Prac 201530(1)147-61

66 Mehta N Compher C ASPEN Board of Directors ASPEN clinical guidelines nutrition support ofthe critically ill child J Parenter Enteral Nutr 200933(3)260-76

67 Ranade D Collins N Children with wounds the importance of nutrition Ostomy Wound Manage201114-24

68 Joosten KF Hulst JM Nutritional screening tools for hospitalized children methodologicalconsiderations Clin Nutr 201433(1)1-5

69 Mehta NM Skillman HE Irving SY et al Guidelines for the provision and assessment of nutritionsupport therapy in the pediatric critically ill patient Society of Critical Care Medicine and AmericanSociety for Parenteral and Enteral Nutrition JPEN 201741(5)706-42

70 Skillman J Wischmeyer P Nutrition therapy in critically ill infants and children JPEN 200832(5)520-34

71 Rodriguez-Key M Alonzi A Nutrition skin integrity and pressure ulcer healing in chronically illchildren an overview Ostomy Wound Manage 200753(6)56-62

72 Allen B Effects of a comprehensive nutritional program on pressure ulcer healing length of hospitalstay and charges to patients Clin Nurs Res 201322(2)186-205

73 Academy of Nutrition and Dietetics Electronic Nutrition Care Process Terminology 2019 wwwncproorg Last accessed December 27 2019

74 Field LB Hand RK Differentiating malnutrition nutrition screening and assessment a nutrition careprocess perspective J Acad Nutr Diet 201515824-8

75 Fuhrman MP Charney P Mueller CM Hepatic proteins and nutrition assessment J Am Diet Assoc2004104(8)1258-64

76 Hand RK Murphy WJ Filed LB et al Validation of the AcademyASPEN malnutrition clinicalcharacteristics J Acad Nutr Diet 2016116(5)856-63

77 Tobert CM Mott SL Nepple KG Malnutrition diagnosis during adult inpatient hospitalizations

analysis of a multi-institutional collaborative database of academic medical centers J Acad NutrDiet 2018118(1)125-31

78 Demling RH Nutrition anabolism and the wound healing process an overview Eplasty 20099e979 Cereda E Klersy C Rondanelli M Caccialanza R Energy balance in patients with pressure ulcers a

systematic review and meta-analysis of observational studies J Am Diet Assoc 20111111868-76

80 Ohura T Nakajo T Okada S Omura K Adachi K Evaluation of effects of nutrition intervention onhealing of pressure ulcers and nutritional states (randomized controlled trial) Wound Repair Regen201119(3)330-6

81 Breslow RA Hallfrisch J Guy DG Crawley B Goldberg AP The importance of dietary protein inhealing pressure ulcers J Am Geriatr Soc 199341(4)357-62

82 Lee SK Posthauer ME Dorner B Redovian V Maloney MJ Pressure ulcer healing with aconcentrated fortified collagen protein hydrolysate supplement a randomized controlled trialAdv Skin Wound Care 200619(2)92-6

83 Hisashige A Ohura T Cost-effectiveness of nutritional intervention on healing of pressure ulcersClin Nutr 201231(6)868-74

84 Morley JE Argiles JM Evans WJ et al Nutritional recommendations for the management ofsarcopenia J Am Med Dir Assoc 201011(6)391-6

85 Vikstedt T Suominen MH Joki A et al Nutritional status energy protein and micronutrient intakeof older service house residents J Am Med Dir Assoc 201112(6)302-7

86 Wolfe RR Miller SL The recommended dietary allowance of protein a misunderstood conceptJ Am Med Dir Assoc 2008299(24)2891-3

87 Clark M Schols JMGA Benati G et al Pressure ulcers and nutrition a new European guidelineJ Wound Care 200413(7)267-72

88 Schols JMGA de Groot CP van der Cammen TJ Olde Rikkert MG Preventing and treatingdehydration in the elderly during periods of illness and warm weather J Nutr Health Aging 200913(2)150-7

89 Volkert D Beck AM Cederholm T et al Management of malnutrition in older patientsmdashcurrentapproaches evidence and open questions J Clin Med 201948(7)

90 Volkert D Beck AM Cederholm T et al ESPEN guideline on clinical nutrition and hydration ingeriatrics Clin Nutr 201838(1)10-47

91 Dorner B Friedrich EK Position of the Academy of Nutrition and Dietetics individualized nutritionapproaches for older adults long-term care post-acute care and other settings J Acad Nutr Diet2018118(4)724-35

92 Hubbard GP Elia M Holdoway A Stratton RJ A systematic review of compliance to oral nutritionalsupplements Clin Nutr 201231(3)293-312

93 Delmi M Rapin CH Bengoa JM Delmas PD Vasey H Bonjour JP Dietary supplementation inelderly patients with fractured neck of the femur Lancet 1990335(8696)1013-6

94 Hartgrink HH Wille J Konig P Hermans J Breslau PJ Pressure sores and tube feeding in patientswith a fracture of the hip a randomized clinical trial Clin Nutr 199817(6)287-92

95 Horn SD Bender SA Ferguson ML et al The National Pressure Ulcer Long-term Care Studypressure ulcer development in long-term care residents J Am Geriatr Soc 200452(3)359-67

96 Houwing RH Rozendaal M Wouters-Wesseling W Beulens JW Buskens E Haalboom JR Arandomised double-blind assessment of the effect of nutritional supplementation on the preventionof pressure ulcers in hip-fracture patients Clin Nutr 200322(4)401-5

97 Stratton RJ Ek AC Engfer M et al Enteral nutritional support in prevention and treatment ofpressure ulcers a systematic review and meta-analysis Ageing Res Rev 20054(3)422-50

98 Banks MD Ross LJ Webster J et al Pressure ulcer healing with an intensive nutrition interventionin an acute setting a pilot randomised controlled trial J Wound Care 201625(7)384-92

99 Cereda E Klersy C Andreola M et al Cost-effectiveness of a disease-specific oral nutritionalsupport for pressure ulcer healing Clin Nutr 201736(1)246-52

100 Cereda E Klersy C Serioli M Crespi A DAndrea F A nutritional formula enriched with argininezinc and antioxidants for the healing of pressure ulcers a randomized trial Ann Intern Med 2015162(3)167-74

101 Neyens J Cereda E Meijer EP Lindholm C Schols JMGA Arginine-enriched oral nutritionalsupplementation in the treatment of pressure ulcers a literature review Wound Medicine 20171646-51

102 Cereda E Gini A Pedrolli C Vanotti A Disease-specific versus standard nutritional support for thetreatment of pressure ulcers in institutionalized older adults a randomized controlled trial J AmGeriatr Soc 200957(8)1395-402

103 Van Anholt R Sobotka L Meijer E et al Specific nutritional support accelerates pressure ulcerhealing and reduces wound care intensity in non-malnourished patients Nutrition 201026(9)867-72

104 Banks MD Graves N Bauer JD Ash S Cost effectiveness of nutrition support in the prevention ofpressure ulcer in hospitals Eur J Clin Nutr 201367(1)42-6

105 Tuffaha HW Roberts S Chaboyer W Gordon LG Scuffham PA Cost-effectiveness and value ofinformation analysis of nutritional support for preventing pressure ulcers in high-risk patientsimplement now research later Appl Health Econ Health Policy 201513(2)167-79

106 Tuffaha HW Roberts S Chaboyer W Gordon LG Scuffham PA Cost-effectiveness analysis ofnutritional support for the prevention of pressure ulcers in high-risk hospitalized patients Adv SkinWound Care 201629(6)261-7

107 Arinzon Z Peisakh A Berner YN Evaluation of the benefits of enteral nutrition in long-term careelderly patients J Am Med Dir Assoc 20089(9)657-62

108 Bourdel-Marchasson I Dumas F Pinganaud G Emeriau JP Decamps A Audit of percutaneousendoscopic gastrostomy in long-term enteral feeding in a nursing home Int J Qual Health Care19979(4)297-302

109 Wild T Rahbamia A Killner M Sobotka L Eberlein T Basics in nutrition and wound healingNutrition 201026(9)862-6

110 Dryden SV Shoemaker WG Kim JH Wound management and nutrition for optimal wound healingAtlas Oral Maxillofacial Surg Clin N Am 20132137-47



111 Malone A Carney IN Mays A eds ASPEN Enteral Nutrition Handbook 2nd ed Silver Springs MDAmerican society for Parenteral and Enteral Nutrition 2019

112 Boyce B An ethical perspective on palliative care J Acad Nutr Diet 2017117(6)970-2113 OSullivan-Maillet J Schwartz DB Posthauer ME Ethical and legal issues in feeding and hydration

J Acad Nutr Diet 2013113(6)828-33114 Druml C Ballmer PE Druml W et al ESPEN guideline on ethical aspects of artificial nutrition and

hydration Clin Nutr 201635(3)545-56115 Harvey SE Parrott F Harrison DA et al A multicentre randomised controlled trial comparing the

clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versusthe enteral route in critically ill patients (CALORIES) Health Technol Assess 201620(28)1-143

116 Rottkamp BC An experimental nursing study a behavior modification approach to nursingtherapeutics in body positioning of spinal cord-injured patients Nurs Res 197625(3)181-6

117 Carlson M Vigen CL Rubayi S et al Lifestyle intervention for adults with spinal cord injury resultsof the USC-RLANRC Pressure Ulcer Prevention Study J Spinal Cord Med 201942(1)2-19

118 Kim JY Cho E Evaluation of a self-efficacy enhancement program to prevent pressure ulcers inpatients with a spinal cord injury Jpn J Nurs Sci 201714(1)76-86

119 Arora M Harvey LA Glinsky JV et al Telephone-based management of pressure ulcers in peoplewith spinal cord injury in low- and middle-income countries a randomised controlled trial SpinalCord 201755(2)141-7

120 Haesler E Cuddigan J Kottner J Carville K Guideline Governance Group International consumerengagement in guideline development surveying patients in 30 countries Presented at the 14thGuideline International Network (G-I-N) Conference Manchester 2018

121 Haesler E Cuddigan J Kottner J Carville K Guideline Governance Group International consumerengagement in pressure injuryulcer guideline development global survey of patient care goals andinformation needs Presented at the National Pressure Ulcer Advisory Panel 2019 AnnualConference St Louis MO 2019

122 Hartigan I Murphy S Hickey M Older adults knowledge of pressure ulcer prevention a prospectivequasi-experimental study Int J Older People Nurs 20127(3)208-18

123 Chaboyer W Bucknall T Webster J et al The effect of a patient centred care bundle interventionon pressure ulcer incidence (INTACT) a cluster randomised trial Int J Nurs Stud 20166463-71

124 Ohlhorst S Russell R Bier D et al Nutrition research to affect food and a healthy life span J Nutr2013143(8)1349-54

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Thepurpose of this article is to review the nutrition-relatedrecommendations presented in the EPUAPNPIAPPPPIACPG and to discuss nutrition for PImanagement in the con-text of the recommendations The recommendations weredeveloped using a rigorous methodology outlined inthe guideline in print and online (internationalguidelinecom) Each recommendation includes a list of implemen-tation considerations Table 1 presents the nutrition-relatedrecommendations from the EPUAPNPIAPPPPIACPG including the strengths of evidence and assigned

recommendations With the recommendations presentedin Table 1 in mind this article will discuss the underpin-ning research and the context in which the recommenda-tions are implemented in the nutritional management ofindividuals with or at risk of PIs

NUTRITION AS A RISK FACTOR FOR PRESSURE INJURIESA large body of prognostic research has reported on theinfluence of impaired nutrition on the risk of PI in adultsAs reported in the EPUAPNPIAPPPPIA CPG of 50

Table 1 2019 INTERNATIONAL GUIDELINE NUTRITION RECOMMENDATIONSThe strength of evidence (SoE) ratings used in this table are defined as follows B1 level 1 studies of moderate or low quality providing direct evidence level 2 studies ofhigh or moderate quality providing direct evidence andor most studies have consistent outcomes and inconsistencies can be explained B2 level 2 studies of low qualityproviding direct evidence level 3 or 4 studies (regardless of quality) providing direct evidence andor most studies have consistent outcomes and inconsistencies can beexplained C level 5 studies (indirect evidence) andor body of evidence with inconsistencies that cannot be explained reflecting genuine uncertainty and Good PracticeStatements (GPSs statements that are not supported by a body of evidence but considered by the Guideline Governance Group to be significant for clinical practice) Thestrength of recommendation (SoR) ratings are as follows uarruarr strong positive recommendation definitely do it uarr weak positive recommendation probably do it

Noa Recommendation SoE SoR or GPSb

110 Consider the impact of impaired nutritional status on the risk of pressure injuries SoE = C SoR =uarr41 Conduct nutritional screening for individuals at risk of a pressure injury SoE = B1 SoR =uarruarr42 Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of

malnutrition and for all adults with a pressure injurySoE = B2 SoR =uarruarr

43 Develop and implement an individualized nutrition care plan for individuals with or at risk of a pressure injury who aremalnourished or who are at risk of malnutrition


44 Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition SoE = B2 SoR = uarr45 Adjust protein intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition GPS46 Provide 30 to 35 kcalorieskg body weightday for adults with a pressure injury who are malnourished or at risk of

malnutritionSoE = B1 SoR = uarr

47 Provide 125 to 15 g proteinkg body weightday for adults with a pressure injury who are malnourished or at risk ofmalnutrition

SoE = B1 SoR =uarruarr

48 Offer high-calorie high-protein fortified foods andor nutritional supplements in addition to the usual diet for adults who areat risk of developing a pressure injury and who are also malnourished or at risk of malnutrition if nutritional requirementscannot be achieved by normal dietary intake

SoE = C SoR = uarr

49 Offer high calorie high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who aremalnourished or at risk of malnutrition if nutritional requirements cannot be achieved by normal dietary intake


410 Provide high-calorie high-protein arginine zinc and antioxidant oral nutritional supplements or enteral formula for adultswith a CategoryStage II or greater pressure injury who are malnourished or at risk of malnutrition

SoE = B1 SoR = uarr

411 Discuss the benefits and harms of enteral or parenteral feeding to support overall health in light of preferences and goals ofcare with individuals at risk of pressure injuries who cannot meet their nutritional requirements through oral intake despitenutritional interventions

GPS

412 Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferencesand goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intakedespite nutritional interventions

SoE = B1 SoR = uarr

413 Provide and encourage adequate waterfluid intake for hydration for an individual injury when compatible with goals of careand clinical conditions

GPS

414 Conduct age appropriate nutritional screening and assessment for neonates and children at risk of pressure injuries GPS415 For neonates and children with or at risk of pressure injuries who have inadequate oral intake consider fortified foods age

appropriate nutritional supplements or enteral or parenteral nutritional supportGPS

222 Provide pressure injury education skills training and psychosocial support to individuals with or at risk of pressure injuries SoE = C SoR = uarraFor ease of reference the recommendation number published in the Clinical Practice Guideline has been usedbAs published in the Clinical Practice GuidelineAdapted with permission from the European Pressure Ulcer Advisory Panel National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance


























Characteristic



X X

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X X

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Documents

The Role of Nutrition for Pressure Injury Prevention and Healing: … · 2020. 3. 5. · 4.12 Discussthe benefits andharmsof enteral or parenteral feeding tosupport pressure injurytreatment