RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineDiscussion of EvidenceOptimal nutrition facilitates wound healing, maintains immune competence and decreases the risk ofinfection. Most wounds tend to heal; however malnutrition and clinically evident deficiencies are riskfactors for the development of pressure ulcers, and are commonly associated with a delayed healingresponse. The deficiencies of carbohydrate, protein, fat, vitamins or trace elements associated withreduced nutritional intake and/or chronic losses from the wound surfaces can delay wound healing.Screening for nutritional deficiencies is an important part of the initial assessment, with the goal ofnutritional assessment and management being to ensure that the diet of the individual with a pressureulcer contains the nutrients necessary to support healing. The Compliance Network Physicians (1999)refers to nutritional management as a component of systemic treatment for the individual with a pressureulcer. Nutritional management should address four rules: determine the nutritional status; ensureadequate nutritional intake; initiate additional nutrient intake and supplementation; and determinevitamin, mineral and trace element deficits and correct them.A screening tool may be used by nurses to identify those at nutritional risk, however referral to those withexpertise in nutritional interventions is necessary to establish an appropriate treatment plan (Ferguson, Cook,Rimmasch, Bender, & Voss, 2000). For a sample tool focusing on nutritional screening and assessment, refer toAppendix D which includes the Mini Nutritional Assessment (MNA). The Mini Nutritional Assessment hasbeen validated for use with adults over the age of 55 (Nestle Clinical Services, 2002). In a small cross-sectionalstudy of Veterans, MNA scores were associated with nutritional indicators, such as biochemical indices andbody composition, in elderly people with stage II or higher pressure ulcers (Langkamp-Henken, Hudgens,Stechmiller, & Herrlinger-Garcia, 2005). Body Mass Index (BMI) is another nutritional screening tool, which is avalid measurement of weight in relation to health. It is not recommended however, for use as the solemeasurement of either body composition or level of fitness. The BMI is available on Health Canada’swebsite at http://www.hc-sc.gc.ca/hppb/ nutrition/bmi/index.html. Early identification and interventionto correct malnutrition can alter the healing trajectory in patients with wounds. A nutritional plan shouldbe comprehensive and individualized, and therefore requires a multidisciplinary approach. Theinvolvement of the interdisciplinary team and the patient in addressing nutritional goals is essential forsuccessful outcomes (Maklebust & Sieggreen, 1996).Nutritional interventions should be staged to meet the nutritional needs of the individual, and move fromscreening, monitoring of intake and supplementation (when necessary) to more intensive interventionsincluding enteral or parenteral feeding (Consortium for Spinal Cord Medicine, 2000; Maklebust & Sieggreen, 1996). Inan open prospective intervention evaluation of older adults with grade III and IV pressure ulcers, daily oralsupplementation resulted in a significant reduction of wound area and an improvement in woundcondition at three weeks (Frias Soriano et al., 2004). One small RCT found supplementary arginine, vitamin Cand zinc to significantly improve the rate of pressure ulcer healing (Desneves, Todorovic, Cassar, & Crowe, 2005).Stratton et al. (2005) completed a systematic review and meta-analysis of 15 studies (eight of which wereRCTs) to address the impact of enteral nutritional support on pressure ulcer incidence and healing and arange of other clinically relevant outcome measures, such as quality of life. This review found that enteralnutritional support, particularly high protein oral nutritional supplements, can significantly reduce the riskof developing pressure ulcers. The results also suggested an improvement in pressure ulcer healing, thoughthere were no robust RCTs identified to confirm this.27