Question #501
What is the role of nutritional support for patients in the prevention and treatment of pressure ulcers?
Overview
The benefit of nutritional evaluation and intensive nutritional support (including vitamin and mineral supplementation) in patients at risk for and with pressure ulcers is not supported by rigorous clinical trials. Despite this "lack of proof," NPUAP endorses the application of reasonable nutritional assessment and treatment for patients at risk for and with pressure ulcers. The following paragraphs summarize the current NPUAP positions on these topics. An NPUAP task force is currently examining the important issues related to nutritional evaluation and support of patients at risk for and with pressure ulcers.
Assessment
Practice standards in hospitals and nursing homes require structured nutritional assessments, and some nutritional parameters (e.g., low body mass index, low serum albumin) are recognized predictors for pressure ulcer development.1,2,3 However, no studies have established any single or combination of nutritional measurements that can accurately predict the risk of pressure ulcer development, or the likelihood of pressure ulcer healing.4 In addition, in many or most patients with pressure ulcers, some markers of "malnutrition" (e.g., low cholesterol, low serum albumin) are probably more likely to be reflective of the acute inflammatory processes associated with the development of Stage III and IV pressure ulcers and/or an underlying chronic disease, rather than to actually represent overall nutritional status.5,6,7
Treatment
Several small studies and expert opinion are consonant with providing enhanced caloric and protein supplementation in patients with pressure ulcers who are underweight or losing weight. Commonly recommended nutritional goals are: 35-40 kcal per kg per day for total calories and 1.0-1.5 g protein per kg per day for total protein. In addition, surveyors also regularly recommend (and enforce the practice of) enhancing caloric and protein intake in nursing home patients with pressure ulcers. Particularly for nursing home residents, no good data show that enteral feeding prevents new pressure ulcers or accelerates healing of those already present, and some data show no benefit or worse outcomes in tube fed patients.4 Ongoing national studies are attempting to better define the role of intensive nutritional evaluation and treatment for nursing home patients at risk for and with pressure ulcers.8 The use of vitamin C and zinc supplementation is widely practiced, but remains unsubstantiated and controversia. No data are available to support the use of other dietary supplements (e.g., arginine and other amino acid supplements). No studies support the use of frequent laboratory monitoring (e.g., weekly or monthly measurement of serum pre-albumin or albumin) as part of a routine treatment plan.
