Vol. 10 •Issue 2
• Page 40
The Pressure Ulcer Prevention Diet
Nutritional elements can play an important role in pressure ulcer prevention.
By Gail R. Hebert, RN, MS, WCC, CWCN, & Tina Hein, RN, CWOCN
Good nutrition is an integral part of pressure ulcer management. But, research on nutrition's effect usually focuses on wound healing, often overlooking the relationship between nutrition and pressure ulcer prevention.
SUPPORTING EVIDENCE
Malnourished residents are twice as likely as well-nourished ones to develop pressure ulcers.1 One study found that among severely undernourished residents, 65 percent developed pressure ulcers, while no breakdown occurred in the mild, moderate or well nourished groups.2
Although the literature clearly supports the correlation between malnutrition and pressure ulcer development, assuming that improved nutrition will result in pressure ulcer prevention is controversial. Some trials intended to prove this correlation have not yielded consistent results.3
Definitive research showing the link between nutrition and wound prevention remains elusive, probably because of the difficulty in controlling the many complex variables in trials. Also, most of the studies have been conducted on animals, the results of which do not directly translate to humans. Expert opinion and anecdotal evidence, however, clearly support the need to focus on nutrition to prevent the development of pressure ulcers.
KEY NUTRITIONAL ELEMENTS
What follows is a review of the key nutritional elements and their impact on pressure ulcer prevention:
Calories. Consuming an adequate number of calories to meet the body's needs is imperative to maintaining good nutritional status. The recommended amount of calories is 30 to 35 calories/kg/day for pressure ulcer patients and those at risk of developing a pressure ulcer.1
In residents who are stressed due to conditions such as infection, trauma or wounds, there is the risk of developing protein calorie malnutrition. Stressed patients who do not take in a sufficient amount of calories and protein are at high risk for involuntary weight loss due to hypermetabolic state. Involuntary weight loss is defined as a 5 percent loss of body weight in 30 days, a 7.5 percent loss in 90 days or a 10 percent loss in 180 days.4
Involuntary weight loss is one of the most rampant problems facing nursing homes today.5 The incidence is estimated at greater than 24 percent.6 When the body is put under stress, it will break down protein from its store of lean body mass (muscle, enzymes, collagen, growth factors, visceral protein and antibodies) to release energy. This depletion of lean body mass jeopardizes vital organ function, muscle strength, immunity and skin integrity.
The resultant weight loss and depletion of visceral protein stores is associated with an increased risk of pressure ulcer development. At a 20 percent loss of lean body mass, decreased healing, increased weakness and infections develop. At a 30 to 40 percent loss, pressure ulcers will develop, existing pressure ulcers will fail to heal and death is a possible outcome.7
Protein. Research indicates that decreased protein is the only nutrient that significantly predicts ulcer development, including total intake of calories, vitamin A and C, iron and zinc.2
High protein intake is important in wound healing. But increasing a resident's protein intake—whether from a prevention or treatment standpoint—beyond 1.5 g/kg per day may not increase protein synthesis and may cause dehydration and place stress on the kidneys' ability to handle the higher load.
An alternative to dietary sources of protein is to provide an amino acid mix that contains the building blocks of protein.7 But although products that contain arginine and glutamine have shown good outcomes as enhancements to wound healing, no data exists to show they are helpful for pressure ulcer prevention.
Vitamin A. Vitamin A deficiency may result in delayed wound healing and increased susceptibility to infections. True vitamin A deficiency is rare, as it is stored in the liver. Deficiency of vitamin A is found among malnourished, elderly and chronically sick populations in the United States, but it is more prevalent in developing countries.8 Supplementation is indicated only for patients who are deficient,7 and the role of vitamin A in pressure ulcer prevention is unknown.
Vitamin C. Vitamin C contributes to the synthesis of connective tissue. It will increase the tensile strength of newly built collagen. Although vitamin C supplementation has been proven to enhance wound healing in deficient patients, the benefit in non-deficient patients remains unclear.
In terms of prevention, a study found that low concentrations of leukocyte vitamin C levels were associated with subsequent pressure ulcer development in older adults with femoral neck fractures.7 Experts in the field agree that the recommended daily intake of vitamin C is extremely low, and support supplementation because it is water soluble, inexpensive and does not cause side effects. Standard multivitamins contain sufficient Vitamin C for prevention, however, larger doses up to 750mg per day for women and 900mg per day for men are recommended when wound healing is the goal.9
Zinc. Zinc is an essential trace mineral required for cell growth and replication. It is involved in DNA synthesis, cell division and protein synthesis. Zinc deficiency decreases protein and collagen synthesis, among other key processes.
Excess zinc can also adversely affect wound healing by interfering with copper metabolism,7 and can have adverse effects in the GI tract including nausea, vomiting and epigastric pain.10 Supplemental zinc should be given only to patients who are deficient. Dietary intake of zinc has not been shown to be a risk factor in developing pressure ulcers. Since there is no way to test for zinc deficiency, experts generally support supplementation for no more than two to four weeks.
Fluid. Dehydration often accompanies malnutrition and is therefore a risk factor for pressure ulcer development. Dehydration reduces blood volume, interferes with peripheral circulation, and decreases nutrient and oxygen supply to the tissues.
Dehydration can also increase a person's risk of pressure ulcer development by causing muscle fatigue, diminished appetite and bowel impaction.11 Medicare's Tag F327 states that facilities must provide each resident with sufficient fluid intake to maintain proper hydration and health.12 A rule of thumb is to provide 30 to 35 ml of fluid per kg of body weight per day in patients who are not on fluid restriction.7
The elderly are at significant risk of dehydration due to the decreased thirst sensation that occurs with aging, as well as other factors.
STAYING PRESSURE ULCER FREE
Preventing pressure ulcers in residents of long-term care facilities requires a multifaceted approach. Studies attempting to prove that enhanced nutrition will result in pressure ulcer prevention are not conclusive, yet most experts agree that nutrition is a key factor.
Research supports the fact that sufficient intake of protein, calories, vitamins and fluids is essential to preventing skin breakdown. Staying abreast of new research will provide clinicians with more tools to help residents maintain skin integrity.
References
1. Schmidt TR. Wound care in long term care: What's new in nutrition? Extended Care Product News May 2002;81(3)18-20.
2. Baronoski S and Ayello E. Wound Care Essentials. Ambler (PA): Lippincott Williams and Wilkins; 2004.
3. Kulkowski K. Nutrition and aging: a transdisciplinary approach. Ostomy/Wound Management 2006;52(10):53-57.
4. Collins N. Nutrition: The team approach to food and nutrition. Extended Care Product News July 2006;111(6)8-10.
5. Collins N. Operation Cooperation, How nursing and nutrition can work together for a successful survey. Extended Care Product News July 2003;88(4)10-12.
6. Fleck CA. The A-B-C of nutrition and wound healing. Extended Care Product News October 2002;83(5) 4-9.
7. Sauer A. Pressure ulcers: A role for nutrition. Ross products division, Abbott Laboratories, Monograph, 2005.
8. Thakore J. Vitamin A Deficiency. Emedicine from WebMD. Retrieved from www.emedicine.com/med/topic2381.htm on Jan. 23, 2007.
9. Collins N. Nutrition and Wound Healing: strategies to improve patient outcomes. September 2004;16(9 Supple)1SÐ7S.
10. Posthauer ME. The role of nutrition in Tag F-314 Compliance. Advances in Skin and Wound Care April 2005;18(3)130-132.
11. Philips EM, Short NM and Reece J. Maximizing the nursing nutrition link: Pressure ulcers and nutritional intervention. Extended Care Product News January 2005;97(1)22-26.
12. Collins N. Managing and Monitoring Dehydration. Extended Care Product News August 2002;82(4)12-14.
Gail R. Hebert and Tina Hein are regional clinical managers with Huntleigh Healthcare, Eatontown, N.J. Hebert can be reached at ghebert@huntleighhealth.com. To contact Hein, e-mail thein@huntleighhealth.com. The authors would like to thank Dr. Nancy Collins, PhD, RD, LD/N, for her consultation on this article. Disclosure: Huntleigh Healthcare manufactures pressure reduction products.
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