Nutrition Essentials: Pressure Injury Prevention and Healing for Adults

Nutrition factors associated with the development of pressure injuries include unintended weight loss, undernutrition, increased nutrient needs, malnutrition, dehydration, low body mass index, inadequate food and fluid intake, and an inability to feed oneself.1 For individuals with compromised nutrition status, time is of the essence. Interprofessional teams must ensure efforts to identify the risk or presence of malnutrition and implement a timely, individualized plan of care. The Table identifies basic nutrition assessment parameters and interventions for adults. Table - NUTRITION-RELATED PRESSURE INJURY (PI) PREVENTION AND HEALING Component Method Procedure Intervention/Recommendation Screen • Use a validated screening tool to identify malnutrition (risk) • Facility should select a screening tool validated for patient age/setting1,2 • Screen at admission, readmission, and/or condition change1 • Unvalidated screening tools are not recommended2,3 • Determine who will be trained to administer the screening process • Notify registered dietitian nutritionist (RDN) of results1,2 • Perform nutrition screening per facility policy • Validated nutrition screening tools for adults: Malnutrition Screening Tool,2 Mini Nutritional Assessment,3 Malnutrition Universal Screening Tool,4 Nutrition Risk Screening 2002,2 Short Nutrition Assessment Questionnaire,2 Canadian Nutrition Screening Tool5 Assessment2 Nutrition status assessment by RDN includes review and evaluation of: Assessment to identify malnutrition is defined as presence of two or more characteristics:6 Laboratory values: • Validated screening tool • Insufficient energy intake • Albumin and prealbumin are acute phase reactants decreased by inflammatory conditions that affect the liver • Food/fluid history and intake • Unintended weight loss • Approximately 5% of the body's albumin is produced in the liver daily, so intake has little impact on protein levels • Anthropometric measurements • Loss of muscle mass • Research indicates albumin/prealbumin are NOT markers of malnutrition6–8 • Weight history • Loss of subcutaneous fat Nutrition-focused physical examination:2 • Biochemical data, medical tests, and procedures • Localized or generalized edema • The RDN is responsible for this essential step malnutrition diagnosis • Ability to eat independently • Diminished functional status as measured by handgrip strength • The RDN is trained to identify conditions such as edema, loss of muscle mass/subcutaneous fat, and micronutrient deficiencies (current standard) • Nutrition-focused physical examination • A decrease in subcutaneous fat and muscle mass is a marker of malnutrition6 Interventions • Provide adequate calories per assessed need to spare protein for PI healing1,7 PI risk: optimize energy intake per assessed need1,7 For individuals with PI and malnutrition or at risk of malnutrition:1,9 • Fortify favorite foods • Provide 30–35 kcal/kg • Offer high-calorie/high-protein supplement between meals • Provide 1.25–1.5 g/protein/kg • Offer modular protein (whey, soy, or hydrolyzed collagen) • Offer high-calorie/high-protein supplement fortified with arginine, zinc, and antioxidant between meals for PI stage ≥2 Fluids • Aids in wound site hydration and oxygen perfusion • Evaluate current daily intake • Provide and encourage adequate hydration for individuals with or at risk for PI (considering goals of care and individual condition)1,9 • Solvent for minerals, vitamins, amino acids, glucose, and other small molecules • Monitor for dehydration including weight changes, skin turgor, urine output, elevated serum sodium, and/or calculated serum osmolality1,9 • Consider 30 mL/kg for healthy individuals or 1 mL/kcal/d1,9 • Transports nutrients through the body and removes waste from cells • Individuals with congestive heart failure and/or chronic kidney disease may not tolerate high fluid intake • Offer hydration during wound/patient care and with each medication pass • Offer choice of beverages at meals and snacks • Offer added fluids for individuals with dehydration, draining wounds, fever, profuse sweating, nausea, or diarrhea1,9 Vitamins/minerals Micronutrients (such as vitamins A, B, and C and zinc) required in trace amounts as part of a healthy diet Observe: • Mega doses of vitamin or minerals are NOT recommended1,9 • Meals/snacks intake • Provide vitamin/mineral supplement daily if meal intake is poor (usually defined as <50% of food served/provided on plate)1,9 • Type of food/beverages • Check the label: oral supplements and fortified foods contain vitamins and minerals • Amount of oral nutrition supplement consumed, if applicable