The Role Of Nutrition For Pressure Ulcer Management .

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APRIL 2015The Role of Nutrition for Pressure UlcerManagement: National Pressure UlcerAdvisory Panel, European Pressure UlcerAdvisory Panel, and Pan Pacific PressureInjury Alliance White PaperC M E1 AMA PRACategory 1 CreditTMANCC3.0 Contact HoursMary Ellen Posthauer, RDN, LD, CD, FAND & President & MEP Healthcare Dietary Services, Inc & Evansville, IndianaMerrilyn Banks, PhD & Director & Nutrition and Dietetics & Royal Brisbane & Women’s Hospital & Herston, Queensland, AustraliaBecky Dorner, RDN, LD, FAND & President & Becky Dorner & Associates, Inc, and Nutrition Consulting Services, Inc &Naples, FloridaJos M. G. A. Schols, MD, PhD & Professor of Old Age Medicine & Department of Family Medicine and Department of HealthServices Research & Maastricht University & Maastricht, the NetherlandsAll authors, staff, faculty, and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationshipswith, or financial interests in, any commercial companies pertaining to this educational activity.To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 13 of the 18 questions correctly.This continuing educational activity will expire for physicians on April 30, 2016.PURPOSE:To review the 2014 Pressure Ulcer Prevention and Treatment Clinical Practice Guideline nutrition strategies.TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.OBJECTIVES:After participating in this educational activity, the participant should be better able to:1. Describe the risk factors for and the pathophysiology of pressure ulcers (PrUs).2. Identify evidence-based nutrition strategies for PrU management.WWW.WOUNDCAREJOURNAL.COM175ADVANCES IN SKIN & WOUND CARE & APRIL 2015Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

PrUs (58.7% vs 32.6%, P .001). Many acute and chronically ill adults,as well as older adults at risk or with PrUs, experience unintendedweight loss.1,6,7 Shahin et al’s8 2010 study in German hospitals andnursing homes clearly established the significant relationship between the presence of PrUs and unintended weight loss (5%–10%).A multicenter study conducted in Australian hospitals and residential older adult care facilities also reinforced the relationshipbetween malnutrition and PrUs.9 Banks et al’s10 study of Queenslandpublic hospital patients in 2002–2003 found one-third of PrUswere attributable to malnutrition at a mean cost of approximatelyAU 13 million. The 2014 National Pressure Ulcer ConsensusConference faculty supported the statement that individuals withmalnutrition in combination with multiple comorbidities are atincreased risk of developing a PrU.11ABSTRACTNutrition and hydration play an important role in preserving skinand tissue viability and in supporting tissue repair for pressureulcer (PrU) healing. The majority of research investigating therelationship between nutrition and wounds focuses on PrUs. Thiswhite paper reviews the 2014 National Pressure Ulcer AdvisoryPanel, European Pressure Ulcer Advisory Panel, and Pan PacificPressure Injury Alliance Nutrition Guidelines and discussesnutrition strategies for PrU management.KEYWORDS: pressure ulcers, nutrition assessment andwounds, nutrition guidelines for pressure ulcers, tissue repairand healingADV SKIN WOUND CARE 2015;28:175–88; quiz 189-90.DEFINING MALNUTRITIONParameters used to define malnutrition/undernutrition vary inmost studies, thus underscoring the need to establish a standardset of criteria to define adult malnutrition. Historically, cliniciansused serum protein levels, including albumin and prealbumin, todetermine nutritional status. However, current research indicates that serum protein levels may be affected by inflammation,renal function, hydration, and other factors.12 During periods ofinflammatory stress, albumin and prealbumin levels drop becausethey are negative acute-phase reactants. In response, there is anincrease in cytokines, including interleukin 1", interleukin 6, andtissue necrosis factor, causing the liver to synthesize positive acutephase reactants rather than negative acute-phase reactants. Inflammatory biomarkers, such as C-reactive protein, ferritin, andother positive acute-phase reactants, quickly rise with acute inflammation and decline as inflammation diminishes. Inflammation maybe a contributing factor when C-reactive protein levels increase, andalbumin and prealbumin levels decline.12,13 Several studies reportedevidence suggesting that serum hepatic proteins correlate withmortality and morbidity, are useful indicators of illness severity, andhelp to identify individuals at risk for developing malnutrition.14–18Hepatic protein levels do not accurately measure nutritional repletion18;thus, serum concentrations may not be markers of malnutritionor caloric repletion. As of 2012, the Academy of Nutrition andDietetics (Academy) and American Society for Parenteral andEnteral Nutrition (A.S.P.E.N.) do not recommended using inflammatory biomarkers such as serum protein levels for diagnosis of malnutrition.18‘‘Adult undernutrition typically occurs along a continuum ofinadequate intake and/or increased requirements, impaired absorption, altered transport, and altered nutrient utilization,’’18 states theAcademy and A.S.P.E.N. Weight loss may occur at various pointsalong this continuum. Inflammation appears to be the commonthread in disease progression and concurrent declining nutritionalINTRODUCTIONNutrition and hydration play an important role in preservingskin and tissue viability and supporting tissue repair processesfor pressure ulcer (PrU) healing. The majority of research investigating the relationship between nutrition and wound prevention and healing has focused on PrUs. The 2014 (second) editionof the Pressure Ulcer Prevention and Treatment Clinical PracticeGuideline was a collaborative effort between the National Pressure Ulcer Advisory Panel (NPUAP), the European PressureUlcer Advisory Panel (EPUAP), and the Pan Pacific PressureInjury Alliance (PPPIA). The goal of this international alliancewas to develop evidence-based recommendations for the prevention and treatment of PrUs that could be used by healthcare professionals globally. The 2009 research was reviewed, confirming thatthe previous nutrition guidelines were appropriate. Current researchon the impact of malnutrition and the role of conditionally essentialamino acids are included in the 2014 guidelines. The purpose of thiswhite paper is to review the 2014 nutrition guidelines and discussnutrition strategies for PrU management.COMPROMISED NUTRITIONAL STATUSInadequate dietary intake and poor nutritional status havebeen identified as key risk factors for both the development ofPrUs and protracted wound healing. Several studies, includingThe National Pressure Ulcer Long-term Care Study, reported thateating problems and weight loss were associated with a higherrisk of developing PrUs.1–3Fry et al4 also reported that preexisting malnutrition and/orweight loss was a positive predictive variable for all undesirablesurgery-related hospital-acquired conditions, including PrUs.Iizaka et al’s5 study of home care patients 65 years or older inJapan noted the rate of malnutrition was higher for those withADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 4176Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.WWW.WOUNDCAREJOURNAL.COM

status.19 Current evidence suggests that inflammation is an important underlying factor, and there are varying degrees of acute andchronic inflammation associated with injury, infection, and disease.12,18–22 Diseases such as diabetes mellitus, cardiovasculardiseases, arthritis, and cancers produce chronic inflammationthat is sustained and persistent. Elevated energy expenditure andcatabolism of lean body mass are associated with chronic inflammation. Individuals with a critical illness, major infection, ortraumatic injury may have a condition associated with an acuteinflammatory response. This acute-phase inflammatory response triggers a sequence of reactions leading to elevated restingenergy expenditure and nitrogen excretion, which increases energyand protein requirements concurrently with anorexia and pathologically altered utilization of nutrients.22 The body reacts with asuboptimal response, and nutrition interventions are not adequateto reverse the mobilization of nutrients and other cytokine-relatedchanges in organ function. Jensen et al22 define the point at whichthe severity or persistence of inflammation leads to a decrease inlean body reserves linked to impaired functional status as diseaserelated malnutrition. Figure 1 describes etiology–based malnutritiondefinitions.In 2009, A.S.P.E.N. and the European Society for ClinicalNutrition and Metabolism convened an International ConsensusGuideline Committee to adopt an etiology-based approach to thediagnosis of adult malnutrition. The definitions developed andendorsed by A.S.P.E.N. and the European Society for Clinical Nutritionand Metabolism to describe adult malnutrition were acceptedby the Academy. The definitions describe adult malnutrition in aframework of acute illness or injury, chronic disease or conditions(lasting 3 months), and starvation-related malnutrition.18 Theidentification of 2 or more of the following 6 characteristics is required for the nutrition diagnosis of malnutrition (also known asundernutrition): insufficient energy intake, weight loss, loss ofmuscle mass, loss of subcutaneous fat, fluid accumulation (thatmay mask weight loss), and/or diminished functional status (asmeasured by hand-grip strength).18 This etiology-based nomenclature takes into account the understanding of the role of theinflammatory response on incidence, progression, and resolutionof malnutrition in adults. Adapting a standardized approach todiagnose malnutrition using these characteristics will lead to earlyidentification of declining nutritional status, which impacts PrUprevention and healing.Figure 1.ETIOLOGY-BASED MALNUTRITION DEFINITIONSAdapted with permission from White.18WWW.WOUNDCAREJOURNAL.COM177ADVANCES IN SKIN & WOUND CARE & APRIL 2015Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

(RD) or the nutrition care team for a comprehensive nutritionassessment.A cross-sectional study investigating the role of clinicalguidelines in the assessment and management of individuals withPrUs found that adopting a formalized, facility-wide nutritionguideline contributes to the ongoing process of regular nutritionscreening in daily practice, as well as reducing barriers to providingnutritional support.34Nutrition screening tools should be validated, reliable, andrelevant to the patient group being screened. The screeningtool should consider current weight status and past weight toassess weight change, which may be linked to food intake/appetiteand disease severity. The nutrition screening tool should be relatively quick to administer, able to detect both undernutritionand overnutrition, and capable of establishing nutritional riskin all types of individuals, including those with fluid disturbances and those in whom weight and height cannot be easilymeasured.35,36RECOMMENDATIONS FOR PRACTICENutritional Considerations in PrU PreventionAccording to a recently updated Cochrane review, there isinconclusive evidence regarding medical nutrition therapy forpreventing PrUs.23 The 11 studies, a subset of 23 studies, considered mixed nutritional supplements as an intervention toprevent PrUs.6,24–33 Nutritional supplements included energyenriched supplements of protein alone and mixed supplementsof protein, carbohydrate, lipids, vitamins, and minerals. All studiescompared the nutritional intervention with a standard intervention, such as a standard hospital diet, or standard diet plus placebo.The intervention was administered orally in all studies, except for2 studies where supplementation was administered by nasogastrictube.26,30 All included studies were prospective randomized controlled trials (RCTs), although generally small and had either anunclear or high risk of bias. Overall findings of the studies were alower incidence of PrUs in the intervention group (except for 1 trial,Arias et al24); however, none of these differences were statisticallysignificant with the exception of the study of Bourdel-Marchassonet al.25 When 8 trials were pooled in a meta-analysis, the authorsfound no clear evidence of an effect of supplementation on PrUdevelopment (Research Report, 0.86; 95% confidence interval,0.73–1.00; P .05).23 They concluded that it remains unclearwhether nutritional supplementation in these studies reducedthe risk of PrU development.Malnutrition is associated with increased risk of PrUs anddelayed healing; therefore, nutrition screening and assessmentare essential to identify risk of malnutrition, including poorfood/fluid intake and unintended weight loss. Many physical,functional, and psychosocial factors can contribute to inadequateintake, unintended weight loss, undernutrition, and/or proteinenergy malnutrition, such as cognitive deficits, dysphagia, depression, food-medication interactions, gastrointestinal disorders, andimpaired ability to eat independently. No clear method exists todetermine when nutritional status decline begins. Despite aggressive nutritional interventions, some individuals are simply unableto absorb adequate nutrients for good health.Nutrition Screening ToolsA number of validated nutrition risk screening tools have beendeveloped for use in different populations. In a comparison of5 of these screening tools in a hospital population, Neelemaatet al37 found the Malnutrition Screening Tool and Short Nutritional Assessment Questionnaire as suitable quick and easy toolsfor use in a hospital inpatient population. The screening toolsperformed as well as the more comprehensive malnutrition screening tools, the Malnutrition Universal Screening Tool (MUST) andNutrition Risk Screening 2002. The MUST was found to be lessapplicable because of the high rate of missing values. However,another study comparing nutrition risk screening tools for use inolder adults on hospital admission found MUST to be the mostvalid tool.38 The Mini Nutritional Assessment ([MNA]; NestleNutrition Institute, Vevey, Switzerland) is the only screening toolvalidated for older adults in both community and long-term-caresettings.Langkamp-Henken et al’s39 cross-sectional study of older menwith PrUs in residential care facilities examined the correlation ofthe MNA tool and clinical indicators and found a positive correlation. A German study comparing the nutritional status of individuals with and without PrUs found the MNA was easy to use toassess individuals with PrUs and multiple comorbidities.40Nutrition Screening and AssessmentPoor outcomes are associated with malnutrition, including therisk of morbidity and mortality, hence the need to quickly identifyand treat malnutrition when there is a risk for development of orexisting PrUs. The nutrition screening process identifies characteristics associated with nutrition risk. Any trained member of thehealthcare team may complete nutrition screening.Nutrition screening should be completed upon admissionto a healthcare setting and when nutrition risk is triggered,there should be an automatic referral to the registered dietitianADVANCES IN SKIN & WOUND CARE & VOL. 28 NO. 4Nutrition Care ProcessIndividuals identified to be malnourished, at risk of PrUs, or atnutritional risk through nutrition screening should have amore comprehensive nutrition assessment by the RD. The RDin consultation with the interprofessional team (including, butnot limited to, a physician, nurse practitioner, nurse, speech178Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.WWW.WOUNDCAREJOURNAL.COM

continuous, and early intervention is critical. A comprehensivenutrition assessment involves a systematic process of collecting,verifying, and interpreting data related to nutritional status andforms the basis for all nutrition interventions.Information obtained and analyzed includes medical, nutritional, biochemical data, and food-medication interactions;anthropometric measurements; and nutrition-focused physicalpathologist, occupational therapist, physical therapist, and dentist)should complete a comprehensive nutrition assessment.41 Figure 2defines the role of the interprofessional team. The Academy’sNutrition Care Process, which was also adapted by the DietitiansAssociation of Australia, includes 4 basic steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.42,43 The nutrition assessment process isFigure 2.NUTRITION FOR PREVENTION AND TREATMENT IS INTERPROFESSIONAL CAREPhysician and nurse practitioner:& Diagnose medical reasons for altered/disturbed nutritional status& Responsible for ordering all medications and treatmentDietitian:& Completes nutrition assessment and estimates nutrition/hydration requirements& Provides dietary recommendations and monitors nutritional statusSpeech therapist:& Screens and evaluates chewing and swallowing ability& Determines training compensation and recommends food/fluid consistencyOccupational therapist:& Assesses feeding skills and/or recommends techniques to improve motor skillsNurse:& Monitors acceptance and tolerance of oral and/or enteral nutrition& Alerts physician, dietitian, and patient of changes in nutritional status, such as meal refusal, changes in weight, or hydration statusNursing assistant or feeding assistant:& Delivers food (trays) and provides feeding assistance, if needed& Alerts nurse and/or other team members of refusal of or decline in oral intakeDentist/dental hygienist:& Assesses oral/dental status (eg, inflamed gums, oral lesions, denture problems)& Offers oral healthcareNote: All members of the interprofessional team educate the patient and/or caregiver on the risks and benefits of specific treatment related to their role on the team.Reprinted with permission.41WWW.WOUNDCAREJOURNAL.COM179ADVANCES IN SKIN & WOUND CARE & APRIL 2015Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

supported the goal of 30 kcal/kg per day but noted limitations ofthe meta-analysis, including a small number of included studies,small sample sizes, and heterogeneity of the groups. The MiffinSt Jeor equation may be more accurate and have a smallermargin of error when used to calculate resting metabolic rate forhealthy obese individuals.45examination results (assessment of signs of malnutrition, oralstatus, chewing/swallowing ability, and/or diminished ability toeat independently). The focus of nutrition assessment should beon evaluating energy intake, weight loss, and presence of acutedisease, as well as estimation of the individual’s caloric, protein,and fluid requirements.Following the comprehensive nutrition assessment, the RDidentifies and determines a specific nutrition diagnosis or problem that is within the scope of practice for the RD to treat. Theintervention is specific to the nutrition diagnosis or problem. Themonitoring and evaluation steps determine the progress madeby the individual to meet the specific goals established. Theinterprofessional team works with the individual and/or surrogate to develop appropriate and individualized interventionsand then monitor and evaluate for needed changes to nutritioninterventions.ProteinProtein is responsible for the synthesis of enzymes involved inPrU healing, cell multiplication, and collagen and connectivetissue synthesis. Protein is essential to promote positive nitrogenbalance.46 All stages of healing require adequate protein, andincreased protein levels have been linked to improved healingrates.47,48 Nitrogen losses may occur from exudat

healthcare team may complete nutrition screening. Nutrition screening should be completed upon admission to a healthcare setting and when nutrition risk is triggered, there should be an automatic referral to the registered dietitian (RD) or the nutrition care team for a comprehensive nutrition assessment.

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