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Nutritional Guidelines
for Pressure Ulcer
Prevention and Treatment
MISSION STATEMENT
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The European Pressure Ulcer Advisory Panel’s objective is
to provide the relief of persons suffering from, or at risk of
pressure ulcers, in particular through research and the
education of the public.
Registered Charity No: 1066856
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CLINICAL NEED FOR THIS GUIDELINE
Pressure ulcers are the result of a complex interplay between myriad extrinsic
and intrinsic risk factors – excessive mechanical loading, immobility,
incontinence, advanced age, among many others. While the consequences
of immobility are often viewed as the key predisposing factors in prompting
the development of a pressure ulcer, it is often assumed that there is
also a direct causal relationship between nutrition and pressure ulcer
development. The scientific basis for this assumption is unclear with
as yet no sound studies linking impaired nutrition and an increased incidence
of pressure ulcers. However, it is possible that impaired nutrition may
influence tissue vulnerability to extrinsic factors such as pressure.
It is important to note that only a few risk factors can be influenced
by our actions – tissue loading and nutrition being two key issues
we can address. The perceived importance of malnutrition in pressure ulcer
development and management is briefly considered within existing EPUAP
guidelines, for example:
- ‘a full risk assessment in patients to include:
general skin condition, skin assessment, mobility, moistness and incontinence,
nutrition and pain’
- ‘Following assessment nutritionally compromised
individuals should have a plan of appropriate support and/or supplementation
that meets individual needs and is consistent with overall goals of
therapy’
- ‘Ensure adequate dietary intake to prevent malnutrition
to the extent that this is compatible with the individual’s wishes
or condition’.
The purpose of this guideline is to expand upon the references
to malnutrition within existing EPUAP guidelines and provide clinicians
with specific guidance upon nutritional screening and assessment, and
following assessment, appropriate intervention. It is intended that the
guidelines be appropriate for all care settings although it is recognized
that the access to specific tools such as weighing scales and personnel
such as dieticians may be limited in some sectors. EPUAP recognize that
other clinical guidelines on nutrition exist (for example: Obesity in
Scotland, Integrating Prevention with Weight Management, SIGN Guideline
no. 8; 1996) and that the specific guidance EPUAP offers on nutrition
and pressure ulcers should be considered within the context of general
guidelines on nutritional management.
The recommendations offered in this guideline have been
graded using the following systems:
Source of evidence that underpins the recommendation
I Evidence from systematic review or meta-analysis of randomised controlled
trials or at least one randomised controlled trial.
II Evidence from at least one controlled trial without randomisation,
or at least one other type of quasi-experimental study.
III Evidence from non-experimental descriptive studies, such as comparative
studies, correlation studies, and case-control studies.
IV Evidence from expert committee reports or opinions and/or clinical
experience of respected authorities
Recommendation Grading
A Directly based on category I evidence,
B Directly based on category II evidence or extrapolated recommendation
from category I evidence,
C Directly based on category III evidence or extrapolated recommendation
from category I or II evidence,
D Directly based on category IV evidence or extrapolated recommendation
from category I, II or III evidence.
Both grading systems were adapted from Eccles M, Mason
J (2001). How to develop cost-conscious guidelines. Health Technology
Assessment 5:8.
Published in 2003.
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