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EPUAP GUIDELINES
On the Role of Nutrition in Pressure Ulcer Prevention and Management
This issue of the EPUAP Review reproduces the
draft text of a new EPUAP guideline covering the role of nutrition in
pressure ulcer prevention and management. This guideline was initiated
by the late Professor Gerry Bennett during the EPUAP Open Meeting held
in Budapest last year. Since September 2002, the guideline development
group (members listed below) met in Amsterdam in February 2003 with subsequent
revisions to the draft text made via e-mail. This draft guideline will
be presented for discussion during the EPUAP Open Meeting to be held in
Tampere. All comments received during this presentation will be considered
by the guideline development group and the text revised where appropriate.
If you have any comments regarding the content of this draft guideline
please send them to the EPUAP Business Office by the end of October 2003.
We have also reproduced the list of references on pressure ulcers and
nutrition considered by the guideline development group.
Membership of the Guideline Development Group:
Professor Gerry Bennett (UK)
Dr Michael Clark (Facilitator, UK)
Dr Joseph Schols (Netherlands)
Dr Giuseppe Benati (Italy)
Mr Gero Langer (Germany)
Mrs Pam Jackson (UK)
Mrs Bernadette Kerry (Ireland)
Draft for Discussion – Version 4:
European Pressure Ulcer Advisory Panel Guideline
on nutrition in pressure ulcer prevention and treatment.
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.
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.
Structure of the Guideline:
The recommendations of this guideline are considered to apply to both
the prevention and management of pressure ulcers. Where guidance relates
solely to pressure ulcer treatment this will be highlighted in the text.
It should also be noted that the EPUAP considers all recommendations to
be equally valid regardless of the grade of evidence upon which they are
based. In the following recommendations where a source and level of evidence
is not explicit, the recommendation should be considered as a level IV,
D recommendation.
Screening and Assessment of Nutritional Status:
Screening and assessment of an individual’s nutritional status can
be performed using a number of measures ranging from tools such as the
Subjective Global Assessment (Detsky et al., 1987) to relatively simple
measures of height and weight (combined as Body Mass Index). However,
some measurements (height, laboratory tests, skin fold thickness) may
not be readily available in all care settings. Undesired weight loss (>10%
of normal body weight in the past six months, or >5% in the past month)
may provide an indication of malnutrition although where possible reasons
for this unintentional weight loss should be explored with the individual
patient.
Accurate measurement of body weight and height, and hence Body Mass Index,
may be problematical in many settings through lack of available equipment
or challenges in measuring body length among some patient groups. While
BMI has been found to be less valid in some patient groups, such as children
and the very elderly, due to an altered/different fat/lean body mass ratio.
Nutritional assessment may also include nutritional intake over the past
1, 3 or 7 days; this information may be gathered using 24-hour recall,
self or carer reported food intake records or through the involvement
of a dietician, where available. It is important to consider why the intake
of food and fluids is at the reported level.
Biochemical measurements such as serum albumin, hemoglobin and potassium
may be helpful when considering the nutritional status of the ill although
these indicators may provide more information upon chronic, rather than
acute depletion of specific nutrients. In general it is unlikely that
biochemical measurements will provide more information than other indicators
such as undesired weight loss although a number of studies cite an association
between albumin and pressure ulcers.
The use of nutritional screening or assessment tools appears to be becoming
more prevalent in managing patients at risk of/with pressure ulcers. These
tools require to be validated and reliable, and like general risk assessment
tools should not replace clinical judgement. However, the use of validated
nutritional assessment tools may help to foster attention upon the need
to consider nutrition when assessing vulnerability to pressure ulcer development.
Nutritional status should be re-assessed regularly following an individualized
assessment plan which includes an evaluation date. The frequency of assessment
should be based upon the condition of the individual and should occur
following specific events such as surgery and any development of infections
or other catabolic processes likely to stress the nutritional status of
the individual.
While looking at the individual patient the clinical judgement of appropriately
trained health professionals may provide sound evaluations of probable
nutritional status, it should be acknowledged that excess of body weight
may mask nutritional deficiencies – for example morbidly obese individuals
may still be malnourished.
Nutritional Intervention:
Where an assessment or screening of nutritional status indicates that
malnutrition may be present, nutritional intervention should be considered.
The primary goal of nutritional intervention is generally to correct protein-energy
malnutrition ideally through oral feeding. When considering any limitations
on normal food and fluid intake, consider the local environment such as
ease of access to food, social and functional issues along with the texture
of the diet. Changes in these aspects may encourage or facilitate increased
oral intake. Overall the goal should be to consider the quality and energy-density
of the food intake rather than its quantity. Considering fluid intake
quantity is equally important as quality.
Where enhanced normal feeding is not possible, protein-energy rich oral
supplements may be considered (Recommendation 1, B; Benati et al., 2001,
Bourdel-Marchasson et al., 2000, Breslow et al., 1993, Chernoff et al.,
1990, Delmi et al., 1990). The value of vitamin and trace element supplementation
in pressure ulcer prevention is unclear (Recommendation 1, B; Taylor et
al., 1974, ter Riet et al., 1995).
Where normal feeding and oral supplementation fail to resolve apparent
malnutrition then other routes (for example tube-feeding) may be undertaken
although the risks associated with these interventions should be considered.
While the amount of supplementation required by individuals will vary,
general guidance can be offered where an individual may require a minimum
of 30–35 kcal per kg body weight per day, with 1 to 1.5 g/kg/day
protein required and 1ml per kcal per day of fluid intake.
Specific guidance on energy expenditure may be provided through the use
of standard equations such as the Harris-Benedict or Schofield formulae
although it is recommended that advice on their use and interpretation
be sought from a dietician (where available) or the multidis-ciplinary
care team.
The success of nutritional intervention should be reviewed within the
on-going regular nutritional assessments and may be indicated by outcomes
such as increased weight or improved functional ability and/or enhanced
health-related quality of life. Successful nutritional intervention may
also be marked by a reduced incidence of new pressure ulcers and the healing
of established pressure ulcers.
Regular evaluation of the effects of nutritional interventions is required
but it should be borne in mind that where individuals are malnourished
the effects of feeding and/or supplementation may not be immediately apparent,
probably because there first needs to be a restoration of already depleted
reserves.
Where patients have established pressure ulcers then a similar strategy
of nutritional intervention should normally be considered (normal feeding,
then oral supplements and finally tube-feeding) although the demands may
be greater. There are a number of observations upon the role of nutritional
deficiencies and pressure ulcer healing that can be extracted from controlled
trials – protein and calorie supplementation, along with the use
of arginine, vitamins and trace elements with antioxidant effects appear
to have a positive effect on healing (Recommendation 1, B; Benati et al.,
2001, Bourdel-Marchasson et al., 2000, Breslow et al., 1993, Chernoff
et al., 1990, Delmi et al., 1990). The evidence for the value of ascorbic
acid supplementation is equivocal (Recommendation 1, B; Taylor et al.,
1974, ter Riet et al., 1995), and the evidence for zinc supplementation
is weak (Recommendation 1, B; Norris 1971).
Specific issues may need to be resolved if normal feeding is to be enhanced
– for example control of wound odour, altered body image, pain associated
with the pressure ulcer and loss of self-esteem because these issues can
reduce nutritional intake.
Where individual patients present with severe pressure ulcers (Grades
3 and 4) then the multidisciplinary team should consider their basal energy
expenditure and pay particular attention to the increased fluid loss through
such wounds.
The nutritional requirements of specific groups may be different from
those outlined in these guidelines, for example the spinal cord injured.
Nutritional assessment and intervention should of course be combined with
all other appropriate interventions including pressure management.
These guidelines have not addressed several specific issues – nutritional
assessment and intervention in neonates and paediatrics, the role of parenteral
nutrition and specific needs of individual patient groups such as the
immuno-suppressed, those with cancers, orthopaedic, trauma and surgical
patients and those who have experienced burns. Pharmacological interventions
such as the use of anabolic steroids also are not included.
In all of the preceding recommendations regarding nutritional assessment
and supplementation all decisions should be taken with regard to patient
choice and in light of the overall goals of treatment.
Education:
There is a requirement for all staff (including but not limited to health
professionals, untrained staff, catering and porters) to be aware of the
importance of nutrition and to understand their role in improving the
nutritional status of patients. This education will range from the performance
of nutritional screening and assessment, the preparation of attractive,
appetizing meals and the delivery and presentation of meals dependent
upon the needs of individual staff members. There is a need to establish
a nutritional culture within healthcare prompting the appropriate availability
and presentation of meals through to continuity of nutritional care across
departments and care settings.
Summary of Recommendations:
The EPUAP recommends that as a minimum, assessment of nutritional status
should include regular weighing of patients, skin assessment, documentation
of food and fluid intake. Additional procedures including anthropometric
measurements and laboratory tests may also be performed although these
may best be viewed as more advanced assessment techniques. Nutritional
intervention should focus upon improving the individual’s intake
of food and fluids – through consideration of the quality of what
is offered along with removing physical or social barriers to its consumption.
Nutritional supplementation may be considered where it is not possible
to enhance the individual’s own consumption of food and fluids.
References used in the Development of this
Guideline:
American Society for Parenteral and Enteral Nutrition Board of Directors.
Definition of terms used in ASPEN guidelines and standards. JPEN 1995;
19: 1–2.
Benati G, Delvecchio S, Cilla D, & Pedone V. Impact on pressure ulcer
healing of an arginine enriched nutritional solution in patients with
severe cognitive impairment. Arch Gerontol Geriatr, 2001, 33 Suppl 1,
43–47.
Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon
N, Emeriau JP, Manciet G, & Dartigues JF. A multicenter trial of the
effects of oral nutritional supplementation in critically ill older inpatients.
GAGE Group. Groupe Aquitain Geriatrique d’Evaluation. Nutrition,
2000, 16(1), 1–5.
Breslow RA, Hallfrisch J, Guy DG, Crawley B, & Goldberg AP. The importance
of dietary protein in healing pressure ulcers. J Am Geriatr Soc, 1993,
41(4), 357–362.
Chernoff RS, Milton KY, & Lipschitz DA. The effect of a very high
protein liquid formula on decubitus ulcers healing in longterm tubefed
institutionalised patients. J Am Diet Assoc,1990, 90, A–130.
Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, & Bonjour JP. Dietary
supplementation in elderly patients with fractured neck of the femur.
Lancet, 1990, 335(8696), 1013–1016.
Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson
RA, Jeejeebhoy KN. What is subjective global assessment of nutritional
status? J. Parenter. Enteral Nutr., 1987, 11: 8–13
Gray-Donald K, Payette H, Boutier V. Randomized clinical trial of nutritional
supplementation shows little effect on nutritional status among free-living
frail elderly. J Nutr., 1995; 125(12): 2965–71
Green CJ. Existence, causes and consequences of disease related malnutrition
in the hospital and the community, and clinical and financial benefits
of nutritional intervention. Clinical Nutrition 1999; 18(Supp 2):3–28.
Keele AM, Bray MJ, Emery PW et al. Two phase randomized controlled clinical
trial of postoperative oral dietary supplements in surgical patients.
Gut 1997; 40: 393–399.
Lipschitz DA, Mitchell CO, Steele RW et al. Nutritional evaluation and
supplementation of elderly subjects participating in a ‘meals on
wheels’ program. JPEN 1985; 9: 343–7
Mathus-Vliegen EMH. Nutritional status, Nutrition and Pressure Ulcers.
Nutrition in Clinical Practice 2001; 16: 286–291.
Norris JR & Reynolds RE. The effect of oral zinc sulfate therapy on
decubitus ulcers. J Am Geriatr Soc, 1971, 19, 793–797.
Robinson G, Goldstein M, Levine GM. Impact of nutritional status on DRG
length stay. JPEN 1987; 11: 49–52
Taylor TV, Rimmer S, Day B, Butcher J, & Dymock IW. Ascorbic acid
supplementation in the treatment of pressuresores. Lancet, 1974, 2(7880),
544–546.
ter Riet G, Kessels AG, & Knipschild PG. Randomized clinical trial
of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol,
1995, 48(12), 1453–1460.
The EPUAP would suggest that a sound starting point
for further exploration of the links between nutrition and pressure ulcers
would be the publication:
Mathus-Vliegen EMH. Nutritional status, Nutrition and Pressure Ulcers.
Nutrition in Clinical Practice 2001; 16: 286–291.
Draft prepared by Michael Clark
on behalf of the Guideline Development Group
13 May 2003
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