Pressure Ulcers
Manual of Clinical Nutrition Management III- 108 Copyright © 2013 Compass Group, Inc.
A daily multiple vitamin and mineral supplement meeting 100% of the Recommended Daily
Allowances (RDAs) (Dietary Reference Intakes [DRIs]) is given if energy intake is substantially
below the required level, or if vitamin or mineral deficiencies are confirmed by laboratory
assessment (2,6). Supplementation should not be greater than 10 times the RDAs (DRIs) for water-
soluble vitamins (2). However, this recommendation should be reevaluated in light of the most
recent DRIs, in which the Tolerable Upper Intake Levels for vitamins are often much less than 10
times the RDA (6). For patients with renal failure, current guidelines recommend giving no more
than 60 to 100 mg of vitamin C per day due to the risk of renal oxalate stone formation (3).Special Considerations
Vitamins: All vitamins are essential in wound healing; however, vitamins A, E, C, and K (especially vitamins C
and A) have been given the most attention (6). Limited research is available to validate the roles of specific
vitamins in wound healing. Although the research may show that increased vitamin intake improves blood
assay results, there is no evidence that vitamins directly impact pressure ulcer healing rates (13). Studies
demonstrate that a lack of adequate energy and protein intake places the patient at the greatest risk of
pressure ulcer development (6).
Trace minerals: The trace elements present in the body, zinc, copper, and iron, have the closest relationship
to wound healing (6,13). However, studies have not demonstrated a significant improvement in pressure ulcer
healing with routine zinc supplementation (14,15). No studies have shown improvement in wound healing
after the administration of zinc to patients who are not zinc deficient (6). The European Pressure Ulcer
Advisory Panel has also concluded that there is no evidence to recommend zinc supplementation for patients
with pressure ulcers (7). If a zinc deficiency is confirmed or suspected, zinc supplementation is warranted (6).
The Tolerable Upper Intake Level of zinc for healthy adults is 40 mg/day (6). Clinicians should be aware of
adverse side effects of zinc supplementation, including an adverse effect on copper and calcium status,
compromised immune responses, and gastrointestinal effects (eg, nausea, vomiting, and diarrhea) (3,6). To
minimize the risk of adverse effects, zinc supplementation should not be given longer than 2 to 3 weeks (3,6).
Although low serum zinc concentrations have been associated with impaired healing and alterations in
immune function (13,14), serum zinc levels decrease with inflammation and may not accurately represent the
total level of zinc in the body (6,16).
Although vitamin C and zinc may play a role in wound healing, the adequacy of total energy, protein, and
fluid to maintain nutritional status remains the most relevant dietary approach to the prevention and healing
of pressure ulcers (3,6). Thompson and Fuhrman’s in-depth review of the literature on nutrients and wound
healing is recommended for further information (17). Table III- 28 lists guidelines for supplementation if a
deficiency is suspected or confirmed.
Table III- 28 : Guidelines for Vitamin C and Zinc Supplementation (3)
Pressure Ulcer
Stage
Vitamin Ca^ Zincb^Stages I and II 100 to 200 mg/day 15 mg elemental zinc per day (or RDA); if
deficiency is suspected, supplement with up to
50 mg/day for no longer than 10 to 14 days.
Stages III and IV Up to 1,000 to 2,000 mg/day in
divided doses for stressed
patients or patients at risk for
deficiency; reassess after 10
to 14 days.
25 to 30 mg elemental zinc per day for patients at
risk for marginal zinc status; reassess after 10
to 14 days; ongoing losses may warrant longer
supplementation.aSome references suggest high-dose vitamin C supplementation is warranted in conditions such as acute stress, smoking, and
malnutrition to ensure adequate tissue stores for wound healing. These data have not been validated. Note that the Tolerable Upper
Intake Level is 2,000 mg/day. There is an increased risk of oxalate stone formation when excessive vitamin C is given to patients with
chronic renal failure. Therefore, doses > 500 mg/day should be reviewed by a nephrologist (3).
bA 220-mg dose of zinc sulfate is equivalent to 50 mg of elemental zinc (a common oral supplement dosage). Continued zinc
supplementation may be warranted with chronic losses (eg, high-volume fistula, ileostomy, or diarrhea losses). In some cases, the
recommended supplementation may exceed the Tolerable Upper Intake Limit of 40 mg/day (3). Parenteral requirements are
significantly less than oral or enteral requirements because of the different absorption rates (3).
Medical nutrition supplements and enteral feedings: If the patient consistently consumes less than 50%
of the estimated energy and protein needs, the need for oral supplementation or enteral nutrition support
should be evaluated (3,6). The use of food alone has shown to be ineffective in improving pressure ulcers (6).