Pressure UlcersManual of Clinical Nutrition Management III- 107 Copyright © 2013 Compass Group, Inc.
conditions that place a patient at risk for the development of pressure ulcers include: diabetes mellitus;
obesity; chronic obstructive pulmonary disease; sepsis; chronic or end-stage renal, liver, or heart disease;
diseases related to immunosuppression; hip fractures; and spinal cord injury. Medical treatments and
medications that may contribute to the risk of pressure ulcer development include antikinetic drugs (eg,
antidepressants and sleeping pills), immunosuppressive drugs, steroids, radiation, chemotherapy, and renal
dialysis. Malnutrition, dehydration, or unintentional weight loss (greater than 5% in 1 month, 7.5% in 3
months, or 10% in 6 months), whether secondary to poor appetite or another disease process, places the
client at risk of tissue breakdown and poor healing (4).
Patients with risk factors for pressure ulcer development should receive a complete nutrition assessment
and care plan designed to address each nutrition problem area that is identified (2). It is important to identify
and assess patients who are at risk of developing pressure ulcers. Assessment of pressure ulcer risk should
be documented with a validated tool, such as the Braden scale (2-5). Patients who are identified to be at risk
should be monitored at regular intervals in a preventive program when appropriate. Monitoring may include
a systematic skin inspection at least daily (paying particular attention to the bony prominences), daily
physical activity or a mobility program (1), and routine evaluation of nutritional and hydration status
according to the organization’s protocols. National guidelines have been established to address the issue of
pressure ulcers and the best practice guidelines for care (2).
Nutrition Intervention
Patients who require treatment of pressure ulcers should receive adequate nutrition, including energy,
protein, fluids, and vitamins and minerals (1,2). The assessment should include a review of the exudate losses
from wounds, in consideration of fluid and protein losses. The following guidelines will usually meet the
patient’s needs (2):
Provide a well-balanced diet adequate in energy, high–biological value protein, and fluid as well as
vitamins and minerals to meet the estimated requirements. The goal is to maintain or regain lost
weight (1). In general, the patient should be on the least restricted diet possible (1).
The energy requirement for wound healing is not known. Recommendations must be individualized
with the goal to provide adequate energy for anabolism and collagen synthesis (6). Adequate energy
intake should be determined by using the appropriate prediction equation as outlined in Section II:
“Estimation of Energy Expenditures”. The general recommendation for people with pressure ulcers is 30
to 35 kcal/kg (1,6-8). In the National Pressure Ulcer Long-Term Care Study, adequate nutrition support at
30 kcal/kg of actual body weight per day was a strong predictor of stage III and IV pressure ulcer healing
(9). The NPUAP recommends increasing the energy level to 35 to 40 kcal/kg per day for people who are
underweight or losing weight (1,6). A recent meta-analysis suggests using the Harris-Benedict equation
multiplying with a correction factor of 1.1 to accurately assess energy needs in patients with pressure
ulcers (10). The analysis found that energy intake of 30 kcal/kg/day is appropriate to cover the daily
requirements of patients with pressure ulcers (10). When available, indirect calorimetry is recommended
to more closely identify the individual energy needs of patients who fail to achieve anabolism; exhibit
delayed wound healing; require more energy to assist in healing larger or multiple wounds; or need a
more aggressive approach to the nutrition care plan (3).
Provide adequate protein for a positive nitrogen balance. Adequate protein is essential in all stages
of wound healing; but, without adequate energy intake, the protein will be used as an energy source
(6). Daily protein intake of 1.25 to 1.5 g/kg of actual body weight from food sources of high–
biological value protein (1) is the most commonly cited recommendation in the literature (1,6) The
European Pressure Ulcer Advisory Panel recommends 1.0 to 1.5 g/kg per day (6,7). Excess dietary
protein in amounts greater than 1.5 to 2.0 g/kg per day can be a risk factor for dehydration,
especially in the elderly (6,8,11).
Provide adequate fluid intake each day to keep the patient well hydrated and prevent dehydration
(6). The optimal fluid intake is 30 to 35 mL/kg of actual body weight or a minimum of 1,500 mL/day
(2,6). It is often difficult to meet fluid needs when fluids are only provided with meals. Ensure
supplementary fluids are provided to meet fluid needs. Patients who are on thickened liquid meal
plans should be carefully monitored and supplemented with fluids as needed (6). In addition,
patients who are medically managed on air-fluidized beds may be at greater risk for dehydration
and should be evaluated for greater fluid needs. Patients who require air-fluidized beds set at a high
temperature will need additional fluids, estimated to be approximately 10 to 15 mL/kg because of
an increase in insensible water loss (6,11,12). Refer to “Nutrition Management of Fluid Intake and
Hydration” in Section IA for guidelines on fluid requirements for patients being treated on an air-
fluidized bed.