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Clinical Management Extra

The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations Nancy Munoz, DNC, MHA, RDN, FAND, Lecturer, University of Massachusetts Amherst, Amherst, Massachusetts, Assistant Chief, Nutrition and Food Service, VA Southern Nevada Healthcare System, Las Vegas, Nevada, Director, National Pressure Injury Advisory Panel Mary Ellen Posthauer, RDN, LD, FAND, President, MEP Healthcare Dietary Services, Inc, Evansville, Indiana, Past President, National Pressure Injury Advisory Panel Emanuele Cereda, MD, PhD, Physician and Research Scientist, Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Jos M. G. A. Schols, MD, PhD, Professor of Old Age Medicine, Department of Family Medicine, Maastricht University, Limburg, the Netherlands Emily Haesler, PhD, BN, P Grad Dip Adv Nurs, Associate Professor, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Australia

C M E 1 AMA PRA

Category 1 CreditTM

ANCC 2.0 Contact Hours

Acknowledgments: Dr M that developed the nutritio article reports. The authors including spouses/partners in, any commercial compan

To earn CME credit, you mu for physicians on February 2 nurses. Complete CE/CME

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GENERAL PURPOSE: To review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline with further discussion of nutrition for pressure injury management in the context of the recommendations. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to: 1. Distinguish nutrition and malnutrition, especially as they relate to the development and healing of pressure injuries. 2. Differentiate the tools and techniques that help clinicians assess nutrition status as well as the causes of pressure injuries in specific populations. 3. Identify interventions for improving nutrition status and promoting pressure injury healing.

ABSTRACT Macro- and micronutrients are required by each organ system in specific amounts to promote the growth, development, maintenance, and repair of body tissues. Specifically, nutrition plays an important role in the prevention and treatment of pressure injuries. The purpose of this manuscript is to review the nutrition-related recommendations presented in the 2019 European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Nutrition for pressure injury management is discussed in the context of the recommendations. KEYWORDS: assessment, clinical practice guidelines, evidence, malnutrition, nutrition, pressure injury, screening

ADV SKIN WOUND CARE 2020;33:123–36.

DOI: 10.1097/01.ASW.0000653144.90739.ad

unoz has disclosed that she is a member of the Board of Director n recommendations for the clinical practice guideline. Dr Haesler thank the other members of the nutrition work group: Merrilyn B (if any), in any position to control the content of this CME/CNE ac ies relevant to this educational activity.

st read the CME article and complete the quiz online, answering 8, 2022, and for nurses March 4, 2022. All tests are now online o information is on the last page of this article.

123

Copyright © 2020 Wolters Kluwer

INTRODUCTION Nutrition plays an important role in the prevention and treatment of pressure injuries (PIs). Macro- and micro- nutrients are required by each organ system in specific amounts to promote growth, development, maintenance, and repair of body tissues. The 2019 European Pressure Ul- cerAdvisory Panel (EPUAP), National Pressure Injury Advi- sory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (EPUAP/NPIAP/PPPIA CPG) provides guidance on the prevention and management of PIs.1 This guideline was a collaboration between the EPUAP, NPIAP, and PPPIA with the assistance of 14 associate orga- nizations. The goal of this international collaboration was to provide an updated, comprehensive review of the research literature and develop recommendations reflecting recent evidence. The intent is for health profes- sionals around the world to use the recommendations generated to prevent and treat PI.

s for the National Pressure Injury Advisory Panel and the cochair of the small work group has disclosed that she is the consultant methodologist for the guideline on which this anks, Angela Liew, and Siriluck Sirlpanyawat. The authors, faculty, staff, and planners, tivity have disclosed that they have no financial relationships with, or financial interests

at least 14 of the 20 questions correctly. This continuing educational activity will expire nly; take the test at http://cme.lww.com for physicians and www.nursingcenter.com for

ADVANCES IN SKIN & WOUND CARE • MARCH 2020

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The purpose of this article is to review the nutrition-related recommendations presented in the EPUAP/NPIAP/PPPIA CPG, and to discuss nutrition for PI management in the con- text of the recommendations. The recommendations were developed using a rigorous methodology outlined in the guideline in print and online (internationalguideline. com). Each recommendation includes a list of implemen- tation considerations. Table 1 presents the nutrition-related recommendations from the EPUAP/NPIAP/PPPIA CPG, including the strengths of evidence and assigned

Table 1. 2019 INTERNATIONAL GUIDELINE NUTRITION RECOM The strength of evidence (SoE) ratings used in this table are defined as follows: B1, lev high or moderate quality providing directevidence, and/or most studies have consisten providing direct evidence, level 3 or 4 studies (regardless of quality) providing direct ev explained; C, level 5 studies (indirect evidence) and/or body of evidence with inconsist Statements (GPSs; statements that are not supported by a body of evidence but consid strength of recommendation (SoR) ratings are as follows: ↑↑, strong positive recomm

No.a Recommendation 1.10 Consider the impact of impaired nutritional status on the risk of pressu 4.1 Conduct nutritional screening for individuals at risk of a pressure injury 4.2 Conduct a comprehensive nutrition assessment for adults at risk of a p

malnutrition and for all adults with a pressure injury. 4.3 Develop and implement an individualized nutrition care plan for individ

malnourished or who are at risk of malnutrition. 4.4 Optimize energy intake for individuals at risk of pressure injuries who 4.5 Adjust protein intake for individuals at risk of pressure injuries who are 4.6 Provide 30 to 35 kcalories/kg body weight/day for adults with a pressu

malnutrition. 4.7 Provide 1.25 to 1.5 g protein/kg body weight/day for adults with a pre

malnutrition. 4.8 Offer high-calorie, high-protein fortified foods and/or nutritional supplem

at risk of developing a pressure injury and who are also malnourished cannot be achieved by normal dietary intake.

4.9 Offer high calorie, high protein nutritional supplements in addition to the malnourished or at risk of malnutrition, if nutritional requirements cann

4.10 Provide high-calorie, high-protein, arginine, zinc and antioxidant oral nu with a Category/Stage II or greater pressure injury who are malnourish

4.11 Discuss the benefits and harms of enteral or parenteral feeding to suppo care with individuals at risk of pressure injuries who cannot meet their nutritional interventions.

4.12 Discuss the benefits and harms of enteral or parenteral feeding to supp and goals of care for individuals with pressure injuries who cannot me despite nutritional interventions.

4.13 Provide and encourage adequate water/fluid intake for hydration for an i and clinical conditions.

4.14 Conduct age appropriate nutritional screening and assessment for neo 4.15 For neonates and children with or at risk of pressure injuries who have

appropriate nutritional supplements, or enteral or parenteral nutritional 22.2 Provide pressure injury education, skills training and psychosocial suppo aFor ease of reference, the recommendation number published in the Clinical Practice Guideline has bAs published in the Clinical Practice Guideline. Adapted with permission from the European Pressure Ulcer Advisory Panel, National Pressure Injury

ADVANCES IN SKIN & WOUND CARE • MARCH 2020 124

Copyright © 2020 Wolters Kluwer H

recommendations. With the recommendations presented in Table 1 in mind, this article will discuss the underpin- ning research and the context in which the recommenda- tions are implemented in the nutritional management of individuals with or at risk of PIs.

NUTRITION AS A RISK FACTOR FOR PRESSURE INJURIES A large body of prognostic research has reported on the influence of impaired nutrition on the risk of PI in adults. As reported in the EPUAP/NPIAP/PPPIA CPG, of 50

MENDATIONS el 1 studies of moderate or low quality providing direct evidence, level 2 studies of toutcomes and inconsistencies can be explained; B2, level 2 studies of low quality idence, and/or most studies have consistent outcomes and inconsistencies can be encies that cannot be explained, reflecting genuine uncertainty; and Good Practice ered by the Guideline Governance Group to be significant for clinical practice). The endation: definitely do it; ↑, weak positive recommendation: probably do it.

SoE, SoR, or GPSb

re injuries. SoE = C; SoR =↑ . SoE = B1; SoR =↑↑ ressure injury who are screened to be at risk of SoE = B2; SoR =↑↑

uals with, or at risk of, a pressure injury who are SoE = B2; SoR = ↑↑

are malnourished or at risk of malnutrition. SoE = B2; SoR = ↑ malnourished or at risk of malnutrition. GPS re injury who are malnourished or at risk of SoE = B1; SoR = ↑

ssure injury who are malnourished or at risk of SoE = B1; SoR =↑↑

ents in addition to the usual diet for adults who are or at risk of malnutrition, if nutritional requirements

SoE = C; SoR = ↑

usual diet for adults with a pressure injury who are ot be achieved by normal dietary intake.

SoE = B1; SoR = ↑↑

tritional supplements or enteral formula for adults ed or at risk of malnutrition.

SoE = B1; SoR = ↑

rt overall health in light of preferences and goals of nutritional requirements through oral intake despite

GPS

ort pressure injury treatment in light of preferences et their nutritional requirements through oral intake

SoE = B1; SoR = ↑

ndividual injury, when compatible with goals of care GPS

nates and children at risk of pressure injuries. GPS inadequate oral intake, consider fortified foods, age support.

GPS

rt to individuals with or at risk of pressure injuries. SoE = C; SoR = ↑

been used.

Advisory Panel, and Pan Pacific Pressure Injury Alliance.

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prognostic studies reporting multivariable analyses that in- cluded at least one measure of nutrition status, 40% identi- fied a measure of nutrition as a significant predictor of PIs. This suggests there is a moderate statistical association be- tween nutrition status and developing a PI. The EPUAP/ NPIAP/PPPIA CPG recommends providers consider the impact of impaired nutrition status on the risk of PI (Table 1).1 Impaired nutrition has not been included in pe- diatric PI risk factor studies to date; however, it is reason- able to assume that this guideline recommendation is also relevant to neonates and children. The research on PI risk factors reports a wide selection of

measures that can be used to identify impaired nutrition, in- cluding food intake, a medical diagnosis of malnutrition, skin fold thickness, arm circumference, weight, body mass index (BMI), nutrition assessment scales, and so on. Some of these measures are included in nutrition screening tools and have been validated as predictors of impaired nutrition.2–4 However, there is low consistency regard- ing the significance of these outcome measures as posi- tive predictors for PI. For example, “food intake” was reported as significant in only 46.7% of studies that included that measure in a multivariate analysis.5–19 There are nu- merous contextual considerations and limitations to this prognostic research. The variability in research quality, choice of other outcomes, and the number of participants all influence the results. Few studies had an adequate num- ber of participants with extremely low or high weights/ BMIs in the sample. Translating research into clinical practice requires clin-

ical judgment informed by knowledge of the literature.1

When undertaking a PI risk assessment, the use of clini- cal judgment that considers the individual’s overall pre- sentation and the significance of that individual’s nutrition status is required. For example, if an individual presents with other risk factors considered highly pre- dictive of PI risk (eg, immobility), and the individual’s clinical condition is vulnerable, nutrition should be con- sidered when assessing that individual’s PI risk.1,20,21

Nutrition status is included on most of the commonly used PI risk assessment tools, including those for specific populations such as pediatric or critically ill patients.20,22–26

In prognostic studies, nutrition assessment scales were not significantly predictive of PIs. Only one of 16 (6.3%) reported a nutrition assessment scale as a significant factor in a multivariate analysis.18 In that study, data from 170 participants recruited prospectively in a private hos- pital were analyzed. From 16 factors included in the pre- dictive model, five were statistically significant, including scores on the Subjective Global Nutrition Assessment (P < .001).18 However, when used as a part of an overall structured PI risk assessment in conjunction with clinical judgment, findings from a PI risk scale can guide nutri- tion (and other) care planning.

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Copyright © 2020 Wolters Kluwer

Malnutrition Malnutrition involves several disorders that include under- nutrition, obesity, and abnormal micronutrient levels. Other nutrition-related disorders that impact an individual’s nutri- tion status include frailty, sarcopenia, and cachexia, which have multifaceted pathogenic origins.27 The European Soci- ety for Parenteral and Enteral Nutrition (ESPEN) defines malnutrition as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease.”27,28

Several organizations have defined criteria to diagnose malnutrition. Most recently, the Global Leadership Initia- tive on Malnutrition developed criteria to help identify malnutrition in adults in healthcare settings, consisting of three phenotype characteristics (weight loss, low BMI,de- creased muscle mass) and two etiologic characteristics (de- creased food intake or assimilation and disease burden/ inflammation). The presence of one phenotype and one etiologic characteristic is required.29 Table 2 outlines the malnutrition criteria used by different organizations. Malnutrition and PIs. Meeting the body’s nutrition

requirements is essential to promote health and well- being. Although the point at which inadequate nutrient intake affects skin integrity has not been defined, it is known that decreased acceptance of food and fluids/ water and weight loss are associated with PIs. Also, in- sufficient nutrient intake and low body weight are both associated with impaired wound healing.5,30–35

International research suggests there is a relationship be- tween nutrition and PI prevalence. In the US, a study of 2,425 patients concluded that 76% of participants were mal- nourished.36 An Australian study conducted in acute and long-term care settings found that, for adults with malnutri- tion, the odds ratio of developing a PI was 2.6 (95% confi- dence interval [CI], 1.8-3.5) in acute care settings, and 2.0 (95% CI, 1.5-2.7) in long-term care.37 In Japan, a study by Iizaka et al32 examined the impact of nutrition on the devel- opment and severity of PIs in home care. The sample consisted of 290 patients with PIs and 456 patients without. Researchers reported the prevalence of malnutrition was higher in older adults with a PI.32 Similarly, a Belgian study found that the odds ratio of an older adult with a PI being malnourished was 5.02 (95% CI, 1.69-14.92; P < .01).33

Malnutrition is a major health concern in community- dwelling older adults. A meta-analysis analyzing data from 111 studies conducted in 38 countries (n = 69,702) reported that malnutrition ranges from 0.8% in Northern Europe to 24.6% in Southeast Asia. In this systematic re- view, older adults receiving home care had the highest prevalence of malnutrition (14.6%). It was also more prevalent in rural versus urban communities (9.9% and 5.7%, respectively).38

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Table 2. DIAGNOSTIC CHARACTERISTICS FOR MALNUTRITION

Characteristic

ASPEN/Academy of Nutrition and Dietetics ESPEN GLIM

Unintended weight loss

X X

Low body mass index

X X

Loss of muscle mass

X X

Loss of subcutaneous fat

X X

Localized or generalized fluid accumulation

X

Decreased functional status

X

Reduced food intake or assimilation

X X

Disease burden/ inflammation

X

At risk per validated screening tool

X

Two of the six characteristics must be present

Once the person is deemed at risk by a validated screening tool, one of the other two items must be present.

One phenotype and one etiologic characteristic must be present

Abbreviations: ASPEN, American Society for Parenteral and Enteral Nutrition; ESPEN, European Society for Parenteral and Enteral Nutrition; GLIM, Global Leadership Initiative on Malnutrition. Sources: White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Parenter Enteral Nutr 2012;36(3):275-83. Cederholm T, Jensen GL, Correia MITD, et al.29

Undernutrition. Decreased intake of calories, protein, vitamins, and minerals is commonly seen in individuals with malnutrition, which is often associated with under- nutrition. This results in unplanned and undesired weight loss, protein-calorie malnutrition, decreased BMI, reduced muscle mass, and dehydration, all of which are linked to PIs.39,40 Unplanned or involuntary weight loss is consid- ered a major risk factor for both malnutrition and PI development.41

Overnutrition/Obesity. Overnutrition is a form of mal- nutrition in which the amount of nutrients consumed ex- ceeds the amount of nutrients needed to support growth,

ADVANCES IN SKIN & WOUND CARE • MARCH 2020 126

Copyright © 2020 Wolters Kluwer H

development, and metabolism. Overnutrition can result in individuals becoming overweight and obese. In 2013, the American Medical Association acknowledged obesity as a disease that should be medically treated.42

In the US, the rate of obesity has reached epidemic pro- portions. The CDC reported its prevalence was 39.8% in 2015 and 2016.43 Obesity has been linked to health condi- tions such as cardiovasculardisease, diabetes, cancer, hyper- tension, dyslipidemia, respiratory problems, and impaired wound healing.43

Comorbidities such as skin infection, dehiscence, PIs, and venous ulcers are common in obese individuals. These con- ditions occur because of hypoperfusion and ischemia in subcutaneous adipose tissue. Hypovascularity also contrib- utes to the prevalence of PIs in patients who are obese.44 The decreased mobility and difficulty with self-repositioning of- ten associated with individuals who are obese or extremely obese further increase the risk of PI development. Microor- ganisms that are attracted to the moist environment created by skin folds contribute to infections and tissue injuries.44

NUTRITION SCREENING This is defined as “the process of identifying patients, cli- ents, or groups who may have a nutrition diagnosis and benefit from nutrition assessment and intervention by a registered dietitian nutritionist.”45 Recognizing that nu- trition screening helps to identify and treat malnutrition in patients with or at risk for a PI, the EPUAP/NPUAP/ PPPIA CPG recommends it for all individuals at risk of a PI (Table 1). Any member of the interdisciplinary team who has been educated on screening tools can use them, and screening can be conducted in any practice setting.46

A validated screening tool can determine nutrition risk in all types of patients, including those with fluid shifts and for whom weight and height cannot be easily ob- tained.47,48 Validated tools should be quick and easy to use, reliable and valid, economical, of low risk to the in- dividual being screened, and appropriate for the popu- lation and care setting. Nutrition screening and rescreening should be con-

ducted in accordance with the mandates outlined by accrediting bodies and a healthcare facility’s internal policies. In acute care facilities in the, nutrition screening is conducted within 24 hours of admission. Information collected through the screen is used by a registered dietitian nutritionist (RDN) to identify patients whose nutrition concerns warrant further assessment. In long- term postacute care, nutrition screening is completed at regular intervals based on the Minimum Data Set regula- tions. In all care settings, communication with the RDN is essential to determine appropriate intervention(s) and discuss opportunities to improve patient outcomes. Many nutrition risk screening parameters are common in

assigning risk level. These include height and weight,

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unintentional weight changes, changes in intake/appetite, lifestyle habits (physical activity, tobacco use), gastrointesti- nal disorders, and medical history. Laboratory data are not used in traditional nutrition screens, and serum proteins such as albumin and prealbumin are not endorsed for nutrition screening.49 There is no association between in- creased or decreased protein intake and changes in these markers. As a result, nutrition screening or assessment based on serum protein levels is not recommended.46

Nutrition Screening Tools Common nutrition screening instruments include the Mini Nutritional Assessment (MNA), Malnutrition Universal Screening Tool, Nutrition Risk Screening 2002, and the Short Nutritio

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