by Nancy Munoz, DCN, MHA, RDN, FAND

The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure injury as localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury can manifest as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure, occasionally in combination with shear.

The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and the condition of the soft tissue.¹ Pathophysiologic and intrinsic factors at the core of pressure injury development include nutrition. Maintaining adequate nutrition is considered a best practice for both the prevention and treatment of pressure injuries. Individuals with or at risk for developing pressure injuries should strive to achieve or maintain adequate nutrition parameters. When we think of nutrients needed by those with or at risk for developing pressure injuries, most often we think of protein. Instinctively, we all want to ensure that these patients receive sufficient protein. Although this is correct, other factors should also be considered to provide care adequately. To ensure that the additional protein being provided is spared to promote tissue healing, the total energy needs of the patients must be met. With decreased energy intake, there is decreased nitrogen balance.

Nutrition Factors to Consider for At-Risk Patients

Protein and Wound Healing

Consuming an adequate amount of protein is an important component in the prevention and treatment of pressure injuries. In the human body, proteins are vital to repair damaged tissues. They are essential components of enzymes and are needed for endless chemical reactions. Proteins are also components of hormones for chemical messaging; they serve as buffers to regulate acid-base balance, act as antibodies for the immune system, and serve as transporters of substances in the blood. Proteins play a role in the activation of macrophages and are necessary for the phagocytosis of dead cells and antimicrobial activity in the inflammation phase of wound healing.

They are essential for the production of antigen-specific cytotoxic T lymphocytes and the release of cytokines such as growth factors. This leads to a response in other cells that are all necessary to wound healing. Decreased protein levels contribute to a decrease in collagen formation, thereby slowing the wound healing process. Adequate protein levels can help achieve optimal wound healing rates.²

Calories and Wound Healing

The chief sources of energy for the human body are carbohydrates and fats. As such, these two nutrients are also essential energy sources for the wound healing process. During this process, energy is needed for collagen formation. Energy (calorie) needs for wound healing rise as the size and the complexity of the pressure injury increases.³ Both monounsaturated and polyunsaturated fats provide energy for wound healing. Fats are a concentrated source of energy, and they have more energy (9 calories per gram) than carbohydrates (4 calories per gram). It is important to supply the body with a sufficient amount of fats to prevent the body from using protein for energy.² Fats are essential to maintain cell membrane integrity. Consuming adequate amounts of carbohydrates prevents other nutrients, such as protein, from being used as a source of energy. For individuals with diabetes mellitus, the amount, quality, and distribution of carbohydrates provided should be monitored.

Energy Deficit and Wound Healing

Pressure injuries can initiate a hypermetabolic and catabolic state in the body. When this happens, the individual’s nutritional needs are drastically increased. To promote wound healing, both the energy and protein stores must be adequate in the body. Increased energy supports anabolism, whereas increased protein in the presence of sufficient energy stimulates protein synthesis to repair the catabolism taking place. The goal is to produce net anabolism and catabolism to promote wound healing. Comorbidities, such as protein-calorie malnutrition, promote a decrease in lean body mass or protein stores. Deficit in protein stores can halt the pressure injury healing process.⁴ We need to screen newly admitted patients to identify both those at risk for malnutrition and those already in a state of malnutrition. Patients with a history of energy deficit as part of their normal eating pattern will need timely interventions.

Obese Patients

With obese patients, we need to look at their overall condition. Overnutrition can be a form of malnutrition. We often think it is acceptable for our obese patients to miss a meal or two. For these patients, we must also ensure that sufficient energy is provided to promote positive nitrogen balance for protein to be spared for tissue healing.

Nutritional Implications for Practice

For individuals identified at risk for developing pressure injuries or those with an actual pressure injury, the first priority should be to promote the intake of sufficient calories from a balanced diet of nutritious foods. A balanced meal pattern should include foods from all MyPlate food groups. Optimum amounts of protein, evenly distributed throughout the day, should be encouraged. This recommendation can be implemented by encouraging patients to consume 20 to 30 grams of protein per meal and 10 to 15 grams of protein at each snack.

References

1. National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. 2016. http://www.npuap.org/resources/educational-and-clinical-resources/npuap…. Accessed February 21, 2018.

2. 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):357–62.

3. Williams JZ, Barbul A. Nutrition and wound healing. Surgl Clin North Am. 2003;83(3):571–96.

4. Demling RH. Nutrition, anabolism, and the wound healing process: an overview. Eplasty. 2009;9:e9.

About the Author

Dr. Nancy Munoz is the Assistant Chief for Nutrition and Food Service for the Southern Nevada VA Healthcare System. Teaching healthcare practitioners the role of nutrition as a modifiable risk in the development of pressure ulcers is at the core of her practice. Dr. Munoz has authored and served as expert reviewer for books and manuscripts for numerous professional publications, and the Academy of Nutrition Evidence Analysis Library. She currently serves as the Professional Development Chair for the Dietetics in Healthcare Communities DPG, is a member of the Academy’s Positions Committe and the WoundSource editorial advisory board, and is the current Vice President for the National Pressure Ulcer Advisory Panel.