“Defendants failed to provide adequate nutrition to prevent plaintiff from suffering severe malnutrition and weight loss. This allowed the development of a severe pressure ulcer, numerous infections, and dehydration and malnutrition. Had defendants provided proper care, the pressure ulcer, infections, and malnutrition and dehydration would not have occurred.”

Introduction

The following is a wrap up of the 2019 pressure injury guidelines of the National Pressure Injury Advisory Panel (NPIAP)¹ related to nutrition, of which there are 15. For guidelines #1 to #10, see my last few blogs (Parts 1, 2, 3 of this blog series).

NPIAP Guidelines #11 and #12: Enteral and Parenteral Feeding

These guidelines are all new. The 2014 guidelines did not address tube feeding!

#11: “Discuss the benefits and harms of enteral or parenteral feeding to SUPPORT OVERALL HEALTH in light of preferences and goals of care for individuals AT RISK of PRESSURE INJURIES who cannot meet their nutritional requirements through oral intake despite interventions.”

#12: “Discuss the benefits and harms of enteral or parenteral feeding to SUPPORT PRESSURE INJURY TREATMENT in light of preferences and goals of care for individuals WITH PRESSURE INJURIES who cannot meet their nutritional requirements through oral intake despite nutritional interventions.” It is important to pay attention to the “preferences and goals” part of this statement. Tube feeding becomes a benefit versus risk consideration, requiring great patient and family communication and education, based on patient goals at the time. Tube feeding is not always a good option for nutritionally compromised patients. This issue with tube feeding will be discussed in a later blog.

NPIAP Guideline #13: Hydration

“Provide and encourage adequate water/fluid intake for hydration for an individual with or at risk of a Pressure Injury, when compatible with goals of care and clinical condition.”

Dehydration is invariably a part of pressure injury lawsuits if malnutrition is alleged (which, let’s face it, it always is). Water is needed to transport nutrients and oxygen through the body and to eliminate waste products.² As wound practitioners, we know that skin with poor turgor and dryness is a risk factor for pressure injury development. Evidence-based guidelines recommend that individualized water requirements be calculated as 1 mL/kcal/day.¹ This is easy to calculate: the calculation should equal the number of calories; so, if 1,800 calories per day are needed, you are going to provide 1,800 mL per day. And as always, this should be individualized based on their needs and status, with special attention to those who may have fluid restrictions. Also, don’t forget to provide additional fluids for febrile patients or for those who are vomiting, have diaphoresis or diarrhea, or have heavily exudating wounds. Their hydration needs will rise.

NPIAP Guidelines #14 and #15: Nutrition Management in Neonates and Children

Guidelines related to neonates and children appear also for the first time in this edition of the NPIAP guidelines.

#14: “Conduct an age-appropriate nutritional screening and assessment for neonates and children at risk of pressure injuries, using a simple, valid, and reliable nutritional screening tool appropriate for the child population group.” Several of these tools are listed in the guidelines.

#15: “For neonates and children with or at risk of PIs [pressure injuries] who have inadequate oral intake, consider fortified foods, age-appropriate nutritional supplements, or enteral or parenteral nutrition support.”

Both recommendations are listed as Good Practice Statements (GPS) only; strong evidence in terms of research is sadly lacking. Further statements in the guideline include the fact that oral intake should be sufficient to prevent weight loss and complications associated with nitrogen wasting (I would think it also should be sufficient to support growth), that increases in protein and micronutrients might be appropriate if wound healing does not progress on the expected trajectory, and that enteral or parenteral nutrition should be commenced when consistent with the care goals. Check out the full guidelines for further recommendations and sources.

Conclusion

Those are the 15 nutritional guidelines from the 2019 NPIAP pressure injury guidelines. For more details and sources, I strongly recommend purchasing the full-length guidelines. They are the basis of standards of care, which must be met to defend pressure injury cases effectively.

Next Up The next blog will contain further discussion about the risk versus benefits of tube feeding in adults, as well as laboratory values in malnutrition.

References

1. National Pressure Injury Advisory Panel. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. 2019. www.npiap.com
2. Stotts NA, Hopf HW. The link between tissue oxygen and hydration in nursing home residents with pressure ulcers: preliminary data. J Wound Ostomy Continence Nurs. 2003;30:184-190.