Chapter 15 Skin Integrity

BOX 15.2 cont. Recommendations from the National Pressure Ulcer Advisory Panel 2014 Guidelines for Prevention and Treatment of Pressure Ulcers Nutrition Screening

Energy Intake

1. Provide individualized energy intake based on underlying medical condition and level of activity. (Strength of Ev- idence = B; Strength of Recommendation = ) 2. Provide 30 to 35 kcalories/kg body weight for adults at risk of a pressure ulcer who are assessed as being at risk of malnutrition. (Strength of Evidence = C; Strength of Recommendation = ) 3. Provide 30 to 35 kcalories/kg body weight for adults with a pressure ulcer who are assessed as being at risk of malnutrition. (Strength of Evidence = B; Strength of Recommendation = ) 4. Adjust energy intake based on weight change or level of obesity. Adults who are underweight or who have had sig- nificant unintended weight loss may need additional energy intake. (Strength of Evidence = C; Strength of Recom- mendation = ) 5. Revise and modify/liberalize dietary restrictions when limitations result in decreased food and fluid intake. These adjustments should be made in consultation with a medical professional and managed by a registered dietitian when- ever possible. (Strength of Evidence = C; Strength of Recommendation = ) Caloric needs are ideally met by a healthy diet; however, some individuals are unable or unwilling to consume an ad- equate diet. Overly restricted diets may make food unpalatable and unappealing and therefore reduce intake.

6. Offer fortified foods and/or high calorie, high protein oral nutritional supplements between meals if nutritional re- quirements cannot be achieved by dietary intake. (Strength of Evidence = B; Strength of Recommendation = ) Oral nutritional supplements (ONS), enhanced foods, and food fortifiers can be used to combat unintended weight loss and malnutrition.

7. Consider enteral or parenteral nutritional support when oral intake is inadequate. This must be consistent with the individual’s goals. (Strength of Evidence = C; Strength of Recommendation = ) If oral intake is inadequate, enteral or parenteral nutrition may be recommended if consistent with the individual’s wishes. Enteral (tube) feeding is the preferred route if the gastrointestinal tract is functioning. The risks and benefits of nutrition support should be discussed with the individual and caregivers early on and should reflect the individu- al’s preferences and goals for care.

Protein Intake

1. Provide adequate protein for positive nitrogen balance for adults assessed to be at risk of a pressure ulcer. (Strength of Evidence = C; Strength of Recommendation = ) 2. Offer 1.25 to 1.5 grams protein/kg body weight daily for adults at risk of a pressure ulcer who are assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes. (Strength of Evidence = C; Strength of Recommendation = ) 3. Provide adequate protein for positive nitrogen balance for adults with a pressure ulcer. (Strength of Evidence = B; Strength of Recommendation = ) 4. Offer 1.25 to 1.5 grams protein/kg body weight daily for adults with an existing pressure ulcer who are assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes. (Strength of Evi- dence = B; Strength of Recommendation = ) 5. Offer high calorie, high protein nutritional supplements in addition to the usual diet to adults with nutritional risk and pressure ulcer risk if nutritional requirements cannot be achieved by dietary intake. (Strength of Evidence = A; Strength of Recommendation = ) 6. Assess renal function to ensure that high levels of protein are appropriate for the individual. (Strength of Evidence = C; Strength of Recommendation = ) Clinical judgment is required to determine the appropriate level of protein for each individual, based on the number of pressure ulcers present, overall nutritional status, comorbidities, and tolerance to nutritional interventions.

7. Supplement with high protein, arginine and micronutrients for adults with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers when nutritional requirements cannot be met with traditional high calorie and protein supplements. (Strength of Evidence = B; Strength of Recommendation = )

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