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09th February 2018

EAT for Pressure Ulcers – Evidence, Assessment, Take Action

Nutrition and hydration play a key role in keeping the skin healthy. NHS Improvement, as part of part of the Stop the Pressure programme to reduce pressure ulcers earlier this year, published an improvement guide resource that draws our attention to the importance of nutrition and hydration in the prevention of pressure ulcers. (https://improvement.nhs.uk/resources/nutrition-and-hydration)

Evidence

Many nutritional risk factors have been identified in the development of pressure ulcers including:

  • Being both underweight or obese
  • Nutritional deficiencies (including inadequate energy (calories), protein, fluid/water and vitamins and minerals)
  • An impaired ability to eat independently such as individuals who need help with meals who, for example, are unable to cut up their own food, need prompting and encouragement with eating along with those who need to be fed.

Assessment

The National Institute for Health and Care Excellence (NICE) recognises deficiencies in diet as a risk for developing pressure ulcers,  and guidelines recommend using a nutritional screening tool to assess the risk of malnutrition and other risk factors. Of course, nutrition assessment and screening should be an integral part of all care home policy but this is also of particular importance in pressure ulcer risk assessment and screening. Early identification and treatment of individuals who are malnourished, or at risk of it, are vital in preventing the development of pressure ulcers and promoting wound healing.

Take Action

But it’s not just screening that is important – action is key. An individualised care plan involving the service user, where possible, should be commenced that provides food, fluid and assistance to best meet each individual’s needs. Such a care plan should be reassessed and reviewed, i.e. monitored and evaluated regularly so the intervention can be revised as required –and, if no improvement is observed, referring to a dietitian according to the local care pathway should be considered.

Five Top Tips

NHS Improvement has also produced 5 top tips. These are to:

Ensure a healthy, balanced diet and adequate energy is provided to help prevent skin breakdown and improve healing rates

In general, this would involve starchy foods (bread, rice, pasta, potatoes, grains, cereals) as the base for each meal. It is also important to ensure adequate protein (meat, fish, eggs, beans, pulses, dairy, soy) at each meal and to serve foods that are rich in vitamins and minerals, including plenty of fruit and veg.

Stay hydrated to maintain skin health

UK recommendations are to drink around 6 to 8 drinks a day – this can include water, tea, coffee, milk and juice. Fluid can also be obtained through foods, so the inclusion of foods like soup, cereal with milk, custard and fruit helps fluid intake.

Serve little and often for service users with poor appetite

Try small meals and snacks that have a high energy and protein density (for example snacks such as cheese and biscuits, whole milk yogurts/rice pudding milky drinks) throughout the day to help ensure enough calories have been served.

Support independence with eating

This may be helped with adapted crockery or cutlery and provided assistance when needed, whether in the form of prompting, encouragement or feeding.

Obesity

Although we more frequently discuss the risk of malnutrition in relation to health outcomes in care home populations, it is important to remember that being obese can also be a risk factor for pressure ulcers. Following a healthy diet for those who are overweight can include using lower fat dairy products and avoiding deep fried and high sugar foods like biscuits, cakes, chocolate, sweets and fizzy drinks, and watching portion sizes.

A case study

NHS Improvement has also provided some interesting case studies in this area. One in a care home particularly highlights the importance of individual care plans.

The Issue

  • This concerned an 80-year old service user in residential care with a grade 3 chronic pressure sore
  • The service user was bedbound but could eat independently although staff were giving her a pureed diet because she could be drowsy at times and it was easier to eat
  • On nutrition assessment, the lady had a weight in the normal BMI range and although she had lost weight it was around 3% in 3-6 months and so the MUST score was 0, and a referral for any further assessment was not successfully implemented
  • However, the longstanding pressure sore meant that, although delayed, she was eventually seen by community dietetic services.

The Solution

  • A ‘food first ‘ approach was taken
    • Hydration needs were assessed at around 1.7 litres/day
    • Fortified foods and snacks were provided including 200ml fortified milk at each meal and snacks such as yogurts and rice pudding as well as fortified meals
  • Telephone reviews every six weeks were put in place to ensure acceptability of the care plan
  • From dressing the wound every 2 days before the care plan, after the first 6 weeks district nursing staff changed the dressing every 4-5 days, and after the second 6 weeks the wound was classified as Grade 1, and nursing staff attended just once a week to monitor it
  • The plan continued with the fortified diet, but with provision to introduce more normal textured snacks and to continue to meet hydration targets. 

The Impact

This case study led to the development of new policies for the care home with regards pressure sores. Firstly, it led to more recognition from staff as to the importance of nutrition and hydration in optimising wound healing. It also resulted in all service users on modified texture diets having a fortified diet. In addition, a care plan was developed by management so that, for service users with grades 1 and 2 pressure sores, a  food first approach should be commenced, and, with grades 3 and 4, an urgent referral to dietetics made in addition to a food first approach.

Maybe you would like to consider whether your staff need a little more training on nutrition and wound care?

*All information is correct at the time of publishing

Ayela Spiro

Nutrition Science Manager, British Nutrition Foundation

Ayela is a nutrition scientist at the British Nutrition Foundation, where her role involves providing expert advice on nutrition and health issues to a number of key audiences including consumers, health professionals, charities, the media and the food industry. At the heart of her work is the communication of nutrition science that promotes understanding of nutrition and health and contributes to the improved wellbeing of all. Read more

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