May 2009 Issue

New Recommendations for Treating Pressure Ulcers
By Becky Dorner, RD, LD
Today’s Dietitian
Vol. 11 No. 5 P. 14

The National Pressure Ulcer Advisory Panel (NPUAP) released a new international classification system and international guidelines for pressure ulcer treatment at the NPUAP Biennial Conference in Washington, D.C. in February. The NPUAP worked with the European Pressure Ulcer Advisory Panel (EPUAP) to review currently available scientific evidence related to pressure ulcer prevention and treatment to develop the guidelines, which will be used in America and Europe. The plan is to translate the guidelines into multiple languages for easier understanding and implementation.

The new NPUAP-EPUAP pressure ulcer classification system is based in part on the NPUAP revised staging system released in February 2007. However, some changes have been enacted to make it internationally friendly. For example, the term “staging” (or “grading,” which was used in Europe) has been replaced by a number system (ie, I, II, III, IV). In addition to classifications I, II, III, and IV, there are categories for use in the United States, including “full thickness skin or tissue loss—depth unknown” (formerly “unstageable”) and “suspected deep tissue injury.”

The 2009 NPUAP-EPUAP Pressure Ulcer Treatment Guideline includes guidelines for nutrition. I worked with Mary Ellen Posthauer, RD, CD; David Thomas, MD, CMD, FACP; and Steven Black, MD, to develop these guidelines. Ours was a true learning experience, as we sifted through years of literature to find the research that would meet the criteria that the NPUAP and EPUAP set for international guideline development.

We conducted a systematic, comprehensive review of the peer-reviewed, published research on pressure ulcer treatment from 1998 through January 2008 and then conducted supplemental reviews of evidence tables from previous guidelines to identify relevant studies published prior to 1998. We reviewed all studies meeting inclusion criteria for quality, summarized in evidence tables, and classified according to their level of evidence using the Sackett Level of Evidence Rating System for Individual Studies (1989). This system rates the evidence based on the type and quality of the study methodology and results.

In addition, after the recommendations were developed based on the scientific evidence available, we rated the strength of evidence supporting each recommendation using the following criteria:

A: Recommendation supported by direct scientific evidence from properly designed and implemented controlled trials on pressure ulcers in humans providing statistical results that consistently support the recommendation (Sackett Level I studies);

B: Recommendation supported by direct scientific evidence from properly designed and implemented clinical series on pressure ulcers in humans providing statistical results that consistently support the recommendation (Sackett Level II, III, IV, and V studies); and
C: Recommendation supported by expert opinion or indirect evidence (eg, studies in animal models and/or other types of chronic wounds).

In addition to developing the NPUAP-EPUAP nutrition guidelines for the treatment of pressure ulcers, we finalized our nutrition white paper, which is scheduled for release this month. This is a comprehensive review of the literature, with detailed suggestions for best practice.

Current Recommendations for MNT for Pressure Ulcer Treatment
The following recommendations are from the 2009 NPUAP-EPUAP Pressure Ulcer Treatment Guideline and “The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel (NPUAP) White Paper.”

For individuals who have a pressure ulcer, the NPUAP/EPUAP guidelines are:

All individuals should have a nutritional assessment upon admission to a healthcare facility or agency and with each condition change. This is particularly true for individuals with pressure ulcer as they tend to suffer from undernutrition.

1.0 Screen and assess nutritional status for each individual with a pressure ulcer at admission and with each condition change and/or when progress toward pressure ulcer closure is not observed. (Strength of Evidence = C)

1.1 Refer all individuals with a pressure ulcer to the dietitian immediately for early assessment and intervention of nutritional problems. (Strength of Evidence = C)

1.2 Assess weight status for each individual to determine weight history and significant weight loss from usual body weight (≥5% change in 30 days or ≥10% in 180 days). (Strength of Evidence = C)

1.3 Assess ability to eat independently. (Strength of Evidence = C)

1.4 Assess adequacy of total food and fluid intake. (Strength of Evidence = C)

2.0 Provide sufficient calories. (Strength of Evidence = B)

2.1 Provide 30-35 Kcalories/kg body weight for individuals under stress with a pressure ulcer. Adjust formula based on weight loss, weight gain, or level of obesity. Individuals who are underweight or who have had significant unintentional weight loss may need additional Kcalories to cease weight loss and/or regain lost weight. (Strength of Evidence = C)

2.2 Revise and modify (liberalize) dietary restrictions when limitations result in decreased food and fluid intake. This is to be done by a dietitian or medical professional. (Strength of Evidence = C)

2.3 Provide enhanced foods and/or oral nutritional supplements between meals if needed. (Strength of Evidence = B)

2.4 Consider nutritional support (enteral or parenteral nutrition) when oral intake is inadequate. This must be consistent with individual goals. (Strength of Evidence = C)

3.0 Provide adequate protein for positive nitrogen balance for an individual with a pressure ulcer. (Strength of Evidence = B)

3.1 Offer 1.25-1.5 grams protein/kg body weight for an individual with a pressure ulcer when compatible with goals of care, and reassess as condition changes. (Strength of Evidence = C)

3.2 Assess renal function to ensure high levels of protein are appropriate for the individual. (Strength of Evidence = C)

4.0 Provide and encourage adequate daily fluid intake for hydration. (Level of Evidence = C)

4.1 Monitor individuals for signs and symptoms of dehydration: changes in weight, skin turgor, urine output, elevated serum sodium, or calculated serum osmolality. (Strength of Evidence = C)

4.2 Provide additional fluid for individuals with dehydration, elevated temperature, vomiting, profuse sweating, diarrhea, or heavily draining wounds. (Strength of Evidence = C) 

5.0 Encourage consumption of a balanced diet which includes good sources of vitamin and minerals. (Strength of Evidence = B)

5.1 Offer vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected. (Strength of Evidence = B)

Research Needs
Undernutrition is associated with increased morbidity and mortality. Early identification and treatment of nutritional problems is critical. There were no studies specifically addressing the obese individual with pressure ulcers. Additional research is also needed for pediatric patients and neonates. Appetite stimulants and anabolic steroids may have a role in improving body weight; however, more research is needed to determine effectiveness in promoting pressure ulcer healing.

Research is needed to better define appropriate caloric range for obese individuals (those with a body mass index greater than or equal to 30) with pressure ulcers. Although weight loss is usually recommended for obese individuals, weight loss efforts may need to be modified or postponed temporarily to provide sufficient nutrients for pressure ulcer healing.

It is essential to meet minimal recommended dietary intake. Protein levels for patients with wounds should be 1.25 to 1.5 g. Randomized clinical trials indicate increased protein levels promote pressure ulcer healing. The research to date does not demonstrate the effectiveness of branched chain or individual amino acids, such as arginine and glutamine, in the treatment of pressure ulcers. Further study is needed.
Recommendations are based on good clinical practice as the evidence specific to fluid requirements and pressure ulcers is lacking.

There is no research to justify the administration of vitamin/mineral supplements that are above the U.S. Recommended Dietary Intake or comparable European or international standards.

©2009 NPUAP. A full list of references is available in the white paper titled “The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel (NPUAP) White Paper,” available on the NPUAP Web site at Note: This article was written prior to the National NPUAP Biennial Conference. Part of the goal of the conference is to come to agreement on new definitions and guidelines. Check the NPUAP Web site at for final details on the new NPUAP-EPUAP Pressure Ulcer Classification System and 2009 NPUAP-EPUAP Pressure Ulcer Treatment Guideline.

— Becky Dorner, RD, LD, is a speaker and an author who provides publications, presentations, and consulting services to enhance the quality of care for the nation’s older adults. Visit for free articles, newsletters, and information.