What is the recommended nutritional intervention for a patient with a pressure ulcer?

Nutritional Assessment and Intervention for Patients with Pressure Ulcers

All patients with pressure ulcers must undergo immediate malnutrition screening at hospital or nursing home admission, regardless of ulcer stage, and malnourished patients should receive specialized nutritional supplementation enriched with arginine, zinc, and antioxidants to improve wound healing. 1

Mandatory Initial Assessment

Screen every patient for malnutrition immediately upon admission using a validated tool (such as NRS 2002 or Malnutrition Universal Screening Tool), independent of whether pressure ulcers are present or their severity. 1 This is non-negotiable because:

• Nutritional risk is strongly associated with pressure ulcer presence (OR = 2.55-2.58 for patients at nutritional risk). 2
• The benefit of nutritional interventions depends critically on baseline nutritional status, yet most studies failed to distinguish between malnourished and well-nourished patients. 1
• Malnutrition screening should occur at hospital and nursing home admission regardless of pressure ulcer risk or presence. 1

Key Assessment Parameters to Document

When screening, specifically evaluate:

• Body Mass Index (BMI): BMI <20 kg/m² has the strongest association with pressure ulcers. 2
• Recent dietary intake: Eating less in the past week strongly correlates with pressure ulcer development. 2
• Age: Patients ≥70 years are at higher risk. 2
• Current hospitalization setting: Medical department patients have higher risk than surgical patients. 2

Treatment Algorithm Based on Nutritional Status

For Malnourished Patients WITH Existing Pressure Ulcers (Stage II-IV):

Provide oral nutritional supplementation specifically enriched with arginine, zinc, and antioxidants rather than standard isocaloric/isonitrogenous formulas. 1 This recommendation is based on the highest quality RCT evidence showing:

• Greater and more frequent reduction in pressure ulcer area in 200 malnourished patients with stage II-IV ulcers. 1
• Cost-effectiveness despite higher formula expense. 1
• This is the only intervention with demonstrated efficacy specifically in malnourished patients with existing ulcers. 1

For Patients at Risk of Developing Pressure Ulcers:

Offer nutritional interventions (high-protein oral nutritional supplements or enteral nutrition) to prevent pressure ulcer development. 1 Evidence shows:

• Nutritional intervention during acute hospital admission may reduce pressure ulcer incidence at 2-4 weeks compared to standard care. 1
• Meta-analysis of eight trials found borderline significance for preventing pressure ulcer development (OR 0.96; 95% CI 0.73-1.00). 1

For Well-Nourished Patients:

The evidence for nutritional supplementation in well-nourished patients with pressure ulcers is weak, as most trials did not distinguish nutritional status and showed no clear benefit. 1 However, maintain adequate nutrition to support wound healing with standard dietary recommendations. 3

Critical Pitfalls to Avoid

• Do not delay malnutrition screening until after pressure ulcers develop—screen at admission regardless. 1
• Do not use generic nutritional supplements for malnourished patients with existing ulcers; the specific arginine-zinc-antioxidant formulation has proven superior efficacy. 1
• Do not assume all patients benefit equally from nutritional interventions; benefits are most clearly demonstrated in malnourished patients. 1
• Do not prescribe weight-reducing diets in overweight older patients with pressure ulcers, as this causes muscle mass loss and functional decline. 1

Referral Criteria

Refer to a registered dietitian nutritionist when:

• Malnutrition screening identifies patients at risk (NRS 2002 score indicating risk). 3, 2
• Pressure ulcers are present in any patient, regardless of nutritional status. 3
• Specialized nutritional formulations need to be prescribed and monitored. 3
• Individualized nutrient requirements need calculation for growth, development, maintenance, and tissue repair. 3

Strength of Evidence Considerations

The 2022 ESPEN guidelines rate nutritional interventions as Grade B recommendations (strong consensus 100% agreement) for both prevention and treatment. 1 However, the underlying study quality is generally low to very low, with only one moderate-quality RCT specifically demonstrating benefit in malnourished patients with existing ulcers. 1 Despite limited evidence quality, the intervention is low-risk and addresses a clear physiological need, making it appropriate for routine clinical practice. 1