Implementing Nutrition Care: What the Revised NPIAP Clinical Practice Guideline Recommends

Wound clinicians treating pressure injuries now have new guidance with the release of a Clinical Practice Guideline by the National Pressure Injury Advisory Panel. This author details the guideline’s updated nutritional information and good practice statements in areas such as calories, protein intake, and more.

In November 2019, the National Pressure Injury Advisory Panel (NPIAP) released an updated Clinical Practice Guideline (CPG) for the prevention and treatment of pressure injuries.¹ This guideline is a collaborative effort among the NPIAP, the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance. It is designed to assist practitioners in the provision of the most up-to-date evidence-based care for pressure injuries.

The 2019 third edition of the international guideline consists of 114 evidence-based recommendations, 62 good practice statements (GPS), and 20 quality indicators contained in a 405-page publication that wound care providers can use across the health care continuum. The complete copy of the guideline can be purchased from https://guidelinesales.com/ and should be reviewed in totality in order to assess your current program and determine if any changes need to be made. Many wound clinics do not have a full-time registered dietitian (RD) on staff and therefore may not focus on the nutrition section.

What follows are common nutrition questions regarding the 10 nutrition recommendations and five nutrition GPSs.

Does the updated guideline support the traditional nutrition care process my facility already has in place?

The nutrition care process has not changed. The first three recommendations focus on nutrition screening, nutrition assessment, and individualized nutrition care planning.¹ Nutrition screening should be conducted using a validated tool. There are a variety of screening tools available for different patient populations and care settings; e.g., community-based, acute care, or older adults. Nutrition screening can be conducted by any member of the health care team and should be done to determine if the patient is at risk for malnutrition or already suffers some degree of malnutrition.

Once the screening has been completed, referral to an RD should be made if needed. The RD will then complete a full nutrition assessment, including assessment of anthropometric, biochemical, and diet history data. The RD may also perform a nutrition-focused physical exam. After the assessment is completed, an appropriate plan of care can be instituted in coordination with the multidisciplinary team.

How many calories should I recommend for healing?

Calorie is another word for energy and because wound healing is an energy-intensive process, it is important to address this question. The guideline does so for both patients at risk of pressure injuries who are malnourished or at risk of malnutrition and for those who present with a pressure injury.¹

For patients at risk of a pressure injury, the recommendation is to optimize energy intake.¹ In a practical sense this means to refer to the relevant nutritional guidelines based on the patient’s overall condition and follow that. For patients not eating well, this might mean liberalizing the diet prescription, encouraging favorite foods, and/or providing oral nutrition supplements to optimize caloric intake.

For a patient with a pressure injury who is malnourished or at risk of malnutrition, the recommendation is to provide 30 to 35 kcalories/kg body weight/day.¹ To achieve this level of intake, it may be necessary to liberalize the diet prescription and/or provide fortified foods or calorically dense oral nutrition supplements (ONS).  

Have protein recommendations changed?

Just like with calories, the guideline provides guidance on protein intake for both patients at risk of pressure injuries and those with a pressure injury who are malnourished or at risk of malnutrition.¹ For those at risk, there is insufficient evidence at this time for a specific recommendation. The advice is in the form of a GPS to adjust protein intake in accordance with reputable nutrition guidelines appropriate for the individual’s medical condition.

For patients with a pressure injury who are malnourished or at risk of malnutrition, it is recommended to provide 1.25 to 1.5 g protein/kg body weight/day.¹ It is important to assess the patient’s overall medical condition, particularly renal status, when recommending higher protein intake.

What if my patients cannot achieve this level of calorie and protein intake?

ONS are a convenient way to fill in nutritional gaps by providing a concentrated source of calories and protein. ONS come in a variety of flavors and textures and comprise more than just shakes. The key is finding something the patient enjoys and will consume.

The guideline has three statements regarding supplements.¹ Two are more general recommendations that support the use of fortified foods and/or ONS for patients who cannot meet their nutritional requirements by traditional dietary intake alone for both those at risk and those with an existing pressure injury. ONS are best served between meals so they do not end up replacing meals.

In addition, the guideline recommends provision of a high-calorie, high-protein, arginine, zinc, and anti-oxidant ONS or enteral formula for adults with a Stage II or greater pressure injury who are malnourished or at risk of malnutrition.¹ Many nutrition protocols call for intervention at Stage III or greater so this recommendation may require an update to current policies.

Arginine is an amino acid, which is typically classified as a conditional indispensable amino acid (CIAA), which is produced in sufficient amounts by healthy individuals. However, in the presence of certain disease states or underlying physiological stress such as a chronic wound, certain amino acids may become indispensable. Essentially this means that the body cannot produce a sufficient amount to meet an increased demand. Thus several studies have studied this topic in order to determine if supplementation is beneficial. There is growing evidence that supports a positive effect on pressure injury healing by adding arginine, zinc, and antioxidants to high calorie, high protein nutritional supplementation via ONS and tube feeding formulas.  

What else besides calories, protein, and ONS should we discuss with patients?

Adequate hydration is another consideration for patients with a pressure injury. The guideline reminds of us of this with a GPS calling for the provision and encouraged consumption of sufficient water and other fluids.¹ Generally, healthy people are assessed as needing 30 mL/kg body weight/day or 1 mL/kcalorie/day.

As with all recommendations, a review of the patient’s specific medical condition must be done to ensure that additional fluids are compatible with the treatment goals. Patients with heart failure or renal impairment may require fluid restrictions. Those with diarrhea, vomiting, or sweating, or heavily exuding wounds may require more than the traditional recommendations. The best way to evaluate a patient’s fluid balance is to monitor for the physical signs of dehydration, assess skin turgor, measure urine output, and review lab data.

What does the guideline say about vitamin C?

Vitamin C generates collagen and provides extra strength and stability to collagen fibers. This is why you often hear about vitamin C in connection to wound healing. However, the guideline does not specify to supplement with vitamin C because there is a lack of evidence to support this.¹ Rather, the guideline encourages monitoring for signs and symptoms of all vitamin and mineral deficiencies and addressing a deficiency when it is confirmed or suspected.

Any patient who is not eating well over an extended period of time may develop a vitamin or mineral deficiency so it is imperative to become adept at noticing the physical and telltale signs. For example, the deficiency signs for vitamin C include bleeding gums, bruised skin with many pinpoint hemorrhages, and skin that has become rough, brown, and blotchy with bruises. The groups at increased risk of vitamin C deficiency include individuals under chronic physical or emotional stress, smokers, users of alcohol, and users of oral contraceptives.

Most people think of oranges and other citrus fruits as being good sources of vitamin C but there are many other good sources including broccoli, cabbage, cantaloupe, guava, kiwi, papaya, red and green peppers, salad greens, strawberries, sweet potatoes, vegetable juice cocktail and watermelon. So rather than automatically supplement, monitor for the signs of deficiency, encourage a good food source of vitamin C daily, and supplement only when a deficiency is suspected or confirmed.

In addition, if you are providing ONS, most contain additional vitamins and minerals including vitamin C. It is a good habit to read the labels on oral and enteral supplements to determine micronutrient content.

Are there any additional sections in the current version of the guideline?

Yes, there are two new sections.¹ The first one addresses patients who are receiving artificial nutrition in the form or enteral or parenteral feedings. The second new section addresses nutrition management in neonates and children.

For artificial nutrition, the guideline recommends discussing the benefits and harms in light of overall treatment goals.¹ For neonates and children at risk of pressure injuries, it is good practice to use age an appropriate nutrition screening and assessment. Obviously, it would not be appropriate to use the same screening that you use for your adult or geriatric population since they have very different nutritional considerations.  

For neonates and children at risk of or with a pressure injury with inadequate nutritional intake, it is also good practice to consider fortified foods, age appropriate ONS, or enteral or parenteral nutrition in accordance with the child’s individualized treatment plan.

Putting It Into Practice

Nutrition is sometimes overlooked but the evidence is mounting that there are several nutritional components that aid the healing of pressure injuries. There have been many new studies since the last time a substantial, systematic review was conducted. The guideline includes an in-depth discussion of the evidence used to formulate the recommendations and GPSs as well as a rating of the strength of the evidence and the strength of the recommendation.¹ Review of the complete guideline should be undertaken to fully understand and implement the best program for your specific patient population.

CPGs are not prescriptive and are not fixed protocols; rather, they give you a basis to design the best program for your unique clientele. To provide truly evidence-based care, you must not only be familiar with the evidence but apply your clinical expertise to it while incorporating the patient’s values and preferences. This tri-pronged approach is your key to success.

Dr. Nancy Collins is a wound care-certified dietitian specializing in the relationship between nutrition and wound healing. She is also a medico-legal expert dedicated to improving provider-patient communication and bettering the patient experience. To contact her, visit her website, www.drnancycollins.com.

1. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines. Emily Haesler (Ed.).EPUAP/NPIAP/PPPIA: 2019. Available for purchase at https://guidelinesales.com/