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Team Approach to Nutrition, Pressure Injuries, and Wounds in Long-term Care
Consuming adequate calories and grams of protein every day becomes more daunting as we age. This is especially true for long-term care (LTC) residents, who often face many challenges maintaining an optimal nutritional status. When nutritional intake and body weight decline, there are often other problems such as a decline in mobility, exacerbation of comorbidities, or depressed mood. In combination, these factors may lead to developing or worsening pressure injuries. It is essential to use a multidisciplinary team to identify residents with poor nutrition indicators to implement appropriate nutrition strategies.
Chronic diseases, poor dentition, dysphagia, decreased self-feeding ability, and cognitive function are just a few factors that contribute to decreased calorie and protein intake. In addition, restrictive therapeutic diets, refusal to consume oral nutritional supplements (ONS), and dislike of texture-modified diets also affect optimal nutritional intake. Although an individualized nutrition plan can help residents at risk of or with pressure injuries, it also takes a collaborative effort among disciplines to promote skin integrity for residents. Registered dietitian nutritionists (RDNs) lead in the nutrition assessment of residents, but they need assistance from other clinicians to help implement the care plan. Table 1 lists some of the multidisciplinary information that RDNs utilize in performing a nutrition assessment.
ALTERED DIETS
Long-term care professionals face many challenges in providing adequate nutrition for those residents with or at risk of pressure injuries. One issue is that most residents receiving therapeutic or mechanically altered diets may already have reduced overall calorie and protein intakes. According to the Academy of Nutrition and Dietetics Evidence Analysis Library, older adults receiving mechanically altered diets have a greater dissatisfaction with foods and often find less enjoyment from meals.1 Individuals with dysphagia or swallowing disorders have a higher prevalence of weight loss and pressure injuries.2
Traditional mechanically altered diets are mechanical soft, dysphagia, and pureed diets with nectar-, honey-, or pudding-consistency liquids. The recent global initiative by the International Dysphagia Diet Standardisation Initiative describes and labels dysphagia diets using a modified framework for all ages and cultures for use in any care setting.3 These updated mechanically altered diets provide residents with textures that are more individualized to their chewing and swallowing ability. This may help increase overall nutritional intake, thus preventing malnutrition. However, accomplishing this in LTC facilities is slow because staffing and budget limitations hinder full implementation of the new framework. It is best practice for the speech-language pathologist (SLP) to become involved as soon as a chewing or swallowing problem is identified. To address the problem, the SLP can determine the most appropriate diet texture and liquid consistency.
THERAPEUTIC DIET INTAKE
In LTC, the RDN is often not present when meals and snacks are served. Therefore, the nursing staff needs to note if residents refuse a meal, eat very little, or dislike the ONS. The nursing staff can notify the RDN, who can then look for the root cause of the problem and modify the intervention plan as needed. Sometimes, the solution is as simple as serving a different-flavored supplement or providing encouragement.
Dorner et al4 advise that restrictive diets can lead to malnutrition and adverse health effects. Furthermore, the Academy of Nutrition and Dietetics Evidence Analysis Library generally suggests that older adults have increased nutritional intake when diets are liberalized.5 It makes sense that restricting calories and favorite foods will cause a decline in nutritional intake, which can lead to malnutrition and, in turn, affect pressure injury healing. Diet liberalization can improve overall intake for some residents. Nutrition care is not a “one size fits all plan,” so clinicians must work with other health care professionals, residents, and families to provide the best approach.
ORAL NUTRITIONAL SUPPLEMENTS
It is natural for calorie intake to diminish as individuals age, making it necessary to maintain energy and protein intake in other ways. Researchers found that those with pressure injuries often have suboptimal nutritional intake, and their goal was to highlight the importance of nutrition, especially when treating those with impaired skin integrity.6 Looking for a solution to this problem, Li et al7 found that ONS had a positive effect on overall appetite and energy intake.
It is no surprise that many elderly individuals turn to ONS to sustain acceptable nutritional parameters. Numerous products are available in many forms, including liquids, puddings, ice creams, and bars. Many facilities provide ONS because it is a simple way to improve overall intake. However, some residents adamantly refuse these supplements, making it harder to improve nutrition. The key is often variety to avoid flavor fatigue and find out what the resident prefers. Not everyone enjoys sweets. Chocolate and vanilla do not appeal to everyone. Some people prefer lemon, orange, and strawberry. However, some facilities have a reduced budget for ONS and may only offer one or two options, creating some of the refusal problems because of limited variety.
FORTIFIED FOODS
A recent trend toward increasing overall calorie and protein intake is to fortify foods by adding fat, whole milk, cream, and sweeteners to foods such as oatmeal, soups, and mashed potatoes. The limitation with this is that residents who have poor intake to begin with must consume the fortified item. The RDN often talks to the residents or their families to see what favorite foods might promote optimal calorie and protein intake. Nursing clinicians or anyone who sees residents regularly can assist with this process by informing the RDN of what they have observed with the patient, thus creating a better care plan.
THE MULTIDISCIPLINARY TEAM
Timely nutrition intervention from the entire care team is one of the keys to preventing malnutrition and promoting skin integrity. Clinicians from all disciplines must assess residents individually and communicate these findings to pertinent team members to promote better outcomes (Table 2). For example, the RDN’s role is to complete the nutrition assessment, but oftentimes, it is the role of nursing staff to implement it. Good communication is the key.
IN PRACTICE
Scenario 1. Mrs Smith is an alert and oriented resident with mild confusion. She generally has good meal intake, but lately, she has struggled with cutting her
meat because of arthritis. She eats what she cuts, but leaves the rest. She develops unintended weight loss and a stage 2 pressure injury a month later. Upon meal rounds, the nursing assistant notes that Mrs Smith did not eat her meat and asks if she is having trouble chewing it. The resident states that she could chew okay but was unable to cut it.
The Team Approach. The nursing assistant makes a notation to provide setup and meal assistance. She then notifies the unit nurse and wonders if the resident needs a different diet texture. The nurse notifies the physician and the RDN. The RDN evaluates the resident and requests that the physician order a consultation with the occupational therapist for appropriate utensils such as a rocker knife and plate guard. The recreational therapist makes sure the resident is seated at a dining table with her friends and encourages the resident to come to the dining room for every meal.
Scenario 2. The nurse notes that Mr Jones has difficulty chewing his regular diet. His overall intake has declined during the past week, but he seems to do well with items such as mashed potatoes and soft sandwiches.
The Team Approach. The nurse believes the resident might need a mechanical soft texture diet and informs the physician, who orders consultations with the SLP and RDN. The SLP determines that the resident would benefit from a texture-modified diet and works with the nurse and physician to get this new order. The order is communicated to the kitchen. The social worker informs the family/responsible party that the diet order has changed and the reasons for changing it.
PRACTICE POINTS
Time is of the essence when dealing with pressure injuries. So as soon as an issue is noted, timely consultations from the RDN, OT, social worker, or SLP are important. Optimal nutritional intake is more achievable if all members of the multidisciplinary team provide individualized input for the residents.
The next time you see a patient with a nutritional concern, remember: You are part of the team. Everyone must work together to communicate the nutrition message.
REFERENCES
1. Academy of Nutrition and Dietetics. Unintended weight loss in older adults: collaboration for modified texture diets. Evidence Analysis Library. 2009.www.andeal.org [by subscription].
2. Peladic NJ, Orlandoni P, Dell’Aquila G, et al. Dysphagia in nursing home residents: management and outcomes. J Am Med Dir Assoc. 2019;20(2):147-151. doi:10.1016/j.jamda.2018.07.023
3. International Dysphagia Diet Standardisation Initiative. A global initiative to improve the lives of over 490 million people worldwide living with dysphagia. Accessed June 27, 2022. https://iddsi.org.
4. Dorner B, Friedrich EK, Posthauer ME, American Dietetic Association. Position of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc. 2010;110(10):1549-1553. [Erratum in J Am Diet Assoc. 2010;110(12):1941]. doi:10.1016/j.jada.2010.08.022
5. Academy of Nutrition and Dietetics. Unintended weight loss in older adults: diet liberalization. Evidence Analysis Library. 2009.www.andeal.org [by subscription].
6. Eglseer D, Hödl M, Lohrmann C. Nutritional management of older hospitalised patients with pressure injuries. Int Wound J. 2019;16(1):226-232. doi:10.1111/iwj.13016
7. Li M, Zhao S, Wu S, Yang X, Feng H. Effectiveness of oral nutritional supplements on older people with anorexia: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 2021;13(3):835. doi:10.3390/nu13030835
Dr Collins is a wound care-certified registered dietitian based in Las Vegas, NV. She is well known for her expertise in the complex relationships among malnutrition, body composition, and tissue regeneration. She can be reached through her website, www.drnancycollins.com.
Ms Rodo specializes in nutrition for the elderly and has more than 30 years of long-term and wound care experience. She has dedicated much time to writing for her blog www.dietitianmentor.com and to assisting students with their internships.
The opinions and statements expressed herein are specific to the respective authors and not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.
