Analysis

How nutrition can help prevent and treat pressure ulcers

A balanced diet and good hydration are vital for patients to maintain robust and healthy skin

A balanced diet and good hydration are vital for patients to maintain robust and healthy skin

  • Almost one in ten people in hospital have pressure ulcers, an audit of 10,000 inpatients in England in 2019 found
  • Identification of malnourished individuals can prevent pressure ulcer development and speed up wound healing
  • Why nutritional assessment should be a routine part of risk assessment for pressure ulcers

Nearly one in ten (9%) hospital inpatients had one or more pressure ulcers, according to a major audit in England in 2019 involving 10,000 people .

The figures serve to highlight the vast number of people affected by these potentially serious, painful, and

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A balanced diet and good hydration are vital for patients to maintain robust and healthy skin

  • Almost one in ten people in hospital have pressure ulcers, an audit of 10,000 inpatients in England in 2019 found
  • Identification of malnourished individuals can prevent pressure ulcer development and speed up wound healing
  • Why nutritional assessment should be a routine part of risk assessment for pressure ulcers
Picture: iStock

Nearly one in ten (9%) hospital inpatients had one or more pressure ulcers, according to a major audit in England in 2019 involving 10,000 people.

The figures serve to highlight the vast number of people affected by these potentially serious, painful, and mainly avoidable, wounds.

Good diet and hydration are essential to keep skin healthy

Of course, the problem is not only apparent in hospitals, but in care homes and the wider community too.

Pressure ulcers can have a devastating impact on those affected. Treating them costs the NHS more than £1.4 million every day, according to national campaign Stop the Pressure.

One crucial area of care when it comes to avoiding and treating pressure ulcers successfully is good nutrition and hydration.

Eating well and getting enough liquid helps keep the skin healthy, preventing its breakdown and improving healing rates for those with wounds.

Causes and complications that can arise from pressure ulcers

But with one in ten people aged over 65 malnourished or at risk of malnutrition, a significant proportion of people are not eating well or drinking enough, according to the Malnutrition Task Force.

Pressure ulcers, also known as bed sores and pressures sores, are damage to the skin and the deeper layer of tissue underneath. They happen when pressure is applied to the same area of skin for a period of time and cuts off its blood supply. It is more likely if a person has to stay in a bed or chair for a long time.

Pressure ulcers can lead to life-threatening infections such as sepsis and gangrene
Picture: Science Photo Library

Without proper care, pressure ulcers can become serious. Severe pressure ulcers can badly damage the muscle or bone underneath the skin and can take a long time to heal.

They cause pain and can lead to social isolation, especially if they are malodorous. They can therefore affect quality of life and can also lead to life-threatening sepsis and gangrene.

Nutritional assessment is crucial to detect pressure ulcer risks

Early identification of individuals who are malnourished, or at risk of being so, is vital in preventing pressure ulcer development and promoting wound healing.

The first step is assessing the nutritional status of patients, and this should be part of checking their pressure ulcer risk.

National Institute for Health and Care Excellence (NICE) guidance says all adults and children admitted for hospital care should have a pressure ulcer risk assessment if they have nutritional deficiency.

The well-known NHS Improvement aSSKINg bundle, which is a tool for preventing and treating pressure ulcers, also stresses the importance of nutrition and nutritional assessment.

The phrase aSSKINg stands for assess risk; skin assessment and skin care; surface; keep moving; incontinence and moisture; nutrition and hydration; and giving information or getting help.

The bundle states that a healthy diet speeds up healing, and advises nurses to monitor food and fluid intake, consider a dietitian referral and complete an assessment such as the Malnutrition Universal Screening Tool (MUST).

This nutritional assessment and screening should be carried out on admission and then weekly for all hospital inpatients, according to aSSKINg.

Nutritional assessment screenings in community settings

Stop the Pressure’s Jacqui Fletcher

In community settings people should be screened on first contact, such as on admission to a care home or during initial registration at GP surgeries, and then when there is clinical concern, according to NHS Improvement.

‘Every patient should have a nutritional assessment,’ says senior clinical adviser for the Stop the Pressure programme Jacqui Fletcher.

‘There should be a part of every pressure ulcer risk assessment that considers nutrition and hydration. MUST is the most common but there are others and ones that cover paediatrics.’

Carrying out a nutrition risk assessment was an area that was improving pre-COVID-19, Ms Fletcher says.

In the major hospital audit of 2019, 89% of inpatients had a MUST completed.

‘That’s pretty good,’ Ms Fletcher says. ‘Out of 18 organisations, the lowest rate was 79%.’

Using the MUST assessment tool

National Nurses Nutrition Group vice-chair Natalie Welsh agrees that carrying out an assessment such as MUST is an essential part of pressure ulcer prevention and management.

The five-step tool takes into account a range of important elements, including current weight and body mass index (BMI) (with advice on how to estimate this if it is not possible to weigh the patient), recent weight history and the impact of acute illness.

‘While we are recommending a healthy, balanced diet, can they actually afford that? A lot of people are living on cheaper options’

Natalie Welsh, vice-chair of the National Nurses Nutrition Group

Using the tool aids communication between different specialties and healthcare professions by providing standardised information.

£1.4 million

Daily cost to the NHS of treating pressure ulcers

Source: Stop the Pressure

‘In hospital, patients should get a MUST score at admission and every seven days,’ Ms Welsh says. ‘But that should be seen as the minimum, as the score can change quite rapidly if someone’s acute illness deteriorates. It is quick to complete and should be completed ideally every time someone’s condition changes.’

Dangers of low and high BMI

Nurses need to be aware of the risks to patients who are underweight or overweight.

‘With nutrition, low and high BMI are a real problem for patients, with different risk factors,’ Ms Fletcher says.

Being overweight can lead to reduced mobility, which can lead to more pressure on fragile skin, as well as deeper skin folds and skin necrosis. It is not a sign that someone is not malnourished.

Meanwhile, being underweight can lead to thin skin vulnerable to abrasions and bony areas that are more prominent, and can be a sign of poor nutrition.

While screening is a good start, it is not enough on its own. Action must be taken after risk assessments have been completed, if indicated.

Eating well to heal pressure ulcers

Fruit, vegetables, carbohydrates and iron are all important for healthy skin Picture: iStock

  • Every patient should have a healthy, balanced diet and adequate energy intake to prevent skin breakdown and improve healing rates
  • Carbohydrates like bread, rice, pasta, potatoes and cereal should form the basis of the diet and be eaten at each meal, along with at least five portions of fruit and vegetables every day and sufficient protein
  • Patients should eat foods that are high in iron. These include meats, fish and eggs. Beans, pulses, green vegetables and dried fruit also contain iron but it is less readily absorbed

  • Patients should aim to have at least five portions of fruit and vegetables every day. Vitamin C promotes iron absorption
  • For those unable to eat a balanced diet, or who have a poor appetite, a multivitamin and mineral supplement can be beneficial
  • Patients should aim to include high-protein foods such as dairy, meat, fish, eggs and pulses in their diet. Those who are overweight should choose low-fat versions that still contain the same amount of protein

Source: NHS Improvement

Personalised care is important to improve diet

NHS Improvement recommends beginning an individualised care plan involving the service user where possible, providing food, fluid and assistance to meet their needs. Nurses should offer simple advice (including in written form) about a balanced diet and healthy fluid intake to promote adequate nutrition and hydration.

This plan should be monitored and evaluated regularly, and revised as required. Refer to a dietitian according to local care pathways or if no improvement is observed.

1 in 10

of 10,000 hospital inpatients in England had one or more pressure ulcer, a 2019 audit found

Source: NHS England / NHS Improvement

NICE says that nutritional supplements should be offered to adults with a pressure ulcer who have a nutritional deficiency.

The individual’s care plan needs to consider the huge range of issues that can present challenges in getting sufficient nutrition and hydration.

Some of the difficulties patients with, or at high risk of, pressure ulcers, may face include altered taste, which may be caused by another condition, such as cancer and COVID-19.

Or the pressure ulcer may creating a bad odour, which can put patients off their food.

‘There is no point recommending things that people don’t like… It has to work for the individual,’

Natalie Welsh, vice-chair of the National Nurses Nutrition Group

‘There are so many factors to consider,’ says Ms Fletcher.

‘Has the patient got appropriate dentition? Is oral hygiene always performed? Is the food in reach and presented in an appetising way? Would they do better with five or six small meals, if their appetite is low? Are there any swallowing issues that may need support from speech and language therapists?’

Including a comprehensive multivitamin tablet is a cheap and straightforward way to ensure people are getting the vitamins and minerals they need, Ms Fletcher says.

Maintaining hydration is often overlooked

Frail older people may need to be encouraged to drink more fluids Picture: Tim George

Drinking sufficient liquid is also an essential part of a healthy skin barrier.

Ms Fletcher says hydration is an often-overlooked element of pressure ulcer prevention and management.

3.9%–27.7%

variation in pressure ulcer prevalence was recorded among patients in the 18 NHS trusts that took part in the audit

Source: NHS England / NHS Improvement

‘The group who are at highest risk, frail older people, are often in warm rooms,’ she says.

‘They may drink less because they are worried about being incontinent and they may have a poor appetite. If they are in hospital, these things can be even worse. They may be worried about falling if they need to go to the toilet, as they may not have the same devices and mechanisms for getting to the bathroom safely, and drink even less.’

Ms Welsh agrees that a personalised, holistic plan is needed for each patient. These need to take into account variables of appetite, preference for different tastes and textures, the different times of day people want to eat, cultural preferences and lifestyle choices, such as vegan and vegetarian diets, as well as physical aspects such as dysphagia.

‘There is no point recommending things that people don’t like. If they don’t like the supplement drinks – some people find them unpalatable – then they won’t drink them. It has to work for the individual,’ she says.

Implications of poverty and the pandemic for improving nutrition

Another aspect that must be considered by someone recommending or prescribing a particular diet or supplement is whether the patient can afford it.

‘It has become more noticeable during the pandemic that a lot of people are struggling financially,’ says Ms Welsh.

‘If they don’t get free prescriptions, are they going to be able to afford them? While we are recommending a healthy, balanced diet, can they actually afford that? A lot of people are living on cheaper options such as ready meals.’

When she is doing quick teaching sessions with nurses, doctors and students, she always asks how they like their cup of tea or coffee.

‘Everyone is specific about it and we should take the same approach to patients’ nutrition care,’ she says.

‘This can be harder in hospital but, when working with patients and their families in the community, should be possible.’

The impact of the Food First approach

A care home has seen improved wound healing after changing its approach and fortifying the food of all residents with pressure ulcers.

They now follow a plan of increasing the energy density of food in a model known as Food First, which includes lots of high-calorie and protein-rich meals and snacks.

For residents of the care home in Warrington, Cheshire, this has led to improved healing of pressure ulcers, reduced pain, increased alertness, being able to eat and enjoy normal textures, reduced number of nurse visits for dressings and improved quality of life.

The approach started due to the experience of an 80-year-old resident, who had a chronic category 3 pressure ulcer on her sacrum for more than 12 months.

She was bedbound but could eat and drink independently, although staff gave her a pureed diet because she could be drowsy at times and that was easier to eat.

A healthy body mass index, no weight loss, and a zero MUST score meant she was considered at low risk of malnutrition. Six months later she was referred to the dietetics team due to weight loss and was seen due to her pressure ulcer.

Her food was fortified with full cream milk at every meal, extra high-calorie and high-protein puddings, two to three snacks or high-protein homemade milkshakes, and a supper.

After three months her weight had increased and the pressure ulcer was healing.

The care home staff now use fortified foods for all residents with a pressure ulcer and put in an urgent referral to dietetics for category 3 and 4 wounds.


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