Medical Nutrition Therapy: A Protocol for Pressure Injury Management
by Mary Ellen Posthauer RDN, CD, LD, FAND
Medical Nutrition Therapy (MNT) should be an integral part of your pressure Injury (ulcer) management plan. Malnutrition/undernutrition is a risk factor for pressure injury formation and prolongs the healing process. Since nutrition is one component of both the treatment and prevention plan (along with dressings, treatments and support surfaces), having a written MNT protocol assists the interdisciplinary team in achieving a positive outcome for the individual/patient. The collaborative, interdisciplinary approach should include the individual and their family/caregiver.
The MNT protocol for pressure injury management should include the following policy, responsibility of the registered dietitian nutritionist, nursing staff, and other team members, and the detailed procedure.
Medical Nutrition Therapy Policy:
MNT will be provided to all individuals at risk for malnutrition and pressure injury, or who have pressure injuries. The nursing staff and registered dietitian nutritionist (RDN) are responsible for implementing the MNT protocol, monitoring interventions, and documenting outcomes. Each member of the interdisciplinary team is responsible for assessing and intervening based on his or her scope of practice. For example, the speech language pathologist will evaluate and treat chewing and swallowing problems and the occupational therapist will evaluate and treat ADLs related to feeding. The goals of MNT are to provide adequate calories, protein, fluid, vitamins, and minerals; to assist in reducing the risk of the pressure injury development; and to assist in healing of pressure injuries.
The following algorithm details the procedures including risk factors, assessment, intervention, and monitoring and desired outcomes for the MNT protocol for pressure injury management.
Based on Estimated Needs, Implement Plan of Care
- Calories: 30-35 kcalories/kg/body weight (adjust per clinical condition)
- Protein: 1.2-1.5g/kg/body weight (adjust per clinical condition
- Fluid: 1mL per day per kcalorie consumed, minimum of 1500mL unless contraindicated and monitor hydration status
- Offer preferred food/beverage at appropriate texture
- Liberalize restrictive diets
- Offer hydration during care and between meals
- Offer vitamin/mineral supplement with 100% of RDIs if intake is poor
- Offer oral high calorie nutritional supplement between meals if needs cannot be met with diet alone
- Consider oral high calorie nutritional supplement fortified with arginine and micronutrients for stage 3 and 4 pressure injuries, when nutritional requirement cannot be met with traditional high calorie oral nutritional supplement
- Consider enteral or parenteral nutrition support when oral intake is inadequate and if consistent with individual's goals
- Weigh weekly or per facility policy
Monitor per facility policy
- Skin condition and wound status
- Acceptance of meals, fluids and/or supplements
- Weight status
- Laboratory values if appropriate
- Effectiveness of interventions - collaborate with interdisciplinary team and adjust interventions as appropriate
- Monitor progress toward healing per facility protocol
- Document all interventions and assessment in the medical records
- Acceptance of nutrition interventions to meet estimated caloric protein, fluid needs
- Improved and/or stable nutritional status
- Progress toward healing or intact skin
- Weight stable or increased to target UBW
- Document and reassess per facility policy until desired outcome is achieved
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Advisory Panel and the American Dietetic Association's Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.