At a recent WoundCon Summer session, panelists defined pressure injuries and their stages and discussed how nutritional intervention, including multidisciplinary collaboration, can prevent these injuries. 

A pressure injury is defined as local damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to a medical device, noted Samuel Nwafor, MD, FACP, FAPWCA.¹ He added that pressure injuries can present as intact skin or an open ulcer and can be painful, noting that these injuries occur due to intense or prolonged pressure or pressure combined with shear. 

Dr. Nwafor also delineated the stages of pressure injuries¹:

Stage 1 pressure injuries involve nonblanchable erythema of intact skin that extends to the epidermis, noted Dr. Nwafor.¹ They may appear differently in darkly pigmented skin, and the presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visible changes. 

Stage 2 pressure injuries extend to the dermis and involve partial-thickness skin loss with exposed dermis.¹ The wound bed is viable, pink or red, and moist. Dr. Nwafor said this stage may present as an intact or ruptured blister filled with serum. 

Stage 3 pressure injuries extend to the hypodermis and consist of full-thickness skin loss with an exposed dermis, noted Dr. Nwafor.¹ Adipose as well as slough and/or eschar will be visible in this stage. Granulation tissue and epibole will also be evident. 

Stage 4 pressure injuries involve full-thickness loss of skin and tissue.¹ Dr. Nwafor said patients with these injuries experience exposed or directly palpable fascia, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. 

Unstageable pressure injuries, noted Dr. Nwafor, involve full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed as slough or eschar obscure the injury.¹ After debridement, one can restage these injuries to stage 3 or 4. 

Anna de Jesus, MBA, RDN, delved into the international guidelines of the National Pressure Injury Advisory Panel (NPIAP).² The guidelines note that screening is associated with lower pressure injury rates and shorter length of hospital stay due to quicker nutritional interventions when one identifies patients who are at nutritional risk. 

As such, De Jesus noted, the guideline says it is good practice to give nutrition screenings to those at risk for pressure injuries, and also to screen at-risk patients for malnutrition.² Nutritional screening tools include the Canadian Nutritional Screening Tool, the Malnutrition Screening Tool, the Mini Nutritional Assessment Full Version, the Malnutrition Universal Screening Tool, Nutrition Risk Screening (2002), Rapid Screen, Short Nutrition Assessment Questionnaire, Seniors in the Community: Risk Evaluation for Eating and Nutrition, and the Subjective Global Assessment Tool. 

The NPIAP advises focusing on a balanced and nutrient-dense diet with adequate hydration, said de Jesus^.2 She added that one should modify or liberalize dietary restrictions when patients have inadequate intake of foods or fluids. A healthy adult should aim for an intake of water or other hydrating fluids at about 30mL per kilogram of bodyweight, or 1mL/kcal per day.² Patients with heart failure or renal failure require less fluid, while patients should drink more fluid if they have conditions like elevated temperature, vomiting, profuse sweating, diarrhea, or heavily exudating wounds, de Jesus said. 

The NPIAP guideline suggests providing nutritional supplementation for those at risk for pressure injuries who have been identified as malnourished, although the recommendation is conditional.² De Jesus noted supplementation includes increased oral intake, fortified foods, enteral/tube feeding, and parenteral supplementation. The guideline is 1.5–2.4 kcal/mL for 4 weeks, followed by reevaluation of the plan. The NPIAP also conditionally recommends protein supplementation for patients identified as malnourished or at risk for malnourishment.² Additionally, carbohydrate-based energy and micronutrient supplements are conditionally recommended for those with malnutrition or micronutrient deficiencies.² De Jesus noted one should consult an RDN for supplementation. 

De Jesus discussed the pros and cons of oral nutritional supplements. She said supplements offer better nutritional status, shorter hospital stays, consistency, and labor savings, but they do come with costs, side effects, and diminished joy of eating.^3,4

Malnutrition comes with economic costs in the form of longer hospital stays, higher infection rates, higher costs of care, more pressure injuries with delayed wound healing, and a higher likelihood of falls, noted Frank Aviles, PT, CWS, FACCWS, CLT-LANA, ALM, AWCC, MLD/CDT Instr.^5-7

As Aviles noted, up to 50% of hospitalized patients are malnourished, and after admission, 69% of inpatients experience nutritional decline. Research has shown malnutrition increases the risk of a pressure injury 2–3 times in hospitalized patients. In long-term care, up to 85% of patients with pressure injuries are malnourished.^8–10

Aviles cited the American Society of Parenteral and Enteral Nutrition (ASPEN), which deems patients malnourished if they meet at least 2 of the following 6 conditions: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.¹¹ 

Dr. Nwafor cited a study by Ellison and colleagues looking at communication between wound care nurse specialists and registered dieticians.¹² In a unit with interdisciplinary collaboration, researchers found, there was a 30% increase in implementing a “bundle” of early pressure injury prevention, leading to a 75% reduction in hospital-acquired pressure injuries, compared to a 25% reduction in another unit.  

Hospital-based team collaboration, noted Dr. Nwafor, can include daily multidisciplinary team care conferences, an interfaced communication platform in the hospital’s electronic medical records system, and multidisciplinary hospital rounds. 

Aviles concluded that one can make an impact with early, aggressive, individualized, and interdisciplinary nutritional screening, assessment, and intervention, emphasizing team collaboration. He noted early intervention is linked to shorter length of hospital stay and fewer complications. 

References 

1. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.0000000000000281
2. National Pressure Injury Advisory Panel. Prevention and treatment of pressure ulcers/injuries: clinical practice guidelines. Available at https://internationalguideline.com/the-international-guideline. Published Feb. 25, 2025. Accessed July 24, 2025. 
3. Riddle E, Munoz N, Clark K, et al. Prevention and treatment of malnutrition in older adults living in long-term care or the community: an evidence-based nutrition practice guideline. J Acad Nutr Diet. 2024;124(7):896-916.e24. doi:10.1016/j.jand.2024.03.013
4. Schuetz P, Sulo S, Walzer S, et al. Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials. BMJ Open. 2021;11(7):e046402. Published 2021 Jul 9. doi:10.1136/bmjopen-2020-046402
5. Sorensen J, Kondrup J, Prokopowicz J, et al. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr. 2008;27(3):340-349. doi:10.1016/j.clnu.2008.03.012
6. Allard JP, Keller H, Jeejeebhoy KN, et al. Malnutrition at hospital admission-contributors and effect on length of stay: a prospective cohort study from the Canadian malnutrition task force. JPEN J Parenter Enteral Nutr. 2016;40(4):487-497. doi:10.1177/0148607114567902
7. Neyens J, Halfens R, Spreeuwenberg M, et al. Malnutrition is associated with an increased risk of falls and impaired activity in elderly patients in Dutch residential long-term care (LTC): a cross-sectional study. Arch Gerontol Geriatr. 2013;56(1):265-269. doi:10.1016/j.archger.2012.08.005
8. Corkins MR, Guenter P, DiMaria-Ghalili RA, et al. Malnutrition diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter Enteral Nutr. 2014;38(2):186-195. doi:10.1177/0148607113512154
9. Amaral TF, Matos LC, Tavares MM, et al. The economic impact of disease-related malnutrition at hospital admission. Clin Nutr. 2007;26(6):778-784. doi:10.1016/j.clnu.2007.08.002
10. de van der Schueren M, Elia M, Gramlich L, et al. Clinical and economic outcomes of nutrition interventions across the continuum of care. Ann N Y Acad Sci. 2014;1321:20-40. doi:10.1111/nyas.12498
11. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738. doi:10.1016/j.jand.2012.03.012
12. 12.  Ellison D, Melhado C, Ashbey-Pejoves J. Interdisciplinary collaboration between clinical dietitians and wound care nurse specialists prevents hospital acquired pressure injuries. J Am Acad Nutr Diet. 2024; 124(10):Suppl A78.