ENTERAL NUTRITION IN THE PREVENTION AND

TREATMENT OF PRESSURE ULCERS IN ADULT

CRITICAL CARE PATIENTS
Jill Cox, RN, PhD, APN-C, CWOCN
Louisa Rasmussen, BS, RD, CNSC
Critical Care Nurse

Savannah Berry, GSU Dietetic Intern

Pressure Ulcer
Localized injury to the skin, the underlying

tissue, or both, usually over a bony

prominence, that develops as a result of
pressure or pressure in combination with
shear.
2.5 million patients annually
14% to 27% highest among hospitalized
patients: critical care patients

Risk Factors
Altered mobility
Moisture
Friction or shear
Older age
Prolonged length of stay in the ICU

Emergency admission to the ICU

Use of vasopressor agents

Pressure Ulcer Staging System

Type of Pressure Description
Ulcer
Suspected deep
tissue injury

Purple localized area of discolored intact skin (bruising)

Stage I

Intact skin with nonblanchable redness of a localized area

typically over a bony prominence.

Stage II

Partial-thickness loss of dermis manifested as a shallow

open ulcer with a red pink wound bed (open blister)

Stage III

Full-thickness tissue loss. Only subcutaneous fat may be

visible

Stage IV

Full-thickness tissue loss with exposed bone, tendon, or

muscle.

Unstageable

Full-thickness tissue loss in which the base of the ulcer is

covered by slough or eschar in the wound bed.

Research Thus Far

Acute lung injury, receiving mechanical

ventilation: development of pressure ulcers was

significantly less when given enteral formula
enriched with micronutrients, eicosapentaenoic
acid (EPA or omega 3 fatty acid), and gammalinolenic acid (omega 6 fatty acid)
Stage II or higher pressure ulcers: progression
was significantly less when given formula
enriched with fish oil than isocaloric formula.

Malnutrition
Imbalance of energy, protein, and other nutrients
Nonsevere or severe based on:
Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized or generalized fluid accumulation
Diminished functional status (hand grip strength)

However, currently there is no ideal lab tests to

detect malnutrition
Albumin, prealbumin, transferrin, and retinol-binding protein

values vary based on fluid, protein, infection, and

inflammation.

Micronutrients in Wound Healing

Phase

Duration

Impact of Nutritional Deficiencies

Inflammatory

Begins at time
of the injury or
within 4-6 days

Vit A: Alterations in immune function; increased

risk of infection
Vit C & Iron: Impaired immune response
Zinc: decreased immunity, increased susceptibility
to pathogenic organisms

Proliferative

Day 3 or 4 &
continues for 23 weeks

Vit C, iron, copper, zinc, manganese: impaired

tensile strength and collagen synthesis
Hypoproteinemia: impaired fibroblast proliferation
and collagen synthesis
Vit C: increased capillary wall and fragility and
angiogenesis, increased risk of wound hemorrhage

Maturation/Re
modeling

Day 21 and
continues up to
2 years

Vit A: impaired collagen synthesis

Vit C: reduced tensile strength
Zinc: impaired wound strength, decreased
fibroblast proliferation, collagen synthesis, &
epithelialization rate

Nutrition Guidelines
Critical care patients should be fed ideally within

the first 24-48 hours after ICU admission

Enteral Feedings:
Ability of the gastrointestinal tract to absorb the

nutrients provided in the feeding

Comorbid conditions
Feeding tolerance (may be reduced d/t gastric
emptying)
Feedings should be calorically dense, protein-

rich, and provide daily requirements of

micronutrients

Macronutrients
Energy:
30-35 kcal/kg to a max of 40 kcal/kg

Protein
Pressure ulcer healing: 1.25-1.5 g/kg
Stage III/IV: 1.5-2.0 g/kg (depending on size and amt of

protein loss from draining wounds)

Fluid
Stage I/II: >30 mL/kg per day
Stage III/IV: 30-40 mL/kg per day
*Adjusted for fluid losses

No specific recommendations of carbohydrates or

fats based on pressure ulcer

Micronutrients
Vitamin A (any stage): 10,000 to 50,000 IU for 10

days
Taking steroids should be considered

Vitamin C
Stage I/II: 100-200 mg/d
Stage III/IV: 1000 to 2000 mg/d
Renal failure: 60-100 mg/d
Zinc: 220 mg bid for 10-14 days
May need more if patient has any fluid losses (ex: small

intestinal fluid, stool output, ileostomy)

Amino Acid Supplementation

Arginine and glutamine
Limited evidence
Wound healing ability is minimal
Arginine: caution in critically ill patients
with sepsis because it can contribute to
unstable hemodynamic status

Administration of Enteral Nutrition and Pressure

Ulcers
Underfeeding:
Increase risk for pressure ulcers
Increased risk for nosocomial infection
Loss of lean body mass
Prolonged duration of weaning from mechanical ventilation
Delayed wound healing in patients with existing pressure

ulcers
Can cause diarrhea or high gastric residual volumes
Feeding within 24-48 hours of admission
More likely 2 to 8 days
Patients only received ~ 63% of their estimated energy

needs

Diarrhea
Not necessarily caused by enteral nutrition
Medications with a sorbitol base
Clostridium difficile
Bacterial overgrowth in the gastrointestinal tract
Intolerance to the formula used for feeding
Enteral feeding should only be

discontinued if all other causes are ruled

out

Nursing
Be sure to keep skin clean and dry from

infectious substances
Elevate the head during feedings (30-45)
to prevent aspirations
Be sure to check sacral and buttocks regions

CAN WE FEED?
C: critical care severity
A: age
N: nutrition risk screening
W: wait for resuscitation
E: energy requirements
F: formula selection
E: enteral access
E: efficacy
D: determination of tolerance

Used by critical care team to determine if a patient

is ready for tube feeding

Conclusion
Early referral to a RD is the essential first step in

improving nutritional outcomes for patients to be

at risk for nutrition and pressure ulcers
If a pressure ulcer is found, vitamins A, C, and
zinc are crucial to the healing process
More research needs to be done to verify the
effectiveness of arginine and glutamine in
pressure ulcer healing