Registered Nurses' Association of Ontario

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Nutrition and Hydration

  • A nutrition and hydration assessment with appropriate interventions should be implemented on entry to any health-care setting and when the client’s condition changes
  • If a nutritional deficit and/or dehydration is suspected:
    • Consult with a registered dietitian;
    • Investigate factors that compromise an apparently well nourished individual’s dietary intake (especially protein or calories) and/or fluid intake and offer the individual support with eating/drinking;
    • Plan and implement a nutritional support and/or supplementation program for nutritionally compromised/dehydrated individuals; and
    • If dietary/fluid intake remains inadequate, consider alternative nutritional interventions.
  • Key components of a nutrition assessment that must be considered for pressure ulcer prevention and/or management are as follows:
    1. Adequacy of intake of nutrition and hydration from all sources (e.g. calories, protein, micronutrients [e.g. vitamins/minerals], fluid);
    2. Precautions and contraindications to nutrient and fluid supplementation;
    3. Routes and extent of nutrition/hydration loss (e.g. gastrointestinal tract, urinary tract, wound exudate, fistulae, diaphoresis, negative pressure therapy);
    4. Weight status – significant unintentional weight loss, weight stability, overweight/ obesity and the importance of frequent weight monitoring.
    5. Nutrition/hydration-related blood work;
    6. Ability to self-feed/need for assistance with eating and drinking; and
    7. Other barriers to optimal food/fluid intake (e.g. impaired dentition, dysphagia, impaired cognition/communication, advanced age, psychosocial factors, inadequate screening/assessment and monitoring).
  • Patients with nutritional risk and pressure ulcer risk factors should be offered:
    • A minimum of 30-35 kcal /kg body weight/day with 1.25-1.5 g/kg/day protein
    • A minimum of 1 ml of fluid/kcal/day
    • For patients with dehydration, diarrhea, vomiting, elevated temperature, profuse sweating or heavily draining wound(s), provide additional fluid;
    • A well balanced diet that includes appropriate sources of vitamins and minerals;
    • If dietary intake is poor or deficiencies are suspected, offer vitamin/mineral supplements.
  • Implementation of greater amounts of calories, protein and fluid, and initiation of vitamins and minerals must be based on clinical assessment and judgment by a registered dietitian based on a comprehensive nutrition assessment that considers concurrent disease processes and the inherent precautions and contraindications to supplementation
  • The chart below outlines some of the nutrition/hydration-related blood work important to pressure ulcer prevention:

Albumin and

Prealbumin

 Albumin and prealbumin are hepatic proteins that are often cited in the literature as markers of protein and nutrition status. There is much discussion among clinicians and authors, with many disputing the value of albumin and prealbumin as nutritional markers, especially in critical care and acute care settings. Low values reflect severity of illness and/or injury regardless of protein status and are “red flags” for the potential of a patient to develop malnutrition or to become more malnourished.
Anemia

If a patient presents with anemia it is imperative that the type of anemia be identified.

Both iron deficiency anemia and anemia of chronic disease (ACD) result in a decreased hemoglobin level, which is a barrier to healing. A chronic non-healing pressure ulcer itself is an inflammatory process that may lead to ACD.
Glycemic Control The physical signs and symptoms of diabetes do not always accompany hyperglycemia that is identified by blood tests (Fraser, 2007). It is recommended that both fasting blood glucose and Hemoglobin A1C be screened in all individuals with pressure ulcers, as an individual may present with normal fasting levels but have impaired glucose tolerance. Screening an individual who has no known history of diabetes mellitus may uncover previously unidentified hyperglycemia that is negatively impacting his or her wound management. Preventing and treating ulcers are more effective when screening and management measures are implemented to address underlying factors such as hyperglycemia that impede successful outcomes. Hemoglobin A1C levels greater than 7.0 per cent (0.070) are associated with significantly increased risk for both microvascular and macrovascular complications. Individuals with diabetes exhibit significantly impaired wound healing and increased complication rates. Controlling serum glucose levels to promote wound healing and prevention cannot be overemphasized
Hypothyroidism Hypothyroidism is a metabolic disorder that exerts biochemical and histological effects on tissue integrity and regeneration that can adversely affect wound prevention and healing. Hypothyroidism and diabetes mellitus can coexist in clinical settings. The influence of these conditions individually and concurrently warrants the screening for, and immediate management of these conditions for optimal wound healing.
Dehydration

Dehydration is a risk factor for skin breakdown and wound healing. The blood urea nitrogen (BUN):creatinine ratio may be used as an indicator of a patient’s hydration status, though may not be accurate in patients with renal failure. An elevated BUN level with a normal or low creatinine level may indicate under-hydration. A BUN:creatinine

ratio greater than 20:1 is a red flag for dehydration which must be investigated and addressed. In addition, BUN and creatinine are indicators of renal function. A clinician must be aware of a patient’s renal status prior to the recommendation of enhanced protein, fluid, vitamins and minerals as there are precautions and contraindications to supplementation in a case of renal insufficiency as well as in other co-morbidities.
  • Whether or not blood work is readily available, it is essential that the patient be assessed for the following clinical signs and symptoms of dehydration:
    • Decreased urine output;
    • Dark, concentrated and/or strong-smelling urine;
    • Frequent urinary tract infection;
    • Dry lips/mouth and thick, stringy saliva;
    • Constipation;
    • Dizziness when sitting up or standing;
    • Confusion or change in mental status;
    • Weight loss of 1.5 kg (3.5lb) in less than seven days;
    • Fever;
    • Decreased skin elasticity, such as on the arm that, when gently pinched, does not spring back into place but remains “pinched up” when released; and
    • Sunken eyeballs.
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