Nutrition and Pressure Ulcer Healing

Laurie Scudder, DNP, NP


March 19, 2013


Siang Choo and colleagues described the methodologic issues of the studies included in their systematic review. Only 1 study reported the use of a power analysis to determine sample size. All but 1 study provided clear descriptions of the statistical methods used. Only 2 studies reported intention-to-treat analyses, although even these were not reported on the entire sample, increasing the possibility of a type 1 (false-positive) error. Most of the studies did not examine cost-effectiveness as a secondary outcome.

The nutritional interventions were equally varied. All but 1 used enriched protein, but often as part of a mixed supplement. One study examined the effect of collagen protein and, although healing was significantly improved in the group treated with the protein, the effect size was only small to moderate. Therefore, the researchers concluded that it is unclear whether protein alone is sufficient to improve the rate of healing of pressure ulcers. All of the trials that used mixed supplements (protein, arginine, zinc, vitamin C, and other micronutrients) found improved healing overall.

This systematic review leaves us essentially where the Cochrane review conducted 10 years ago did -- with a cluster of small studies that provide tantalizing and sound, although not conclusive, evidence that nutrition matters in the healing of pressure ulcers. Exactly what that nutritional supplementation should be, the necessary duration of use, the patient populations for whom it is indicated, and the types of pressure ulcers that would most benefit remain unclear. The lack of evidence is reflected in current clinical guidelines, which do not provide clear direction for the use of nutritional supplementation. The development and management of pressure ulcers remains an important benchmark for the quality of nursing care. Sadly, however, with an aging, increasingly frail elderly population, pressure ulcers are not likely to become true "never events." Therefore, nurses must develop methodologically sound, adequately powered studies to definitively determine the most appropriate treatment strategy for patients with pressure ulcers.



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