Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 24

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

The poor nutritional state of many patients
often goes unrecognized by health professionals
who receive little training on nutritional issues
(Wong et al. 2012: Spinal Cord 50, 446-451).
The use of a SCI specific nutrition screening tool,
such as the Spinal Nutrition Screening Tool
(SNST) may improve the identification of persons
at nutritional risk for developing pressure ulcers.
The SNST assesses eight criteria, of which the
majority are recognized predictors or symptoms
of undernutrition: history of recent weight loss,
body mass index (BMI), age, level of SCI,
presence of co-morbidities, skin condition,
appetite, and ability to eat. Each step of screening
has a score of up to 5, and the total score reflects
the patient's degree of risk. A score of 0-10
indicates a low risk of undernutrition, 11-15
indicates moderate risk of undernutrition, and
greater than 15 indicates high risk of
undernutrition (Wong et al. 2013, Eur j Clin Nutr
66, 382-387). However, in a recent multicenter
study from the United Kingdom on malnutrition
risk, the percentage of patients identified at risk
of undernutrition using the SNST was only slightly
greater at 44.6% compared with 40.0% using a
generic nutrition screening tool (Wong et al.,
2012 Br J Nutr 108, 918-923).
D I E TA RY I N TA KE

A dietary history can illustrate the
adequacy of an individual's usual food intake.
Factors that contribute to inadequate nutritional
intake are poor appetite, food intolerances and
allergies, difficulty with chewing and swallowing,
difficulty with food acquisition and preparation,
immobility, social neglect, lack of knowledge
about healthy food choices, depression, and
poverty (Waterlow, 1996).
Inadequate intake of food and a consecutive
3-day worsening of appetite have been identified
as significant predictors of pressure ulcer
development (Berglund and Nordstrom, 1995;
Bergstrom and Braden, 1992; Ek et al., 1991;
Tourtual et al., 1997). Individuals who develop
pressure ulcers have significantly lower calorie
and protein intake than do those who do not have
pressure ulcers (Bergstrom and Braden, 1992).
Successful dietary management of malnutrition
often includes advice regarding meal planning,
assistance with meal preparation, use of assistive
eating devices, and change of meal patterns to six
small feedings daily. Healthy high calorie and high
protein foods (e.g., coconut milk, nuts/nut
butters, avocados, whole grain pastas and whole
grain breads, dried fruits, whey protein, and
cottage cheese) can also be included in the
individual's diet to enhance intake. When dietary

intakes do not meet estimated requirements,
interventions are necessary to provide required
nutritional support.
ORAL SUPPLEMENTS

Commercial oral supplements are available
in liquid and solid forms as well as in puddings
and bars to supplement an individual's usual diet
(Himes, 1997). Liquid supplements are provided
with different nutrient densities, ranging from
1.0 to 2.0 kilocalories per mL, with 13% to 25%
of total calories as protein, and the recommended
dietary allowance for vitamins and minerals
in approximately 1,000 to 1,500 mL of formula.
Commercial flavored breakfast drinks are not
recommended as these drinks are often laden
with sugar, artificial flavors, and colors.
In one study, 200 mL of liquid nutritional
supplement given twice daily in addition to a
standard hospital diet was associated with the
development of fewer pressure ulcers and the
healing of existing pressure ulcers to a greater
extent than in an unsupplemented control
group (Ek et al., 1991).
ENTERAL F EEDI NG

When the gastrointestinal tract (GI) is
functional but oral dietary intake is inadequate,
enteral nutrition through a feeding tube is the
preferred method of nutritional support. The
decision regarding the route of enteral access
depends on the anticipated duration of tube
feeding and the risk of pulmonary aspiration of
stomach contents. Short-term access (less than
4 to 6 weeks) is possible through the nasogastric,
nasoduodenal, or nasojejunal routes. For longterm access (greater than 6 weeks), surgical or
percutaneous endoscopic gastrostomy or
jejunostomy tubes can be inserted.
Use of enteral feedings should be strongly
considered if an individual is unlikely to meet
his or her estimated nutritional needs within
3-5 days.
Enteral feeding formulas differ by calorie
and protein density, fiber content, form of
nutrients, and amounts of micronutrients.
Selection of the appropriate formula depends
on the individual's digestive and absorptive
capacity and on specific indications for the
formula. Formulas can be administered by bolus,
intermittent, cyclic, or continuous methods.
The most common complications associated with
tube feedings are diarrhea and tube obstruction.

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