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ressure ulcers have been and continue to be long-term concerns of long-term care facilities. The prevalence of ulcers ranges from 7 to 23 percent with an annual incidence of 10 to 21 percent.1 Studies show that the longer residents live in a nursing home, the greater their likelihood of developing an ulcer. Of those patients who have been in a home for three months, approximately five percent will suffer an ulcer. That number jumps to 26 percent when residents have stayed in a facility 12 to 18 months.1
       The repercussions of pressure ulcers are more than significant. They are associated with increased morbidity and mortality; they can cause substantial pain in those afflicted; and they consume a large proportion of a facility's staff and financial resources. On average, it takes five months for a pressure ulcer to heal.1 Multiply these effects by the number of patients who have an ulcer or are at risk for developing one, and the impact can be staggering.

The Role of Nutrition
       Nutrition is a preventive and restorative tool for managing the problem of pressure ulcers. Good nutrition fortifies the body and strengthens the immune system, whereas poor nutrition weakens the body's defenses and can increase a person's risk for developing a wound (see Table 1). In fact, malnourished patients are believed to be twice as likely as well-nourished patients to develop an ulcer.2 In short, poor nutrition:
- Complicates wound care treatment by altering the body's metabolism
- Inhibits tissue regeneration
- Affects the body's inflammatory response to an ulcer
- Depresses immune function, which increases the risk for infection.3

Poor Nutrition is Common
       Poor nutrition is a very real issue for long-term care patients. Studies have shown a high incidence of malnutrition in hospital patients (often the primary source of extended care admissions). Statistics range from 25 percent to 45 percent.4 A recent study that followed patients from hospital discharge through their admission into subacute care facilities found that nearly one-third of patients were malnourished, while almost two-thirds were at risk of malnutrition.5

Nutrition Support for Pressure Ulcer Prevention and Treatment: The Basics
       The nutritional cornerstone to wound prevention and treatment is a well-balanced diet that provides adequate calories and protein.
       Calories. A patient needs to consume enough calories to meet the body's energy needs. Calories must be sufficient enough to spare protein so that it can be used for manufacturing new tissue. The recommended amount of calories is 30 to 35 calories/kg/day for individuals who have a pressure ulcer and individuals who are nutritionally compromised. (This same level is also recommended for clients at risk of developing a pressure ulcer.6)
       Protein. Protein is a building block for all cells and is essential for tissue maintenance and repair. The nitrogen found in protein is required for the replication and growth of lymphocytes, fibroblasts, granulation tissue, and other wound healing substances. If the body does not get enough protein, its ability to restore injured tissue and support new growth is diminished. A high protein diet is recommended for healing. The recommended amount of protein is 1.25 to 1.50 grams/kg of body weight/day.6
       Fluids. Hydration status often takes a back seat to other nutritional needs. However, dehydration is a risk factor for pressure ulcers because of its relationship to blood volume and circulation. Blood transports oxygen, nutrients, and cell-building substances to wounds. Dehydration reduces blood volume and circulation thereby reducing the delivery of these components to help heal wounds.
       Older adults are at a higher risk for dehydration. They have a reduced sensitivity to thirst and may have personal concerns about incontinence. Some residents intentionally reduce fluid intake hoping to limit urine output. Adequate hydration is a priority--it is essential for effective wound care management. The recommended amount of fluids is 30 to 35 milliliters/kg of body weight/day or one milliliter of fluid per calorie if a resident is being fed enterally.2

Additional Nutrients of Value
       Zinc. Zinc supports cell division and tissue synthesis and has a role in immunity. The ability of a wound to heal is compromised when a person is deficient in zinc. A diet history can help determine whether or not a resident's diet contains adequate amounts of zinc. The recommended amount of zinc is 15 milligrams/day.
       Vitamin C. Like zinc, vitamin C participates in tissue growth and wound healing through collagen formation. And like zinc, adequate levels are important for successful wound management. An evaluation of oral or enteral intake can ascertain whether needed levels are being consumed. The recommended amount of vitamin C is 250 milligrams or more per day for patients with wounds.7
       Vitamin A. Vitamin A supports collagen synthesis and has a role in immune function and epithelial development and maintenance. A deficiency in vitamin A may delay wound healing and increase a person's susceptibility to infection.8 The recommended amount of vitamin A is 5000 international units/day.

A New Tool for Healing Wounds
       Until recently, there has been little new on the nutrition and pressure ulcer front. Traditional recommendations as outlined above were the gold standard for pressure ulcer prevention and treatment. Within the past five years, however, arginine and new arginine supplemental products have been recognized as effective therapies for pressure ulcer management.

Why Arginine?
       Arginine is considered essential following injury and metabolic stress because it supports protein synthesis and immune response. Though the exact mechanisms that make arginine beneficial to wound care are unknown, animal studies have found that it can decrease tissue breakdown and increase collagen deposition. Arginine has several qualities that researchers believe may benefit wound care management including:9
- Nitrogen content. Arginine contains twice the nitrogen of most other amino acids: 32-percent nitrogen to 16 percent in the average amino acid. More nitrogen is believed to more effectively and efficiently replace the nitrogen losses that occur in wounds.
- Tissue growth. Arginine increases the body's levels of IGF-1--a hormone that promotes tissue growth and wound healing--and is a precursor to polyamines, which are building blocks to new cell formation.
- Blood supply. Arginine is the only substrate for nitric oxide synthesis; nitric oxide can increase blood supply to wounds.
- Immune function. Arginine has immune-enhancing properties, which can reduce the risk for infectious complications. It supports T-lymphocyte and macrophage function.

Recommended Levels
       A typical, well-balanced diet contains four to five grams of arginine. Studies suggest approximately 9 to 17 grams of supplemental arginine per day will hasten wound healing.9-11 To reach that level, arginine-containing products, including certain types of tube feedings and oral beverage supplements, are helpful. Both expedite the delivery of arginine into the diet. No adverse effects have been shown for supplemental doses in this range.

Other Diet Enhancements
       Like arginine, fish oils and dietary nucleotides are considered immune-enhancing ingredients. Studies have shown they can boost immune status, which in turn could reduce wound complications. Strengthening the immune system can also prevent infection elsewhere in the body thereby enabling the body to focus on wound healing versus fighting a secondary infection.
       Glutamine, another amino acid, is being studied for its potential role in wound healing. Supplementation may accelerate tissue repair and boost the immune system. Consensus is that further research is needed to determine the magnitude and significance of glutamine's role in pressure ulcer management.