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. 2022 Nov 15;14(11):8252–8262.

Evidence summary on nutrition management for post-stroke dysphagia

Yuan Wang 1,2, Lijun Xiang 1,2, Yansi Luo 1, Meng Cao 1, Xuemei Song 1, Jing Hong 1, Xiaomei Zhang 1
PMCID: PMC9730085  PMID: 36505333

Abstract

Objective: To summarize and evaluate the relevant evidence on nutrition management of post-stroke dysphagia (PSD) to provide evidence-based basis for clinical staff. Methods: We searched evidence in BMJ Best Practice, Up To Date, Cochrane Library, PubMed and so on from their inception to May 31, 2021. The quality assessment was conducted by two researchers by using AGREE II for guidelines, JBI evidence-based health care center evaluate standards for systematic review and expert consensus. Results: An initial searching of 445 literatures resulted in 26 literatures that met inclusion criteria. Finally, a total of 38 pieces of evidence were summarized from 5 aspects including nutrition risk screening and assessment, nutrition support principles, enteral nutrition, parenteral nutrition, and hydration management. Conclusions: This study summarized the evidence of the nutrition management for PSD patients. Since evidences are from different countries, it’s better to assess the clinical environment and other related factors before their application.

Keywords: Post-stroke dysphagia (PSD), nutrition management, nutrition support, evidence-based nursing, evidence summar

Introduction

Stroke has become the second leading cause of death and disability in the world, threatening human health [1]. Stroke patients often suffer from dysphagia, disturbance of consciousness, cognitive impairment, emotional disturbance, etc. These brain dysfunctions can cause patients to have difficulty eating, insufficient nutrient intake, and/or increased nutrient consumption (such as fever, etc.), thereby causing malnutrition or increased nutritional risk after stroke [2]. Post-stroke dysphagia (PSD) is one of the most common complications, with an incidence of 45%-65% [3]. It can not only lead to aspiration, pneumonia, dehydration, electrolyte disorders, and nutritional disorders, but also greatly increase the risk of death and poor prognosis. Among these complications, malnutrition is one of the most important one after stroke dysphagia. Malnutrition caused by dysphagia accounts for 8%-34%, and 15% of stroke patients may suffer from malnutrition due to long-term dysphagia [4]. Malnutrition not only affects the recovery of neurological function and living ability, but also significantly increases the risk of stroke complications such as stroke-related pneumonia, gastrointestinal bleeding and so on, prolongs the hospitalization time, and increases the risk of disability and mortality after stroke [2]. Although drugs can effectively prevent the occurrence and development of diseases, but the importance of nutrition is undeniable. Therefore, early detection of malnutrition and appropriate nutrition management have important clinical significance for PSD patients.

Nutrition management after stroke is an important part of organized stroke management and a potential intervention target for improving stroke prognosis. Although there are many guidelines on stroke that include nutrition management, most of them are comprehensive guidelines and target a large range of patients. So, this study retrieved, analyzed and summarized the relevant evidence of nutrition management for PSD patients, in order to provide theoretical guidance for clinical staff when providing nutrition interventions, to promote the implementation of nutrition support, and to improve their clinical outcome.

Materials and methods

Question identification

Using Problem Development Tool of Evidence-based Nursing Center of Fudan University, and identifying questions according to PIPOST principle [5]. The formed initial question was as follows: P (Population): Post-Stroke Dysphagia (PSD); I (Intervention): The content of the included literature involves the evaluation, management, and intervention of diet or nutrition; P (Professional): Medical staff; O (Outcome): Nutritional status, incidence of related complications, and clinical outcome; S (Setting): The Department of Internal Neurology and Neuro Intensive Care Unit; T (Type of evidence): Clinical decision, guidelines, systematic reviews, meta-analysis, expert consensus and evidence summary.

Retrieval strategy

According to the “6S” evidence mode [6], we searched BMJ Best Practice, UpToDate, Cochrane Library, Joanna Briggs Institute (JBI) Library, National Institute for Health and Clinical Excellence (NICE), American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism (ESPENR), Chinese Society of Parenteral and Enteral Nutrition (CSPEN), PubMed, Web of Science, Medlive, CNKI, Wanfang Database and Chinese Biomedical Literature Database to collect clinical decision, guidelines, systematic reviews, meta-analysis, expert consensus and evidence summary on nutrition management for PSD patients. The English search terms were “stroke/cerebral stroke/cerebrovascular accident*/cerebrovascular apoplexy/cerebralinfarction/cerebral hemorrhage/apoplexy/cerebrovascular stroke*/CVA*”, “deglutition disorders/dysphagia/swallowing disorder”, “nutritional support/nutrition/diet/nutrition therapy/nutrition strategies/enteral nutrition/parenteral nutrition/nasogastric tube/nasointestinal tube/EEN”, and “meta-analysis/guideline*/evidence/practical guidance*/expert consensus/systematic review”. Retrieval time was from database establishment to May 31, 2021.

Inclusion and exclusion criteria

Inclusion criteria: (i) the objects comprised PSD (≥ 18 years old); (ii) the content involves nutrition screening, nutrition assessment, enteral nutrition support, parenteral nutrition support and oral nutrition support; (iii) outcome indicators include the nutritional status, the incidence of related complications, and the clinical outcome; (iv) type of evidence includes clinical decision, guidelines (nearly 10 years), expert consensus, systematic reviews, meta-analysis, and evidence summary and (v) the article was published in the Chinese or English language. Exclusion criteria: (i) the literature was a direct translation of foreign guidelines or duplicate guidelines; (ii) clinical practice guidelines or systematic reviews with incomplete information and (iii) full text cannot be obtained.

Literature quality evaluation

(i) Guidelines: the “Appraisal of Guidelines for Research and Evaluation (AGREE II)” updated in 2017 [7] was used for evaluation, including 6 fields, 23 items and 2 comprehensive evaluation items. According to the degree of consent, each item is scored from 1 (very disagreeable) to 7 (very agreeable). And the two comprehensive evaluation items are scored on a 7-point system (1 the article quality may be the lowest, 7 the article quality may be the highest). After standardizing the total score of each item in a certain field, the final score obtained is the score in this field. The score determines the quality of the guideline [8].

(ii) Expert consensus, meta-analysis and systematical review were evaluated by the relevant evaluation tools of the Australian JBI Evidence-based Health Care Center (2016 Edition) [9].

(iii) For clinical decision and evidence summary included, we traced the original literature, and then evaluated the quality according to the type of the original literature.

Literature quality evaluation process

Two researchers trained by the JBI Collaborating Center for Evidence-based Care at Fudan University independently evaluated the literatures in accordance with the above criteria. The researchers discussed the evaluation results of each literature together. If a dispute arose, the issue was discussed with a 3rd researcher who decided whether to include or exclude the literature. If there were any conflicts about the conclusions drawn for different sources of evidence, this study followed the principle of evidence priority, high-quality evidence priority and the latest published authoritative literature priority.

Results

General characteristics of included literatures

In this study, we initially obtained 445 literatures. After removing duplicate literatures, reading abstracts and further reading the full text, deleting the guidelines and including the corresponding latest version and evaluating the quality of the literatures, 26 literatures were obtained, including 12 guidelines [10-21], 9 systematic reviews [22-30], 4 expert consensus [31-34], and 1 evidence summary [35]. The general characteristics of the included literatures are shown in Table 1. Screening flow chart for literatures is shown in Figure 1.

Table 1.

General characteristics of included literatures

Included literatures Year Source Type of evidence Topic
CSA [10] 2020 PubMed Guideline Clinical management of stroke rehabilitation
CSA [11] 2020 PubMed Guideline Clinical management of ischaemic cerebrovascular diseases
AHA/ASA [12] 2019 PubMed Guideline Early Management of Patients With Acute Ischemic Stroke
AHA/ASA [13] 2016 PubMed Guideline Adult Stroke Rehabilitation and Recovery
NICE [14] 2019 NICE Guideline Diagnosis and management of stroke
Burgos et al [15] 2017 ESPEN Guideline Clinical nutrition in neurology
NSF [16] 2017 Medlive Guideline Clinical Guidelines for Stroke Management
RCP [17] 2016 NICE Guideline National clinical guideline for stroke
Wirth et al [18] 2013 PubMed Guideline Clinical nutrition in patients with stroke
Teasell et al [19] 2019 BMJ Best clinical practice guideline Rehabilitation, Recovery, and Community Participation following Stroke
Boulanger et al [20] 2018 BMJ Best clinical practice guideline Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care
Umay et al [21] 2021 PubMed Best clinical practice guideline Management, Diagnosis, and Follow-up for Stroke Patients with Dysphagia
Liu X et al [22] 2021 PubMed Systematic review Effect of probiotics on the nutritional status of severe stroke patients with nasal feeding
Geeganagee et al [23] 2012 Cochrane Library Systematic review Interventions for dysphagia and nutritional support in acute and subacute stroke
Sun et al [24] 2020 CNKI Systematic review Safety of quantifying food consistency in patients with dysphagia after stroke
Yuan et al [25] 2020 CNKI Systematic review Effects of intermittent tube feeding on stroke patients with dysphagia
Dong et al [26] 2020 CNKI Systematic review Effects of intermittent tube feeding on swallowing function and nutrition status of stroke patients with dysphagia
Luo et al [27] 2020 CNKI Systematic review The effect of enteral nutrition support on patients with acute stroke with dysphagia
Dang et al [28] 2019 CNKI Systematic review Effects of different nutrition therapies for dysphagia patients of stroke
Wang et al [29] 2016 CNKI Systematic review Enteral nutrition combined with parenteral nutrition in the treatment of patients with cerebral hemorrhage
Xu et al [30] 2017 CNKI Systematic review efficacy of intermittent oro-esophageal tube feeding on post-stroke dysphagia
CSPEN et al [31] 2015 Medlive Expert consensus Percutaneous endoscopic gastrostomy feeding for patients with nervous system diseases
CSPEN et al [32] 2019 Medlive Expert consensus Enteral nutrition support for neurological diseases
China Expert Consensus Group on Rehabilitation Evaluation and Treatment of Dysphagia [33] 2018 Medlive Expert consensus Evaluation and treatment of dysphagia
China Stroke Nutrition Standardization Management Expert Committee [34] 2020 Medlive Expert consensus Standardized nutrition management of stroke patients
Zhang et al [35] 2017 CNKI Evidence summary Nursing Management of Eating Difficulty after stroke
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CSA: Chinese Stroke Association; AHA/ASA: The American Heart Association/American Stroke Association; NICE: The National Institute for Health and Care Excellence; ESPEN: The European Society for Clinical Nutrition and Metabolism; NSF: National Stroke Foundation; RCP: Royal College of Physicians; CSPEN: Chinese Society of Parenteral and Enteral Nutrition.

Figure 1.

Figure 1

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Screening flow chart for literatures.

Quality evaluation results of the included literatures

Quality evaluation results of the guidelines

In this study, 12 guidelines were included. Table 2 is the quality evaluation results of the guidelines.

Table 2.

AGREE II scores of the included guidelines

Guidelines Scope and purpose Involved personnel Preciseness of guideline development Clarity of presentation Applicability Independence of writing The overall quality score Recommend using this guideline
10 72.2 63.9 20.8 77.8 41.7 100 5 7
11 73.4 64.6 34.4 80.2 57.6 100 5 7
12 92.4 69.2 88.4 93.2 48.3 95.9 6 7
13 89.8 76.4 88.1 91.1 64.5 85.6 6 7
14 80.5 75.3 64.8 94.3 60.4 100 7 7
15 85.4 66.1 72.8 80.2 54.3 89.2 6 7
16 85.7 69.2 67.7 92.8 57.1 92.1 6 7
17 92.3 80.1 85.9 93.2 73.3 100 6 7
18 83.2 65.6 80.7 90.2 47.5 82.3 6 7
19 90.4 67.6 89.3 85.6 56.4 100 6 7
20 84.3 78.6 75.3 88.3 60.2 100 6 7
21 75.9 69.5 52.5 79.5 55.8 93.2 6 7
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Quality evaluation results of systematic reviews

In this study, 9 systematic reviews were included. Table 3 is the quality evaluation results of systematic reviews.

Table 3.

JBI scores of included systematic reviews

Items 22 23 24 25 26 27 28 29 30
1. Is the review question clearly and explicitly stated? Yes Yes Yes Yes Yes Yes Yes Yes Yes
2. Were the inclusion criteria appropriate for the review question? Yes No Yes Yes Yes Yes Yes Yes Yes
3. Was the search strategy appropriate? Yes Yes Yes Yes No No Yes No No
4. Were the sources and resources used to search for studies adequate? Yes Yes No Yes No No Yes No No
5. Were the criteria for appraising studies appropriate? Yes Yes Yes Yes Unclear Yes Yes Yes Yes
6. Was critical appraisal conducted by two or more reviewers independently? Yes Yes Yes Yes Yes Yes Yes Unclear Yes
7. Were there methods to minimize errors in data extraction? Yes Yes Yes Yes Yes Yes Yes Yes Yes
8. Were the methods used to combine studies appropriate? Yes No Yes Yes Yes Yes Yes Yes Yes
9. Were the methods used to combine studies appropriate? Yes No Unclear No Unclear Unclear Unclear Yes Yes
10. Were recommendations for policy and/or practice supported by the reported data? Yes Yes Yes Yes Yes Yes Yes Yes Yes
11. Were the specific directives for new research appropriate? Yes Yes Yes Yes Yes Yes Yes Yes Yes
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Quality evaluation results of expert consensus

In this study, 4 expert consensus were included. Table 4 is the quality evaluation results of expert consensus.

Table 4.

JBI scores of included expert consensus

Items 31 32 33 34
1. Is the source of the opinion clearly identified? No Yes Yes Yes
2. Does the source of opinion have standing in the field of expertise? Yes Yes No Yes
3. Are the interests of the relevant population the central focus of the opinion? Yes Yes Yes Yes
4. Is the stated position the result of an analytical process, and is there logic in the opinion expressed? Yes Yes Yes Yes
5. Is there reference to the extant literature? Unclear Yes Yes Unclear
6. Is any incongruence with the literature/sources logically defended? Yes No Yes No
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Quality evaluation results of evidence summary

In this study, 1 evidence summary was included. After tracing the original literature, we got 3 guidelines, one of which is not a recent 10-year guideline, so it was excluded; one was a duplicate of this study included [13]; the other one was also excluded because we had included its latest version [19].

Evidence summary and description

The Australian JBI Evidence-based Health Care Centre Evidence Recommendation Level System (2014 edition) was used to grade the included evidence (grades 1 to 5). Using the FAME evaluation principle to evaluate the feasibility, suitability, clinical significance and effectiveness of the evidence, and give recommendations (A is a strong recommendation, and B is a weak recommendation). Finally, a total of 38 pieces of evidence were summarized from 5 aspects including nutrition risk screening and assessment, nutrition support principles, enteral nutrition, parenteral nutrition, and hydration management, as shown in Table 5.

Table 5.

Evidence summary of nutrition management for PSD

Evidence item Content of evidence Evidence level Recommendation level
Nutrition risk screening and assessment All PSD patients should receive nutrition risk screening within 48 hours of admission [15,16,18,19,21,32,34]. 5 A
Nutrition risk screening should be performed by trained medical personnel [14]. 4 A
NRS-2002 is recommended for nutrition risk screening [15,32]. 3, 5 A
Stroke patients at nutrition risk and/or with dysphagia should be referred to an Accredited Practising Dietitian for further assessment [16,18]. 3 B
Nutrition support principles It is reasonable to provide nutritional supplements for PSD patients [11-13]. 1 A
To patients at risk of malnutrition, nutrition support including oral nutrition supplements, therapeutic diets and/or tube feeding should be offered according to their wishes. If they lack mental capacity, offered in their best interests [17,23]. 1-3 B
It is suggested to form a nutrition management team involving professional nutritionists [33]. 5 B
Enteral nutrition Enteral nutrition is preferred if there is no contraindication [27,28,32,33]. 1 A
Enteral nutrition is initiated within 7 days and nasogastric feeding tube is preferred [11,16,18,32,34]. 2 A
Nasointestinal tube is appropriate for those with high risk of aspiration [34]. 1 A
Continuous infusion is recommended when adopting nasojejunal or duodenal feeding tube [18]. 3 B
Enteral nutrition combined with parenteral nutrition is preferred for postoperative patients with cerebral hemorrhage [29]. 1 A
During feeding tube, the bed head should be continuously raised ≥ 30° [32]. 4 A
The amount of feeding tube should be from less to more and reach the full amount as early as possible (within 3 days) [32]. 3 B
Tube feeding speed should be slow to fast, that is, the infusion volume on the first day was 20-50 ml/h, and that on the next day was 80-100 ml/h. If possible, adopting a infusion pump to control the speed [32]. 5 A
Flushing the tube with 20-30 ml warm water every 4 h [32]. 5 A
For PSD patients, the decision of enteral nutrition should be made as early as possible (within 3 d of admission) in cooperation with the patients, families and the interdisciplinary team [19,20]. 2 A
If the patient unexpectedly removes the gastric tube repeatedly, and he/she needs enteral nutrition for more than 14 days, a nasal loop can be adopted to fix it [15]. 2 A
The position of nasogastric tube should be controlled endoscopically in patients with unexplained worsening of dysphagia [15]. 3 A
Intermittent feeding tube is preferred during the recovery period of PSD patients [25,26,30]. 1 B
Nasointestinal tube should replace nasogastric tube, if patients need to prolong enteral nutrition time [19]. 1 B
Probiotics can be added to enteral nutrition [22]. 1 B
Encourage quantified food or liquid consistency such as thickening agents for PSD patients [16,24]. 1 A
Different types of thickening agents should be offered for choice [15]. 1 A
Nutrition assessment, guidance and monitoring of patients who need to change the texture of food or fluid viscosity should be conducted by the dietitian [17]. 5 A
Additional oral feeding should be given to conscious PSD patients, according to the kind and severity of dysphagia [18]. 3 B
It’s suggested to monitor regularly the intake and tolerance of PSD patients with altered food texture or fluid viscosity [16]. 2, 3 A
If enteral nutrition lasts more than 28 days, PEG should be used after the patient’s clinical condition is stable (14-28 days) [10-12,15,18,31,32]. 2 B
PEG feeding is not recommended for acute stroke patients with dysphagia (within 7 days) [31]. 1 A
If the patient refuses or doesn’t tolerate the nasogastric tube (after many attempts) and the nasal cage is not feasible or the patient is intolerant of it, but medical nutrition may take more than 14 days, PEG can be started early [15]. 2 A
If the patients have no obvious complications after PEG operation, enteral feeding can be started after 4 h [31]. 1 A
Upright or Fowler’s positions should be adopted during PEG feeding [31]. 5 B
For patients with PEG and long bed time, it is best to adopt an infusion pump to control the speed [31]. 1 A
Parenteral nutrition Parenteral nutrition is recommended for patients with good nutrition status currently if enteral nutrition cannot meet their nutrition needs for more than 7 days [18]. 5 A
If enteral nutrition is contraindicated, not feasible, or cannot satisfy the patient to obtain sufficient hydration, parenteral nutrition should be applied immediately [18]. 3, 5 A
Hydration Management At regular follow-up, unthickened water can be given to patients at risk of aspiration in accordance with their wishes [15]. 5 B
Carbonated liquids are available for PSD patients with pharyngeal residue [15]. 5 B
Crystalloid solutions are preferred to colloid solutions for treatment or prevention of dehydration [16]. 1 A
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PSD = Post-stroke dysphagia; MUST = Malnutrition Universal Screening Tool.

Discussion

Nutrition risk screening and assessment

Evidence 1-4 summarized the timing, tools, screening personnel and precautions of nutritional risk screening for PSD patients. Davis’ study [36] reported that among 185 patients with acute stroke, 30 (16%) were already malnourished at the time of admission. Therefore, it is necessary to carry out early admission nutrition risk screening for stroke patients, in order to determine the nutrition assessment and support program. Nutrition risk screening 2002 (NRS-2002) is an objectively basal nutrition risk screening tool established by the ESPEN expert group in 2002 on the basis of 128 randomized controlled clinical studies [37]. Beginning in 2005, the National Collaboration Group of the CSPEN branch had carried out specific work on nutrition risk screening, except that the BMI adopted domestic standards (18.5 kg/m2), the rest of the nutrition screening tools were consistent with the European [34]. Therefore, it is recommended to use NRS-2002 for nutrition risk screening in hospitalized stroke patients in China. Indeed, there are many guidelines recommending that nutrition assessment be performed by a dietitian, however, the number of dietitians is not always accessible in China, therefore, we think that trained medical personnel can perform it.

Enteral nutrition management

Evidence 8-33 summarized the relevant recommendations of enteral nutrition for PSD patients, of which 8-22 pieces of evidence are feeding tube; 23-27 are oral feeding; 28-33 are percutaneous endoscopic gastrostomy (PEG). Nearly half of stroke patients have difficulty swallowing, which hinders oral nutrient intake and worsens their nutrition status. In addition, severely ill stroke patients will experience disturbances in consciousness and strong stress responses, leading to loss of oral nutrition, change in gastrointestinal motility, and intestinal barrier dysfunction. Nutrients given through the gastrointestinal tract are easier to be absorbed and more in line with the physiological needs of the human body, which can help maintain intestinal mucosal structure and the integrity of intestinal barrier. Therefore, enteral nutrition is significant for PSD patients.

In the FOOD trial-2 [38], compared with delayed feeding tube, early initiation of feeding tube (within 7 days) reduced the mortality of the PSD patients by 5.8%. The FOOD trial-3 [38] showed that in the first 2-3 weeks after acute stroke, feeding by nasogastric feeding would achieve better functional results than feeding by PEG. So, we recommend early enteral nutrition, but don’t support early PEG feeding for PSD patients. At the same time, it is recommended that nasogastric tube is the first choice for short-term nutrition support, and the decision of feeding tube needs to be made as soon as possible. But, for patients with a high risk of aspiration, it is recommended to choose naso-intestinal tube feeding. Because, the ligament of flexion is involved in the feeding process of the naso-intestinal tube, making reflux difficult to occur. And the feeding process is more in line with the normal physiological process of people, and reduces the damage to the gastric mucosa, so the incidence of complications is low [39], and this result was also confirmed in a meta-analysis [40]. Enteral malnutrition caused by the repeated extubation of the nasogastric tube is a common problem in feeding tube. A study showed that the nasal loops were safe, well tolerated and provided adequate enteral nutrition [41], providing time for the patient to resume normal swallowing, thereby avoiding PEG. Therefore, the guidelines recommend that when patients accidentally extubate the gastric tube repeatedly, it can be fixed with a nasal loop. PEG can prevent the stimulation of nasopharynx caused by long-term catheterization, avoid damage to esophageal mucosa, preserve anti-reflux ability, reduce the risk of reflux and aspiration, and the incidence of complications [42]. A meta-analysis [23] also showed that PEG was superior to nasogastric in PSD patients with long-term enteral nutrition. Therefore, the guidelines suggest that if a longer period (> 28 days) of enteral nutrition may be required, PEG should be selected. However, a survey study in China showed that the actual utilization rate of PEG was less than 2% in patients with PEG indications [43]. Therefore, for these patients, they and their families should be fully informed of PEG and its benefits of the feeding.

For PSD patients, the primary goal of rehabilitation is to restore oral eating and improve the quality of life [44]. Therefore, patients who are conscious and highly cooperative should be encouraged to adopt the nutrition support method of oral feeding. The thickening agents and texture-modified foods have become a priority for such patients. However, because the resistance to them affects the patient’s enthusiasm for fluid intake and increases the risk of dehydration, it is necessary to monitor fluid intake and tolerance to the thickening agents and texture-modified foods. There was evidence that different kinds of thickening agents differ in viscosity, texture, taste and appearance, causing differences in palatability and compliance of the patients [15]. In addition, another study [45] showed that various thickening agents had different popularity and taste in different patient groups. Therefore, in the process of providing thickening agents, the preferences of patients should be considered to improve their compliance.

Parenteral nutrition management

Parenteral nutrition is a high-risk and complex feeding method. Improper implementation can lead to problems such as overfeeding, metabolic complications, catheter-related infections, and even serious adverse consequences due to incorrect liquid formulation [46]. In addition, long-term parenteral nutrition support will damage the patient’s intestinal mucosal barrier function, cause translocation of bacteria, and increase the risk of infection. Therefore, parenteral nutrition is usually as a way of nutritional supplementation. For PSD paatients, enteral nutrition is still the first choice.

Hydration management

A meta-analysis [47] showed that there was no significant difference in the effect of colloids and crystalloids on the mortality of patients, but colloids were associated with greater odds of pulmonary oedema. Therefore, crystalloids should be the choice to treat or prevent dehydration.

Conclusions

This study summarized and evaluated the relevant evidence of nutrition management for PSD patients, involving five aspects: nutrition risk screening and assessment, nutrition support principles, enteral nutrition, parenteral nutrition, and hydration management. This provides practical guidance for medical staff when carrying out nutrition interventions. Since the great mass of guidelines included are foreign literatures, taking into account the differences in race, concepts and values, as well as the regional and cultural differences in the medical service system, it is recommended that medical staff should combine the clinical context and clarify facilitating and hindering factors in the process of applying evidence. On this basis, a personalized nutrition support program is developed to maximize the benefits of patients and improve the quality of life.

Acknowledgements

We extend our gratitude to the university library for providing us with databases and providing us with convenient conditions for searching literatures. This study was funded by 2021 Nanfang Hospital Nursing Excellence-Evidence-based Nursing Project [grant numbers: 2021EBNc008].

Disclosure of conflict of interest

None.

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