SUBJECT: Identification and Monitoring of Patients in SNF/LTC Units with Impaired Skin

POLICY: Patients with pressure ulcers, pressure ulcers that are increasing in stage level, deep tissue injury, necrotizing
fasciitis, wound dehiscence, burns, surgical wounds, infected wounds, and/or are admitted with chronic wounds will be
given additional nutrition support utilizing ProNutra

PROCEDURE:
1. Nursing will screen all patients per facility policy for any wounds and any signs of actual or potential skin breakdown.
2. Nursing will screen those patients that are found to have wounds for possible contraindications for the use of ProNutra:
• Milk protein allergy (If patient can tolerate small amounts of milk/yogurt/cheese etc, he or she will probably tolerate
ProNutra without problems. ProNutra contains < .07 % lactose.)
• Immune suppression therapies/medications unless under physician supervision
• Transplantation
3. Nursing will alert clinical nutrition services per facility policy.
4. Registered dietitian will assess patient and make suggestions for appropriate nutrition interventions including dosage of
ProNutra taking into consideration if patient has renal problems, is diabetic, has multiple wounds, or 3rd/4th degree burns.
5. Registered dietitian will evaluate the current intake of the patient versus current needs for the following key nutrients:
Protein, Vitamins A and C, Iron, and Zinc.
6. Registered dietitian will request additional protein using ProNutra (18.13 grams per bottle) to meet but not exceed estimated
total protein requirements.
7. Registered dietitian will review BUN/creatinine levels and adjust protein and fluid recommendations accordingly.
8. Registered dietitian will consider fat content provided by ProNutra if pertinent (5.55 grams/bottle).
9. Registered dietitian will adjust current vitamin/mineral supplements to ensure total supplementation does not exceed
estimated requirements with the addition of ProNutra. Note: When ProNutra reaches 4 bottles per day, there is no need for
oral or intravenous vitamin/mineral supplementation.
10. To assure uniformity of care, the following physician ordered administration protocol may be used to meet the patient’s
needs:
a. Prophylactic: For patient <190 lbs, if Braden score is high, or patient has lost 5% of body weight (PEM) in 30
days or 10% in 180 days, or if patient has alb. <3.1, give ProNutra 1 bottle (37 g) every day. For every 50 pounds
over 190 lbs, 1 more bottle of ProNutra may be necessary as a prophylactic.
b. Stage I and II: Patient should receive ProNutra 1-2 bottles (37 g) QD depending on weight, age of wound, and co-
committing factors/diagnoses until fully resolved.
c. Stage III and IV and multiple wounds: Patient should receive ProNutra 1 bottle (37 g) BID. Need may be as much
as 3-4 bottles per day depending on weight, age of wound and co-committing factors/diagnoses. Monitor Patient
using the PUSH tool and ProNutra Intervention Flow Chart indicators (e.g., odor stoppage, drainage clear,
granulation, wound “pinking up”, skin tone normal, tunneling stopped) for first 2-3 weeks.
d. Post Initial 2-3 Week Assessment: If at least 3 of the ProNutra Intervention Flow Chart indicators are not present,
increase supplement of ProNutra 1 bottle (37 g) to TID for an additional 2-3 weeks, or until at least 3 of the 6
indicators are present per wound.
e. For those patients with severe wounds, necrotizing fasciitis, burns, etc, the use of 3-4 bottles daily may not be
uncommon and depending on age of wound and weight, 4-6 bottles may be the norm.
f. If a wound begins to heal and then inexplicitly stops progressing for two weeks; increases in size; or if new
wounds break through because of deep tissue injury, increase ProNutra an additional bottle from dosage being
currently used. Investigate conditions or patho-physiology that may be increasing nutritional/glutathione needs.
g. Post Resolution of Wound: Chronic wounds or patient with a propensity to develop wounds should receive
continued ProNutra intervention at 1 bottle (37 g) every other day for a period of 3-4 weeks, or according to
nutritional needs. For those at upper weights, 1 bottle should be provided daily rather than every other day. Note:
discontinuing ProNutra for more than 2 weeks will require that you build up nutritional reserves of ProNutra as
described in 10d above.
11. All recommended interventions will be documented in the patient’s plan of care.
12. Nursing will communicate to patient all interventions to be initiated.
13. All interventions will be reviewed by physician, nursing and dietetics professional to determine their effectiveness.
Adjustments to the interventions will be made as needed:
a. If area is decreasing in size and/or showing improvement, the interventions will be continued.
b. If area is not improving or has deteriorated, a reevaluation of all interventions will be completed.
c. If area has remained closed for 3-4 weeks, additional nutrition intervention may not be needed.
14. When patient is transferred from unit, orders should be written to continue protocol until wounds are closed and underlying
tissue has been sufficiently developed.