Stage Iv Pressure Ulcer
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Transcript of Stage Iv Pressure Ulcer
STAGE IV PRESSURE ULCERKathryn AtwaterPVAMU Internship Spring 2013
Patient Background 88 year old, Caucasian male Middle Class Previous Occupation: Mechanical
Engineer Never Married 4 years in military No Children 2 sisters No past history of smoking, alcohol, or
drug use
General Health History Sleeps well Alert Non-ambulatory Mobile through use of wheelchair Tires easily Variable Appetite
Family History Mother
CHF Cause Death
Father Lung Cancer Cause of Death
No other reported family history
Past Medical History Atrial Fibrillation Hypothyroidism UTI Peripheral
Neuropathy Pressure Ulcers Protein Deficiency Leukocytosis Diabetes Mellitis
Hypertension GERD Anemia Lower, Above-the-
Knee Amputation Prostate Cancer Suprapubic
Catheter Colostomy
MedicationsMedication Use Drug/Nutrient
InteractionCarafate Treat/Prevent Ulcers Antacids with
aluminum, some antibiotics, digoxin
Acetaminophen Pain reliever/Fever reducer
BP medication, cholesterol medication, antibiotics, etc
Remeron Anti-depression/Stimulate appetite
MAO inhibitors, BP medications
Metoprolol Reduce BP Fingolimod, some anti-depressants, grapefruit
Amiodarone Reduce BP Fingolimod, dirueticsLisinopril Reduce BP Birth control pills,
ibuprofenNifedipine Reduce BP, treat
anginaErythromycin, some general cold remedies, seizure medications, grapefruit
Medications Cont’d…Medication Use Drug/Nutrient
InteractionMagnesium-oxide Mineral supplement
to treat low magnesium in blood
Tetracycline, thyroid medications, biphosophonate
Vitamin D3 Low PTH, low Vitamin D
n/a
Gabapentin Seizure medication Antihistamines, depression drugs, anxiety drugs, narcotics, muscle relaxants
Omeprazole GERD Warfarin, St. John’s Wort, other antacids
Levothyroxine Treat an underactive thyroid e.g. hypothyroidism
Blood thinners, digoxin
Coumadin treat/prevent blood clots
Alcohol, aspirin-like drugs, non-steroidal anti-inflammatory drugs
Recent Medical History Admitted to Grace Care Cypress 1/11/13
Admitting Diagnosis: Pneumonia Other Diagnoses:
Protein malnutrition Stage 4 Pressure Ulcer on Right Ischial
Tuberosity UTI
Hospitalized 1/26/2013 for esophageal strictures Placed on Mechanical Soft Diet
Re-admitted to Grace Care Cypress 1/28/2013
Pressure Ulcer: General Info Pressure Ulcer: An injury to the skin and
underlying tissues from prolonged pressure on the skin.
Common areas: Locations on skin that cover “bony” areas of body Heel Ankle Elbow Buttocks
4 Stages or Categories
Pathophysiology
Contributing Factors Sustained pressure to area of body Friction Shear
Risk Factors Immobility Age Weight Loss Poor Nutrition/Hydration Urinary/Fecal Incontinence Poor Circulation Smoking
Diagnosis Evaluation:
Size & Depth If bleeding, debris, or fluids exist If odor exists Check for spreading tissue damage
Tests: Blood tests Tissue cultures
Stages Depends on “depth” of ulcerStage DescriptionStage 1 Skin intact; underlying tissues unaffected; changes
in color, temperature, and consistency of skin; skin does not blanch on touch
Stage 2 Epidermal layer of skin affected; may extend into the dermis; often appear as shallow, open areas, intact serum-filled, or serosanguineous blisters; break in skin; shallow wound
Stage 3 Extends into the subcutaneous tissue; presence of any necrotic slough; can involve tunneling and undermining, e.g. extends beneath normal tissue; full-thickness tissue loss
Stage 4 Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often has tunneling or undermining; can extend into surrounding structures
Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed.
MNT Stage 4: Justification Kcal:
Depends on % IBW Promote healing
Protein: Amount dependent on protein status Aids with wound healing/prevention
Fluid: Increased needs with drainage
MVI with minerals Needed with Stage 3, 4, and UN ulcers Ulcer level indication of nutrient deficiency Promotes healing
MNT Stage 4 Pressure Ulcer cont’d…
Vitamin C Needed for Stage 3, 4, UN ulcers Tissue repair & regeneration
Zinc Needed for Stage 3, 4, and UN ulcers Antioxidant Collagen formation & cell proliferation Protein synthesis Over-supplementation can lead to anemia
Illustration Stage IV pressure ulcer
Treatment Identify stage or ulcer Remove pressure from affected area Preserve surrounding tissue & skin health Removing necrotic & infected tissue Reduce/remove bacteria Reduce pain as much as possible Nutrition intervention Treat any conditions increasing risk of
developing more ulcers
MNT for Stage 4 Pressure Ulcer Kcal: 25-35 kcal Protein: 1.0-1.5 g/kg Fluid: 30-35 cc MVI with minerals: Daily Vitamin C: 500 mg bid Zinc: 220 mg q day x 1 month
PES Statement
Severe protein malnutrition related to sacral stage 4 pressure ulcer as
evidenced by low protein, albumin, and pre-albumin lab values.
Admission Values Ht: 6’2” (74 in) Wt: 169 lb. (76.8 kg) IBW: 178.6 lb. (86.4 kg) % IBW: 94.6% BMI: 23.1
Lab ValuesPatient Normal
Sodium (mEq/L) 139 136-146Potassium (mEq/L) 3.9 3.5-5.3Chloride (mEq/L) 106 98-107Total CO2 (mEq/L) 27 21-31Glucose (mg/dL) 86 70-110BUN (mg/dL) 21 7-25Creatinine (mg/dL) 0.9 0.6-1.2Calcium (mg/dL) 7.8 (L) 8.6-10.3Total Protein (g/dL) 5.6 (L) 6.0-8.0Albumin (g/dL) 2.3 (L) 3.5-5.7Prealbumin (mg/dL)
12.1 (L) 17-42
General Diet Information Mechanical Soft, Large Portions diet Variable PO intake (25-100%) Eats meals in room 3 meals a day “Various” snacks
Estimated Diet Needs Based on Stage IV Pressure Ulcer Recs:
Kcal: 1920-2304 (25-30 kcal/kg) Protein: 108 g (1.4 g/kg) Fluid: 2304 mL
Residents Stage 4 Pressure Ulcer
Right Ischial Tuberosity Unknown Duration Admission Size: 1x1x0.28 cm
Resident’s MNT for Stage 4 Pressure Ulcer
Wound Healing Recommend to start Vitamin C supplement Recommend to start Zinc Supplement
(ZnSO4) Recommend to start Multivitamin with
minerals Wound Healing & Increase Protein Needs
Start MedPlus SupplementProvides 576 kcal & 30 g protein
Nursing Treatment Cleanse Ulcer thoroughly Pat dry Apply Calcium Alginate to wound bed Cover with dry dressing Monitor Change position every hour
Monitoring & Evaluation Monitor/prevent dehydration Monitor weekly weights Monitor for wound healing Monitor PO intake
Status Updates 2/14/13:
Stage IV pressure ulcer still present Decreasing in size: 0.5 x 1 x 0.21 cm
Weight increase: 174.9 lb ( Increased Protein Needs: 111.3 g
Start Prostat Supplement @ 30 mL x 90 days Provides 120 kcal & 30 g protein
Continue current MNT
Follow-up 3/4/13
Stage IV pressure ulcer healed Nursing to apply Bamer Cream as
preventative measure & reposition every 2 hours
Continue MNT Weight: 177 lb. (below IBW) Aide with weight increase/stability Help decrease possibility of wound re-
occurence
Prognosis MNT & Nursing treatment beneficial Reduce possibility of re-occurrence:
Continued monitoring Continued good PO intake
If keep up current MNT & nursing precautions, prognosis good!
As of 4/10/13: No Pressure Ulcer No discharge plans
Summary Early diagnosis & screening: Help with
ulcer progression Treat for highest level of ulcer present Stage dependent on depth Nutrition intervention key component for
healing
References 1. American Nursing Association. NDNQI: Pressure Ulcer Module. 2013. Available at:
https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinition_1.aspx. Accessed April 13, 2013.
Dorner B, Posthauer ME, Thomas, D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. 2009. Available at: http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf. Accessed April 13, 2013
Moskowitz RJ, Zieve D. Pressure Ulcer. University of Maryland Medical Center Online Encyclopedia website. November 2010. Available at: http://www.umm.edu/ency/article/007071.htm. Accessed April 14, 2013.
Gebhart KS. Pt. 1 Causes of Pressure Ulcers. Nursing Times J. March 2002; 98(11): 41 Gender, Aloma. Pressure Ulcer Prevention and Management. Gerontology Update page. October/November
2008. Available at: http://www.rehabnurse.org/pdf/GeriatricsPressureUlcer.pdf. Accessed April 14, 2013. Wake WT. Pressure ulcers: what clinicians need to know. Perm J. 2010;14(2):56-60. Bluestein D, Javaheri A. Pressure Ulcers: Prevention, Evaluation, and Management. American Family Physician
website. November 2008; 78 (10). Available at: www.aafp.org/afp. Accessed April 13, 2013 Wound Committee. WOCN Society Position Statement: Pressure Ulcer Staging page. Revised April 2011.
Available at: http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28B-C41E24551CCC/Position_Statement_-_Pressure_Ulcer_Staging_(2011).pdf. Accessed on April 15, 2013.
American Hospital Association. Wound Guidance page. Available at: http://www.aha.org/advocacy-issues/postacute/homehealth/woundguidance.shtml. Accessed April 18, 2013.
Morgan J. The Role of Nutrition in Pressure Ulcer Prevention and Treatment. HM Composite, Inc. page. Available at: http://www.hmcomposite.com/documents/TheRoleofNutritioninPressureUlcerPreventionandTreatmentMFS.pdf. Accessed April 15, 2013.
Dorner B. Nutrition and MNT: Lesson Plan 6, Determine Basic Concepts of Medical Nutrition Therapy. Medical Nutrition Therapy for Pressure Ulcers: Becky Dorner & Associates page. March 2004. Available at: http://portal.bccc.edu/dmr/MNT_LP_06_N.html. Accessed April 16, 2013.