Stage iv pressure ulcer
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Stage Iv Pressure Ulcer. Kathryn Atwater PVAMU 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.

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Stage Iv Pressure Ulcer

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Stage iv pressure ulcer

Stage Iv Pressure Ulcer

Kathryn Atwater

PVAMU Internship Spring 2013


Patient background

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

General Health History

  • Sleeps well

  • Alert

  • Non-ambulatory

  • Mobile through use of wheelchair

  • Tires easily

  • Variable Appetite


Family history

Family History

  • Mother

    • CHF

    • Cause Death

  • Father

    • Lung Cancer

    • Cause of Death

  • No other reported family history


Past medical 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


Medications

Medications


Medications cont d

Medications Cont’d…


Recent medical history

Recent Medical History

  • Admitted to Grace Care Cypress 1/11/13

    • Admitting Diagnosis: Pneumonia

    • Other Diagnoses:

      • Protein malnutrition

      • Stage 4 Pressure Ulcer on Right IschialTuberosity

      • 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: 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

Pathophysiology


Contributing factors

Contributing Factors

  • Sustained pressure to area of body

  • Friction

  • Shear


Risk factors

Risk Factors

  • Immobility

  • Age

  • Weight Loss

  • Poor Nutrition/Hydration

  • Urinary/Fecal Incontinence

  • Poor Circulation

  • Smoking


Diagnosis

Diagnosis

  • Evaluation:

    • Size & Depth

    • If bleeding, debris, or fluids exist

    • If odor exists

    • Check for spreading tissue damage

  • Tests:

    • Blood tests

    • Tissue cultures


Stages

Stages

  • Depends on “depth” of ulcer


Mnt stage 4 justification

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

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

Illustration Stage IV pressure ulcer


Treatment

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

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

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

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 values

Lab Values


General diet information

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

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

Residents Stage 4 Pressure Ulcer

  • Right IschialTuberosity

  • Unknown Duration

  • Admission Size: 1x1x0.28 cm


Resident s mnt for stage 4 pressure ulcer

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 Supplement

      • Provides 576 kcal & 30 g protein


Nursing treatment

Nursing Treatment

  • Cleanse Ulcer thoroughly

  • Pat dry

  • Apply Calcium Alginate to wound bed

  • Cover with dry dressing

  • Monitor

  • Change position every hour


Monitoring evaluation

Monitoring & Evaluation

  • Monitor/prevent dehydration

  • Monitor weekly weights

  • Monitor for wound healing

  • Monitor PO intake


Status updates

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 mLx 90 days

      • Provides 120 kcal & 30 g protein

    • Continue current MNT


Follow up

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

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

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

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 & Associatespage. March 2004. Available at: http://portal.bccc.edu/dmr/MNT_LP_06_N.html. Accessed April 16, 2013.


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