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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

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
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
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
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
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.