Download Stage 4 Pressure Ulcer Case Study Research Paper

Kathryn Atwater
Major Case Study #2
Stage 4 Pressure Ulcer
Introduction/Patient Profile
The patient is an 88-year-old, middle class, Caucasian male. He has never been
married and has no children. He had two sisters, both of whom are deceased. In his earlier
years, he worked as a mechanical engineer and served four years in the military. He
received a primary school education and continued his education in the military. He is of
the Roman Catholic religion. No previous history of smoking or alcohol use was reported.
Before being admitted to Grace Care Cypress, he lived in an assisted living home for six
years. The residence was not obtained as he was admitted from the hospital.
The resident was admitted to Grace Care Cypress on January 11, 2013 from
Methodist Hospital with an admitting diagnosis of pneumonia. His other diagnoses were
severe protein malnutrition, a stage 4 pressure ulcer on the right ischial tuberosity, and a
urinary tract infection. Other medical history pertaining to the patient include atrial
fibrillation, hypothyroidism, recurrent UTI’s, peripheral neuropathy, pressure ulcers,
chronic protein deficiency, leukocytosis, diabetes mellitus, hypertension, GERD, anemia,
prostate cancer, a suprapubic catheter, and a colostomy. He has been in and out of the
hospital many times over the past years for his long line of medical diagnoses. His mother
passed away from CHF and his father passed away from lung cancer. No other family
history was provided, as it did not prove relevant for the patient’s current diagnosis. On
January 26, 2013 he was admitted to Cypress Medical Center from Grace Care for
esophageal strictures. He was then readmitted to Grace Care Cypress on January 28 with a
doctor ordered mechanical soft diet.
The patient is non-ambulatory without the use of a wheelchair secondary to a lower,
above the knee amputation. He is alert, but generally does not get out of bed often as he
tires easily. This has majorly contributed to his development of a stage 4 pressure ulcer.
On average, he is able to “sit up” in bed for an hour, but any more than that he becomes
overexerted and chooses to lie back down. This makes physical activity difficult for the
patient. In general, he sleeps well. He is encouraged to move around as much as possible,
but given his amputation and lack of energy, he chooses not to do so very often. Due to
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stage 4 pressure ulcer diagnosis and his unwillingness to get out of bed often, nursing is
ordered to reposition him every hour in effort to relieve pressure from the wound site.
The patient is 6’4” (74 in) tall and weighs 169 lbs (76.8 kg) with an IBW 178.6 lb
(80.4 kg) and a BMI of 23.1. His IBW is based off of his amputation, which deducts 6% from
what would be the IBW of a person who is 74 inches tall without an amputation.
Previously, his weight was on a decline but has been slowly gaining weight back over the
past 3 months. He has a variable appetite (25-100%) depending on how he feels that day
and eats his meals in his room. Due to his esophageal strictures, he does have a problem
with swallowing and therefore, sometimes does not consume as much as he normally
would. He is ordered a mechanical soft diet to ease the swallowing process. He has a
colostomy bag and a suprapubic catheter, which serves as his methods of elimination.
Disease Background
The diagnosis for which this case study will focus on is the patients “Stage 4
Pressure Ulcer”. A pressure ulcer is an injury to the skin and possible underlying tissue
that is a result of prolonged, chronic pressure to the area of skin usually located on an area
of the body with a bony prominence (6). Bony prominences are the common areas because
a bone prominence “sticks out” and has more forcible contact with the surface beneath it
than a soft tissue area does. This then creates more pressure on the area of interest. The
most common areas include but are not limited to the shoulders, elbows, knees, heels, feet,
and areas of the buttocks (1).
The pathophysiology of a pressure sore is rather simple but the contributing factors
are what determine who is most susceptible. The three main contributing factors are
sustained pressure, friction, and sheer. The area of skin (and underlying tissues) is trapped
between a surface (often a bed e.g. bedsores) and the bony prominence for a prolonged
period of time. This sustained pressure upon the skin area covering the bony prominence,
can become greater than the pressure that is pushing blood through the blood vessels
(capillaries) within that area. These blood vessels are what provide nutrients and oxygen
to the skin area e.g. help to “feed” the skin. The lack of proper and adequate delivery of
these essential nutrients to the skin area can cause tissue damage and cell death due to the
“starvation” of the tissues. This creates the perfect area for a pressure ulcer to develop.
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The pressure, in conjunction with friction and shear, is what creates the ulcer itself. Shear
is when two objects move in opposite directions of one another. In the instance of a
pressure ulcer, one tissue slides in the opposite direction of another. An example of shear
is when an individual is laying in a hospital bed (or a nursing home bed) and when the head
of the bed is elevated and the individual “slides” down. The skin may stay in place as the
rest of the body moves and underlying tissue slides down. This can cause further damage
to the skin and tissues in that area, especially if it happens often (1,2). When an individual
is of compromised nutritional status, they can become more susceptible to ulcers and it can
cause the process described above occur more rapidly than with someone who is of
adequate nutritional status. This includes those who have experienced unintentional
weight loss, protein malnutrition, overall poor nutrition status, and dehydration (2).
There are many possible etiologies that are involved with pressure ulcers.
Immobility is one of the main risk factors. Being immobile, it means that the individual will
not be able to change positions often. By lying or sitting in the same spot for an extended
period of time, it can cause the individual to be more prone to increased pressure, shear,
and friction as described earlier. Age is another contributing factor. With age, skin
becomes less elastic, thinner, and more fragile. This means that skin and tissue breakdown
occurs more easily. Weight loss, especially unintentional, is another factor. With weight
loss, the individual could be at a compromised state nutritionally and have less cushioning
on the bony areas of the body e.g. more pressure. Poor nutrition/hydration is another risk
factor as adequate nutrition and hydration is necessary for healthy skin, so with a poor
level, the person will be more prone. Urinary and fecal incontinence, which is common in
the elderly population, is another risk factor. It causes the skin to become frequently moist
and if it stays moist for an extended period of time, the skin can breakdown more easily. In
the feces category, it can cause severe infection once skin breakdown does occur. Another
risk factor is poor circulation. Since the pressure to the specific area is already affecting
normal circulation to that area, having a condition associated with poor circulation will
make nutrient supply even less. This then means, that smoking is another contributing
factor because it effects circulation. Lastly, any condition that makes the individual
unaware they need to change positions, such as neuropathy, is at an increased risk (3,4).
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There are 4 different stages or classification of pressure ulcers. There is also a stage
known as “unstageable” because necrosis, slough and eschar within the wound is so dense,
the physician is unable to determine the stage from the initial assessment. A wound is
staged based on how “deep” it is and what tissues are affected. Pressure ulcers are painful
however, many people who have them have a loss of sensation in the area (neuropathy)
and they do not realize the severity of the ulcer (4). Necrotic and devitalized tissue are
common within stage 3 and 4 wounds however, tunneling and undermining are often also
present. Tunneling a course path of tissue destruction in any direction from the wound
resulting in “tunnels” away from the wound. They can form dead space under the skin and
increase infection risk. Undermining is when there is extended tissue destruction around
the perimeter of the wound. It is “under” the skin and does not appear from superficial
viewing of the wound. It is important to diagnose and treat undermining and tunneling as
one or both of the conditions can exist in wounds and need to be treated to prevent further
infection (9). The symptoms associated with pressure ulcers depend on what stage the
sore is in. The 4 stages and unstageable phase are defined in Table 1.
Table 1. Stages of Pressure Ulcers with Stages (1,5,6)
Stage
Description
Stage 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.
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Treatment of wounds varies on what type of wound it is. For the purpose of this
case study, the treatment of only a Stage 4 pressure ulcer will be discussed. Many different
factors play into the medical aspect of treatment, depending on the state of the wound. The
most important step in treatment is to fully assess what type of wound is present (6). If
necrosis is present, it is important to perform a debridement of the wound to remove the
dead tissue (7). Sometimes, however, there is stable eschar present, it is not removed, as it
is the body’s natural biological defense against outside pathogens. If removed it can cause
complications and inhibit healing. This is what classifies an unstageable wound, as it is not
possible to get to the base of the wound. Until you the base of the wound is visible, it is not
possible to clearly stage it(5). If cellulitis or necrotic tissues are not present (or the
necrotic tissue has been removed and the bottom of the wound is present), application of a
moist, absorbent dressing is applied. This includes dressings such as hydrogel, alginate, or
foam. A surgical consultation sometimes occurs but only after wound treatment is not
proving beneficial. The wound must be fully cleansed and a dry dressing is to be placed on
top. If cellulitis is present, a topical antibiotic may also be applied, as this can be an
indication of infection (7). An individual with a pressure ulcer should be repositioned at
least every 2 hours, however, it is dependent on the severity of the wound as relieving
pressure to the affected area is extremely important to increase blood flow. After all,
pressure is what started the ulcer process in the first place, so decreasing it is the most
important ingredient for treatment. In general, ulcers need to be closely monitored as each
and every one can provide unique and variable obstacles (5).
The overall treatment of a pressure ulcer has a few key principles. First and
foremost, remove and relieve outside pressure from the wound site and surrounding skin
and tissues. Removing this pressure can be done by placing pillows around the individual,
using special airbeds that change firmness routinely, repositioning, and so on. Next, avoid
any possible ways friction or shear could occur within that area or other areas susceptible
to pressure ulcers. This will help to reduce the possibility of further damage and additional
ulcer formation. Then, make sure to always keep the area clean and free of necrosis or
devitalized tissue. Daily dressings are recommended in order to reduce possibility of
infection (3). It is important not only to pay attention to the ulcer itself but to all
surrounding tissues so complications or wound spreading does not occur. Adequate pain
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relief is necessary as pressure ulcers are extremely painful, but many people with ulcers
have lost sensation in the area. Nutritional intervention is necessary in order to facilitate
the body’s natural defense and healing mechanisms, but also to help treat nutrition
conditions related to pressure ulcers (6). Treatment depends on the specific factors
surrounding each individual ulcer. Not one ulcer is completely the same. Staging is the
most important factor in what treatment is the most beneficial (8).
Nutrition intervention is especially important for stage 4 pressure ulcers. There is a
specific intervention for each of the different stages of pressure ulcers, but for the purpose
of this document, stage 4 nutrition interventions will be focused on. In general, the
following list shows the overall recommendations. Justifications will be provided
following. The nutrition intervention for a stage 4 pressure ulcer is as follows (11):

Kcal: 25-35 kcal

Protein: 1.0-1.6 g/kg

Fluid: 30-35 cc

MVI with minerals: Daily

Vitamin C: 500 mg bid

Zinc: 220 mg q day x 1 month
Increased calories are needed for pressure ulcer healing. Increased calories are in
the form of the macronutrients of fats, proteins, and carbohydrates. This will help to
provide adequate energy consumption to the individual. As with most wound patients,
they are malnourished, so necessary nutrients are needed. Energy is essential for overall
wound healing in the form of cell proliferation, collagen formation, and skin regeneration.
Many times, these individuals are not consuming adequate calories, so it is necessary to
increase them in order to meet their needs (5). Calories also need to be increased so that
protein is not being broken down and used as the main energy source (10, 11).
Protein is another key component, if not one of the most important factors, in
wound healing. Generally, approximately 1.4 g/kg are recommended for stage 4 wound
healing, and will be adjusted from there. Often, lab tests will indicate a low protein level in
the individual so supplementation is necessary. As with any trauma to the body, protein
levels are affected depending on the severity. It is essential to any type of healing. It
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produces the enzymes that are necessary for collagen formation, cell proliferation, and
ulcer healing. Without increasing protein, the stage 4 pressure ulcer will not have the
proper tools to attempt heal itself. Protein is also essential in for production of antibodies
necessary for fighting off infection. All stages of pressure ulcers require increased protein
(5, 10).
Fluids are another key component. Many times, patients become easily dehydrated
and hydration is important for wound healing. Fluids serve as a solvent for the vitamins
being supplemented in wound healing. Dehydration can make skin more brittle and tear
more easily. By increasing fluids, you decrease the possibility of other wounds forming and
aide the body in properly hydrating tissues involved directly with the wound to promote
healing (5). As discussed earlier, wounds require increased protein consumption.
Increased fluids are needed in order to properly excrete the higher amount of protein now
in the patients diet. Increasing protein to over 2.0 g/kg, however, does not show any
benefit and may result in dehydration (10).
Vitamin C and a multivitamin with minerals are also prescribed for a stage 4
pressure ulcer (also used for a stage 3). A multivitamin is necessary because the patient is
in a nutritionally compromised state as indicated by the severity of ulcer stage. Taking a
multivitamin will supply the individual with essential nutrients they are lacking and
improve their overall nutritional status. Vitamin C is a water-soluble vitamin. It is irons
cofactor during the hydroxylation of proline and lysine. This reaction produces collagen.
This is again where the multivitamin comes in as it provides iron supplementation for the
individual to pair with the Vitamin C. A lack of Vitamin C can result in delayed healing of
the wound. More Vitamin C is needed for a stage 4 wound than a stage 3 wound. Overall,
Vitamin C works for collagen formation and tissue regeneration (5, 10).
Zinc is the last component for the nutrition intervention of wound healing. Zinc
works in collagen formation, cell proliferation, an antioxidant, synthesis of protein, and
DNA and RNA production. If not enough zinc is supplemented; the wound may result in
increased drainage, poor appetite, weight loss, and GI disturbances. It is important,
however, to stop zinc supplementation once the wound has healed as it can adversely effect
copper levels and result in anemia. If the wound does not heal for an extended period of
time, it is advised to give zinc for intermittent time frames. This way, over-
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supplementation is less likely to occur. In summary, zinc is beneficial for short periods of
time for healing but if over-supplemented it can interfere with healing so it should be
closely monitored (5).
The nutrition intervention stated above all works together to promote wound
healing. For a stage 4 ulcer, without the defined nutritional intervention, a stage 4 wound
would be difficult to heal with medical intervention alone. Each feeds off of the other in
effort to maximize all nutritional efforts to provide a positive outcome. Not all wounds
heal; each is unique with its individual needs. A dietitian is advised to reassess the patient
every month for increased needs and monitor healing. All interventions are made in hopes
that the wound will fade, but wounds are very delicate and an individual’s nutrition and
overall health status will offer some insight into whether or not healing can even occur.
They require intense amounts of monitoring and care. Teamwork between the nursing and
dietitian is crucial. The prognosis for an ulcer is this: Proper nutrition and medical
intervention is necessary for increasing the possibility of wound healing even though not
all wounds heal, continued care is the only means of creating a positive outcome (10, 11).
The patient in this case study came to Grace Care Cypress with a Stage 4 pressure
ulcer, which included both tunneling and undermining to some extent. It was 1x1x0.28 cm
in size and was of unknown duration. It had been cleaned of necrotic material prior to
admittance. He was placed on a wound care plan and assessed by the dietitian to
determine his specific needs. The patient is alert, but was tiresome due to his age and
compromised nutritional status. He understood the reasons behind his treatment. He did
not complain of pain, as he no longer had sensation in the buttocks area where the wound
was located due to his peripheral neuropathy. He willingly participated in wound care.
Current Admission
The patient in this case study had a primary diagnosis of pneumonia followed by
protein malnutrition, stage 4 pressure ulcer, and a UTI. This case study is focusing on the
diagnosis of the stage 4 pressure ulcer. The stage 4 ulcer was located on the right ischial
tuberosity and was 1x1x0.28 cm in size. The ulcer diagnosis was provided by Methodist
Hospital. Upon re-admission, he was administered a blood test on January 28, 2013 to
determine his overall health and nutrition status. A prealbumin test indicated that he was,
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in fact, still at a severe protein malnourishment level at 12.1 mg/dL. A low protein level
was to be expected, as the pressure ulcer at hand had been present for an extended period
of time. Low protein is common with the diagnosis of a stage 4 pressure ulcer. The low
level could also be due to his diagnosis of pneumonia. With infection and disease, protein
levels usually go down as the protein within the body is working to create antibodies to
fight off the disease state. It is the body’s main component for healing. Since the duration
of his pressure ulcer was unknown, it is possible his levels are also due to insufficient
supplementation of protein and other nutrients necessary for proper wound healing. The
ulcer is most likely the main contributing to his severe protein malnutrition and in turn, the
low protein levels are inhibiting the wound from improving. This can create a vicious cycle.
In the hospital a complete evaluation of a pressure wound takes place. The size and
depth are determined. The depth and tissues affected by an ulcer determines what stage it
is in. It is evaluated for the existence of bleeding, fluid, or debris, and odor exists to indicate
if an infection is present. The physician performing the exam will also determine if
tunneling, undermining, or tissue damage to surrounding areas are present. Blood tests
are conducted to determine the overall health and nutritional status of the patient. Lastly,
tissue cultures are drawn to more closely determine if infection (and what type) is present
within the wound (7).
The treatment for the wound was a combination of both the nursing staff at Grace
Care Cypress, the dietitian, and the medical staff. For nursing, they were ordered to
reposition him every hour secondary to him not getting out of bed often. This was to
relieve pressure from the area of the buttocks (ischial tuberosity) where the stage 4 ulcer
was located. Nursing was to cleanse the wound daily. Then, they were to pat try, apply
calcium alginate, and cover with a dry dressing. Close monitoring was required. No
medication was being provided for pain, as the patient reported having no pain secondary
to losing sensation in the area of the wound. There was no surgery plans being made, and
the only therapy implemented was the nutrition therapy provided by the dietitian. The
nutrition therapy will be discussed later on.
The patient was on a variety of medications. Table 2 outlines those medications
upon admission to Grace Care Cypress. Supplements ordered for the patient will be
discussed later as they were not ordered until a nutrition assessment was performed.
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Table 2. Patient Medications
Medication
Use
Drug/Nutrient Interaction
Carafate
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, diuretics
Lisinopril
Reduce BP
Birth control pills, ibuprofen
Nifedipine
Reduce BP, treat angina
Erythromycin, some general cold remedies,
seizure medications, grapefruit
Medication
Use
Drug/Nutrient Interaction
Magnesiumoxide
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 antiinflammatory drugs
Nutrition Care Process
Originally, the patient was ordered a regular diet and preferred his meals to be
eaten in his room. After being hospitalized on January 26, 2013 he was readmitted to Grace
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Care on a mechanical soft diet secondary to esophageal strictures. His anthropometrics
included a height of 74 inches and a weight of 169 lbs (76.8 kg). His ideal body weight of
178.6 lb (86.4 kg) is adjusted based on his below the knee amputation. This accounts for a
6% deduction from what would be the IBW for a 74 inch male without an amputation.
This, in turn, will also affect his BMI, which, after adjustment, is 23.1 putting him at 94.6%
of his adjusted IBW.
Table 3 outlines the biochemical labs of the patient upon re-admission to Grace Care
Cypress on January 28, 2013 after being admitted to Cypress Medical Center for esophageal
strictures.
Table 3. Patient Biochemical Labs
Lab
Patient
Normal
Sodium (mEq/L)
139
136-146
Potassium (mEq/L)
3.9
3.5-5.3
Chloride (mEq/L)
106
98-107
Total CO2 (mEq/L)
27
21-31
Glucose (mg/dL)
86
70-110
BUN (mg/dL)
21
7-25
Creatinine (mg/dL)
0.9
0.6-1.2
Calcium (mg/dL)
7.8 (L)
8.6-10.3
Total Protein (g/dL)
5.6 (L)
6.0-8.0
Albumin (g/dL)
2.3 (L)
3.5-5.7
Prealbumin (mg/dL)
12.1 (L)
17-42
As indicated, his protein levels were low; the interpretation of these results is
located within the current admission section of this case study.
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Being that the patient is a resident of Grace Care Cypress, a 24-hour recall was not
performed as there is a set menu for each resident. The menu follows USDA and long-term
healthcare facility regulations regarding required food groups and macronutrient content.
It would be understood that if the patient ate his meal, then he was meeting his nutrient
requirements and further supplementation for wound treatment as an additional source of
nutrients. He was not able to prepare his own foods so whatever was on the menu, was
what he ate. The patient had a variable food intake ranging from 25-100% depending on
his mood or activity level that day. He had two nephews who would come and visit him.
They reported him having a good appetite, but was lethargic many times so he had to be
stimulated during mealtime. They also stated they visited three to five times a week and
would bring him a variety of snacks such as assorted cakes and pudding. It was reported
that he enjoyed his meals and when his appetite was there, he would eat most of his food
and sometimes have a snack. They said he generally ate half of his breakfast, all of his
lunch, and about 75% of his dinner. They left the snacks with him for other times during
the day when he would become hungry. Overall, Grace Care Cypress was the provider of
his meals and his nephews provided outside snacks.
Before initially being admitted to Grace Care Cypress, the patient was being
supplemented a Glucerna shake twice daily. This was in order to increase his calories,
protein, and macronutrient intake to help heal the wound. After admission, this was
discontinued as Grace Care Cypress does not have this product available and alternative
supplementation was provided.
The stage 4 wound was of unknown duration when upon admission. When he was
diagnosed, it was 1x1x0.28 cm in size and had some tunneling and undermining. By
February 14, 2013, the Stage 4 pressure ulcer was still present but decreased to a size of
0.5x1x0.21 cm. The patient’s weight also increased to 174.9 lb (79.5 kg) so his protein
needs increased to 111.3 grams. His wound status was improving from admission. The
patient was a relative high level of risk as a stage 4 pressure ulcer is the highest defined
class and severe protein malnutrition can be detrimental to overall health. He was to be
monitored closely but due to his improving status, it was hopeful that he would continue to
improve.
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For his diagnosis of a Stage 4 pressure ulcer his macronutrient needs were as
follows:

1920-2304 kcal (25-30 kcal/kg)

108 g protein (1.4 g/kg)

2304 mL fluid (30 mL/kg)
The PES Statement for this patient is: Severe protein malnutrition related to sacral stage 4
pressure ulcer as evidenced by low protein, albumin, and pre-albumin lab values.
Upon his initial admission to Grace Care Cypress on January 11, 2013 the nutrition
intervention for the resident was as follows:

Recommend to start MVI with Minerals

Recommend to start Vitamin C @ 500 mg big

Recommend to start Zinc Supplement (ZnS04) @ 220 mg daily x 1 month

Monitor/prevent dehydration by providing recommended fluids and keeping
water pitcher at bedside

Start MedPlus Supplement @ 90 mL x 90 days

Provides: 288 kcal, 15 g protein

To aide with increased kcal and protein needs

Aide with wound healing

Monitor weekly weights

Monitor for wound healing in 1 month

Monitor PO intake
After his re-admission on January 28, 2013, the previous MNT was restarted and reevaluation took place on February 14, 2013. As stated, the wound was smaller in size and
indicated healing was occurring. The resident went up in weight, therefore increasing his
protein needs. His needs were re-assessed and another supplement was added to his
nutrition care plan. A protein supplement called Prostat was ordered @ 30 mL x 90 days to
meet his new protein requirements. This provides 120 kcal and 30 g of additional protein.
This supplement would aide with further wound healing and contribute to increasing his
low protein lab values. The previous MNT was kept in place, as it proved beneficial within
the first month.
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As of March 4, 2013 the stage 4 pressure ulcer had was healed. Nursing was to
apply Bamer cream to the previously affected area as a preventative measure. In
congruence, they were to continue to reposition the resident every 2 hours to relieve
pressure to his buttocks. His weight again increased to 177 lb, which was within 1% of his
IBW. The weight gain was beneficial as it displayed an improving nutritional status. The
current MNT was to be carried out for its duration in order to aid with weight stability and
help to decrease possibility of wound reoccurrence. He is to be assessed monthly for
possible wound appearance. The patient was grateful to the staff for helping him heal the
wound that had been there for such an extended period of time. As of April 10, 2013, still
no pressure ulcer was present. There were no discharge plans secondary to patient being
long-term healthcare individual.
Summary
The combination of both the nursing staff and nutrition intervention proved
beneficial for the healing of this patient’s wound. Stage 4 pressure ulcers have specific
caloric, protein, vitamin, and fluid needs. Pressure ulcers are a tissue injury due to
prolonged pressure to a certain area of the body, usually located at a bony prominence. It
is most likely a result of the individual being immobile. This causes them to remain in the
same position for an extended period of time. Depending on the nutritional status of the
individual, the wound can progress slowly or quickly and also how well it heals. There are
4 stages of wounds with each being defined by how deep it is. Medical and nutritional
interventions are necessary to aide with the healing process. Continued monitoring and
preventative measures can help to decreases the possibility of an ulcer reoccurring.
Overall, I thought it was interesting to see the progression of the ulcer and how well
it healed. I was the first person to chart on the resident when he was first admitted to
Grace Care, so I was very interested in seeing his progress. The nursing staff told me stage
4 pressure ulcers in the elderly are very difficult to heal but they were extremely pleased
with the results. He was a rather irritable at times because he was not very mobile but it
was more of his choice than anything else. Nutrition intervention is extremely important
for wound healing and I really enjoyed seeing how it worked. It demonstrated how
important protein is and how different nutrients interact to produce on solid end result.
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References
(1) American Nursing Association. NDNQI: Pressure Ulcer Module website. 2013. Available at:
https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinit
ion_1.aspx. Accessed April 13, 2013.
(2) Dorner B, Posthauer ME, Thomas, D. The Role of Nutrition in Pressure Ulcer Prevention and
Treatment: National Pressure Ulcer Advisory Panel White Paper page. 2009. Available at:
http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-WebsiteVersion.pdf. Accessed April 13, 2013
(3) Moskowitz RJ, Zieve D. Pressure Ulcer. University of Maryland Medical Center Online
Encyclopedia page. November 2010. Available at:
http://www.umm.edu/ency/article/007071.htm. Accessed April 14, 2013.
(4) Gebhart KS. Pt. 1 Causes of Pressure Ulcers. Nursing Times J. March 2002; 98(11): 41
(5) 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.
(6) Wake WT. Pressure ulcers: what clinicians need to know. Perm J. 2010;14(2):56-60.
(7) Bluestein D, Javaheri A. Pressure Ulcers: Prevention, Evaluation, and Management. American
Family Physician page. November 2008; 78 (10). Available at: www.aafp.org/afp. Accessed
April 13, 2013
(8) Wound Committee. WOCN Society Position Statement: Pressure Ulcer Staging website.
Revised April 2011. Available at:
http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28BC41E24551CCC/Position_Statement_-_Pressure_Ulcer_Staging_(2011).pdf. Accessed on April
15, 2013.
(9) American Hospital Association. Wound Guidance website. Available at:
http://www.aha.org/advocacy-issues/postacute/homehealth/woundguidance.shtml. Accessed
April 18, 2013.
(10) Morgan J. The Role of Nutrition in Pressure Ulcer Prevention and Treatment. HM Composite,
Inc. page. Available at:
http://www.hmcomposite.com/documents/TheRoleofNutritioninPressureUlcerPreventionand
TreatmentMFS.pdf. Accessed April 15, 2013.
(11) 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.
Atwater 16
Glossary of Terms: Stage 4 Pressure Ulcer

Bony prominence- area of body where the bone lies close to the skin

Calcium alginate- Soft, white sterile dressing used in wound care to absorb wound
drainage; can be used to pack wound dead space

Chronic- a health condition or disease marked by a long duration

Collagen- fibrous protein constituent; part of bone, tendons, cartilage, and other
connective tissues

Debridement- surgical removal of dead, devitalized, or contaminated tissues from the
body

Eschar- scabbing; in wounds, it refers to the thick, black, dead tissue; it can be removed
naturally or surgically, but it is advised not to forcibly remove it as it can be a natural
defense against infection

Esophageal stricture- narrowing or tightening of the esophagus that can cause
swallowing difficulty

Friction- resistance to motion

Full-thickness- tissue damage that involves the total loss of both epidermis and dermis
through to the subcutaneous tissue (and sometimes to bone and muscle)

Mechanical soft diet- diet prescribed for possible difficulty with chewing and
swallowing; hard or coarse foods are “chopped” in effort to make them more digestable

Necrosis-death; in wounds it is cell or tissue death

Partial-thickness- tissue damage that involves only the superficial layers of skin

Neuropathy- medical condition where the nerves do not carry the signals of the brain
throughout the body; this can create pain, numbness, bladder problems, fecal
elimination problems, muscle problems, and so on; the body is not able to properly
sense what the brain is transmitting to it

PO- per oral or by mouth

Pressure ulcer- an injury to the skin and possible underlying tissue that is a result of
prolonged, chronic pressure to the area of skin usually located on an area of the body
with a bony prominence

Shear- when two objects move in opposite directions of one another e.g. one stays in
place as another moves

Slough- soft, moist, devitalized tissue; can be white, gray, yellowish, tan, green
Atwater 17

Tunneling- a course path of tissue destruction in any direction from the wound
resulting in “tunnels” away from the wound

Undermining- extended tissue destruction around the perimeter of the wound. It is
“under” the skin and does not appear from superficial viewing of the wound