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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 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 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 antidepressants, grapefruit Amiodarone Reduce BP Fingolimod, diruetics Lisinopril Reduce BP Birth control pills, ibuprofen Nifedipine Reduce BP, treat angina Erythromycin, some general cold remedies, seizure medications, grapefruit Medications Cont’d… Medication Use Drug/Nutrient Interaction Magnesium-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 Blood thinners, digoxin thyroid e.g. hypothyroidism Coumadin treat/prevent blood clots Alcohol, aspirin-like drugs, non-steroidal antiinflammatory 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 Trapped between bone and a surface Greater pressure than blood vessels Less blood flow Cell Death Damaged cells Deprived of nutrients Pressure ulcer 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 ulcer 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. MNT Stage 4: Justification Kcal: Protein: Amount dependent on protein status Aids with wound healing/prevention Fluid: Depends on % IBW Promote healing 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 Values 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 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 Supplement Provides 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 Weight increase: 174.9 lb ( Increased Start in size: 0.5 x 1 x 0.21 cm Protein Needs: 111.3 g Prostat Supplement @ 30 mL x 90 days Provides Continue 120 kcal & 30 g protein 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/advocacyissues/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.