Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Atwater 2 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. Atwater 3 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). Atwater 4 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. Atwater 5 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 Atwater 6 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 Atwater 7 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- Atwater 8 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, Atwater 9 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. Atwater 10 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 Atwater 11 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. Atwater 12 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. Atwater 13 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. Atwater 14 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. Atwater 15 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