Stage 4 Pressure Ulcer Case Study Powerpoint
Download
Report
Transcript Stage 4 Pressure Ulcer Case Study Powerpoint
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.