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Stage Iv Pressure Ulcer

Stage Iv Pressure Ulcer. Kathryn Atwater PVAMU Internship Spring 2013. Patient Background. 88 year old, Caucasian male Middle Class Previous Occupation: Mechanical Engineer Never Married 4 years in military No Children 2 sisters No past history of smoking, alcohol, or drug use.

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Stage Iv Pressure Ulcer

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  1. Stage Iv Pressure Ulcer Kathryn Atwater PVAMU Internship Spring 2013

  2. 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

  3. General Health History • Sleeps well • Alert • Non-ambulatory • Mobile through use of wheelchair • Tires easily • Variable Appetite

  4. Family History • Mother • CHF • Cause Death • Father • Lung Cancer • Cause of Death • No other reported family history

  5. 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

  6. Medications

  7. Medications Cont’d…

  8. Recent Medical History • Admitted to Grace Care Cypress 1/11/13 • Admitting Diagnosis: Pneumonia • Other Diagnoses: • Protein malnutrition • Stage 4 Pressure Ulcer on Right IschialTuberosity • UTI • Hospitalized 1/26/2013 for esophageal strictures • Placed on Mechanical Soft Diet • Re-admitted to Grace Care Cypress 1/28/2013

  9. 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

  10. Pathophysiology

  11. Contributing Factors • Sustained pressure to area of body • Friction • Shear

  12. Risk Factors • Immobility • Age • Weight Loss • Poor Nutrition/Hydration • Urinary/Fecal Incontinence • Poor Circulation • Smoking

  13. Diagnosis • Evaluation: • Size & Depth • If bleeding, debris, or fluids exist • If odor exists • Check for spreading tissue damage • Tests: • Blood tests • Tissue cultures

  14. Stages • Depends on “depth” of ulcer

  15. MNT Stage 4: Justification • Kcal: • Depends on % IBW • Promote healing • Protein: • Amount dependent on protein status • Aids with wound healing/prevention • Fluid: • Increased needs with drainage • MVI with minerals • Needed with Stage 3, 4, and UN ulcers • Ulcer level indication of nutrient deficiency • Promotes healing

  16. 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

  17. Illustration Stage IV pressure ulcer

  18. 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

  19. 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

  20. PES Statement Severe protein malnutrition related to sacral stage 4 pressure ulcer as evidenced by low protein, albumin, and pre-albumin lab values.

  21. 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

  22. Lab Values

  23. General Diet Information • Mechanical Soft, Large Portions diet • Variable PO intake (25-100%) • Eats meals in room • 3 meals a day • “Various” snacks

  24. 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

  25. Residents Stage 4 Pressure Ulcer • Right IschialTuberosity • Unknown Duration • Admission Size: 1x1x0.28 cm

  26. 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

  27. Nursing Treatment • Cleanse Ulcer thoroughly • Pat dry • Apply Calcium Alginate to wound bed • Cover with dry dressing • Monitor • Change position every hour

  28. Monitoring & Evaluation • Monitor/prevent dehydration • Monitor weekly weights • Monitor for wound healing • Monitor PO intake

  29. Status Updates • 2/14/13: • Stage IV pressure ulcer still present • Decreasing in size: 0.5 x 1 x 0.21 cm • Weight increase: 174.9 lb ( • Increased Protein Needs: 111.3 g • Start Prostat Supplement @ 30 mLx 90 days • Provides 120 kcal & 30 g protein • Continue current MNT

  30. 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

  31. 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

  32. 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

  33. References • 1. American Nursing Association. NDNQI: Pressure Ulcer Module. 2013. Available at: https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinition_1.aspx. Accessed April 13, 2013. • Dorner B, Posthauer ME, Thomas, D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. 2009. Available at: http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf. Accessed April 13, 2013 • Moskowitz RJ, Zieve D. Pressure Ulcer. University of Maryland Medical Center Online Encyclopedia website. November 2010. Available at: http://www.umm.edu/ency/article/007071.htm. Accessed April 14, 2013. • Gebhart KS. Pt. 1 Causes of Pressure Ulcers. Nursing Times J. March 2002; 98(11): 41 •  Gender, Aloma. Pressure Ulcer Prevention and Management. Gerontology Update page. October/November 2008. Available at: http://www.rehabnurse.org/pdf/GeriatricsPressureUlcer.pdf. Accessed April 14, 2013. •  Wake WT. Pressure ulcers: what clinicians need to know. Perm J. 2010;14(2):56-60. •  Bluestein D, Javaheri A. Pressure Ulcers: Prevention, Evaluation, and Management. American Family Physician website. November 2008; 78 (10). Available at: www.aafp.org/afp. Accessed April 13, 2013 • Wound Committee. WOCN Society Position Statement: Pressure Ulcer Staging page. Revised April 2011. Available at: http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28B-C41E24551CCC/Position_Statement_-_Pressure_Ulcer_Staging_(2011).pdf. Accessed on April 15, 2013. • American Hospital Association. Wound Guidance page. Available at: http://www.aha.org/advocacy-issues/postacute/homehealth/woundguidance.shtml. Accessed April 18, 2013. •   Morgan J. The Role of Nutrition in Pressure Ulcer Prevention and Treatment. HM Composite, Inc. page. Available at: http://www.hmcomposite.com/documents/TheRoleofNutritioninPressureUlcerPreventionandTreatmentMFS.pdf. Accessed April 15, 2013. • Dorner B. Nutrition and MNT: Lesson Plan 6, Determine Basic Concepts of Medical Nutrition Therapy. Medical Nutrition Therapy for Pressure Ulcers: Becky Dorner & Associatespage. March 2004. Available at: http://portal.bccc.edu/dmr/MNT_LP_06_N.html. Accessed April 16, 2013.

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