1. Clinical Case Study Pressure Ulcers Edited by Edward Warren, MD, Chair Geriatrics Carolinas Campus, March 2012

2. History of present illness An 89 year old white male patient who is a resident at your nursing home has been being treated for right hip bursitis for the past month with injections and ice with moderate to good relief. During your routine evaluation of this patient you notice a slight area of erythema about the size of a silver dollar over the contralateral greater trochanter. This patient is able to respond to your questions but he is unable to completely sense painful areas on his lower extremities.

3. Past medical/surgical history • Early Alzheimer’s dementia • COPD (chronic obstructive pulmonary disease) • Fracture of the right hip 10 years ago with ORIF • Occasional urinary incontinence

4. Family History • Negative for malignancy, coronary artery disease, NIDDM, or stroke in 1st degree relatives.

5. Medications • Aricept – 10mg per day • Aspirin (ASA) – 81 mg per day • Advair 500/50 – 1 puff twice per day

6. Allergies • No known drug allergies ( NKDA)

7. Review of systems ( ROS ) • Unremarkable except tenderness on bilateral greater trochanteric areas • Patient is occasionally moist - wet when checked by staff in genital area • Unable to ambulate w/o assistance, mostly chair bound • Nutrition poor • Patient able to move himself slightly in bed but needs complete assistance to get out of bed.

8. Physical exam • Vitals: T98.0 R 20 BP 120/70 P 80 and regular Wt 60 kg Ht 180 cm • HEENT - unremarkable • Neck - supple, No JVD, no bruit, no lymphadenopathy • Heart - RRR w/o murmur , no S3 nor S4 • Lungs - Bilateral lower lobe end inspiratory crackles, no rhonci • Abdomen - BS+ x 4 Q, no mass or organomegaly • Extremities - slight tenderness to palpation over bilateral greater trochanters R>L. Pulses intact in posterior tibial and dorsalispedis bilaterally • Skin - slight erythema to area of greater trochanter, no warmth, but nonblanching, and no skin breakdown yet.

9. Case Questions • If the area on the right greater trochanter is a decubitus ulcer, what stage would it be classified as? • Stage 1 • Stage 2 • Stage 3 • Stage 4 • Non-stageable

10. Case Questions • If you had been evaluating this patient prior to his ulcer formation what would be his risk of ulcer formation using the Braden Scale? • High risk • Low risk • Not enough information to calculate risk

11. Case Questions • The staff nutritionist feels that this resident should receive 60 grams of protein per day. You feel on closer evaluation that 60 grams of protein is not the correct amount for this patient. What is the correct minimal amount in grams/day? a. 50-55 b. 60-72 c. 40-50 d. 70-84 e. 80-96

12. Case Questions • In spite of your best efforts this patients ulcer seems to be getting worse. If it progresses to, but not through the fascia, what stage is it considered? • Stage 1 • Stage 2 • Stage 3 • Stage 4 • Non-stageable

13. Case Questions • On a standard mattress (if a geriatric patient is not being turned) in what amount of time can the patient develop skin erythema on areas of bed contact? a. 1 hour b. 2 hours c. 3 hours d. 4 hours e. 5 hours

14. Answers • aNonblanching erythema without ulceration is stage 1. • a Sensory = 1; Moisture = 3; Activity = 2; Mobility =1; Nutrition = 1; Friction = 1; Total Score = 9 (<18  high risk) • b 1.0 - 1.2 gm protein/kg/day times 60 Kg = 60 – 72 gm protein daily minimally • c Through the skin but not through the underlying fascia is stage 3. • b 2 hours at most