STAGE IV PRESSURE ULCERKathryn AtwaterPVAMU 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

MedicationsMedication Use Drug/Nutrient

InteractionCarafate 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, dirueticsLisinopril Reduce BP Birth control pills,

ibuprofenNifedipine Reduce BP, treat

anginaErythromycin, some general cold remedies, seizure medications, grapefruit

Medications Cont’d…Medication Use Drug/Nutrient

InteractionMagnesium-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 thyroid e.g. hypothyroidism

Blood thinners, digoxin

Coumadin treat/prevent blood clots

Alcohol, aspirin-like drugs, non-steroidal anti-inflammatory 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

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 ulcerStage DescriptionStage 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:

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

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 ValuesPatient Normal

Sodium (mEq/L) 139 136-146Potassium (mEq/L) 3.9 3.5-5.3Chloride (mEq/L) 106 98-107Total CO2 (mEq/L) 27 21-31Glucose (mg/dL) 86 70-110BUN (mg/dL) 21 7-25Creatinine (mg/dL) 0.9 0.6-1.2Calcium (mg/dL) 7.8 (L) 8.6-10.3Total Protein (g/dL) 5.6 (L) 6.0-8.0Albumin (g/dL) 2.3 (L) 3.5-5.7Prealbumin (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 SupplementProvides 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 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 mL x 90 days Provides 120 kcal & 30 g protein

Continue 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/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 & Associates page. March 2004. Available at: http://portal.bccc.edu/dmr/MNT_LP_06_N.html. Accessed April 16, 2013.