A 34-year-old paraplegic male with a history of type 1 diabetes, pressure ulcers, and transverse myelitis was admitted for a UTI and had severe pressure ulcers including a stage IV sacral ulcer and unstageable scrotal ulcer that were complicated by osteomyelitis and poor social support despite receiving home health services.
Ringkasan dokumen tersebut adalah sebagai berikut:
Dokumen tersebut menjelaskan tentang sistem Kaizen yang bertujuan untuk mendorong ide kreatif dan pemecahan masalah guna mendukung pencapaian sasaran perusahaan melalui langkah-langkah perbaikan berkelanjutan secara konsisten. Sistem ini mendorong peningkatan kualitas kerja personal dan hasil kerja serta membangun budaya peka terhadap masalah. Dokumen tersebut jug
Catálogo en el que se pueden ver arrancadores de coches, cargadores de baterías, salvadores de memoria y una amplia gama de productos.
Más información en nuestra web.
Cualquier consulta: 947215125
This short deck introduces the key concepts of Objective and Key Results (OKR). OKR is a goal driven management process that thousands of top companies use to engage staff and deliver exceptional performance
Dokumen tersebut membahas tentang kondisi kekurangan zat makanan seperti Kekurangan Vitamin C, Kekurangan Besi, Marasmus (kekurangan karbohidrat), dan Kwashiorkor (kekurangan protein) beserta gejala klinis, faktor risiko, diagnosis, dan pengobatannya.
Vitamins are organic compounds that are needed in small amounts for good health. They are classified as either water-soluble or fat-soluble. The presentation summarized key vitamins including their sources, functions, and daily requirements. Vitamin A supports vision and immune function. Vitamin D aids in calcium absorption and immunity. Vitamin E is a powerful antioxidant that protects cells. Vitamin K is needed for blood clotting. The B vitamins help release energy from carbohydrates and support nervous system function. Vitamin C supports immune function and collagen production.
The document discusses using Kanban techniques to help families manage daily tasks and chores in a more organized way. It suggests that families can visualize tasks on a board, prioritize tasks, and have daily stand-up meetings to discuss what was done, what needs to be done, and any impediments. Doing this for 10 minutes a day can result in more productive routines and foster healthier family communication by preventing arguments and allowing families to work together and learn from mistakes through retrospective meetings. The techniques are meant to empower and teach kids responsibility while making family tasks more fun and adding value to the family's day-to-day activities.
Kepner Tregoe Developing Your Hr Project Management SkillsJessica Booth
The document discusses developing project management skills. It introduces Kepner-Tregoe, an international consulting firm, and their approach to project management. Their approach focuses on critical success factors like project organization, culture, process, and reporting. Effective project management requires defining the project, objectives, and work breakdown structure. It also requires factors like commitment, planning, and clear success criteria.
Ringkasan dokumen tersebut adalah sebagai berikut:
Dokumen tersebut menjelaskan tentang sistem Kaizen yang bertujuan untuk mendorong ide kreatif dan pemecahan masalah guna mendukung pencapaian sasaran perusahaan melalui langkah-langkah perbaikan berkelanjutan secara konsisten. Sistem ini mendorong peningkatan kualitas kerja personal dan hasil kerja serta membangun budaya peka terhadap masalah. Dokumen tersebut jug
Catálogo en el que se pueden ver arrancadores de coches, cargadores de baterías, salvadores de memoria y una amplia gama de productos.
Más información en nuestra web.
Cualquier consulta: 947215125
This short deck introduces the key concepts of Objective and Key Results (OKR). OKR is a goal driven management process that thousands of top companies use to engage staff and deliver exceptional performance
Dokumen tersebut membahas tentang kondisi kekurangan zat makanan seperti Kekurangan Vitamin C, Kekurangan Besi, Marasmus (kekurangan karbohidrat), dan Kwashiorkor (kekurangan protein) beserta gejala klinis, faktor risiko, diagnosis, dan pengobatannya.
Vitamins are organic compounds that are needed in small amounts for good health. They are classified as either water-soluble or fat-soluble. The presentation summarized key vitamins including their sources, functions, and daily requirements. Vitamin A supports vision and immune function. Vitamin D aids in calcium absorption and immunity. Vitamin E is a powerful antioxidant that protects cells. Vitamin K is needed for blood clotting. The B vitamins help release energy from carbohydrates and support nervous system function. Vitamin C supports immune function and collagen production.
The document discusses using Kanban techniques to help families manage daily tasks and chores in a more organized way. It suggests that families can visualize tasks on a board, prioritize tasks, and have daily stand-up meetings to discuss what was done, what needs to be done, and any impediments. Doing this for 10 minutes a day can result in more productive routines and foster healthier family communication by preventing arguments and allowing families to work together and learn from mistakes through retrospective meetings. The techniques are meant to empower and teach kids responsibility while making family tasks more fun and adding value to the family's day-to-day activities.
Kepner Tregoe Developing Your Hr Project Management SkillsJessica Booth
The document discusses developing project management skills. It introduces Kepner-Tregoe, an international consulting firm, and their approach to project management. Their approach focuses on critical success factors like project organization, culture, process, and reporting. Effective project management requires defining the project, objectives, and work breakdown structure. It also requires factors like commitment, planning, and clear success criteria.
Dokumen ini memberikan panduan pemakanan untuk pasien diabetes meliputi penjelasan tentang faktor risiko diabetes dari gizi yang tidak seimbang, piramid makanan seimbang, dan contoh porsi makanan untuk satu harian yang sesuai untuk mengontrol kadar gula darah. Dokumen ini juga memberikan daftar makanan yang harus dihindari, dibatasi, dan dikonsumsi oleh pasien diabetes.
This document provides an introduction to vitamins, including their structure, sources, and diseases associated with deficiency and excess. It discusses fat-soluble vitamins A, D, E, K and water-soluble vitamins B1, B2, B3, B5. For each vitamin, it describes sources, structure, deficiency diseases, and in some cases therapeutic uses. The document aims to inform readers about the essential roles and health impacts of various vitamins.
Lecture 12 nutrients involved in energy metabolismwajihahwafa
At the end of this lecture, the student should be able to:
Describe how coenzymes enhance the activities of enzymes.
For each of the eight B-complex vitamins, describe their primary functions and their food sources.
Describe the association between folate, vitamin B12, and vascular disease.
Identify at least two minerals that function as coenzymes in energy metabolism.
Discuss the role that iron plays in oxygen transport.
Distinguish between iron-deficiency anemia, pernicious anemia, and macrocytic anemia.
Keynote: The Phoenix Project: Lessons Learned - PuppetConf 2014Puppet
This document summarizes a presentation about DevOps lessons learned. It discusses that DevOps can provide higher business value than expected, benefits both development and operations teams, and requires high-trust management. It also notes that DevOps is applicable to all types and sizes of organizations, not just large tech companies, and shares an example of a COBOL application adopting DevOps practices across 20 technology stacks. The presentation encourages attendees to learn more about an upcoming DevOps Enterprise Summit for organizations applying DevOps.
This document discusses mineral metabolism and provides details on specific minerals including sodium, potassium, chloride, sulfur, and calcium. It covers their sources, absorption, functions, normal levels, and clinical conditions related to abnormal levels. For each mineral, absorption and excretion processes are described along with roles in the body. Causes and symptoms of both hypo- and hyper- conditions are outlined.
Effectiveness Through Strategy And Organizational Design Seta Wicaksana
Organization Design is a process for shaping the way organizations are structured and run.
It involves many different aspects of life at work, including team formations, shift patterns, lines of reporting, decision-making procedures, communication channels, and more.
Organization Design – and redesign – can help any type of organization to achieve its goals. Sometimes, a large-scale reorganization is necessary. At other points, more subtle shifts in structures and systems can ensure that an organization continues to thrive.
Comparing Ways to Scale Agile at Agile Product and Project Manager MeetupBernd Schiffer
Session "Comparing Ways to Scale Agile" at the Agile Product and Project Manager Meetup in Melbourne, Australia.
These days organisations are looking for support to scale their Agile environment. There’s a difference between having one Agile team on its own, or to have several Agile teams providing value to the customer and interacting with each other.
This session will give an overview and comparison of all the different Agile scaling approaches out there, i.e.:
* Scaled Agile Framework (SAFe)
* Evidence-Based Management (EBMgt)
* Disciplined Agile Delivery (DAD)
* Enterprise Transition Framework (ETF)
* Large-Scale Scrum (LeSS)
* ScALeD Agile Lean Development
* Scaling Agile @ Spotify (SA@S)
* Product Development Flow by Reinertsen (PDFbyR)
Lack of minerals like calcium, iron, chromium, and magnesium can lead to serious health conditions. Iron deficiency is the most common nutritional deficiency and causes iron-deficiency anemia with symptoms like fatigue, weakness, and decreased immune function. Calcium is important for bone health and deficiency can cause osteoporosis. Vitamin deficiencies can also cause diseases like scurvy with symptoms of bleeding gums and spots on the skin or rickets, a softening of the bones in children. Nutrition involves taking in nutrients from food for growth, tissue repair, and energy through absorption and assimilation.
Pengantar "Sistem Manajemen dan Audit Sistem Manajemen" _AUDIT SISTEM MANAJEM...Kanaidi ken
Sistem manajemen dibuat untuk membantu organisasi mencapai tujuan. Audit sistem manajemen penting untuk meningkatkan kinerja organisasi dan memastikan kepatuhan. ISO 19011 memberikan panduan audit berdasarkan prinsip-prinsip seperti integritas dan objektivitas.
This slides-share describes best practices to implement Jira in software development organizations who practice Agile.
The focus is on simple implementation based on Jira core and portfolio to achieve high ROI
Zinc is a trace mineral that is important for many functions in the body. The total body content of zinc is about 2 grams, with high concentrations found in the prostate gland, muscle tissue, and bone. Good dietary sources of zinc include meat, dairy products, legumes, nuts, and spinach. Zinc is required for the function of many enzymes and is involved in processes like DNA synthesis, wound healing, growth, and taste sensation. Zinc deficiency can result in issues like hypogonadism, growth failure, and skin lesions. Toxicity from excess zinc intake is rare but can cause nausea and gastrointestinal issues.
This document provides an overview of nutrition including defining key terms and concepts. It discusses the six major classes of nutrients - carbohydrates, lipids, proteins, vitamins, minerals, and water. Carbohydrates, lipids and proteins are macronutrients that provide energy, while vitamins and minerals are micronutrients needed in smaller amounts. The document also examines the essential roles various nutrients play and how dietary choices can impact chronic disease risk.
Copper is an essential trace element found in all human tissues. It plays an important role in many processes including iron transport, collagen formation, antioxidant activity and enzyme function. The average adult contains around 100-150mg of copper stored primarily in the muscles, bones and liver. Dietary sources include meat, shellfish, nuts and cereals. The recommended daily allowance is 900mcg for adults. Copper absorption requires special mechanisms and can be inhibited by other minerals or vitamins taken in excess. A copper deficiency can result in issues like anemia, bone disorders and grey hair.
Agility boosts performance: Guide for your agile transformation journeySebastian Olbert
ORGANIZATIONAL AGILITY AS A COMPETITIVE FACTOR
The Agile Performer Index
In the Agile Performer Index, goetzpartners and the NEOMA Business School clearly demonstrate the correlation between agility and entrepreneurial success. The more agile the company, the better it performs financially. The purpose of the study was to investigate what agility can really do for organizations. Is it just a temporary trend? With the right methodology, can agility deliver sustainable success?
Resulting from a broad survey among 285 leading European companies, the Agile Performer Index documents that agility programs are a suitable way for organizations to achieve lasting performance and competitive advantage.
Selected key findings:
Agile companies perform ~ 2.7 times better than non-agile companies
CxOs rate their company’s agility higher than do middle managers.
Sector check: Digital maturity doesn’t guarantee agility
The document describes the three core Scrum roles - Product Owner, Scrum Master, and Development Team - and two ancillary roles. The Product Owner represents stakeholders and ensures the product meets business needs. The Scrum Master coaches the team and removes impediments to workflow. The multi-functional Development Team is self-organizing and completes the work. The ancillary roles of customers and management provide feedback but are not directly involved in sprints.
Agile Development in Large-Scale: Challenges and Insight from ResearchTorgeir Dingsøyr
Keynote at the SPA Software in Practice, London, 26 June 2019.
Agile methods were aimed at small, co-located teams developing non-critical software products. The success of these methods for small teams have led to use in projects with tens of teams and hundreds of developers. Are agile methods suited in this new context? What fundamental assumptions in agile methods become challenging with scale? What can we learn from prior studies on key areas such as managing uncertainty, coordination, sharing knowledge, self management and tailoring of development method?
This document summarizes information about zinc, including its dietary sources, recommended daily allowances, physiological functions, deficiency, and treatment. Some key points include:
- Zinc is an essential micronutrient found in high amounts in oysters, meat, and nuts. It plays roles in over 300 enzymes and 2000 transcription factors.
- Recommended daily zinc intake ranges from 2-11 mg per day depending on age. Pregnant and lactating women should have 11-12 mg.
- Zinc deficiency can cause impaired immunity, growth retardation, skin disorders, and is common in developing countries. It is diagnosed through blood tests.
- Treatment involves oral zinc supplementation, with doses ranging from 0.
Care of aging_skin_spring 2014 abridgedShepard Joy
This document discusses aging changes to the skin and common skin conditions seen in older adults. It begins by outlining normal age-related changes including thinning and drying of the skin. Key skin conditions discussed include xerosis/pruritus, actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and melanoma. Nursing assessments and interventions for dry skin and skin cancers are provided.
Pressure ulcers, also known as bedsores or decubitus ulcers, are localized areas of tissue necrosis that occur when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. They are commonly staged from Stage 1 to Stage 4 based on depth of tissue damage. Key risk factors include immobility, moisture, malnutrition, and aging. Prevention focuses on risk assessment, pressure relief, skin care, and nutrition. Treatment involves debridement, dressings, management of bacterial infection, and surgery for advanced cases. Complications can include infection, osteomyelitis, and rarely, cancer.
Dokumen ini memberikan panduan pemakanan untuk pasien diabetes meliputi penjelasan tentang faktor risiko diabetes dari gizi yang tidak seimbang, piramid makanan seimbang, dan contoh porsi makanan untuk satu harian yang sesuai untuk mengontrol kadar gula darah. Dokumen ini juga memberikan daftar makanan yang harus dihindari, dibatasi, dan dikonsumsi oleh pasien diabetes.
This document provides an introduction to vitamins, including their structure, sources, and diseases associated with deficiency and excess. It discusses fat-soluble vitamins A, D, E, K and water-soluble vitamins B1, B2, B3, B5. For each vitamin, it describes sources, structure, deficiency diseases, and in some cases therapeutic uses. The document aims to inform readers about the essential roles and health impacts of various vitamins.
Lecture 12 nutrients involved in energy metabolismwajihahwafa
At the end of this lecture, the student should be able to:
Describe how coenzymes enhance the activities of enzymes.
For each of the eight B-complex vitamins, describe their primary functions and their food sources.
Describe the association between folate, vitamin B12, and vascular disease.
Identify at least two minerals that function as coenzymes in energy metabolism.
Discuss the role that iron plays in oxygen transport.
Distinguish between iron-deficiency anemia, pernicious anemia, and macrocytic anemia.
Keynote: The Phoenix Project: Lessons Learned - PuppetConf 2014Puppet
This document summarizes a presentation about DevOps lessons learned. It discusses that DevOps can provide higher business value than expected, benefits both development and operations teams, and requires high-trust management. It also notes that DevOps is applicable to all types and sizes of organizations, not just large tech companies, and shares an example of a COBOL application adopting DevOps practices across 20 technology stacks. The presentation encourages attendees to learn more about an upcoming DevOps Enterprise Summit for organizations applying DevOps.
This document discusses mineral metabolism and provides details on specific minerals including sodium, potassium, chloride, sulfur, and calcium. It covers their sources, absorption, functions, normal levels, and clinical conditions related to abnormal levels. For each mineral, absorption and excretion processes are described along with roles in the body. Causes and symptoms of both hypo- and hyper- conditions are outlined.
Effectiveness Through Strategy And Organizational Design Seta Wicaksana
Organization Design is a process for shaping the way organizations are structured and run.
It involves many different aspects of life at work, including team formations, shift patterns, lines of reporting, decision-making procedures, communication channels, and more.
Organization Design – and redesign – can help any type of organization to achieve its goals. Sometimes, a large-scale reorganization is necessary. At other points, more subtle shifts in structures and systems can ensure that an organization continues to thrive.
Comparing Ways to Scale Agile at Agile Product and Project Manager MeetupBernd Schiffer
Session "Comparing Ways to Scale Agile" at the Agile Product and Project Manager Meetup in Melbourne, Australia.
These days organisations are looking for support to scale their Agile environment. There’s a difference between having one Agile team on its own, or to have several Agile teams providing value to the customer and interacting with each other.
This session will give an overview and comparison of all the different Agile scaling approaches out there, i.e.:
* Scaled Agile Framework (SAFe)
* Evidence-Based Management (EBMgt)
* Disciplined Agile Delivery (DAD)
* Enterprise Transition Framework (ETF)
* Large-Scale Scrum (LeSS)
* ScALeD Agile Lean Development
* Scaling Agile @ Spotify (SA@S)
* Product Development Flow by Reinertsen (PDFbyR)
Lack of minerals like calcium, iron, chromium, and magnesium can lead to serious health conditions. Iron deficiency is the most common nutritional deficiency and causes iron-deficiency anemia with symptoms like fatigue, weakness, and decreased immune function. Calcium is important for bone health and deficiency can cause osteoporosis. Vitamin deficiencies can also cause diseases like scurvy with symptoms of bleeding gums and spots on the skin or rickets, a softening of the bones in children. Nutrition involves taking in nutrients from food for growth, tissue repair, and energy through absorption and assimilation.
Pengantar "Sistem Manajemen dan Audit Sistem Manajemen" _AUDIT SISTEM MANAJEM...Kanaidi ken
Sistem manajemen dibuat untuk membantu organisasi mencapai tujuan. Audit sistem manajemen penting untuk meningkatkan kinerja organisasi dan memastikan kepatuhan. ISO 19011 memberikan panduan audit berdasarkan prinsip-prinsip seperti integritas dan objektivitas.
This slides-share describes best practices to implement Jira in software development organizations who practice Agile.
The focus is on simple implementation based on Jira core and portfolio to achieve high ROI
Zinc is a trace mineral that is important for many functions in the body. The total body content of zinc is about 2 grams, with high concentrations found in the prostate gland, muscle tissue, and bone. Good dietary sources of zinc include meat, dairy products, legumes, nuts, and spinach. Zinc is required for the function of many enzymes and is involved in processes like DNA synthesis, wound healing, growth, and taste sensation. Zinc deficiency can result in issues like hypogonadism, growth failure, and skin lesions. Toxicity from excess zinc intake is rare but can cause nausea and gastrointestinal issues.
This document provides an overview of nutrition including defining key terms and concepts. It discusses the six major classes of nutrients - carbohydrates, lipids, proteins, vitamins, minerals, and water. Carbohydrates, lipids and proteins are macronutrients that provide energy, while vitamins and minerals are micronutrients needed in smaller amounts. The document also examines the essential roles various nutrients play and how dietary choices can impact chronic disease risk.
Copper is an essential trace element found in all human tissues. It plays an important role in many processes including iron transport, collagen formation, antioxidant activity and enzyme function. The average adult contains around 100-150mg of copper stored primarily in the muscles, bones and liver. Dietary sources include meat, shellfish, nuts and cereals. The recommended daily allowance is 900mcg for adults. Copper absorption requires special mechanisms and can be inhibited by other minerals or vitamins taken in excess. A copper deficiency can result in issues like anemia, bone disorders and grey hair.
Agility boosts performance: Guide for your agile transformation journeySebastian Olbert
ORGANIZATIONAL AGILITY AS A COMPETITIVE FACTOR
The Agile Performer Index
In the Agile Performer Index, goetzpartners and the NEOMA Business School clearly demonstrate the correlation between agility and entrepreneurial success. The more agile the company, the better it performs financially. The purpose of the study was to investigate what agility can really do for organizations. Is it just a temporary trend? With the right methodology, can agility deliver sustainable success?
Resulting from a broad survey among 285 leading European companies, the Agile Performer Index documents that agility programs are a suitable way for organizations to achieve lasting performance and competitive advantage.
Selected key findings:
Agile companies perform ~ 2.7 times better than non-agile companies
CxOs rate their company’s agility higher than do middle managers.
Sector check: Digital maturity doesn’t guarantee agility
The document describes the three core Scrum roles - Product Owner, Scrum Master, and Development Team - and two ancillary roles. The Product Owner represents stakeholders and ensures the product meets business needs. The Scrum Master coaches the team and removes impediments to workflow. The multi-functional Development Team is self-organizing and completes the work. The ancillary roles of customers and management provide feedback but are not directly involved in sprints.
Agile Development in Large-Scale: Challenges and Insight from ResearchTorgeir Dingsøyr
Keynote at the SPA Software in Practice, London, 26 June 2019.
Agile methods were aimed at small, co-located teams developing non-critical software products. The success of these methods for small teams have led to use in projects with tens of teams and hundreds of developers. Are agile methods suited in this new context? What fundamental assumptions in agile methods become challenging with scale? What can we learn from prior studies on key areas such as managing uncertainty, coordination, sharing knowledge, self management and tailoring of development method?
This document summarizes information about zinc, including its dietary sources, recommended daily allowances, physiological functions, deficiency, and treatment. Some key points include:
- Zinc is an essential micronutrient found in high amounts in oysters, meat, and nuts. It plays roles in over 300 enzymes and 2000 transcription factors.
- Recommended daily zinc intake ranges from 2-11 mg per day depending on age. Pregnant and lactating women should have 11-12 mg.
- Zinc deficiency can cause impaired immunity, growth retardation, skin disorders, and is common in developing countries. It is diagnosed through blood tests.
- Treatment involves oral zinc supplementation, with doses ranging from 0.
Care of aging_skin_spring 2014 abridgedShepard Joy
This document discusses aging changes to the skin and common skin conditions seen in older adults. It begins by outlining normal age-related changes including thinning and drying of the skin. Key skin conditions discussed include xerosis/pruritus, actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and melanoma. Nursing assessments and interventions for dry skin and skin cancers are provided.
Pressure ulcers, also known as bedsores or decubitus ulcers, are localized areas of tissue necrosis that occur when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. They are commonly staged from Stage 1 to Stage 4 based on depth of tissue damage. Key risk factors include immobility, moisture, malnutrition, and aging. Prevention focuses on risk assessment, pressure relief, skin care, and nutrition. Treatment involves debridement, dressings, management of bacterial infection, and surgery for advanced cases. Complications can include infection, osteomyelitis, and rarely, cancer.
this topic is on bed sores. discusses the definition, etiology , pathophysiology of bed sore development as well as prevention and managemene of pressure sores
A pressure ulcer is an injury to the skin caused by prolonged pressure that cuts off blood flow. Ulcers are common in people who are confined to beds or wheelchairs and cannot shift positions to relieve pressure. Factors like limited mobility, incontinence, poor nutrition, and aging can increase risk. Ulcers are staged from 1 to 4 based on their depth, with stage 1 being the least severe. Preventing ulcers involves regularly shifting positions, using special beds and cushions, keeping skin clean and moisturized, and addressing other risk factors through diet and exercise.
Pressure ulcer assessment and managementFurqan Khan
This document provides information on pressure ulcer assessment and management. It defines pressure ulcers and describes the common sites where they occur. It also outlines the classification system for staging pressure ulcers from Stage I to IV, as well as categories for suspected deep tissue injury and unstageable ulcers. For each stage and category, the document details approaches for assessment, wound cleaning, debridement if needed, dressing selection, and offloading of pressure. It lists causative factors for pressure ulcer development and nursing interventions for prevention.
2015: Wounds in the Geriatric Population-SalasSDGWEP
This document discusses wound care in the geriatric population. It outlines risk factors for wounds in older adults and describes assessing and managing different wound types like pressure ulcers, venous stasis ulcers, and diabetic foot ulcers. Standard wound treatments involve addressing underlying causes, cleaning the wound bed, and dressing changes. If wounds do not improve with standard care after 4 weeks, advanced therapies may be considered, such as skin substitutes, growth factors, and negative pressure wound therapy to aid healing. The goal is to diagnose and correct risk factors while managing the wound to assess progress and determine if specialized treatments could help non-healing or chronic wounds.
This document provides an overview of pressure sores including their definition, epidemiology, pathogenesis, risk factors, staging classifications, prevention, and management. Pressure sores, also known as bedsores or decubitus ulcers, are localized skin or tissue injuries caused by unrelieved pressure. They are common in hospital and nursing home patients and costly to healthcare systems. The document outlines the traditional theories behind their pathogenesis as well as intrinsic and extrinsic risk factors. Staging classifications from the National Pressure Ulcer Advisory Panel are presented along with the Braden and PUSH risk assessment tools. Prevention strategies aim to reduce pressure, shearing forces, and moisture on the skin. Management is based on the stage and may involve wound cleaning, dress
This document provides an overview of spinal cord injury (SCI) management. It describes a case of a 47-year-old male who suffered a cervical spine injury in a motor vehicle accident 4 months ago and is now presenting with paraplegia and paraparesis. The document then outlines key topics related to SCI, including anatomy, causes, types, pathophysiology, clinical syndromes, diagnosis, neurological assessment classification, and management. Tables and diagrams are provided to illustrate spinal cord anatomy and tracts, dermatomes, myotomes, and the American Spinal Injury Association classification system.
Spinal cord injuries can cause partial or complete loss of motor and sensory function below the site of injury. There are several types of spinal cord injuries including complete and incomplete injuries. Risk factors include men, young adults, seniors, and those active in sports. Causes include trauma, bullet wounds, and falls. Symptoms depend on the injury level but may include paralysis, numbness, loss of bowel/bladder control. Diagnostic tests include imaging like CT, MRI to determine injury level and severity. Complications can include autonomic dysreflexia, pressure sores, loss of sexual function. Treatment involves stabilizing the spine, managing complications, and long-term rehabilitation.
The document discusses using the Braden Scale to assess patient risk of developing bedsores. The Braden Scale evaluates six categories and assigns a score between 6-23, with lower scores indicating higher risk. Based on the score, the document outlines preventive intervention protocols for patients at risk (score 15-18), moderate risk (13-14), high risk (10-12), and very high risk (score of 9). These interventions include regular turning, positioning, special surfaces, and small shifts in position. The document also introduces the MAP monitoring system which uses a pressure-sensing mat and monitor to provide feedback on patient repositioning.
Trauma causes physical damage and metabolic stress. Early enteral nutrition within 72 hours of injury decreases sepsis risk, while total enteral nutrition preserves gut function and immunity. For severe trauma, an immune-enhancing diet with higher protein of 2.2-2.5 g/kg daily for a week may reduce infections. Severe head trauma increases energy expenditure and protein breakdown while impairing immunity. Early enteral nutrition can improve outcomes if given after intracranial pressure is controlled, while overfeeding must be avoided to prevent increased intracranial pressure from excess nutrient processing.
This document discusses bedsores, also known as pressure sores or ulcers. Bedsores develop from prolonged pressure on skin, especially over bony areas, and people at highest risk are those confined to beds or wheelchairs. Bedsores are staged from I to IV based on severity, from changes in skin color to deep wounds exposing tissue below. Common sites for bedsores in those using wheelchairs are tailbones, shoulders, and limbs, while bedridden patients often develop them on heads, ears, hips and heels. Treatment focuses on reducing pressure through repositioning and support surfaces, and cleaning and dressing wounds.
This document discusses care of aging skin. It begins by outlining objectives related to summarizing effects of aging on skin, distinguishing age-related skin changes from disease-related changes, and describing good skin care practices and common skin conditions in older adults. Key terms are defined. The document then discusses normal age-related changes to the epidermis, dermis, subcutaneous tissue, glands, and hair and nails. Common skin conditions in older adults like xerosis, pruritus, actinic keratoses, seborrheic keratoses, and skin cancers are described. Treatment options for dry skin, itching, and various skin cancers are provided.
MEDICAL NUTRITION THERAPY FOR METABOLIC STRESSDewi Sophia
This document discusses various topics related to nutrition support for critically ill patients. It covers causes of injury and metabolic stress, phases of the stress response, differences between starvation and stress-induced metabolic changes, major causes of death, and considerations for providing nutrition support to critically ill patients with conditions like infection, trauma, burns, and obesity or undergoing surgery. Key points emphasized include the importance of early initiation of nutrition support to minimize complications, meeting calorie and protein needs while avoiding overfeeding, and managing fluid, electrolytes and glycemic control.
Nutritional issues in sepsis, trauma & burn patientsSaurabh Debnath
This document discusses the nutritional needs of patients with sepsis, trauma, or burns who are in a hypermetabolic state with high metabolic demands. It outlines the objectives of nutritional support which are to detect and correct any preexisting malnutrition, prevent further protein-calorie malnutrition, and optimize the patient's metabolic state through fluid and electrolyte management. The goals are to meet the high substrate demands to support hypermetabolism and prevent catabolism while reversing any malnutrition.
WoundRounds: Clinical Reimbursement and Wound Care webinar slideswoundrounds
Presentation slides for the November 9, 2011 webinar on Clinical Reimbursement & Wound Care presented by Dave Rokes, Post Acute Consulting, sponsored by Wound Rounds
AFP is a clinical syndrome characterized by rapid onset of weakness or paralysis in one or more limbs. Common causes of AFP include Guillain-Barré syndrome, poliomyelitis, transverse myelitis, and traumatic neuritis. For polio eradication efforts, all AFP cases must be reported and investigated within 48 hours by collecting two stool specimens at least 24 hours apart and analyzing them for the presence of wild poliovirus. Isolating wild poliovirus from stool specimens would classify the case as confirmed polio.
The document discusses wound dressing basics and moist wound healing. It emphasizes the importance of thorough wound cleansing and maintaining a moist environment to promote healing. Various dressing types are described, including their properties, advantages, and appropriate uses. Autolytic debridement using dressings to maintain a moist wound surface is highlighted as an effective method. Bacterial balance and bioburden in chronic wounds are also addressed.
The document provides information on caring for unconscious and terminally ill patients. It discusses assessing level of consciousness using the Glasgow Coma Scale. It outlines steps to care for unconscious patients such as maintaining airway and circulation, preventing injury and malnutrition. It also covers managing chronic illnesses through prevention, adjusting lifestyle, and using assistive devices. The stages of terminal illness and palliative/hospice care to improve quality of life are summarized.
SB Adults Multidisciplinary clinic, United KingdomIFsbh
This document describes an adult multi-disciplinary clinic in the UK for patients with spina bifida and/or hydrocephalus. The clinic has 19 years of experience providing specialized care for this patient population to address their complex medical needs. It utilizes a team of specialists from various disciplines to provide comprehensive, coordinated care. Through case studies, it illustrates some of the common issues patients face with mobility, continence, sexuality, shunt complications and how the clinic works to optimize patients' physical, psychological and social health through specialized treatment and management plans.
PALLIATIVE CARE AND PRINCIPLES OF MANAGEMENT OF TERMINALLY ILL - ITANKA.pptxUbong Itanka
This document outlines palliative care and the management of terminally ill patients. Palliative care aims to improve quality of life for patients with life-limiting illnesses through early identification and treatment of pain and other symptoms. It takes a holistic, multidisciplinary approach. The principles of management for terminally ill patients focus on proper evaluation, symptom management, counseling, and respecting patient wishes regarding end-of-life care. Palliative care faces some challenges in resource-limited settings like Nigeria due to lack of policies, healthcare workers, and access to palliative medications.
Palliative care aims to improve the quality of life for patients facing life-limiting illnesses through symptom management and end-of-life care. It focuses on relieving suffering at all stages of disease through pain control, addressing nutrition and hygiene needs, and providing psychosocial and spiritual support to patients and their families. As death approaches, palliative care monitors for signs like irregular breathing and changing skin temperature to ensure patient comfort. It also counsels grieving families and helps them understand the dying process.
health care facilities in quebec avjot kauravvyrandhawa
This document summarizes different types of healthcare facilities that provide both acute and long-term care. Acute care facilities like hospitals provide diagnosis and treatment over a short period, usually days to weeks, for recent illnesses or injuries. They focus on stabilization and recovery. Long-term care facilities provide ongoing support for patients with chronic illnesses over months or years, such as for Alzheimer's disease. The document then discusses the services provided at several Montreal acute care facilities, including the Jewish General Hospital and an emergency department. It also outlines the services and patients at a long-term care residence.
This document outlines components of maternal and child health care services including antenatal care, intranatal care, and postnatal care. It discusses the objectives and services provided at each stage of care. Antenatal care aims to promote the health of the mother and baby during pregnancy through regular checkups and health education. Intranatal care focuses on a clean delivery through aseptic measures. Postnatal care monitors for complications and provides family planning services after birth. The document provides details on the services, advantages, and disadvantages of care delivered at home or in institutions.
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Functional constipation with bleeding anal fissure is the most likely diagnosis for the 4-year-old girl presenting with a 2-year history of constipation. No investigations are necessary. Treatment includes disempaction using oral polyethylene glycol, followed by a maintenance regimen of laxatives and lifestyle modifications to achieve regular soft bowel movements and prevent recurrence, along with analgesia for the anal fissures.
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hii guys this is my ongoing presentation from my speciality class i hope u guys lije that please so i hope it is been useful for u in ur specialities by getting little help with that
Similar to Pressure ulcers in a spinal cord injury patient (20)
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
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GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
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Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
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Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
2. Learner Objectives
• Learners should be able to…
• Gain a comprehensive understanding of how a patient’s
social, health and medical history can influence their
condition and recovery.
• Explain the pathophysiology of pressure ulcers.
• Recall conditions or factors that may increase a patient’s risk
for developing a pressure ulcer(s) and how these conditions
may complicate the treatment of pressure ulcers.
• Demonstrate the medical nutrition therapy and nutrition
care process for a patient with pressure ulcers.
3. Introducing the Patient
• A.L.
• 34 year old male
• Paraplegic T8 down
• Admitted Sept 6, 2014
• Dx: complicated UTI
• Severe pressure ulcers
4. Role of the RD in SCI
• Active in acute phase, rehabilitation setting and
community setting
• Evidence suggests MNT provided by RD results
in…
• Improved nutrition-related outcomes
• Adequate nutrient intake
• Weight
• Bowel management
• Dysphagia
• Pressure ulcers
6. Nutrition Assessment
• Client history
• Food- and nutrition-related history
• Anthropometrics
• Nutrition-focused physical findings
• Biochemical and medical tests,
procedures
7. Medical History
• Anxiety, GERD, CKD
• Suicide attempt 09/2009– stab wound to RUQ
• Multiple ER visits for ETOH intoxication
• Pressure ulcers first appeared in 2012
• MGL 12/2013 for ulcers
• Per ER Triage: wounds neglected, down to the bone
• MGL 01/2014 for stage 4 pressure ulcers, osteomyelitis
• DKA 4 times, hyperglycemia 4 times
8. Medical History
• Type 1 diabetic for 26 years
• States BS well-controlled at home
• Checks BS at least 2x/day, usually 3 with meals
• Home medications
• Multivitamin
• Levemir– 40 units
• Long acting insulin
• Aspart Injection– 6 units
• Fast-acting mealtime insulin
• Preferably TID with meals
9. Social History
• July of 2011– lost house
• August 2011– bought new house in Lansing
• Needed repairs, which AL did himself
• Spent weeks working in moldy basement, no
mask
• Fell ill Hospitalization Dx of Transverse
Myelitis
10. What is Transverse Myelitis?
• Rare neurological disorder; inflammatory disease
that causes injury to spinal cord
• Exact cause is unknown
• “viral, bacterial, fungal and/or even parasitic […]
etiology.”
• Attacks of inflammation can damage/destroy myelin
• Creates nervous system scars that interrupt
communication between spinal nerves and rest of
body
12. What is Transverse Myelitis?
• Symptoms advance in as little as hours to weeks
• 1/3= full recovery
• 1/3= fair recovery, some significant deficits
• Spastic gait
• Sensory dysfunction
• 1/3= no recovery
• Paraplegic or quadriplegic
13. Social History
• Earned GED
• LCC MSU
• Licensed builder and certified mechanic
• Unemployed since becoming paraplegic
• Disability Medicaid coverage
14. Social History
• Lives alone in apartment with his cat
• “Plain” and “boring” life
• No socialization outside of family
• Family support:
• Mother, brother and sister all live in same complex
• Very close with nephew
• Father passed away from renal disease
15. Social History
• Does not drink– Hx of ETOH abuse
• Smokes tobacco, chews tobacco @ hospital
• Sleeps 8-10 hours/night
• Does not exercise d/t paralysis
• Could do arm exercises but chooses not to
• No appetite
• Uses medical marijuana to increase PO intake
16. Appetite in SCI
• “A person with a [SCI] above the level of the abdomen cannot
feel if their stomach is hungry or full, so they have to remember
when to eat and how much to eat.”
• Visceral sensory information is transmitted to the brain
through the afferent vagus nerve
• Ghrelin, a peptide produced in the stomach, travels to the
hypothalamus to stimulate feeding
• A study done in rats found that blockade of the gastric vagal
afferent abolished ghrelin-induced feeding
• This explains why a person with a spinal cord injury does not feel
hunger sensations
17. Medical Marijuana and
Appetite
• Cannabinoids: natural compounds found in marijuana, act on
specific receptor sites within the brain and reflect the
physiological role of their natural ligands
• Ex: Delta-9-tetrahyrdocannibinol (THC)
• Endocannabinoids: substances occurring naturally in the body
that activate cannabinoid receptors
• Ex: N-arachidonoylethanolamine (anandamide)
• Cannabinoid receptors: cell membrane receptors that are
activated by three major groups of ligands: endocannabinoids,
plant cannabinoids and synthetic cannabinoids
• CB1 (located in central nervous system)
• CB2 (located in periphery)
18. Medical Marijuana and
Appetite
• Endocannabinoids initiate appetite by stimulation of CB1
receptors in the hypothalamic areas involved in the
control of food intake
• Endocannabinoids contribute to incentive processes and
to hedonic evaluation of food
• “wanting” and “liking”
• Induce a psychological craving for
food and not just a physiological
19. Nutrition Knowledge
• States knowledge of nutrition is “stellar”
• Food intake history:
• Lots of protein/meats
• Hamburgers, eggs, chicken, peanut butter, whey
• Drinks mostly water, no pop or sugary beverages
• Wide variety of vegetables
• Asparagus, squash, eggplant, Brussels sprouts
• Stays away from sugar
• Small portions d/t not being able to feel full
21. Homecare Nurse
• 5 days/week, 8 hrs/day through Home Care
Alternatives
• Provides wound care (pt does not f/u w wound clinic)
• Per social work: pt regularly declines in-home skilled
care soon after he returns from the hospital
repeatedly d/c from homecare for noncompliance
• Does not want strangers in his home
• Pt recently d/c with Sparrow Hospice declined
visits from hospice nurse discon’t for
noncompliance admitted to MGL next day
22. Handicaps Related to Eating
• Does not cook for himself
• Able to take bus to grocery store if
needed
• Usually brother or caregiver shops for him
• Brother/caregiver prepares food
• 3 meals/day
• Snacks he gets himself
23. Anthropometrics
• Ht: 66”
• Current wt: 145#
• BMI: not to be used for pt’s with SCI
• IBW: 142#
• AIBW for paraplegia: see Metropolitan Life Tables
• UBW pre-paraplegia: 172#
• Wt Hx: 10/10/12 165#, 01/12/14 157#
25. Nutrition-Focused Physical
Findings
• Gastrointestinal issues and bladder/bowel dysfunction
• Occur in 27%-62% of pt’s with a SCI
• Multiple UTI’s
• Unable to control bladder need for catheter increased risk
of infection
• Colostomy
• Dental issues
• Cavities had to get 19 teeth pulled
• Full upper denture set
• States does not affect his eating
26. Nutrition-Focused Physical
Findings
Stage IV Ulcer Sacrum
• 3 cm long
• 2 cm wide
• .4 cm deep
• Slough pink
• Granulation pink
Unstageable Ulcer
Posterior Scrotum
• 2 cm long
• 1 cm wide
• .7 cm deep
• Moderate tan
drainage
27. Pressure Ulcers
• AKA bedsores, pressure sores, decubitus ulcers
• Injuries to skin and underlying tissue resulting from prolonged
pressure
• Often develop on skin that covers bony areas of the body
• Buttocks
• Hips
• Elbows
• Heels
• Shoulders
• Can quickly develop, often difficult to treat
28. Epidemiology
• Incidence:
• 2.3% to 23.9% in long-term care
• 0.4% to 38% in acute care
• 0% to 17% in home care
• Prevalence:
• 2.3% to 28% in long-term care
• 10% to 18% in acute care
• 0% to 29% in home care
• Higher level SCI lesions = risk
• Fuhrer MJ, et al: 33 of 100 pt’s with stage II or greater
29. Pathophysiology
• Pressure disrupts normal circulation to skin and deep
structures
• Complex vascular system (large veins and capillaries)
runs throughout the dermis to supply the skin
• Arteriole capillary pressure 32 mmHG = disrupted
blood flow
• Venous capillary closing pressure 8-12 mmHG =
impedes return of flow
• Prolonged pressure ischemia, necrosis, ulceration
41. Medical Treatment
• Negative pressure wound therapy (NPWT)
• Vacuum pump, drainage tubing, foam or gauze wound
dressing, and an adhesive film dressing that covers and
seals the wound
• Wound V.A.C.
• Creates continuous or intermittent negative pressure
inside the wound to remove fluid, exudates, and
infectious materials
• Maggots
• To clean out the necrotic tissue
43. Medical Treatment
• Surgical/sharp debridement: use to remove
large amounts of thick eschar and infected
tissue; or need for urgent debridement
• Mechanical debridement: used on wounds
with moderate necrotic tissue (eschar)
• Pressurized irrigation device
• Low-frequency mist ultrasound
• Specialized dressings
45. Medical Treatment
• Autolytic debridement: used on wounds with small to
moderate amounts of eschar; enhances body’s
natural process of using enzymes to breakdown dead
tissue
• Hydrocolloids
• Hydrogels
• Transparent film
• Enzymatic debridement: used on wounds with a
significant amount of necrotic tissue; involves
applying chemical enzymes and appropriate dressings
47. Medical Treatments
• Skin flaps
• Portion of skin and tissue moved to fill defect
• Results in a new defect at donor site
• Often can be closed primarily, sometimes requires skin grafting
• Axial
• Random
• Rhomboid
• Rotation
• V-Y Advancement
• Muscle flaps
• Moving a local muscle to cover an exposed bone or
fracture
49. AL’s Infection
• On 9/10 found infection in wound
• Gram negative bacilli three colony types, proteus species
+/T/ group D enterococcus
• Enterococci are a part of the normal intestinal flora of
humans and animals
• One study found in its subjects group D enterococcus was
one of the most common aerobic isolates from pressure
ulcers
50. Hospital Medications
Medication Classification Use Mechanism Possible FDI
Rocephin
Cephalosporin
Antibiotic
Treat bacterial
infections
Inhibits
mucopeptide
synthesis in the
bacterial cell
wall
Anorexia, dry
mouth, metallic
taste, N/V,
diarrhea,
constipation
Diflucan
Anti-fungal
medicine
Treat infections
caused by
fungus
Inhibits fungal
cytochrome
dependent
enzyme
N/V, abdominal
pain, taste
changes
Lovenox
Anticoagulant Treat or
prevent a DVT
or PE
Binds to and
accelerates the
activity of
antithrombin III
Nausea,
diarrhea
51. Hospital Medications
Medication Classification Use Mechanism Possible FDI
Nicoderm
Smoking
cessation
adjunct
Reduce craving
and withdrawal
symptoms
associated with
smoking
Binds to
nicotine
receptors in
body
Nausea
Protonix
Proton pump
inhibitor
Treatment of
conditions such
as ulcers or
GERD that are
caused by
stomach acid
Suppresses final
step in gastric
acid production
by binding to
the H+, K+
ATPase enzyme
system
at the secretory
surface of
gastric parietal
cell
Long-term use
may may it
harder for your
body to absorb
vitamin B12,
weight
changes, N/V,
diarrhea, gas,
stomach pain
52. Hospital Medications
Drug Class Mechanism Use Possible FDI
Cipro Quinolone
antibiotic
Inhibits
enzymes
required for
DNA processes
Treat infections
of the skin,
bone, sinus,
lung, abdomen
and bladder
Do not take
along with
dairy products
or
multivitamins
NovoLog Insulin aspart Bind to insulin
receptors and
increase cellular
uptake of glucose
and inhibiting the
output of glucose
from the liver
Fast-acting
form of insulin
that acts to
lower blood
glucose
N/A
Levemir Insulin detemir See above Basal insulin
that acts to
lower blood
glucose
N/A
64. Infection
• “The healing process in diabetes is also jeopardized by the
patient’s susceptibility to infection due to deficiencies on
the innate immunity.” Berlanga-Acosta et al.
• Hyperglycemia reduces the function of immune cells and
increases inflammation
• Dysregulation of the inflammatory response can lead to
extensive tissue damage
• Excess glucose reduces the functional longevity of
neutrophils
• Once a wound becomes infected it has a lower
probability of healing
65. Now that we have gathered all of the factors
affecting AL’s disease process, we are able to
make an appropriate diagnosis.
68. Nutrition Intervention
• Reduced metabolic activity d/t denervated muscles
• BMR reported to be 14-27% lower for SCI pt than able-
bodied individuals
• Increased fat mass and loss of fat-free mass
• Sympathetic blunting, cardiopulmonary dysfunction, reduced
work capacity, and diminished anabolic hormones
• “Without diet adjustment to new metabolic requirements
after SCI, energy intake quickly exceeds energy
requirements, resulting in weight gain.” Crane DA et al.
• Clinical observations suggest SCI pt become obese within
first 12 months after injury
69. Nutrition Intervention
• Energy needs in paraplegia without pressure ulcer present
• 27.9 kcal/kg
• Protein needs in paraplegia without pressure ulcer present
• 0.8-1 g/kg
• Energy needs in paraplegia with pressure ulcer present
• 30-35 kcal/kg
• Protein needs in paraplegia with pressure ulcer present
• 1.2-1.5 g/kg for stage II
• 1.5-2.0 g/kg for stage III and IV
70. Nutrition Intervention
• Normal fluid requirements: 30 ml to 40 ml/kg
• No less than 1 ml/kcal
• May need additional 10 ml to 15 ml/kg
• Evaporation of fluids from severe pressure ulcer
• Draining or open wounds
• Fever
• Use of air fluidized bed set at high temperature
71. Nutrition Intervention
• Zinc
• Decrease in collagen and protein synthesis and impaired immune
competence
• Recommendation: 50 mg elemental zinc BID for 2-3 weeks maximum
• Vitamin A
• Impaired wound healing and altered immune function
• Recommendation: 10,000-50,000 IU/day
• Vitamin C
• Delayed wound healing
• Recommendations:
• 100-200 mg/day for stage I and II pressure ulcers
• 1,000-2,000 mg/day for stage III and IV pressure ulcers
72. Nutrition Intervention
• Glutamine
• Conditionally essential amino acid
• Key role in immune system, deficiency can slow healing
• Arginine
• Semi-essential amino acid
• Promotion of nitrogen balance, cell proliferation, T
lymphocyte fxn, collagen accumulation
• HMB
• Metabolite of leucine
• Inhibits muscle proteolysis, modulates protein turnover
73. Nutrition Intervention
• Williams JZ, Abumrad N, Barbul A. Ann Surg Sept
2002.
• Double-blind, randomized trial
• 35 healthy, nonsmoking humans 70 yrs or older
• 18 received HMB, glutamine and arginine suppl.
• 17 received isonitrogenous, isocaloric nonessential AA suppl.
• “Collagen synthesis is significantly enhanced in
healthy elderly volunteers by the oral administration
of a mixture of arginine, HMB and glutamine.”
74. Nutrition Intervention
• Wong A, Chew A, Wang CM, et al. J Wound Care May 2014
• Placebo-controlled trial
• 23 inpatients with stage II, III or IV pressure ulcers in an acute
care hospital
A. HMB, arginine and glutamine mixture BID
B. Standard nutrition care + oral nutritional supplements
• “The use of specialised amino acid does not appear to reduce
wound size and PUSH scores but may improve tissue viability
after 2 weeks. Further confirmation on a larger scale is required
to determine the benefits of supplementing additional HMB,
arginine and glutamine in patients with pressure ulcers.”
75. AL’s Nutrition Intervention
• 1600-2000 kcal/day (25-30 kcal/kg)
• 79-99 g PRO (1.2-1.5 g/kg)
• 1980 ml fluid (30 ml/kg)
• Regular diet
• Fruit punch Juven BID
• Strawberry Glucerna TID
76. What Would I Have Done
Differently?
• 2200 ADA diet (33.4 kcal/kg)
• Increased kcal intake for wound healing
• ADA diet for better glucose control
• 99-132 g PRO (1.5-2.0 g/kg)
• Stage IV pressure ulcers
• Special K protein bars, Glucerna only BID
• 50 mg elemental zinc BID
• 10,000-50,000 IU vitamin A
• 1,000-2,000 mg vitamin C
77. Monitoring and Evaluation
• Weight
• Anthropometrics
• Nutrient intake
• Wound stage/healing
• Hydration status
78. Monitoring and Evaluation
• Weight was stable throughout hospital visit
• Per meal intake record AL was eating 80-100% of
meals
• See previous slides for laboratory tests
• Post-op:
• Unstageable pressure ulcer debrided to stage III
• 9/10 started getting bedside I and D’s
• For wound healing and to help clear the infection
79. Prognosis
• After 6 months of treatment
• > 70% of stage II
• 50% of stage III
• 30% of stage IV
• Often develop in pt’s receiving sub-optimal care
• Long-term outcome is poor if care cannot be improved
(even if short-term wound healing was accomplished)
• Agency for Health Care Research and Quality 2006
• Pressure ulcers as primary diagnosis: 1 in 25 ended in death
• Pressure ulcers as 2nd diagnosis: 1 in 8 ended in death
80. Prevention
• Repositioning (q 2 hrs)
• Specialty mattresses
• Foam, water, air to help with positioning
• Head of bed raised no more than 30° to prevent
shearing
• Adequate nutrition to maintain skin integrity
• With care to pt’s activity status to prevent obesity
• Smoking cessation
81. Health Care Cost
• Estimated cost of treating pressure ulcers in 2008
• $9.2 to $15.6 billion
• Factor in 7% per year for health care inflation to get today’s
cost
• Reported cost for treating a pressure ulcer in an acute-
care setting (Centers for Medicaid/Medicare Services)
• $43,180 per hospital stay
• Cost Factors
• Increased length of stay d/t pressure ulcer complications:
pain, infection, decreased functional ability
82. Cost Effectiveness
• Likely that cost of prevention less than
treatment
• Reduced hospital visits
• Less recurrence of pressure ulcers
• i.e. ensuring adequate protein and
micronutrient intake to promote healthy
skin integrity and reduce risk of developing
a pressure ulcer
83.
84. References
American Dietetic Association. Spinal cord injury. Evidenced-based nutrition practice guidelines. Chicago (IL): American Dietetic
Association; 2009. Various p. [340 references]
National Institute of Neurological Disorders and Stroke and National Institutes of Health. Transverse Myelitis Fact Sheet. Bethesda MD:
Office of Communications and Public Liaison; April 16, 2014
West TA. Transverse myelitis—a review of the presentation, diagnosis, and initial management. Discovery Medicine. 2013;16(88):167-177.
Curators of the University of Missouri. Spinal Cord Injury. http://www.dps.missouri.edu/resources/orient/refrnc/encycl/sci.htm. Copyright
2000-2005. Accessed 2014.
Date Y, Murakami N, Toshinai K, et al. The role of the gastric afferent vagal nerve in ghrelin-induced feeding and growth hormone
secretion in rats. Gastroenterology. 2002;123(4):1120-1128.
Tibirica E. The multiple functions of the endocannabinoid system: a focus on the regulation of food intake. Diabetology and Metabolic
Syndrome. 2010:;2(5).
Kirkham TC. Cannabinoids and appetite: food craving and food pleasure. International Review of Psychiatry. 2009;21(2):163-171.
Mayo Clinic Staff. Bedsores (pressure sores) Definition. Mayo Clinic Web Site. http://www.mayoclinic.org/diseases-
conditions/bedsores/basics/definition/con-20030848. Updated March 25, 2014. Accessed 2014.
Dorner B, Posthauer ME, Thomas D. The role of nutrition in pressure ulcer prevention and treatment: national pressure ulcer advisory
panel white paper. National Pressure Ulcer Advisory Panel. 2009: 1-15.
85. References
Mayo Clinic Staff. Bedsores (pressure sores) Risk Factors. Mayo Clinic Web Site. http://www.mayoclinic.org/diseases-
conditions/bedsores/basics/risk-factors/con-20030848. Updated March 25, 2014. Accessed 2014.
National Pressure Ulcer Advisory Panel. NPUAP Web Site. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-
pressure-ulcer-stagescategories/. Published 2001. Updated 2007. Accessed 2014.
Mayo Clinic Staff. Bedsores (pressure sores) Treatments and Drugs. Mayo Clinic Web Site. http://www.mayoclinic.org/diseases-
conditions/bedsores/basics/treatment/con-20030848. Updated March 25, 2014. Accessed 2014.
Sermer N. Practical Plastic Surgery for Nonsurgeons. The University of Michigan: Hanley and Belfus; 2007.
Yoshikawa TT, Ouslander JG. Infection Management for Geriatrics in Long-Term Care Facilities. 2nd ed. New York, NY: Informa Healthcare
USA; 2007.
RxList Inc. Drugs A-Z. RxList Web Site. http://www.rxlist.com/drugs/alpha_a.htm. Accessed 2014.
Breslow RA, Bergstrom N. Nutritional prediction of pressure ulcers. Journal of the American Dietetic Association. 1994;94(11):1301-1304.
Berlanga-Acosta J, Schultz GS, Lopez-Mola E, et al. Glucose toxic effects on granulation tissue productive cells: the diabetics’ impaired
healing. BioMed Research International. 2013;2013:15 p.
How Diabetes Affects Wound Healing. Wound Care Centers Web Site. http://www.woundcarecenters.org/article/living-with-wounds/how-
diabetes-affects-wound-healing. Accessed 2014.
86. References
Academy of Nutrition and Dietetics. Nutrition Care Manual. Pressure Ulcers.
http://www.nutritioncaremanual.org.proxy2.cl.msu.edu/topic.cfm?ncm_category_id=1&lv1=5546&lv2=16668&ncm_toc_id=16668&nc
m_heading=Nutrition%20Care. Accessed 2014.
Crane DA, Little JW, Burns SP. Weight gain following a spinal cord injury: a pilot study. J Spinal Cord Med. 2011;34(2):227-232.
Williams JZ, Abumrad N, Barbul A. Effect of a specialized amino acid mixture on human collagen deposition. Ann Aurg.
2002;236(3):369-74.
Wong A, Chew A, Wang CM. The use of a specialised amino acid mixture for pressure ulcers: a placebo-controlled trial. J Wound Care.
2014;23(5):259-60, 262-4, 266-9.
Tanhoffer RA, Tanhoffer AIP, Raymond J, et al. Comparison of methods to assess energy expenditure and physical activity in people
with spinal cord injury. J Spinal Cord Med. 2012;35(1):35-45.
Kroshinsky D, Strazzula L. Pressure Ulcers. The Merck Manual Web Site. Updated March 2013. Accessed 2014.
Editor's Notes
Osteomyelitis is a bone infection (or spinal infection) caused by bacteria or other germs. The infection can reach the bone via a nearby tissue, or from traveling through the bloodstream. Osteomyelitis can be extremely painful, or show no symptoms at all. AL’s chronic osteomyelitis likely 2nd to his pressure ulcers, as pressure ulcers that do not heal have an increased risk for infection.
Admitted for DKA four times and hyperglycemia four times since 2002
This shows a short-acting insulin injection before breakfast, before lunch, before dinner and a long-acting injection before bed.
I’m going to spend a bit of time talking about this pt’s background he has a particularly interesting background and I believe it is imperative to his case.
Transverse myelitis is a very interesting and complex disease.
No familial predisposition and it occurs in all races and genders.
Peak incidences between 10 and 19, 30 and 39.
Only about 1400 new cases per year.
Read quote… this is because Ghrelin, the hormone that tells you to eat, is produced in the stomach and is transmitted to the hypothalamus to induce hunger. However, when the route that ghrelin takes to reach your brain is destroyed, it abolishes ghrelin-induced feeding. This was actually discovered in an experimentation performed on rats who underwent a vagotomy.
http://www.dps.missouri.edu/resources/orient/refrnc/encycl/sci.htm resource for that quote
http://www.sciencedirect.com/science/article/pii/S0016508502002172 resource for the study
Because AL’s pathway is compromised, he uses medical marijuana to induce appetite. Medical marijuana consists of natural compounds called cannabinoids, which act on receptors in the brain, called cannabinoid receptors, to reflect the physiological role of their ligands (reword last part.) An example of an appetite-inducing cannabinoid is THC. When a person smokes marijuana, THC overwhelms the EC system and attaches itself to the cannabinoid receptors. Endocannabinoids are produced in the body and also activate cannabinoid receptors. An example of an appetite-inducing endocannabinoid is anandamide. THC and anandamide both bind to the same cannabinoid receptor in the brain called CB1.
http://www.dmsjournal.com/content/2/1/5
So if our ghrelin pathway is disturbed, how can medical marijuana cause us to have an appetite? Don’t our hunger hormones have to travel from our stomach to tell us to eat? Well, yes, but there’s more to the story. When a person smokes, there are large amounts of THC in the body and they attach themselves to cannabinoid receptors, taking on the role of their natural ligand. Endocannabinoids increase appetite as well as increasing the pleasure associated with food. It produces a psychological craving more than a physiological craving. It’s almost like it tricks your brain into thinking you are hungry.
This is a relatively new area of study and research is still being done. Little research has been done on humans to clarify the drug’s specific effect on appetite regulation. However, from the research I gathered and critical thinking I employed I think it can be said that endocannabinoids act on the brain to induce pleasure-based eating, and they do not act solely act on the gut to tell your brain to keep eating. In essence, they “trick” your brain into believing you are hungry.
file:///Users/doherlil/Downloads/kirkham_2009.pdf
By walking distance I mean that there are no grocery stores near by that he is able to access by wheelchair
Per social work, pt regularly declines the in-home skilled care soon after he returns from the hospital, primarily because he does not want strangers visiting his home, thus he is repeatedly discharged from home care for non-compliance. Pt was discharged with Sparrow Hospice, which was discontinued on 9/5 for non-compliance, as pt declined home visits by the hospice nurse. He was admitted to MGL the next day. Pt has hospital bed, manual and electric wheel chairs at home. Declined bath the last four days before admission because he did not feel well.
BMI and skinfold measurements are not to be used in patient’s with a SCI as these tools are meant for able-bodied persons and may not produce reliable results. Instead, tools such as bioelectric impedance analysis or dual-energy X-ray absorptiometry should be utilized.
http://www.guideline.gov/content.aspx?id=14889
He has had a slow decrease in weight, likely d/t losing his muscle mass and protein leakage from his wounds. He has lost 12# since January and 20# since Oct 2012.
According to frame ages 25-59.
RDs should estimate the IBW of patient’s with SCI by using the Metropolitan Life Insurance Tables for patient’s of equivalent height and weight. This can be done for paraplegics either by subtracting 10-15#, or 5-10% of those weights. AL is a 5’6” medium-framed male, so his AIBW should be between 139 and 151#. I subtracted 8#, as that is the average of 5 and 10#s. Thus, AL’s AIBW should be 131-143#s.
http://sci.washington.edu/info/forums/reports/nutrition_2011.asp#weigh
When using an indwelling catheter, you will always have bacteria in your urine, and the catheter provides a direct pathway for the bacteria to reach your bladder. Bacteria living in your bladder can develop into a UTI if the catheter becomes blocked, your immune system is low, or if you become dehydrated.
http://www.dps.missouri.edu/resources/orient/refrnc/encycl/sci.htm
Prevalence is how many people in the population have this condition right now whereas incidence is how many people per year acquire this condition?
Some studies also indicate that black patients have more severe pressure ulcers than other groups, and some authors speculate this is because detecting erythema can be more difficult in skin with darker pigmentation.
http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf
This chart shows how all of the risk factors, which I will discuss in the next slide, contributes to the decreased flow of blood to areas and leads to ischemia and cell death, the stages before creation of a pressure ulcer
Immobility d/t: general weakness, coma, paralysis, bed rest, obesity, etc.
Age: elderly have thinner, more fragile and drier skin. They also produce new skin cells more slowly.
Lack of sensory perception: inability to feel pain or discomfort d/t SCI or neuro disorder or other insensate conditions
Weight loss: loss of fat and muscles results in less cushioning between bones and bed/wheelchair
Moisture/dryness: increases friction between skin and bed
Bowel incontinence: bacteria from fecal matter can cause infection
Reduced blood flow: limits amount of oxygen to the area
Smoking: decreases blood flow/oxygen in blood, tend to develop more severe wounds and their wounds heal more slowly
http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con-20030848
There are 6 subscales within the Braden scale, each having a score of 1-4 aside from friction and shear, which is only scored from 1-3
Scores range 6-23, lower score= higher risk
Of the factors increasing risk of pressure sore development, AL had…
I said questionable poor nutrition because although he states he has good nutrition at home, I am inclined to believe that he doesn’t d/t his un-healing wounds and uncontrolled blood sugars
Non-blanchable erythema. The skin is not broken. It appears red on people with lighter skin color and the skin does not briefly lighten (blanch) when touched. On darker skinned people, the skin may show some discoloration, but it may be harder to identify. The site may appear tender, painful, firm, soft, warm or cool compared with the surrounding skin.
http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
Partial thickness. The epidermis (outer layer) and part of the dermis (underlying layer) is damaged or lost. The wound may be shallow and pinkish or red. The wound may look like a fluid-filled blister or ruptured blister.
Full-thickness skin loss. Deep wound, loss of skin usually exposes some fat. The ulcer will appear crater-like. The bottom of the wound may have some yellowish dead tissue. The damage may extend beyond the primary wound and below the healthy skin.
Full-thickness tissue loss. Large-scale tissue loss. The wound may expose muscle, bone or tendons. The bottom of the wound likely exposes dead tissue that is yellowish or dark and crusty. Damage often extends beyond the primary wound and below the healthy layers of the skin.
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined, but it will either be a category III or IV.
Depth unknown. Purplish or maroon localized area of intact skin or blood-filled blister d/t damage of underlying soft tissue from pressure and/or shear.
Surgical debridement involves removing material using scissors, scalpel or laser at the bedside or in the OR.
In mechanical debridement, when changing a wet to moist dressing, necrotic tissue adheres to the dressing and is removed when the dressing is pulled off.
Surgical up top, pressurized debridement on bottom.
Surgical debridement produces rapid results and is highly effective, however it can be very painful and expensive.
Mechanical debridement may only require sterile normal saline and gauze, but it can damage the surrounding tissues.
Autolytic debridement involves using occlusive dressings to retain wound secretions and maintain contact between eschar and secretions.
Enzymatic debridement is applying fast-acting topical agents that turn eschar into slough.
Autolytic debridement is fast acting and will not damage healthy tissues. However, it is a slow process and may increase the risk of wound infection. It cannot be used on infected wounds.
Enzymatic debridement using a hydrocolloid. It is painless, safe, easy and protects surrounding tissues. However, it may cause stinging pain and can only be applied to necrotic tissue.
Compared with skin flaps, muscle flaps bring in a robust, new circulation to the injured site and thus enhance wound healing.
http://practicalplasticsurgery.org/docs/Practical_13.pdf
AL had muscle flap surgery at Sparrow hospital in 2013. Flap surgery is fore deep wounds that do not respond to wound care. Muscle flap surgery is a procedure where a local muscle is used to cover a wound site. The muscle, along with its attached blood supply, is attached to the defect and brings new circulation to the wound site to enhance healing.
http://practicalplasticsurgery.org/docs/Practical_13.pdf
This figure is a muscle flap surgery adjacent to the spinal cord. In picture A the wound is aggressively debrided. In B the paraspinous muscles are elevated. In C the muscles are arranged to overlap the spine and in D the deep dermis and skin is closed.
I don’t know exactly what his infections were, and I don’t think it’s of particular importance to his case. It is just important to note that infection was present, which will affect the healing of the pressure ulcer.
http://books.google.com/books?id=P7OZt24014kC&pg=PA261&lpg=PA261&dq=group+D+enterococcus+pressure+ulcer&source=bl&ots=uy3xNnoTGO&sig=hKFWGDG1C8mD21OWxJKor7g_GlQ&hl=en&sa=X&ei=lF97VMLyLcmHsQTs5oHoBg&ved=0CDAQ6AEwAg#v=onepage&q=group%20D%20enterococcus&f=false
Rxlist.com
http://www.andjrnl.org/article/0002-8223%2894%2992464-3/fulltext
This quote is from the journal of the american dietetic association on an article of nutritional predictors of pressure ulcers.
These “malnutrition markers“ are likely reflective of the acute inflammatory processes associated with the development of stage III and IV prssure ulcers and/or an underlying chronic disease, rather than to actually represent overall nutrition status.
http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf ^
These are some of the complications associated with diabetes that can effect the wound healing process.
This is a simplified chart I made of the effects of hyperglycemia on endothelial cells. Hyperglycemia causes systemic inflammation, a rise in acute-phase proteins such as CRP, and increased oxidative stress. The insulin axis prevents cell self-catabolism, and because it is deficient it causes cells to self-catabolize. This self-destruction results in decreased anabolism at the wound site. Because of the toxicity of glucose, more proteins become glycated, and this increase in glycated end products (advanced glycation end products) contributes to a number of complications in diabetes, disrupting normal cell growth and impairing tissue granulation (new CT and tiny blood vessels that form on the surface of a wound during healing.) The inability of these cells to heals causes a release of cytokines, which lead to more inflammation, perpetuating the cycle.
http://www.hindawi.com/journals/bmri/2013/256043/fig2/
When there is an abundance of glucose it gets diverted to the polyol pathway where it is reduced to sorbitol
http://www.hindawi.com/journals/bmri/2013/256043/
http://www.woundcarecenters.org/article/living-with-wounds/how-diabetes-affects-wound-healing
These are some of the common nutrition diagnoses from the Academy for patients with pressure ulcers.
eatright.org
These are the PES statements I have chosen for AL.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066508/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3240915/
“Sympathetic blunting…. also contribute to a lower energy expenditure in patients with SCI”
http://www.guideline.gov/content.aspx?id=14889
Nutrition care manual
Protein of up to 2.0 g/kg is not recommended in the elderly as it can increase the risk for dehydration
http://www.guideline.gov/content.aspx?id=14889
Deficiencies of these micronutrients are associated with…
http://www.guideline.gov/content.aspx?id=14889
http://www-ncbi-nlm-gov.proxy1.cl.msu.edu/pubmed/12192323
Another thing to point out is that this study was done in healthy individuals. Those pts with other comorbidities may not benefit from the supplementation.
http://www.ncbi.nlm.nih.gov/pubmed/24810310
This study was done in Singapore. Said there were no other studies examining the effects of this supplementation on pt’s with chronic pressure ulcers.
PUSH: pressure ulcer scale for healing.
http://www.guideline.gov/content.aspx?id=14889
After 6 months of treatment… resolve.
http://www.merckmanuals.com/professional/dermatologic_disorders/pressure_ulcers/pressure_ulcers.html#v8381665
http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf
Skin care: clean, protect and inspect skin on a daily basis. Manage incontinence to keep the skin dry and help prevent infection.
http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf