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Formal Case Study: Pressure Ulcers
- 1. Formal Case Study: Pressure Ulcers Chad Wessinger
- 3. Background1 • Also known as bedsores or decubitus ulcers • Continuous pressure impeding capillary blood flow to skin and underlying tissue • Multifactorial • Older adults with neurological problems, those heavily sedated, and those with dementia often unable to alleviate pressure • Paralysis, incontinence, sensory losses, rigidity • Protein-energy malnutrition (protein deficit) and under-nutrition (calorie deficit) delay wound healing Wessinger 2017
- 4. Presence in Infancy, Childhood, and Adolescents2 • American Journal of Critical Care article: Factors Associated With Occipital Pressure Ulcers in Hospitalized Infants and Children. • Four-year period: 60 cases of occipital pressure ulcers (PU) • Median age: 12 months • Most patients were in the intensive care unit with cardiovascular or pulmonary problems • Multiple medical devices in place, restricted head movement • Average Braden score was 16 • Braden Score: valid and reliable risk assessment tool for predicting risk for immobility-related PU Wessinger 2017
- 5. Braden Score3 • Sensory 1. Completely limited 2. Very limited 3. Slightly limited 4. No impairment limited • Moisture 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moist • Activity 1. Bedfast 2. Chair-fast 3. Walks occasionally 4. Walks frequently • Mobility 1. Completely immobile 2. Very limited 3. Slightly limited 4. No limitations • Nutrition 1. Very poor 2. Probably inadequate 3. Adequate 4. Excellent • Frictions and Shear 1. Problem 2. Potential problem 3. No apparent problem Wessinger 2017 • Total score out of 23 – the closer to 23, the lower the risk of developing a PU
- 6. Pathophysiology Throughout Lifecycle1,4 • Can affect any bed-ridden, wheelchair-bound, or generally immobilized individual • Of concern in bed-ridden or sedentary elderly • Staging: based on depth of sore and level of tissue involvement Wessinger 2017
- 7. Wessinger 2017 http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/ Pressure Injury Staging Illustrations5
- 8. Wessinger 2017 http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/ Pressure Injury Staging Illustrations5
- 9. Wessinger 2017 Pressure Ulcer Stage Nutritional Recommendations Suspected Deep Tissue Injury Energy: 30 calories/kg BW, Protein: 0.8 g/kg BW in healthy adults, 1 g/kg BW in elderly Stage I Energy: 30-35 calories/kg BW, Protein: 1.25-1.5 g/kg BW, Fluid: 30-33 mL/kg Stage II Energy: 30-35 calories/kg BW, Protein: 1.25-1.5 g/kg BW, Fluid: 30-33 mL/kg Stage III Energy: 35-40 calories/kg BW, Protein: 1.5-1.75 g/kg BW, Fluid: 30-33 mL/kg, Multivitamin with 15 mg of Zn Stage IV Energy: 35-40 calories/kg BW, Protein: 1.75-2. g/kg BW, Fluid: Fluid: 30-33 mL/kg, Multivitamin with 15 mg of Zn Unstageable Energy: 35-40 calories/kg BW, Protein: 1.75-2. g/kg BW, Fluid: Fluid: 30-33 mL/kg, Multivitamin with 15 mg of Zn Information adapted from Table 21-2 on page 450 of “Krause’s Food and the Nutrition Care Process” Nutritional Recommendations for Pressure Ulcer Stages1
- 10. Additional Treatments/Interventions6 • Support surface • Alternating pressure beds, air-fluidized beds, low air loss mattresses • Nutrition • Protein-containing nutritional supplements, vitamin C supplementation • Local wound applications • Hydrocolloid dressings, foam dressings, radiant heat, topical collagen, platelet derived growth factor • Adjunctive Therapy • Electrical stimulation, electromagnetic therapy, therapeutic ultrasound, sham, negative pressure wound therapy, light therapy, laser therapy • Surgery • Cutaneous, fasciocutaneous, myocutaneous Wessinger 2017
- 11. Coding and Reimbursement7 • L89: code for pressure ulcer (non-specific/non-billable) • Numerous codes for specific sites and stages • L89.0: pressure ulcer of elbow (non-specific/non-billable) • L89.01: pressure ulcer of right elbow (non-specific/non-billable) • L89.013: stage 3 (specific/billable) • Example: L89.154: stage 4 pressure ulcer of sacral region Wessinger 2017
- 12. Case/Patient Overview* DN – Resident: Presbyterian Senior Care *Data obtained from PSC medical records Wessinger 2017
- 13. Socio-Economic Background • Marital status: widowed • No children • Living situation: alone • Education: not reported • Occupational hx: hair dresser Wessinger 2017
- 14. Medical History • Medical and Surgical Conditions • Dx upon admittance to PSC: severe anemia, ischemic stroke, hypernatremia, pressure ulcer on sacrum, pressure ulcer on left heel • Other medical conditions: anxiety, arthritis, edema, lumbago (low back pain), obesity, obstructive sleep apnea, left knee joint pain, right knee joint pain, hypertension, vitamin D deficiency, hx of stroke • Surgical hx: ovary removal, lipoma from right shoulder, vein stripping in both legs, scheduled hip surgery (6/26/12) • Alcohol intake: resident reported no regular intake • Tobacco use: resident reported never Wessinger 2017
- 15. Current Medications8 • Atorvastatin 40 mg bedtime • Metoprolol 50 mg q 12 hrs • Fe sulfate 325 mg qd • KCl 20 meq qd • Vitamin D3 1000 units qd • Prilosec 40 mg qd • Miralax 17 g qd • Vitamin c 500 mg bid • Coumadin 3 g bedtime qhs • Zoloft 50 mg qd • Lasix 40 mg qd • Lasix 20 mg 2pm qd • Tylenol 1000 mg 3x tid • Oxycodone 5 mg q 6 hrs PRN • Oxycodone 5 mg 30 min before dressing change qd • Ibuprofen 400 mg q 8 hrs PRN- increased temp for pain • Voltaren gel 1 app L knee bid Wessinger 2017
- 16. Other Physician’s Orders • Diet: regular • Liquids: thin (regular) • Supplements: Prosource liquid protein 30 mL tid • 100 kcal, 15 g protein per 30 mL • Treatment (for PU): • float bilateral heels topical qs • skin prep bilateral heal bid • cleanse BLE mild soap and water bid • limit time OOB max 2 hrs • cleanse sacral wound with NS qd and PRN • knee high TED hose on 7 off 6 • low air loss mattress • Weights: weekly on admission, then monthly after first 4 weeks Wessinger 2017
- 17. Chronic Disease Risk1 • Increased risk due to: • Increased age of 71 years old • BMI of 36.8 (obese) • Pre-existing comorbidities • Sedentary lifestyle • Family history of chronic disease • Heart disease, heart failure, coronary heart disease, rheumatoid arthritis, osteoporosis Wessinger 2017
- 18. Braden Score3 12/20/16 Sensory: no impairment (4) Moisture: rarely moist (4) Activity: occasionally walks (3) Mobility: slightly limited (3) Nutrition: probably inadequate (2) Friction & shear: potential problem (2) Total score: 18 (preventative interventions) 12/27/16 Sensory: no impairment (4) Moisture: rarely moist (3) Activity: very limited (2) Mobility: slightly limited (3) Nutrition: probably inadequate (2) Friction & shear: potential problem (2) Total score: 16 (preventative interventions) Wessinger 2017
- 19. Nutrition Care Process Wessinger 2017
- 20. Nutrition Assessment* 71 year old Caucasian female Ht: 61” Wt: 194 lbs BMI: 36.8 ABW: 154 lbs Estimated Energy Needs: 2450 kcal/day Estimated Protein Needs: 123 g/day Estimated Fluid Needs: 2310 mL/day Reason for Skilled Nursing Facility Visit: DN was found on the ground in her apartment by a friend. Family last reports talking to her 5 days prior to admittance; it is unclear how long she was down. Dx upon hospital discharge are: fall with retrograde amnesia, severe anemia, left occipital infarction, hypernatremia, hypokalemia, HTN, sacral ulcer stage IV, lower extremity edema Current Conditions/Complaints: stage IV pressure ulcer on sacral region, stage III pressure ulcer on left heel Family Hx: Heart disease, heart failure, coronary heart disease, rheumatoid arthritis, osteoporosis Diet Hx: No known food allergies. DN stated that she loves salmon, but does not enjoy Mexican food. Intake inconsistent in the hospital. *See appendix C for calculations usedWessinger 2017
- 21. Biochemical Measurements 1/11/17 Na: 144 mmol/L K: 4.4 mmol/L Glu: 95 mg/dL CR: 0.57 mg/dL BUN: 11.6 mg/dL Hgb: 9.1 g/dL Hct: 29.2% 1/26/17 Na: 142 mmol/L K: 3.8 mmol/L Glu: 99 mg/dL CR: 0.51 mg/dL BUN: 19 mg/dL Hgb: 9.5 g/dL Hct: 30.0% Wessinger 2017 Normal Ranges Na: 135-145 mmol/L K: 3.5-5 mmol/L Glu: 65-110 mg/dL CR: 0.8-1.3 mg/dL BUN: 8-21 mg/dL Hgb: 12-15 g/dL (women) Hct: 36%-47% (women)
- 22. Nutrition Diagnostic Statement Increased nutrient needs R/T increased demand for energy and protein AEB loss of skin integrity; stage IV pressure ulcer on the resident’s sacral area and a stage III pressure ulcer on the resident’s left heel. Wessinger 2017
- 23. Nutrition Intervention Plan: resident will consume >75% of their meals and supplements Implementation: recommend Zn sulfate 220 mg qd, vitmain C 500 mg bid for 10 days, MVI with minerals, Prosource liquid protein supplement 30 mL tid Wessinger 2017
- 24. Nutrition Monitoring and Evaluation Staff will monitor and document meal and supplement intake, and will report frequent poor intake to the Registered Dietitian (RD). Staff will monitor and document the size, tissue type (e.g. granulation, slough), amount of drainage, odor, type of exudate, and the stage of the resident’s pressure injuries. The RDs and wound nurse will meet weekly to evaluate the progress and treatment of the resident’s wounds and suggest/implement changes to the treatment as necessary. Wessinger 2017
- 25. Sacral Wound Healing Progress 12/20/16 – 9 cm x 7 cm x 5 cm (stage 4) 12/27/16 – 7 cm x 6 cm x 6 cm (stage 4) 1/4/17 – 7 cm x 6 cm x 4.5 cm (stage 4) 1/11/17 – 6 cm x 4.5 cm x 3.5 cm (stage 4) 1/17/17 – 6 cm x 4 cm x 2.5 cm (stage 4) 1/25/17 – 4.5 cm x 3.5 cm x 2.5 cm (stage 4) 2/1/17 – 4.5 cm x 3.5 cm x 2.5 cm (stage 4) 2/6/17 – 4.5 cm x 4.5 cm x 2.5 cm (stage 4) Wessinger 2017
- 26. Treatment Changes 12/21/16 – Cleanse SACRAL WOUND with NSS, pack with 1/4 strength 0.125% Dakin's Solution dampened gauze in wound base, then apply Santyl ointment to Periwound, cover with foam NON-LATEX dressing topically daily and as needed for soilage and/or displacement. 1/4/17 – Irrigate SACRAL WOUND with entire contents of 100 ml NSS bottle, apply Santyl ointment, pack w 1/4 strength 0.125% Dakin's Solution dampened gauze, then cover w/foam NON-LATEX dressing topically twice QD and as needed for soilage and/or displacement. 1/17/17 - Cleanse SACRAL wound with 1/4 strength Dakins Solution, apply Santyl ointment, then pack with NSS moistened ROLLED KERLIX gauze ONLY, cover w/foam NON-LATEX dressing daily and as needed for soilage and/or displacement. 1/25/17 - Cleanse SACRAL wound with NSS, pat dry, apply Collagen, then cover with foam dressing daily and change outer dressing as needed for soilage and/or displacement 2/6/17 - Cleanse SACRAL wound with NSS, pat dry, apply Collagen Matrix dressing to wound bed, pack lightly behind collagen with NSS moistened gauze, then cover with foam dressing daily and change outer dressing as needed for soilage and/or displacement Wessinger 2017
- 27. Conclusion • DN was in the nursing home to rehab • Was expected to discharge at some point during the week of February 13th • Pressure ulcer size greatly reduced • Interdisciplinary collaboration Wessinger 2017
- 28. References 1. Mahan, et al. (2012). Nutrition in Aging. In K. Wellman, & Y. Alexopoulos (Ed.), Krause's Food and the Nutrition Care Process. (13 ed., pp. 448-451). St. Louis, Missouri, United States: Elsevier. 2. Manning, et al. (2015, July). Factors Associated With Occipital Pressure Ulcers in Hospitalized Infants and Children. (American Journal of Critical-Care Nurses) American Journal of Critical Care, 24(4), 342-348. 3. Kingsley. (2014, July 7). Braden Scale Presentation. Retrieved February 13, 2017, from Pennsylvania Health Care Association: https://www.phca.org/wp-content/uploads/2016/01/webinar-20140805.pdf 4. Liao, et al. (2013, May). Skin blood flow dynamics and its role in pressure ulcers. Journal of Tissue Viability, 22(2), 25-36. 5. National Pressure Ulcer Advisory Panel. (2016). Pressure Injury Staging Illustrations. (N. P. Panel, Ed.) Retrieved February 12, 2017, from National Pressure Ulcer Advisory Panel: http://www.npuap.org/resources/educational- and-clinical-resources/pressure-injury-staging-illustrations/ 6. Smith, et al. (2013, July 2). Pressure Ulcer Treatment Strategies: A Systematic Comparative Effectiveness Review. Annals of Internal Medicine, 159(1), 39-50. 7. ICD10Data.com. (2017). Pressure Ulcer L89. Retrieved February 12, 2017, from ICD10Data.com: http://www.icd10data.com/ICD10CM/Codes/L00-L99/L80-L99/L89- 8. Pronsky, et al.(2015). Food-Medication Interactions (18 ed.). (Crowe, Epstein, Ayoob Ed.) Birchrunbille, PA: Food-Medication Interactions. Wessinger 2017
- 30. Wessinger 2017 Appendix A1: Pressure Injury Staging Illustrations
- 31. Wessinger 2017 Appendix A2: Pressure Injury Staging Illustrations
- 32. Appendix B: Nutritional Recommendations for Pressure Ulcer Stages1 Pressure Ulcer Stage Nutritional Recommendations Suspected Deep Tissue Injury Energy: 30 calories/kg BW, Protein: 0.8 g/kg BW in healthy adults, 1 g/kg BW in elderly Stage I Energy: 30-35 calories/kg BW, Protein: 1.25-1.5 g/kg BW, Fluid: 30-33 mL/kg Stage II Energy: 30-35 calories/kg BW, Protein: 1.25-1.5 g/kg BW, Fluid: 30-33 mL/kg Stage III Energy: 35-40 calories/kg BW, Protein: 1.5-1.75 g/kg BW, Fluid: 30-33 mL/kg, Multivitamin with 15 mg of Zn Stage IV Energy: 35-40 calories/kg BW, Protein: 1.75-2. g/kg BW, Fluid: Fluid: 30-33 mL/kg, Multivitamin with 15 mg of Zn Unstageable Energy: 35-40 calories/kg BW, Protein: 1.75-2. g/kg BW, Fluid: Fluid: 30-33 mL/kg, Multivitamin with 15 mg of Zn Wessinger 2017
- 33. Appendix C: Equations • BMI = mass in kg / (height in m)2 • Ideal Body Weight (female) = 100 lbs + 5 lbs for every inch over 5 feet • Adjusted Body Weight for Obesity = IBW + [0.25(Actual BW – IBW)] • Energy Needs (stage IV PU) = 35 kcal x bw in kg • Protein Needs (stage IV PU) = wt (in kg) x 1.75 • Fluid Needs (stage IV PU) = wt (in kg) x 33 mL Wessinger 2017
Editor's Notes
- Epidermis – outermost layer Dermis – tough connective tissues, hair follicles, sweat glands Hypodermis – fat and connective tissue (subcutaneous tissue) Stage 1 – non-blanchable redness, injury to epidermis and dermis
- Stage 2 – skin breakdown starts to occur into epidermis and dermis Stage 3 – wound moves deeper into hypodermis Stage 4 moves through hypodermis and in severe cases exposes muscle and/or bone Deep tissue P injury – injury to the layers of the skin without
- Atorvastatin – antihyperlipidemic Take wo regard to food, take w food to inc abs, last meal of day Dec fat, dec chol, dec kcal if needed caution w grapefruit/related citrus (increases drug effect) oral/gi: N, dyspepsia, abd pain, constipation, diarrhea, gas Metoprolol – antihypertensive take w food to increase bioavailability do not crush or chew decreased Na, decreased kcal recommended oral/gi: dry mouth, N/V, dyspepsia, gas, diarrhea, constipation May mask hypoglycemia (red insulin response) Fe sulfate 8 oz of water or juice (vit c) on empty stomach, food dec abs 50% Meat/fish/poultry Take sep from Ca, P, Zn, Cu >2 hrs High doses dec Zn abs Oral/gi: dental stains w liquid, N/V, dyspepsia, bloating, constipation, diarrhea, dark stools KCl – electrolyte With meals, 8 oz liquid Avoid salt subs, keep K sources consistent Oral/gi: gi irritation, N/V, abd pain, diarrhea, gas Vitamin D – vitamin May be dropped in mouth or mixed with soft foods or juice Inc Ca abs Oral/gi: dry mouth, metallic taste, N/V, constipation, diarrhea Prilosec – proton pump inhibitor, antiGERD Take 30-60 min before meals Do not chew Dec Fe abs, dec B12 abs, Ca supp may be advised Oral/gi: dec acid sec, increase gastric pH, N, abd pain, diarrhea Miralax – laxative Enough fluid Oral/gi: N, bloating, cramps, gas, diarrhea, icr stools Vitamin C – vitamin Taper off high dose slowly Inc Fe abs Oral/gi: N/V, dyspepsia, gastric cramps, diarrhea, excess chewable can break down tooth enamel Coumadin – anticoagulant Consistentintake of vit K inc vit K inc effect, avoid UL of vit A Avoid products affecting coagulation (ginger, ginko, ginseng etc.) No coenzyme Q10, SJW, avacado Oral/gi: taste changes, N/V, cramps, diarrhea Zoloft – antidepressant Take consistently w or wo food Take w water, ginger ale, lemon/lime soda, lemonade, oj and drink immediately Avoid tryptophan – inc side effects, avoid SJW, caution w grapefruit Anorexia Oral/gi: dry mouth, N/V, dyspepsia, diarrhea, constipation Lasix – diuretic (K-depleting) Inc K in diet, inc Mg, dec Na, avoid natural licoricse Anorexia, inc thirst Tylenol – analgesic Take wo regard to food High vit c dec drug excretion, toxicity risk Caffeine inc abs and effect Oxycodone – analgesic, narcotic, opioid Take w food or milk to dec gi distress Do not chew crush or break Caution w grapefruit Anorexia Oral/gi: dry mouth, dyspepsia, gastritis, N/V, diarrhea, constipation Ibuprofen – NSAID Take w food or milk to dec gi irritation Caution w gi irritants (K, caffeine), avoid products which affect coagulation Decrease appetite Oral/gi: N/V, dyspepsia, abd pain, bloating, constipation, diarrhea, colitis, gas, GI ulcers Voltaren – NSAID Topical
- Give examples of comorbidities
- [Problem] related to [etiology] as evidenced by [signs and symptoms]
- Height x width x depth
- Interdisciplinary collab: RDs, wound nurse, nurses, aides, etc work together in the treatment and care of PU