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STAGE IV PRESSURE ULCER Kathryn Atwater PVAMU Internship Spring 2013.

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Presentation on theme: "STAGE IV PRESSURE ULCER Kathryn Atwater PVAMU Internship Spring 2013."— Presentation transcript:

1 STAGE IV PRESSURE ULCER Kathryn Atwater PVAMU Internship Spring 2013

2 Patient Background  88 year old, Caucasian male  Middle Class  Previous Occupation: Mechanical Engineer  Never Married  4 years in military  No Children  2 sisters  No past history of smoking, alcohol, or drug use

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

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

5 Past Medical History  Atrial Fibrillation  Hypothyroidism  UTI  Peripheral Neuropathy  Pressure Ulcers  Protein Deficiency  Leukocytosis  Diabetes Mellitis  Hypertension  GERD  Anemia  Lower, Above-the-Knee Amputation  Prostate Cancer  Suprapubic Catheter  Colostomy

6 Medications

7 Medications Cont’d…

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

9 Pressure Ulcer: General Info  Pressure Ulcer: An injury to the skin and underlying tissues from prolonged pressure on the skin.  Common areas:  Locations on skin that cover “bony” areas of body  Heel  Ankle  Elbow  Buttocks  4 Stages or Categories

10 Pathophysiology Trapped between bone and a surface Greater pressure than blood vessels Less blood flow Deprived of nutrients Damaged cellsCell DeathPressure ulcer

11 Contributing Factors  Sustained pressure to area of body  Friction  Shear

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

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

14 Stages  Depends on “depth” of ulcer

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

16 MNT Stage 4 Pressure Ulcer cont’d…  Vitamin C  Needed for Stage 3, 4, UN ulcers  Tissue repair & regeneration  Zinc  Needed for Stage 3, 4, and UN ulcers  Antioxidant  Collagen formation & cell proliferation  Protein synthesis  Over-supplementation can lead to anemia

17 Illustration Stage IV pressure ulcer

18 Treatment  Identify stage or ulcer  Remove pressure from affected area  Preserve surrounding tissue & skin health  Removing necrotic & infected tissue  Reduce/remove bacteria  Reduce pain as much as possible  Nutrition intervention  Treat any conditions increasing risk of developing more ulcers

19 MNT for Stage 4 Pressure Ulcer  Kcal: kcal  Protein: g/kg  Fluid: cc  MVI with minerals: Daily  Vitamin C: 500 mg bid  Zinc: 220 mg q day x 1 month

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

21 Admission Values  Ht: 6’2” (74 in)  Wt: 169 lb. (76.8 kg)  IBW: lb. (86.4 kg)  % IBW: 94.6%  BMI: 23.1

22 Lab Values

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

24 Estimated Diet Needs  Based on Stage IV Pressure Ulcer Recs:  Kcal: (25-30 kcal/kg)  Protein: 108 g (1.4 g/kg)  Fluid: 2304 mL

25 Residents Stage 4 Pressure Ulcer  Right Ischial Tuberosity  Unknown Duration  Admission Size: 1x1x0.28 cm

26 Resident’s MNT for Stage 4 Pressure Ulcer  Wound Healing  Recommend to start Vitamin C supplement  Recommend to start Zinc Supplement (ZnSO4)  Recommend to start Multivitamin with minerals  Wound Healing & Increase Protein Needs  Start MedPlus Supplement Provides 576 kcal & 30 g protein

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

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

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

30 Follow-up  3/4/13  Stage IV pressure ulcer healed  Nursing to apply Bamer Cream as preventative measure & reposition every 2 hours  Continue MNT Weight: 177 lb. (below IBW) Aide with weight increase/stability Help decrease possibility of wound re-occurence

31 Prognosis  MNT & Nursing treatment beneficial  Reduce possibility of re-occurrence:  Continued monitoring  Continued good PO intake  If keep up current MNT & nursing precautions, prognosis good!  As of 4/10/13: No Pressure Ulcer  No discharge plans

32 Summary  Early diagnosis & screening: Help with ulcer progression  Treat for highest level of ulcer present  Stage dependent on depth  Nutrition intervention key component for healing

33 References  1. American Nursing Association. NDNQI: Pressure Ulcer Module Available at: https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinition_1.aspx. Accessed April 13, https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinition_1.aspx  Dorner B, Posthauer ME, Thomas, D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper Available at: Accessed April 13, 2013  Moskowitz RJ, Zieve D. Pressure Ulcer. University of Maryland Medical Center Online Encyclopedia website. November Available at: Accessed April 14,  Gebhart KS. Pt. 1 Causes of Pressure Ulcers. Nursing Times J. March 2002; 98(11): 41  Gender, Aloma. Pressure Ulcer Prevention and Management. Gerontology Update page. October/November Available at: Accessed April 14,  Wake WT. Pressure ulcers: what clinicians need to know. Perm J. 2010;14(2):  Bluestein D, Javaheri A. Pressure Ulcers: Prevention, Evaluation, and Management. American Family Physician website. November 2008; 78 (10). Available at: Accessed April 13, 2013  Wound Committee. WOCN Society Position Statement: Pressure Ulcer Staging page. Revised April Available at: _Pressure_Ulcer_Staging_(2011).pdf. Accessed on April 15,  American Hospital Association. Wound Guidance page. Available at: issues/postacute/homehealth/woundguidance.shtml. Accessed April 18,  Morgan J. The Role of Nutrition in Pressure Ulcer Prevention and Treatment. HM Composite, Inc. page. Available at: Accessed April 15,  Dorner B. Nutrition and MNT: Lesson Plan 6, Determine Basic Concepts of Medical Nutrition Therapy. Medical Nutrition Therapy for Pressure Ulcers: Becky Dorner & Associates page. March Available at: Accessed April 16, 2013.


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