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PROVIDING SUPPORT SURFACE "CONTINUITY OF CARE"
RESULTS IN POSITIVE OUTCOMES
Glenda J. Motta, RN, BSN, ET, MPH
Kathi Thimsen-Whitaker, RN, CETN, MSN, CNS, FS
Abstract:
A high percentage of residents in long-term care facilities suffer from debilitating and complex medical conditions. A comprehensive skin wound and care treatment plan must address specific factors, including pressure, friction, shear, nutrition and topical treatment. This clinical case report demonstrates the positive outcomes achieved by using support surface "continuity of care" for an elderly resident with multiple areas of skin breakdown, including a Stage IV pressure ulcer. The SenTech Medical Systems, Inc. Stage IV™ and AIR CHAIR™ systems provided optimal therapy for this resident while in the chair or the bed. Wound healing outcomes, as demonstrated by a 75% increase in viable tissue, prove that this approach assures quality patient care.
Patient Assessment
KM, a 91 year old male, has resided in a long-term care facility for four months since suffering a cerebral vascular accident. Additional diagnoses include: closed head injury, thrombo-phlebitis, congestive heart failure, atrial fibrillation, malnutrition, and dementia. Daily medications are an oral antihypertensive/diuretic and a multi-vitamin with iron. However, the resident receives periodic antibiotic therapy for recurring cellulitis of the penis.
Nutritional lab values recorded on 8/4/97 were: Pre-albumin 16.0 and albumin 3.1. He is fed a pureed diet but percent of intake is only 25-30% daily. Height is 6'1" and weight varies between 118-130 pounds. The patients (see Risk Assessment Score pdf/14k) is 20 (High Risk=15-24). Documentation in the medical record indicates a history of extreme skin fragility that requires pressure relief.
Wound Assessment
On the initial ET nursing skin and wound evaluation conducted on 8/8/97, skin breakdown was noted on the coccyx, left heel, buttocks, and right knee and documented. The resident was admitted from the hospital in April with multiple areas of skin breakdown. The wound on the coccyx worsened, becoming covered 100% with non-viable tissue (yellow slough and eschar). Depth could not be determined. The surrounding skin color turned gray. Drainage was purulent and foul smelling. The edges were defined, but not attached to the wound base.
The assessment parameters of the full-thickness coccyx wound were documented on the Wound Assessment Parameter Scoring Tool (see Wapst (pdf/23k)). This clinically validated method uses sequential scoring that correlates to the actual process of wound healing. Progress reporting is streamlined, concise, and truly shows objective, measurable data previously tracked by wound measurements alone.
Wound assessments were completed weekly (see Table 1 (pdf/28k)). The initial (see Wapst (pdf/23k)) score recorded was 41. Scores documented for 8/8/97-8/2797 reflect the status of the wound prior to initiating SenTech support surface therapies on 8/28/97. For the remaining ten weeks when the support surface "continuity of care" was provided, (9/3/97-11/5/97) the scores reflect continued progress. Subsequent objective wound assessments showed decreasing (see Wapst (pdf/23 k)) scores, an indicator of wound healing (see Chart A (pdf/19 k)).
Treatment plan
The resident care committee developed and implemented the following comprehensive skin and wound treatment plan, based on the factors identified by the (see Risk Assessment Score (pdf/14 k)) and the Wound Assessment Parameter Scoring Tool:
1) Topical wound care: The coccyx wound was cleansed with an antimicrobial wound cleanser. Initially, and enzymatic debriding agent was applied with an antibiotic powder and the wound was then covered with a gauze dressing. Dressing changes were once per day and prn for 21 days. When the non-viable tissue was loosened, treatment was changed to a hydrogel impregnated gauze to pack dead space and promote a moist wound environment. A secondary dressing was then applied. Dressing changes were once daily.
2: Therapeutic support: Prior to initiating this treatment plan with the SenTech Stage IV and AIR CHAIR systems, no support surface was available to the resident while out of bed in the chair. When in bed he was turned and repositioned per schedule and laid on a two-inch convoluted foam overlay placed over a standard hospital mattress. Because the treatment plan included having the patient sit in a bedside chair for a minimum of 4 hours each day, pressure relief was clearly required for this time period.
The SenTech Stage IV Mattress Replacement and AIR CHAIR were used for pressure relief, weight distribution, and shear and friction reduction. In combination, they provided support surface "continuity of care" and the same therapy for this resident while in a chair or the bed. The resident was able to stay up for long periods of time, allowing greater mobility and positive outcomes, such as decreased pulmonary congestion and a reduced potential for pneumonia and other complications related to immobility.
3) Systemic Support: Dietary interventions aimed at maximizing caloric and protein intake as well as hydration were initiated. The resident's wife would not permit tube feedings. A pureed diet with supplements did not provide complete nutrition required to support would healing because the resident had difficulty swallowing and ate only 25 to 30% of his diet. The care team included the resident's wife at conferences to help identify specific care goals outcomes that respected the resident and his family's wishes.
Summary
In spite of continuing poor nutritional intake and resulting malnutrition, KM showed significant improvement in the condition of the coccyx wound. Analyzing the wound healing progress must include the assessment of the periwound tissue. Wound healing is demonstrated by the initial tissue response observed in the periwound region.
Subsequent objective wound assessments provide evidence of tissue response, with decreasing Wound Assessment Parameter Scores, an indicator of wound healing (see Table 1 (pdf/28k)). The trend analysis of tissue type demonstrates wound improvement as evidenced by a decrease in non-viable tissue with a corresponding increase in viable tissue (see Chart B (pdf/18 k))
Conclusion
Immobilized high risk individuals are typically poor candidates for wound healing, particularly of full-thickness necrotic pressure ulcers. In spite of malnutrition and poor general health, KM's case report data supports the benefits and demonstrate the positive outcomes of using support surface "continuity of care" and other appropriate treatment modalities.
Within one week after initiating SenTech Stage IV and Air Chair therapies, viable tissue increase to 50% and the tissue type changed from pale and dusky to bright red and glossy. As support surface "continuity of care" continued, viable tissue increased to 75% and it remained at that amount for the duration of the case study. However, the resident spent increasingly longer periods of time out of bed in the chair. Using the optimal therapy for this resident while in a chair or the bed changed this resident's potential outcome for healing from low to high probability and assured quality patient care shown by specific wound healing parameters.
(see Case Photos (pdf/160 k))--warning: graphic content
References
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SenTech, Stage IV, and Air Chair are Registered Trademarks of SenTech Medical Systems, Inc., Ft. Lauderdale, Florida
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