Nursing care plan for the Kennedy terminal ulcer patient. Case report

We present the clinical case report of an 81-year-old bedridden woman with severe cognitive impairment, who initially presented with a category II pressure ulcer in the sacral region. At 48 h, progression to a category IV ulcer was observed. Given the rapid evolution, the characteristics of the lesion and the patient's condition, a diagnosis of terminal Kennedy ulcer was established. In consensus with the family, a conservative approach was adopted, and the therapeutic effort was limited due to the irreversibility situation. Three days later, the patient died of respiratory failure. The care plan is developed based on Marjory Gordon's assessment by patterns, allowing the identification of the patient's problems, setting realistic outcomes (NOC) and developing nursing interventions (NIC) that lead to a dignified death.

[Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations]

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well.

Prevalence, incidence and risk factors for foot pressure ulcers in hospitalized elderly patients. An observational and prospective study

BACKGROUND

Incidence and clinical characteristics of foot pressure ulcers (FPU) in hospitalized elderly patients are not well known. The aim of the study was to determine the incidence of FPU during hospitalization, to describe main FPU characteristics and to assess main risk factors for FPU in hospitalised elderly subjects.

METHODOLOGY

An observational prospective study was performed in which patients 65 years or older admitted to Vascular Surgery, Orthopaedic or Geriatric departments were followed from admission to discharge. Trained nurses evaluated all recruited patients on a daily basis for possible FPU. Main characteristics of the patient (age, sex and co-morbidities) and the ulcer (location, grade) were registered.

RESULTS

299 patients were recruited (62.2% women, mean age 82.3 years, mean number of co-morbidities 2.8). Prevalence of FPU was 30.1% at admission and 73.9% at discharge. Incidence of FPU during hospitalization was 9.5 new FPU/100 person-day. 97.0% of the new FPU were grade 1 (erythema) and the most common locations were in the heel (57.6%), the external lateral part of the foot (13.1%), and the hallux of the fist toe (11.8%). Apart from immobility, main risk factors for FPU are age, geriatric residence origin and not able to outdoor life.

CONCLUSIONS

FPU has a high incidence among hospitalised elderly patients; most of them are grade 1 and located in the heel. More attention must be paid in the prevention of pressure ulcers in hospitalized frail subjects.

[Functional and clinical outcomes in patients admitted to nursing homes after hip fractures. Implementation of a multi-level intervention program]

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the clinical and functional outcomes of patients discharged to nursing homes after a hip fracture.

METHODS

The study included all patients admitted to a group of nursing homes after a hip fracture in 2016. A geriatric assessment protocol was applied, and patients were treated with a specific protocol for 90 days. They were assessed for nutritional status (Mini-Nutritional Assessment and Body Mass Index), pain (Visual Analogue Scale, and the PAINAD Scale), the presence of pressure ulcers, blood test (D vitamin, haemoglobin, proteins), and functional status (Barthel index and Functional Assessment Categories).

RESULTS

Out of a total of 175 patients, 116 (75%) met the inclusion criteria. The mean age was 84.9 years old (±6.7 SD), and 91 (78.4%) were women. At admission, 73.8% of 65 residents had anaemia, 76.7% hypovitaminosis D, 88% malnutrition or «at risk of malnutrition», and 15.3% had pressure ulcers. After 90 days, the moderate-severe functional status (Barthel index < 60) was reduced from 90.4 to 39.6%, dependence due to gait from 97.3 to 36.1%, and moderate-severe pain from 88.9 to 14.4%. Most of the pressure ulcers healed (94.4%).

CONCLUSIONS

Patients admitted to nursing homes after a hip fracture had poor clinical and functional status. This study shows that after 90 days from admission these patients had positive outcomes in terms of functionality, gait, pain control, and pressure ulcers healing.

Reliability of the use of photographs for the classification of dependence-related lesions

OBJECTIVE

To examine the reliability of the classification of dependence-related lesions using photography.

METHOD

A panel of 5 experts carried out a blind, anonymous and independent assessment of 24 photographs. Images were sent by electronic mail, together with an anonymous questionnaire that was sent back to a referee of the research group. We suggested 8 options for classification: pressure ulcer (categories I, II, III, IV, or 'suspect of deep-tissue damage'), moisture-associated damage, pressure-moisture combined aetiology and multifactorial lesion. Concordance index was calculated for every photography. Cohen's Kappa index with 'jackknife' technique were calculated for every photograph and category. We used the statistical programme Epidat 4.2.

RESULTS

Observed agreement was variable, between 4 and 1 depending on the photography. A consensus of 100% was observed in 6 images. Global Kappa resulted as moderate: 0.5202 (IC95%: 0.3850- 0.6542). Intra-group concordance resulted moderate in 4 categories, low in 3, and high only for pressure ulcer category II (Kappa 0.8924. IC 95%: 0.7388-1.0456). Inter-observer concordance was 0.6602 (IC 95%: 0.4969-0.8081).

CONCLUSIONS

The reliability of the use of photographs for the categorization of dependence-related lesions is moderate, being higher for category II pressure ulcers and low for more complex wounds. This method must be used with care, and education on the subject is required.

Nursing records, prevention measures and incidence of pressure ulcers in an Intensive Care Unit

OBJECTIVES

The aim of this paper is to determine the incidence and most incident pressure ulcers (PU) category. Establish the main clinical characteristics of these PU. Determine whether there is adequate documentation of PU and of the measures used to prevent them.

METHOD

Observational descriptive and retrospective study during 2014 at Intensive Care Unit (ICU)-University Hospital of Araba. Study sample, all patients suffering from PU at the time of the study by accidental sampling. Computerised records regarding risk assessment, clinical assessment and pressure sore treatment, provided by the 'Metavision' computer programme and descriptive statistics using SPSS version 22.0. Approval from the Ethics Committee for Clinical Research of the University Hospital of Araba was obtained.

RESULTS

The incidence of patients suffering from PU during 2014 was 6.78%. The most common locations for PU were the sacral region and the heels: the most incident pressure ulcers category was grade II, followed by grade I. Out of the 98 PU treated in our patients, 43 occurred outside the ICU and 55 in the unit itself. The lack of records, in all the variables described about PU, was 19.10%.

CONCLUSIONS

The incidence of pressure ulcers was lower than in the current literature. The most frequent category, location and clinical characteristics are comparable to previous studies. There is a high rate of failing to record the characteristics of the PU declared. Good PU prevention measures and recording were carried out.

[Impact of interventions in the pressure ulcer rate]

OBJECTIVE

To evaluate the impact of a risk management program for prevention of pressure ulcers (PUs) in an adult Intensive Care Unit (ICU).

MATERIAL AND METHODS

A quantitative, prospective study performed with a «before and after» evaluation, and designed in three stages: 1) PU incidence study; 2) Intervention by implementing a risk management program, and 3) Assessment of the impact.

RESULTS

Adherence to the preventive measures showed a significant increase (11.7%) between the first month of the program and the final month (58.5%) of the assessment. Initial PU rate was 20.9, with a decrease in the rate to 14.0 per 1000 bed occupancy days (P<.05) after the risk management program.

CONCLUSIONS

The data show that the risk management program, using prevention measures, was effective in reducing the rate of PU in the period under study by more than 33%.

Assessment of the extension of pressure ulcers into soft tissue and osteomyelitis diagnosis using 18F-FDG PET/CT

The precise assessment of pressure ulcer extension in patients with neurological diseases has crucial therapeutic implications, especially in the early detection of fistula to interior structures and osteomyelitis. Two case reports are presented on patients with a similar ischial ulcer, in whom an ¹⁸F-FDG PET/CT study enabled a precise assessment of infectious complications in underlying tissues. These cases support the implementation of ¹⁸F-FDG PET/CT as a first-line technique in their management.

Predictive validity and reliability of the Braden scale for risk assessment of pressure ulcers in an intensive care unit

OBJECTIVE

Contribution to validation of the Braden scale in patients admitted to the ICU, based on an analysis of its reliability and predictive validity.

DESIGN

An analytical, observational, longitudinal prospective study was carried out.

SETTING

Intensive Care Unit, Hospital Virgen del Rocío, Seville (Spain).

PATIENTS

Patients aged 18years or older and admitted for over 24hours to the ICU were included. Patients with pressure ulcers upon admission were excluded. A total of 335 patients were enrolled in two study periods of one month each.

INTERVENTIONS

None.

VARIABLES OF INTEREST

The presence of gradei-iv pressure ulcers was regarded as the main or dependent variable. Three categories were considered (demographic, clinical and prognostic) for the remaining variables.

RESULTS

The incidence of patients who developed pressure ulcers was 8.1%. The proportion of gradei andii pressure ulcer was 40.6% and 59.4% respectively, highlighting the sacrum as the most frequently affected location. Cronbach's alpha coefficient in the assessments considered indicated good to moderate reliability. In the three evaluations made, a cutoff point of 12 was presented as optimal in the assessment of the first and second days of admission. In relation to the assessment of the day with minimum score, the optimal cutoff point was 10.

CONCLUSIONS

The Braden scale shows insufficient predictive validity and poor precision for cutoff points of both 18 and 16, which are those accepted in the different clinical scenarios.

[Differentiation between moisture lesions and pressure ulcers using photographs in a critical area]

OBJECTIVES

To identify difficulties for nurses in differentiating between moisture lesions and pressure ulcers, proper classification of pressure ulcers to assess the adequate classification of the Grupo Nacional para el Estudio y Asesoramiento de Úlceras por Presión y Heridas Crónicas (GNEAUPP) and the degree of agreement in the correct assessment by type and category of injury.

METHOD

Cross-sectional study in a critical area during 2014. All nurses who agreed to participate were included. They performed a questionnaire with 14 photographs validated by experts of moisture lesions or pressure ulcers in the sacral area and buttocks, with 6 possible answers: Pressure ulcer category I, II, III, IV, moisture lesions and unknown. Demographics and knowledge of the classification system of the pressure ulcers were collected according to GNEAUPP.

RESULTS

It involved 98% of the population (n=56); 98.2% knew the classification system of the GNEAUPP; 35.2% of moisture lesions were considered as pressure ulcers, most of them as a category II (18.9%). The 14.8% of the pressure ulcers photographs were identified as moisture lesions and 16.1% were classified in another category. The agreement between nurses earned a global Kappa index of .38 (95% CI: .29-.57).

CONCLUSION

There are difficulties differentiating between pressure ulcers and moisture lesions, especially within initial categories. Nurses have the perception they know the pressure ulcers classification, but they do not classify them correctly. The degree of concordance in the diagnosis of skin lesions was low.

[Incidence of dependence-related lesions in a population of critical patients]

AIM

To determine the incidence of various types of dependence-related lesions (DRL) on a population of critically ill patients.

METHOD

Descriptive, longitudinal and prospective study in an Intensive Care Unit from January 2014 to January 2015. Adult patients who did not present DRL at the moment of admission were included. Those with brain death and/or stay at the unit for more than two days were excluded. Patients were studied till they developed DRL, were exitus, discharged or stayed for more than 14 days. Each patient was evaluated daily till DRL did develop or was excluded from the study. If DRL did develop it was photographed and related data were recorded. The comparison between quantitative variables of normal distribution was done with the t de Student. The Mann-Whitney U was used to compare the other variables. Qualitative variables were compared through Pearson's chi square. In both cases p≤.05 was considered significant.

RESULTS

295 patients were included, 27.45% of them developed DRL. The density of incidence was 41 DRL/1,000 days at risk. 50.62% of DRL were categorized as PU. 17.28% were moisture injuries, 13.58% were due to friction and the rest were combined injuries. The risk according to EMINA and Braden scale was significantly different in the group of patients with lesions compared to the group without them.

CONCLUSIONS

Not all injuries were caused by pressure. Specific prevention strategies based on different causal mechanisms are required.

[Validation of EMINA and EVARUCI scales for assessing the risk of developing pressure ulcers in critical patients]

OBJECTIVE

To contribute to the validation of the EMINA and EVAUCI scales for assessing the risk of pressure ulcers in the critical patient and compare their predictive capacity in this same context.

METHOD

Prospective study from December 2012 until June 2013.

SETTING

Polyvalent intensive care unit of 14 beds in a reference hospital for two sanitary areas.

PATIENTS

patients of 18 years of age or older and without pressure ulcers were included. They were followed until development of a pressure ulcer of grade I or greater, medical discharge, death or 30 days.

MAIN VARIABLES

presence of ulcers, daily score of the risk of developing pressure ulcers through EMINA and EVARUCI evaluation. The validity of both scales was calculated using sensitivity, specificity, and positive and negative predictive value. The level of significance was P≤0.05.

RESULTS

A total of 189 patients were evaluated. 67.2% were male with a mean age of 59.4 (DE: 16,8) years old, 53 (28%) developed pressure ulcers, being the incidence rate of 41 ulcers per 1000 admission days. The mean day of diagnosis was 7.7 days (DE: 4,4) and the most frequent area was the sacrum. The sensitivity and specificity for the mean of observations was 94.34 (IC95% 87.17-100) and 33.33 (IC95% 25.01-41.66) for the EMINA scale for a risk>10 and 92.45 (IC95% 84.40-100) and 42.96 (IC95% 34.24-51.68) for the EVARUCI scale for a risk of>11.

CONCLUSIONS

No differences were found in predictive capacity of both scales. For sensitivities>90%the scales show to be insufficiently specific in the pressure ulcer risk detection in critical patients.