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

RISK ASSESSMENT SCALE

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 (Wapst) (see Appendix A). 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).

The initial  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 scores, an indicator of wound healing (see Chart A).

Treatment plan

The resident care committee developed and implemented the following comprehensive skin and wound treatment plan, based on the factors identified by the Risk Assessment Score 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 (Table 1).

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)

References

 

Bergstrom N., Bennett M.A., Carlson C. E., et. al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No. 15. Rockville, MD: U.S. Dept. Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publ. No. 95-0652. Cec. 1994

Conner L. M., Clark J. W. In vivo (CT Scan) comparison of vertical shear in human tissue caused by various support surfaces. Decubitus 1993: 6 (2), 20-28

Kemp M. G., Krouskop T. A. Pressure ulcers: reducing the incidence and severity managing pressure.  J Gerontol Nurs 1994: 9: 27-34

Lazarus G. S., Cooper D. M., Knighton D. R., et. al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol 1994: 6 (130), 489-493

Maklebust J., Siegreen M. Pressure Ulcers: Guidelines for Prevention and Nursing Management 199 1. W. Dundee, IL: S-N Publications.

Motta G., Whitaker K. Defensive Wound Management 1995. Mitchellville, MD:. Pathways to Empowerment.

Olson E. The hazards of immobility. Am J Nurs 1967: 67 (4).

Rubin, M. The physiology of bed rest. Am J Nurs 1988.

APPENDIX A
WOUND ASSESSMENT PARAMETER SCORING TOOL (WAPST)

CLINICAL EVALUATION OF
THE STAGE IV MATTRESS OVERLAY
Laurie Miller, MSN, RN

Introduction
The author has written this paper with two intentions, the first is to introduce the reader to the STAGE IV MATTRESS OVERLAY; the second is to provide the clinical outcome of a patient with a Stage IV pressure ulcer to both buttocks. It is not the author's intention to endorse any product; rather, information will be presented in a case study format.

It is estimated by the National Pressure Ulcer Advisory Panel that over 1 million Americans have pressure ulcers (1989). Studies have shown the prevalence of pressure ulcers to be between 3 and 10 percent in the acute care setting and as high as 45 percent in chronic care facilities (Steinberg, 1989). Pressure ulcers are associated with a fourfold increase in mortality risk among geriatric patients and nursing home residents (Allman, 1989). The cost of pressure ulcers has been estimated to be between $15,000 and $86,000 per patient with a median cost of $27,000 (Melcher et al., 1989).

These figures are astounding and health care costs will continue to escalate as we approach the twenty first century. Caregivers must be knowledgeable, cost effective and efficient regarding moneys spent for health care. The use of specialty beds is one important economic issue facing all health care personnel in acute care settings, extended care facilities and home care settings. Since their introduction in the 1970's, specialty mattresses and beds have become a widely accepted and utilized method of providing pressure relief. Most hospitals rent theses elaborate devices at a daily rate and although rental rates can vary, the extensive service and support needed for maintaining the beds makes them a considerable expense.

The cost and prevalence of pressure ulcers forces health care providers to utilize cost-effective solutions without compromising the quality of care or efficacy of the specialty bed. Due to recent technological advances, a new generation of therapeutic pressure relief has emerged - the low air loss mattress overlay. The following is an example of one such device, with a description of its advances and benefits.

THE STAGE IV MATTRESS OVERLAY

The STAGE IV MATTRESS OVERLAY, designed by SenTech Medical Systems, Inc., fits over the existing mattress on hospital beds, turning them into the equivalent of the high cost specialty low airless alternating beds currently being used in most hospitals today. The STAGE IV MATTRESS OVERLAY has a unique self monitoring function that allows the pump to maintain the preset pressure within the air sacs, automatically compensating for position changes. The quilted fitted coverlet, as well as the STAGE IV MATTRESS OVERLAY's low airless benefits, helps to maintain a dry and cool environment under the patient's body. All these features combined, allows the STAGE IV MATTRESS OVERLAY to effectively address four of the major causes of skin breakdown.

The following is a case study presentation of an actual patient placed on the STAGE IV MATTRESS OVERLAY on the day of admission to a rehabilitation facility. To maintain confidentiality the author has agreed at her request to change her initials and to not disclose the facility. To maintain confidentiality the author has agreed at her request to change her initials and to not disclose the facility where she was a patient.

Mrs. J, is an 83 year old woman, with a past medical history significant for squamous cell carcinoma of the anus which was resected 11 years ago and subsequently treated with radiation therapy. She was presented to an acute care facility in April, 1994 after she had developed some pain in her buttocks region. She was found to have a large abscess overlying her sacrum and on 4/9/94 underwent a primary diverting colostomy with extensive excision of the sacral abscess. Her course was complicated by septicemia and multiple adjacent soft tissue infections. Other past medical history includes; 1. Insulin Dependent Diabetes Mellitus. 2. Hypertension. 3. History of urinary incontinence. Prior to the present illness she was completely independent, community mobile and driving.

On 4/29/94 she underwent an attempt at local repair with bilateral gluteal rotation flaps. The wounds were dressed with normal saline wet to dry dressing changes every 4 hours and the patient was ordered to remain in the prone position until healing had occurred. Postoperative necroses of the flaps developed and she underwent debridement and marsupialization of the wound. After continued significant breakdown in the sacral region, on 7/8/94 she had a split thickness skin graft with a harvest site from the posterolateral thigh on the left.

After an extended three and one half month stay in acute care it was felt that the wounds were stable and ;plans were begun for discharge. Mrs. J was admitted to a rehabilitation facility in the Boston area on 7/22/94 for continued management of this complicated sacral wound and for rehabilitative therapies. On admission to rehabilitation, the patient was evaluated and placed on a STAGE IV MATTRESS OVERLAY. Prior to this the patient had been lying prone since her admission to acute care. In order to participate in rehabilitative therapies it was determined that she could now be supine since low air loss therapy had been instituted. A Foley catheter was placed to prevent urine from leaking into the wound.

On examination, the buttock wound measured 41 cm long from left hip to right hip. The edges measured 9 cm wide and the middle of the wound measured 13 cm wide. The wound bed was pink and clean with scattered pinpoint areas of necrotic tissue (Figures 1--warning: graphic content). A graft site to the left posterior thigh was evident with scabbing and minimal bleeding and no evidence of infection. There was only a scant amount of purulent drainage and a culture was obtained. The patient was allowed to lay supine and went prone only for dressing changes. Normal saline wet to dry dressings were ordered with packing to the buttocks wound and the graft site was left open to air.

Three days later the culture grew back MRSA (Methicillin Resistant Staphylococcus Aureus) and she received a 10 day course of Vancomycin. Within three weeks there was remarkable improvement to the wound. There continued to be minimal drainage, however it was now serous in nature. The graft site had completely healed and the buttock wound had demonstrated significant granulation. On 9/28/94 the patient's wounds were re-photographed (Figures 2--warning: graphic content). Wound measurements at this time were as follows; there was one area to the lower aspect of the right buttock which measured 7 cm long and 2 cm wide. Finally the third area still remaining open to the lower aspect of the left buttock measured 7 cm long, 1 cm wide at the edges, and 4 cm wide in the middle. The rest of the wound had granulated.

The nursing care that was provided to Mrs. J. while a patient in rehabilitation was an integral factor in the healing of her decubitus ulcer. In this situation, meticulous nursing care combined with the low airless and pressure relieving properties of the STAGE IV MATTRESS OVERLAY, provided an ideal situation for rapid and successful wound healing. The staff and Mrs. J. were all very pleased with the performance of the STAGE IV MATTRESS OVERLAY. Mrs. J stated that it was very comfortable and that she never felt as if she was floating on air. She was able to shift her weight readily on the mattress and participate in therapy while lying supine. The staff reported that the mattress was easy to maintain and that it was easy to transfer Mrs. J. while she was on it. Mrs. J. remained on the SenTech STAGE IV MATTRESS OVERLAY throughout her stay in rehabilitation and was discharged to a nursing home on 10/4/94.

References

Allman, R. M., Pressure Ulcers Among the Elderly. The New England Journal of Medicine, 320: 850-853, March 30, 1989.

Melcher, R. E., Long, R. L., Gelbart, A.O. Pressure Sores in the Elderly: A Systematic Approach to Management. Postgrad Med. 83:229, 1988

Steinberg, J. Prevalence of Decubitus Ulcers: Issues of Concern. Decubitus, 2:50, 1989.

The National Pressure Ulcer Advisory panel: Pressure Ulcers Prevalence, Cost, and Risk Assessment. Consensus Development Conference Statement. Decubitus, 2:24, 1989.