Subjective:
1) What is one more piece of information you would want to collect? Provide a rationale for asking that question.
- “Has your weight changed recently?”
i. The patient spends the majority of his waking time lying in bed or in his wheel chair. Because of the location of the wound (over the greater trochanter), a recent weight gain could mean that his wheelchair seat width is now too narrow, or may make it more difficult to move around in bed and inside of the wheelchair. This could lead to him changing position less frequently as well as create a less even distribution of weight while he is sitting or lying in bed.
2) What is the answer to that question? (Provide a realistic answer; it may affect your later decisions.)
- Yes, has recently gained 40 pounds in the past 4 months, which has led to being more reliant on others to help him change position. His daughter works so she is only able to be present during the evening/night, so he pretty much stays on his R side-lying or supine, since he can’t roll independently onto L side-lying.
Objective:
3) What are two more tests or measures you would want to perform during your evaluation or find out? Provide a rationale for each.
- BWAT: I think the BWAT would be very valuable with answering a series of questions and providing objective information about the wound, allowing for easy re-evaluation further into his treatment. The BWAT assesses a large number of aspects of the wound, including but not limited to the size, depth, presence of granulation tissue, and periwound presentation.
- Gross MMT of hips, knees, and trunk: This information would be very helpful for me in determining which strength deficits, if any, may be compounding the negative impact of his contractures, and further limiting his available range of motion, thereby impacting his ability to be mobile. Being able to increase his strength, even if the ROM remains limited, may give this patient the ability to mobilize himself at home and reduce the risk of future wound development.
4) What findings do you expect for each of those tests or measures? (Provide a realistic answer; it may affect your later decisions.)
- BWAT = 45/60
- (B) hip flexion, extension, and abduction are all 2/5. Lower abdominals are 3/5, upper abdominals are 2/5. Back extensors are 3/5.
Assessment:
5) Wound description
Pt presents with a large stage 4 pressure ulcer over R greater trochanter. Necrotic slough present surrounding the exposed bone, granulation tissue throughout rest of wound with moderate purulent exudate. Periwound borders are regular, oval in shape, and consists of hyperpigmented epibole. Wound measures 13.26 cm 2.
7) PT diagnosis: Chronic wound over R greater trochanter affecting patients’ tolerance for ADLs, general mobility, and increases burden on caregivers.
8) PT prognosis- Patients prognosis is fair to poor based on the chronic nature of the wound, his sedentary nature, and recent institutionalization, and myriad co-morbidities.
9) Assessment: Include the following components
a) Key problems- Wound is very deep, is producing moderate amounts of purulent exudate, and patient is very limited in his mobility by contractures and very likely, also weakness.
b) What will support healing- Patient was receiving skilled nursing for the next two months. Cognitively intact. Currently in PT, working on bed mobility, transfer training, WC propulsion. Pedal pulses are strong, at 2+, in addition to the granulation tissue in the wound, indicate that the limb has at least decent perfusion
c) What will impede healing- Patient has multiple comorbidities (end stage COPD, history of L CVA (and possible residual hemiplegia), patient is sedentary throughout the day, pain with wound changes
d) How do the factors relate to each other? The history of L CVA in addition to the R TKR likely contributing to his sedentary activity level, and the development of his hip and knee contractures, which may have contributed in turn to the development of this pressure ulcer, as it would be difficult for him to be positioned in prone with these contractures, leading to increased time spent supine and sidelying.
Plan:
10) Plan of care
a) Dressing(s), with frequency of changing them, with rationales
-For this patient, I would recommend a non-adhesive hydrofiber dressing with a film cover, to be changed every 2 days in conjunction with his interventions (mentioned below. Hydrofiber is able to handle moderate exudate, is non-adhesive which would reduce pain and anxiety regarding dressing changes, and is appropriate for this deep of a wound. The film would be able to cover the entire wound to hold the hydrofiber in place, and its water resistance nature would protect the wound from any potential incontinence related maceration/infection.
b) Interventions (e.g.: modalities, relevant functional mobility interventions, etc.), with frequency and parameters, with rationales
My recommendation would be for sharp debridement and pulsed lavage with suction, timed so that it occurs 30-60 minutes after dosage of pain medications to improve his tolerance for these interventions. Pulsed lavage with suction is able to debride, cleanse the wound, leads to proliferation, and reduces bio-burdern; It can also be helpful with addressing progressive inflammation.
c) Frequency and duration of visits
-Patient would ideally receive e-stim every 2rd day, concurrent with dressing changes, to maximize the amount of time that he is able to rest. Additional, there has been a lot of research in the past which has indicated that e-stim can be an excellent treatment for chronic pressure ulcers as it can decrease pain and exudate and improve healing times. 1,2 To minimize his pain, I would utilize HVPC because it has a lower risk of skin damage than other monophasic options and has been shown to reach deeper tissues without increasing pain. The settings would be 100 pps, 100 μs, 150 V, and for 45 minutes.3 If the patient were willing, I would also spend 15-25 minutes working with him on bed mobility, transfers (sit to stand, toilet transfers), and ambulation. This time would also include stretching to try to decrease the contractures and prevent their worsening.
d) Patient, family, and caregiver education
-Patient and family should be educated on the benefits of therapy, of more frequent mobilization not only to increasing his available ROM, but increase his physiologic reserve and therefore his physical and respiratory tolerance for activity, and improve the healing of his wound.
e) Referrals, further testing, other concerns
-I would recommend a social work consult for this patient and his family, to ensure that they can prepare for his return to his daughters home safely. This includes discussion about coping with the stress of being a caregiver, financial concerns, and any other psychosocial issue that may arise. At this time I would not be recommending follow up testing, but this would change if the wound did not demonstrate expected improvement over the first couple of weeks.
f) Anticipated discharge needs
-If all goes well, this patient will be discharged from the SNF to return to his daughters home. The family may benefit from a home consult to assess for fall hazards in the home and help them determine if there is any DME that is feasible to install before the patient returns. This could include but is not limited to a grab bar in the shower and next to the tub, a tub bench, and a bedside commode.
g) Plan of care is appropriate for the setting
11) At least 3 short term goals
STG’s
- Wound size will decrease by 20% in 2 weeks.
- Wound exudate will decrease to minimal within 2 weeks.
- Wound will be 100% granulated in 3 weeks.
12) At least 2 long term goals (at least one must have a functional component)
- Wound will be >/= 90% closed within 8 weeks.
- Patient will be Independent with all transfers and bed mobility to reduce risk burden on family members and development of future pressure ulcers.
13) Modified plan based on change in the situation
Plan:
10) Plan of care
a) Dressing(s), with frequency of changing them, with rationales
-For this patient, I would recommend a non-adhesive hydrofiber dressing with a film cover, to be changed every 2 days in conjunction with his interventions (mentioned below. Hydrofiber is able to handle moderate exudate, is non-adhesive which would reduce pain and anxiety regarding dressing changes, and is appropriate for this deep of a wound. The film would be able to cover the entire wound to hold the hydrofiber in place, and its water resistance nature would protect the wound from any potential incontinence related maceration/infection.
b) Interventions (e.g.: modalities, relevant functional mobility interventions, etc.), with frequency and parameters, with rationales
c) Frequency and duration of visits
-Patient would ideally receive e-stim every 2rd day, concurrent with dressing changes, to maximize the amount of time that he is able to rest. Additional, there has been a lot of research in the past which has indicated that e-stim can be an excellent treatment for chronic pressure ulcers as it can decrease pain and exudate and improve healing times. 1,2 To minimize his pain, I would utilize HVPC because it has a lower risk of skin damage than other monophasic options and has been shown to reach deeper tissues without increasing pain. The settings would be 100 pps, 100 μs, 150 V, and for 45 minutes.3 If the patient were willing, I would also spend 10-15 minutes on active-assisted/active range of motion and reassessing and adjusting bed position to reduce high pressure spots.
d) Patient, family, and caregiver education
` Pt and family need to be educated on the benefits of therapy, of more frequent mobilization not only to increasing his available ROM, but his increase his physiologic reserve and therefore his physical and respiratory tolerance for activity and ADLs, and improve the healing of his wound.
e) Referrals, further testing, other concerns
-For this patient and his family, I would recommend consultations with psychologist, a social worker, and spiritual care professional. He and his family are preparing for the end of his life at this point, and I believe that by incorporating these professionals into his established list of health care providers would give him the best opportunity to make the most of the time that he has left. The status change did not indicate that the patient and his family have any desire to leave the SNF and move back to their home, which is common for patients who have accepted that they are approaching the end of their lives, and no longer want to attempt aggressive treatments. If this were the case, however, I would also refer the patient for a home nursing consult.
f) Anticipated discharge needs
- Since they appear to be staying in the SNF, I would feel comfortable with his being discharged from PT care after the wound was better managed, the family and patient were well educated about the continued benefits of movement in terms of maximizing his physiologic reserve and helping his would to close more quickly. He will continue to have round the clock nursing while he is in the SNF, so his wound will be closely monitored and he will have nursing help him turn every 2 or so hours to try to prevent worsening of the wound integrity.
g) Plan of care is appropriate for the setting
11) At least 3 short term goals
STG’s
- Patient will transition to a non-powered constant low-pressure support surface bed to better disperse pressure while patient is in bed in 1 visit.
- Patient will report a 50% decrease in wound pain during dressing changes in 2 weeks.
- Wound exudate will decrease to minimal within 3 weeks.
12) At least 2 long term goals (at least one must have a functional component)
- Patient will perform >/=
- Patient will perform >/= 75% of bed mobility during dressing changes to reduce risk of development of future pressure ulcers in 8 weeks.