Case Presentation:

The Integrative Care of a Patient Diagnosed with

Stage III Pressure Ulcer

By:
Rakhi Sharma
CSUSM

MSN Cohort -9
 OBJECTIVES
After attending this case presentation, participants will be able to:

 Describe the Epidemiology of Pressure Ulcers.

 Identify risk factors for developing Pressure Ulcers
 Incorporateevidence-based CAM into the plan of care for a patient
diagnosed with Pressure Ulcers.
 Analyze a case presentation of a 75 years old patient diagnosed with
Stage III Pressure Ulcer.
 Demographics

75 years old Hispanic male, with 6 months history of stage III pressure ulcer on
the sacrum , secondary to immobility and incontinence.
 Medical History
Type 2 Diabetes- diagnosed at age at age 35, Hyperlipidemia , Diabetic foot
ulcers, Diabetic neuropathy.
 Surgical History
Right leg below knee amputation, 5 years ago- at age 70.
 Family History
Mother - Type two Diabetes, Hypertension and ESRD-passed away ay age 56.
Sisters - age 50 and 58 with Type 2 Diabetes.
 PRESENT THE PATIENT
 List of medications:
 Metformin 500 mg P.O. BID.
 Atorvastatin 40 mg P.O. daily.
 Gabapentin 300 mg P.O BID
 Norco 5mg every 4 hours P.O PRN for pain

 Use of CAM including lifestyle modifications.

 Daily wound care with Honey dressings.
 Iyengar Yoga Therapy Intervention
 Recommended change in diet, exercise or yoga daily.
 PRESENT THE PATIENT
REVIEW OF SYSTEM ( SUBJECTIVE)

 75,year old male with complaints of pain due to Stage III pressure ulcer.
 Denies shortness of breath, chest pain.
 Reports tenderness on bilateral greater trochanteric areas.
 Reports unable to ambulate w/o assistance, mostly wheelchair bound
 Nutrition poor
 Reports that he is able to move himself slightly in bed but needs complete
assistance to get out of bed.
 Reports episodes of incontinence both bowl and bladder.
 Feels depressed due to disease process ( immobility , poor healing pressure
ulcer).
 PRESENT THE PATIENT
Physical Examination (Objective)

 Vitals: T98.0, R 20, BP 120/70, P 80 and regular, Wt 60 kg, Ht 180 cm, Labs: HgbA1C- 6.8%
 General: Well groomed. Sitting in a wheel chair.
 HEENT - unremarkable
 Neck - supple, No JVD, no bruit, no lymphadenopathy
 Heart - RRR w/o murmur , no S3 nor S4
 Lungs - Bilateral lower lobe end inspiratory crackles, no rhonci
 Abdomen - BS+ x 4 Q, no mass or organomegaly
 Extremities - slight tenderness to palpation over bilateral greater trochanters R>L. Left leg
pulses intact in posterior tibial and dorsalis pedis. Right leg with BKA , stump without any
skin breakdown.
 Skin - Stage III diabetic ulcer noticed on the sacrum measuring 3inch x 3inch x 3 cm deep, No
tunneling . Scant purulent drainage was observed , wound bed covered with white slough.
Sensory = 2; Moisture = 3; Activity = 2; Mobility =2; Nutrition = 3; Friction =
1; Total Score = 13 (<18 high risk)
 PRESENT THE PATIENT:
Assessment

 Diagnosis:
- Stage III Pressure Ulcer
 Differential Diagnosis:
- Compromised skin integrity Secondary to age, immobility, incontinence and
poor nutrition.
 Plan:

- Daily wound care with Honey dressings.

- Iyengar Yoga Therapy Intervention
-Nutritional consultation and/or institute dietary supplements.
 PRESENTATION OF THE CLINICAL PROBLEM

Skin injuries like pressure ulcers, diabetic, venous and arterial ulcers are
becoming a significant problem in all healthcare settings specially
effecting geriatric population.
 Epidemiology :
According to Agency for Healthcare Research and Quality ( AHRQ)
Each year, more than 2.5 million people in the United States develop
pressure ulcers. These skin lesions bring pain, associated risk for serious
infection, and increased health care utilization.
 PRESENTATION OF THE CLINICAL PROBLEM

 Pressure ulcers remain a serious problem among geriatric population ,despite

regulatory and market approaches to encourage prevention and treatment.

 Pressure ulcers cause pain, disfigurement, and increased infection risk. They are
associated with longer hospital stays and increased morbidity and mortality.
PRESENTATION OF THE CLINICAL PROBLEM

Etiology/Pathophysiology
Different Stages Of Tissue Injury
 PRESENTATION OF THE CLINICAL PROBLEM

Risk factors include:

 Immobility.
 Lack of sensory perception.
 Poor nutrition and hydration.
 Medical conditions affecting blood flow such as
Diabetes and vascular disease.
PRESENTATION OF THE CLINICAL PROBLEM
Therapeutic interventions
 Daily wound care with honey dressing.
 Patient repositioned every 2 hours.
 Implement an incontinence management plan to prevent exposure to chemicals in
urine and stool that can strip or erode the skin.
 Assess Patients nutritional status; refer for a nutritional consultation and/or
institute dietary supplements.
 Pressure redistribution surface for the bed and wheelchair.
RETURN TO THE PATIENT: THE PLAN
 What did you try, What didn’t work:
-Implement an incontinence management plan to prevent exposure to chemicals in
urine and stool that can strip or erode the skin. Patient refused bowel and bladder
training or willingness to reposition himself every 2 hours.
 What worked:
 Daily wound care with honey dressing. The natural antiseptic properties of honey
soothe the mild bed sores in the skin. It can provide relief from pain, reduce
itching and promote healing . Honey can also reduce the risk of infection.
 Family and caregivers help and encourage patient to be repositioned every 2
hours.
 Pressure redistribution surface for the bed and wheelchair.
RETURN TO THE PATIENT: THE PLAN
 Current Plan :
 Continue daily wound care with honey dressing.
 Continue to reposition patient every 2 hours.
 Continue to implement an incontinence management plan to prevent exposure to
chemicals in urine and stool that can strip or erode the skin.
 Nutritional consultation and/or institute dietary supplements.
 Continue use of Pressure redistribution surface for the bed and wheelchair.
 Continue oral anti-hypoglycemic medication and pain management medications.
 Future Plan :
 Iyengar Yoga Therapy for upper body strength, so that the patient can reposition or
transfer in and out of chair and bed.
 Routine follow up to prevent complications.
 SUMMARY
75 years old Hispanic male, with 6 months history of stage III pressure ulcer on
the sacrum , secondary to immobility and incontinence. Medical history of
Type 2 Diabetes- diagnosed at age at age 35, Hyperlipidemia , Diabetic foot
ulcers, Diabetic neuropathy. Surgical history of right leg below knee
amputation, 5 years ago- at age 70. Feels depressed due to disease process
( poor healing pressure ulcer).

Plan is for daily wound care with honey dressing, continue to reposition
patient every 2 hours, continue to implement an incontinence management plan to
prevent exposure to chemicals in urine and stool that can strip or erode the skin,
Nutritional consultation and/or institute dietary supplements, continue use of
Pressure redistribution surface for the bed and wheelchair, continue oral anti-
hypoglycemic medication and pain management medications.
 Conclusion
 Pressure ulcers, diabetic ulcers and chronic wounds can have a significant impact on a
patient’s quality of life. Wound healing is a complex biological process in human body,
involving four major steps like homeostasis, inflammation, proliferation, and
remodeling (Mosby, 2009, P. 1510).

 Honey has had a valued place in traditional medicine for centuries. Honey has been
employed in wound care since ancient times. Many cultures and ethnic groups has
incorporated and used honey as antibacterial to treat different illness and wound
healing. China and India and many other nations have used honey as remedy for nearly
every illness (Al-Waili et al, 2011). The natural antiseptic properties of honey soothe
the mild bed sores in the skin. It can provide relief from pain, reduce itching and
promote healing . Honey can also reduce the risk of infection.
 References:
 AHRQ. (2016, April). AHRQ’s Safety Program for Nursing Homes: On-Time Pressure
Ulcer Prevention | Agency for Healthcare Research & Quality. Retrieved May 3, 2017, from
https://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/index.
html

 Al-Waili, N. S., Salom, K., Butler, G., & Ghamdi, A. A. (2011). Honey and Microbial 
Infections: A Review Supporting the Use of Honey for Microbial Control. Journal of
Medicinal Food, 14(10), 1079-1096. doi:10.1089/jmf.2010.0161

 Al-Waili, N. S., Al-Waili, F. S., Akmal, M., Ali, A., Salom, K. Y., & Ghamdi, A. A.
(2014).Effects of natural honey on polymicrobial culture of various human pathogens.
Archives of Medical Science, 2, 246-250. doi:10.5114/aoms.2012.28603
 
 Reference
 
 Al-Waili, N., Salom, K., Al-Ghamdi, A., Ansari, M. J., Al-Waili, A., & Al-Waili, T.
(2013). Honey and Cardiovascular Risk Factors, in Normal Individuals and in Patients with
Diabetes Mellitus or Dyslipidemia. Journal of Medicinal Food, 16(12), 1063-1078.
doi:10.1089/jmf.2012.0285

 American Diabetes Association. (2016). Classification and diagnosis of diabetes. Diabetes care
2016, 39(1). doi: 10.2337/dc16-S005
 Reference
 Bergstrom, N., & Braden, B. (1992). A prospective study of pressure sore risk among
institutionalized elderly. Journal of the American Geriatrics Society, 40(8), 747-758.

 Ribeiro, S. (2015). Iyengar Yoga Therapy Intervention for Ischial Pressure Ulcers in a
Patient with Amyotrophic Lateral Sclerosis: A Case Study. The Journal of Alternative and
Complementary Medicine, 21(9), 578-582. doi:10.1089/acm.2014.0163

 Mosby's dictionary of medicine, nursing & health professions (8th ed.). (2009). St. Louis,
MO: Mosby. Page- 1510