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                         CASE STUDY
•    84 year old female with history of diabetes, hypertension, coronary artery disease
     and depression, found in her home sitting in feces for unknown amount of time;
     Perineal and anal area detached, hanging down all necrotic.
•    Multiple wounds upper mid back and lower calf of both legs admitted to a local
     Hospital in septic shock. – Debridement (versajet hydrodissection debridement) to all
     necrotic area.
    - Measurement 40 x 40 (cm)
    - Right Heel 7.5 x 10 ( cm)
    - Left Heel 7.5 x 10 (cm)
    - Colostomy for diversion of fecal matter to enhance wound healing
•    Underwent surgical debridement of multiple profoundly large pressure wounds and
     creation of colostomy to divert stool from area of wounds.
•    Transferred to LTACH on 4/25/08.
•    Initial wound measurements were as follows:
       – Sacrum 37.5cm x 30cm x 4cm
       – Right heel 4.5cmx 7.5cm Left heel 6cm x 6cm
       – Upper back unstageable wound
       – Right and left thigh wounds Stage 2
Admission Photos to Bayshore
Admission Photos to Bayshore
Photos on Admission to
   Bayshore Contd.
Left Heel
Right Heel
Admission Photos to Bayshore
                      CASE STUDY
•   Patient was pan-cultured on admission and wounds grew
    Acinetobacter and yeast.
•   Labs on admission as follows:
     – pre albumin 10.3
     – Albumin 1.5
     – Protein 5.0.
•   KCI wound VAC sponge was applied to sacral wound and
    maintained at -125mmHg suction.
•   All other wounds were treated with Safgel /Versiva dressing and
    changed every two days as per wound care nurse.
•   Dietary Consult
    --- Patient was started on 1800 calorie ADA diet with Prosource protein
    supplement three times daily.
                       Nutritional Care
•  Initial Nutritional Assessment 4/28/08
•  Diet: 1800 Kcal with H.S. Snack
  - Good PO intake
  - Supplements:
                 Vitamin C 500mg PO BID
                 Zinc Sulfate 220mg PO BID
                 MVI with mineral 1 tab PO daily
• Labs:
        4/25/08 Albumin 1.5 ( low)
       4/25/08 Prealbumin 10.3(low)

•   RD Recommended:
       Prosource Supplement 30ml TID and MD ordered on 4/29/08 ( approx. 180 Kcals, 45 g
           Post Debridement
• Patient was admitted to CareOne LTACH on 4/25/08
          Heels on Admission
    Right Heel                        Left Heel
Wound bed presents with a mixture of granulated and
 necrotic tissue
Photos of Heels 5/5/08
              CASE STUDY
• 5/5/08 - Wounds all noted to have clean wound
  beds. Measurements as follows:
  – Sacrum- 36.5x25x3.5(cm) with 100% granulated
    tissue, tendons and muscle exposed.
  – Right heel 4x7.5(cm) Left heel 6x5.8(cm)
  – Both heels with 50% granulation tissue, exposed
  – Bilateral thighs with 100% granulation tissue.
  – Upper back with 50% slough, 50% granulation tissue.
Follow-Up Photos 5/13/08
wound update
             CASE STUDY
• 5/29/08 Treatments continued and monitored by
  wound nurse with Dietary management.
• Sacrum 33x24x2(cm) with less exposed
  tendons, wound VAC treatment continued.
• Upper back 100% granulation tissue.
• Left thigh 3.5x1.5(cm)
• Right thigh 8x3(cm) both with 100% percent
  granulation tissue.
• Left heel 7x4(cm)
• Right heel 6x3(cm).
Photos 5/29/08
Wound Care Follow-up
                CASE STUDY
• Patient continually followed by dietary and labs
  monitored regularly.
• Encouraged to eat protein as well as Prosource
  supplements three times a day by dietician.
• Treatments monitored by consults plastics and surgical.
• Plastic Surgeon considered patient for muscle flap,
  however felt patients albumin and pre-albumin levels too
  low for this.
• 6/9/08 Sacrum 33x12x2(cm)
• Right heel 5.5x4(cm)
• Left heel 5.5x4(cm)
•   Wound VAC therapy with continuous suction.
•   Dressing changes every 48 hours
•   Weekly wound assessment and measurement
•   Specialty bed (Clinitron)
•   Dietary management and Nutritional Labs
        6/12/08 Albumin 1.8
        6/12/08 Prealbumin 10.5
• RD F/U on 6/12/08- Recommended increasing
  Prosource to QID.
            Prior to Discharge
• 6/13/08
             CASE STUDY
• 6/13/08 Patient transferred to Care One Holmdel
  for continued nursing care and physical therapy.
Update Photos from CareOne at
• Sacral Area(7/18/08)
Update Photos from CareOne at
• Mid Upper Back (7/18/08)
 Update Photos from CareOne at
Left Heel
• Patient was readmitted to CareOne LTACH on
  September 15th, 2008 for wound management
• Sacral Wound
        Measurement (35.0cm x 13.5cm x 1.0cm)

• Right Leg Heel wound
        Measurement( 5.5cm x 4.0cm)

• Left Leg Heel Wound
          Measurement (7.0cm x 4.0cm)

• PO intake very good (75-100%), encouraged to eat
  foods high in protein
• Patient remained on Vitamin C, Zinc Sulfate and MVI
Re-admission Photos.
Right Leg Wound
Left Leg Wound
     Documentation 10/13/08
Sacral Wound
Measurement (31.0cm x 10.0cm x 0.7cm)
Documentation 11/15/08
Documentation 12/15/08
Documentation 12/15/08
Right Leg        Left Leg
• Patient presently waiting for Flap surgery
  to sacral area; Out of bed to the chair once
  a day, working with PT/OT trying to
  maintain range of motion and increase
  strength in both bilateral and upper
  extremities and bilateral lower extremities.


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