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1 ISOFLEX CASE STUDY Autumn View Nursing Home Mary Ann Huber, RN, ADON On June 28 th a ninety-five year old female resident, Mrs. O. E., was re-admitted to our extended care facility following a brief stay in the local hospital. In 1998, at the time of her initial admission to our facility, her primary diagnosis was severe arterial occlusive disease. Her vascular condition precipitated an above the knee amputation of her right lower extremity on June 11th Upon readmission to us, her skin assessment revealed an unstageable sacral pressure ulcer. Her other medical history is significant for anemia, osteoarthritis, hypertension and chronic obstructive pulmonary disease. According to our pressure ulcer prevention protocol, we completed a Braden Scale for risk assessment at the time of re-admission. Mrs. O. E. was found to score fourteen. In our resident population, we have designated a threshold often as high risk. At that time, she was placed on our mattress replacement support surface. Since Mrs. O. E. spent approximately four hours out of bed in the chair each day, she was also provided with a gel chair cushion. A nutritional consult was ordered, due to a low albumin level of 2.7. Dietary recommendations for a high protein diet were implemented because nutrition plays such a vital role in wound healing. Mrs. O. E. also received weekly Vitamin B12 injections and daily oral iron supplements. Within our institution, wound assessments are documented weekly on our standardized skin integrity forms. On June 28 t \ the unstageable sacral pressure ulcer measured 6.4 em X 3.6 em and was covered with yellow/gray eschar. Periwound skin was erythemic. We began topical therapy with Normal Saline cleansings, application of Cleocin T Gel every 4 hours with dry sterile dressing. Within three weeks the eschar was lifting at the edges and there was evidence of granulation tissue at the wound edges. By July 20 th the surface area of the wound bed measured 3.8 ern X 3.0 ern with clear demarcation of eschar 2.5 em X 2.0 cm. On August io", six weeks into treatment, the entire wound bed measured 2.5 em X 2.0 cm. Since the eschar had softened and sloughed, we could now measure a depth of 0.4 ern and we determined the wound bed to be a Stage III. We continued with the Cleocin T Gel applications, but we changed Mrs. O. E. 's support surface to the ISOFLEX pressure and shear management system. By August 31st, the wound bed measured 2.0 em X 1.4 ern, the necrotic tissue had sloughed and become stringy and was very loosely attached. The base of the wound bed was pink with granulation tissue. By September io-, the wound bed was clean with pale pink granulation tissue, no odor and minimal serous drainage. Throughout the next month, the wound continued to decrease in size with epithelialization occurring and contraction of the wound edges. On November 2 od, the wound had progressed to a small denuded area measuring 0.3 em X 0.4 ern. No further drainage was noted and no odor or inflammation was present. A comprehensive pressure ulcer treatment plan was successful in promoting progress to healing of this sacral wound. We kept Mrs. O. E. on her lsoflex pressure and shear management system until complete resurfacing of her sacral wound on November 23rd. A pressure ulcer does not heal in isolation. Addressing the needs of the compromised individual who is at risk for pressure ulcer development or who already has an existing pressure ulcer includes meticulous skin care, nutritional supplementation and pressure and shear management. All components of the plan, including pressure and shear management must be addressed to promote positive outcomes. oj< <l.l <oj ; <l.l 10 GAYMAR" GAYMAR INDUSTRIES. INC. Orchard Park, NY Gaymar Industries Inc. MAW4599 = 8 '" <l.l.. 6 ~ <l.l N 2 c;j l"'l r- ~... N lfl 00 N l"'l... N =... N ~ =... N... '<, '<, N '<, '<, '<, --- r- --- r- ee ~ ~ = = Time

2 ISOFLEX Case Study Natalie Turner, RN Gowanda Nursing Home Gowanda, New York Mrs. S., an 81 year-old white female, was admitted to the Gowanda Nursing Home, Gowanda, New York, on 12/03/99 for a rehabilitation stay, status post a light displaced subcapital femoral neck fracture. The patient had an insertion of a bipolar hemiarthroplasty of the right hip on 11128/99. During surgery, the patient was transfused with packed red blood cells due to low hemoglobin. Other diagnoses include coronary artery disease, hyperlipidemia, urinary incontinence, degenerative arthritis, and hypertension. Current medications include Zocor", Fosamax", Calcium Carbonate, Methotrexate, and Darvocet" as needed for pain. Upon admission to the nursing home, the patient was placed on a restorative physical and occupational therapy program, with future plans to return home. The patient was considered high risk for pressure ulcer development due to occasional urinary and bowel incontinence, decreased mobility, and poor nutritional intake. The patient only consumed 25-40% of her meals, meeting less than her daily body requirements. The patient had experienced a 4 lb. weight loss during the week of hospitalization. Upon admission to the nursing home, her weight was lbs. (52.95 kg) with a height of 5 feet 4 inches. Following a nutritional assessment, the dietician recommended that Mrs. S. receive TwoCal'!; HN dietary supplements and Forta" Shakes on a daily basis. At the time of admission the patient's skin was documented as intact. On ]2/07/99, two superficial open areas were noted on the patient's left buttock region and a third area was noted on the coccyx. Dermagram spray and ointment treatment was started and a gel cushion was applied to her wheelchair. The superficial open areas had progressed to Stage III pressure areas within one week. The pressure areas remained clean and free from drainage. Several topical treatments were implemented without success. On 12!l9/99 the treatment was changed back to Dermagram spray and ointment, protected by a 2x2 gauze and an Opsite dressing. On 12/23/99, Mrs. S. was placed on an ISOFLEX mattress. At this time, the left upper buttock (outer) pressure area measured 0.7 ern x 0.4 em, with a 0.1 cm depth noted. The left upper buttock (inner) pressure area measured 1.7 em x 1 em, with a depth of 0.2 ern noted. The coccyx area measured I cm x 0.5 em, The center of the ulcers contained a yellowish matter, and the wound edges were slightly reddened with a minimal amount of granulation tissue noted. The pressure areas were monitored on a weekly basis and every week improvement was noted. On 1113/00, the coccyx pressure area was completely resurfaced and scar tissue was noted at the site. On 1119/00, the left upper buttock (outer) pressure area was noted to be resolved and on 1/27/00, the upper buttock (inner) area was resurfaced with only slight erythema noted at the site. The ISOFLEX mattress was removed from the patient's bed on 2/1/00. All areas remained resurfaced at this point. The patient stated that the ISO FLEX mattress was comfortable and also helped her back pain. The staff was impressed with the rate of the healing process upon the initiation of the ISOFLEX mattress. CONCLUSION The patient's decreased mobility, urinary and bowel incontinence, poor nutritional status, and medical diagnoses constituted her as a prime candidate for pressure ulcer development. When the pressure areas were. discovered, treatment was implemented. The ulcers required ongoing treatment evaluation due to the deterioration of the wounds. It was at the point when the ISOFLEX mattress was introduced that progress to healing was noted. Weekly improvement evidenced by decreased dimensions and wound resurfacing was noted with the ISOFLEX mattress as and intricate part of the treatment plan. The patient's mobility improved on a daily basis with restorative therapy. The nursing staff monitored the patient on a daily basis to ensure repositioning every two hours and the dietary staff closely monitored the intake and the weight ofthe patient. With all the treatment modalities in place, the outcome was positive for both the patient and the staff. GAVMAR" GAYMAR INDUSTRIES, INC. Orchard Park, NY MAW Gaymar Industries, Inc.

3 A Case Study Valerie Ryan, RN, CWOCN Levindale Baltimore, Maryland Ms.A.B., a resident in a long-term care facility, has been with us since early in Although she presented with a myriad of medical problems including IDDM, ASeVD, multiple eva's, progressive dementia as well as a total hip replacement, she stablized at the time of admission. She was admitted to the sub-acute unit for rehabilitation, but over time she did not respond well and she progressively became chair bound. Her admission skin assessment revealed Stage I pressure ulcers of both heels, a Stage II pressure ulcer on her trochanter and evidence of several healed wounds on her sacrum. The trochanteric ulcer went on to resurface. Though her Norton Scale reflected a moderate risk, the fact that she has a previous history of ulcers predisposed her to further sacral breakdown. In October, 2000 she experienced difficulty in swallowing which necessitated a G.T. placement for continuous tube feedings. Her health continued to decline with a UTI and C. difficile for which she was given Flagyl. On December 5, 2000, two Stage III pressure ulcers of the sacrum were documented measuring 2x2 and lxl. Although small in circumference, the wounds did have necrotic tissue. Her vulnerable sacrum, the site of previous breakdown was showing the effects of pressure and shear. Recidivism is high in patients with history of previous pressure damage. She was immediately placed on a pressure-reducing overlay, the Acucair", along with other pressure reducing devices, cushion and boots. Her tube feedings continued and despite a pre-albumin of 28.3 she developed an additional Stage II pressure ulcer of her heel (2xl.5) in January, While her heel ulcer resolved, frequent episodes of e. difficile made the healing on her sacral ulcers difficult. The ulcers would rotate through cycles of resurfacing and opening. On March 5, she was transferred from the pressure reducing overlay to the ISOFLEX Pressure and Shear Management System. Her sacral Stage III pressure ulcers resolved within one week and she remained stable despite repeated episodes of diarrhea and decreased responsiveness. The sacral area remains intact two months following placement on the ISOFLEX. GAVMAR" GAYMAR INDUSTRIES. INC. Orchard Park. NY MAW Gaymar Industries. Inc.

4 ISOFLEX Pressure and Shear Management Support Surface Diane Gronwell, RN McAulley Residence Western New York Mrs.s. is a 77 year old woman admitted to a long term care facility in Western New York, weighing 114 lbs. with a height of 5' 1". Prior to her admission she had been hospitalized with a history of falls. Other medical history included atrial fibrillation, osteoarthritis, osteoporosis, depression, anemia, history of colon cancer, and pilonidal disease. On April 20, her admission date, it was noted that Mrs. S. had a Stage III pressure ulcer at the scar site of a pilonidal cyst that had been removed at age 17. It measured 2cm long and lcm wide with a depth of 1cm. The pressure ulcer had no drainage or odor but had some yellow slough. She was placed on a standard hospital mattress, and Intrasite Gel BID was ordered. Generally, she had dry skin and multiple ecchymotic areas. She remained in bed 20 to 22 hours a day due to back pain and was out of bed only for meals and Physical Therapy. Pain was managed with Lortabs pm and then Vicodin pm. She was able to reposition herself every two hours. With the exception of some stress incontinence, she was continent of bowel and bladder. Her risk factors for pressure ulcers included poor nutritional intake, an albumin level of 2.9, systemic steroids, anemia, and a Vitamin B J 2 deficiency. She was on a regular, NAS diet along with supplements with and between meals. Multiple vitamins were given daily. On May 17, the area measured 1.6cm x 0.7cm with a depth ofo.2cm. There was still a small amount of slough noted in the center of the wound. On May 20, she was placed on an ISOFLEX Pressure and Shear Management Support Mattress. In a three week period of time, the wound measured 0.6cm x 0.3cm and had a depth ofo.2cm. Staff reported pink granulation tissue in the wound. On June 23, she was removed from the ISOFLEX Pressure and Shear Management Support Mattress and admitted to the hospital for treatment of atrial fibrillation. She returned to the long term care facility on June 29 and it was noted that the pressure ulcer had increased in length to 0.8cm. The width and depth were unchanged, however the wound again had slough tissue in the center. There was no odor or drainage. She was returned to the ISO FLEX Pressure and Shear Management Support Mattress and Intrasite Get'" BID was also reordered. By July 9 the pressure ulcer had improved to 0.6cm X O.lcm and a depth of 0.1 em. The following week it was documented in the chart as a 0.2cm "slit" and on July 20 the pressure ulcer was closed. The resident remained on the ISOFLEX Pressure and Shear Management Support Surface because she felt her back pain was improved with this mattress since she spent a great deal of her day in bed. On July 27 she was removed from the ISOFLEX Pressure and Shear Management Support Mattress and admitted to the hospital for nine

5 days. She retumed on August 4, with the pressure ulcer open again. The pressure ulcer now measured 1.7em x O.5cm and a depth ofo.1cm. The upper wound bed had soft yellow slough and the lower wound bed had pink granulating tissue. She was returned to the ISOFLEX Pressure and Shear Management Support Mattress and Intrasite Gel Jil BID was also reordered. On August 10 the wound measured 1.4cm x O.2cm and a depth ofo.lcm with pink granulating tissue. On August 24, it was closed. CONCLUSION This resident's poor nutritional status, use of systemic steroids, and immobility made her a poor candidate for healing. The use of the ISOFLEX Pressure and Shear Management Support Mattress along with attentive nursing care contributed to the positive outcome for this resident. The opening and closing of this wound had a direct correlation between being placed on the ISOFLEX Pressure and Shear Management Support Mattress and being removed from it. Treatment Date Range Episode Ulcer Dimensions Measurement Episode of Episode Duration Length Width Depth Date Measurement Prior to ISOFLEX On ISOFLEX 5/20/99 to 6/23/ em 0.7 em 0.2 em 5/17/99 34 days 0.6 em 0.3 em 0.2 em 6/10/99 Hospitalized 6/23/99 to (Off ISOFLEX) 6/29/99 6 days 0.3 em 6/29/99 6/29/99 to 0.8 em 0.2 em On ISOFLEX 28 days 0.1 em 7/9/99 7/27/ em 0.1 em Ulcer is closed 7/20/99 Hospitalized 7/27/99 to (Off ISOFLEX) 8/4/99 8 days 0.5 em 8/4/99 8/4/99 to 1.7 em 0.1 em On ISOFLEX 20 days 0.2 em 8/10/99 8/24/ em 0.1 em Ulcer is closed 8/24/99 I GAVMAR" I GAYMAR INDUSTRIES. INC. Orchard Park, NY Phone: (716) FAX: (716) MAW Gaymar Industries, Inc.

6 Effective Treatment: Stage III Pressure Ulcer Using ISOFLE~, a Non-powered Support Sur a Donna McMullen RN CWOCN, E.T. Consultants, Inc., Clarksburg, MD This study was presented at WOCN Conference, 2003 A 78-year-old male was admitted to a long-term care facility. His medical history included a CVA with left-sided hemiplegia. He was considered at high risk for developing a pressure ulcer. He had: a Braden score of 13 a Stage I pressure ulcer on left lateral upper back Initial treatment Thick foam mattress / positioning Nutrition consultation Appropriate wound treatment included facility protocol: Day 5 the following changes were noted: Progressed to a Stage III 100% slough Switched to ISOFLEX Treatment changed to address the slough Day 12: Wound decreased in size 100% granular Treatment changed to address granulation Day 19: Wound closed Conclusion: Application of the ISOFLEX was clearly instrumental in resolving this pressure ulcer so quickly. Resident verbalized comfort on the ISOFLEX as compared to the previous mattress with easier transfer to wheelchair due to the firmer support Resident refused to change back to the facility mattress There was a 72% cost savings using the ISOFLEX. ISOFLEX is a registered trademark of Gaymar Industries, Inc. BIBLIOGRAPHY: Pressure Ulcer Treatment, Clinical Practice Guidelines Number 15. U.S. Department of Health and Human Services Public Health Service. Agency for Health Care Policy and Research. Rockville, Maryland. AHCPR Publication No December 1994 Bennett L. Kavner D. Lee B, Trainor F. Shear vs. pressure as causative factors in skin blood flow occlusion. Arch. Phys. Med. Rehab. 1979; 60: Rodheaver GT, Stotts NA. Methods for assessing change in pressure ulcer status. Advances in Wound Care 1995; 8:34-6. MAW Gaymar Industries, Inc ~ ---

7 Clinical Effectiveness of ISOFLEX*in the Treatment of a Patient with Multiple Wounds Rose Marie Boroch, RN EDD CWOCN, E.T.Consultants, Inc., Silver Spring, MD This study was presented at SAWC 2003, WOCN Conference 2003 and Clinical Symposium 2003 Ms. S'I an 81-year-old women. returned from the hospital with comfort care orders only. She had: a Braden score of 10 a Stage III sacral pressure ulcer with 100% yellow slough a Stasis ulcer on right calf a Stage" pressure ulcer on the right heel Initial treatment included: Facility specific wound treatment protocol, including turning and repositioning Nutritional consultant Removal of the standard facility foam mattress placement on ISOFLEX Day 21 the following All wounds decreased in size Sacral ulcer had 85% thin yellow Heel ulcer had 100% granular tissue and changes were noted: slough Right calf was covered with 100% epithelial tissue Day 36: Sacral wound decreased in size and 100% granular Heel wound covered with epithelial tissue Calf wound remained intact Day 49: Sacral wound new epithelial tissue Heel and calf wounds remained intact Conclusion: Of significance, this patient healed with multiple wounds in different locations and a poor prognosis for healing. The protocol at this long-term facility required the rental of a low-air-ioss mattress. There was a 72% cost savings using the ISOFLEX. ISOFLEX" Pressure Ulcer Management Support Surface. ISOFLEXis a registered trademark of Gaymar Industries, Inc. MAW Gaymar Inudstries, Inc.

Challenge Scenario. Featured TAG TOPIC SCENARIO NOTES F314

Challenge Scenario. Featured TAG TOPIC SCENARIO NOTES F314 TAG TOPIC Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. SCENARIO In this scenario, the facility failed to ensure that residents who were admitted without