Maxine XXXXX DOB: 06/14/YYYY

MEDICAL CHRONOLOGY

Specific Instructions:
·  The pressure ulcer matrix focuses on the skin assessment, pressure ulcer prevention interventions, development and treatment of pressure ulcer in XXXXX Kentucky, Louisville from 10/08/YYYY to 10/28/YYYY. Kindly click here (Ref 2) to refer the corresponding table
·  Only the pressure ulcer details have been captured, whereas the other medical conditions have not been included as they do not carry any significance to the case
·  Records from 10/02/YYYY to 10/08/YYYY are narrated in brief to showcase the skin condition of the patient before being transferred to XXXXX Kentucky, Louisville and the development of the pressure ulcer. Kindly click here (Ref 1) to refer to the corresponding table
·  Records from 10/28/YYYY to 11/04/YYYY are reviewed and are summarized in brief to showcase the condition of the pressure ulcer and the care rendered for the same during the hospitalization course. Kindly click here (Ref 3) to refer to the corresponding table
·  Blank cells determine that there are no corresponding details in the record.

Patient History

Past Medical History: Pinched nerve in neck, Arthritis, Osteoporosis, Gastroesophageal reflux disease, Chronic kidney disease - Dialysis, Kidney stones, Hypotension

Surgical History: Nephrectomy, Hysterectomy, Cholecystectomy, Lumbar discectomy, Carpal tunnel release, Parathyroidectomy

Family History: Non-contributory

Social History: Currently non-smoker. Quit habit in YYYY. She is a social drinker.

Allergy: Dilaudid, Latex, Codeine, Vicodin, Betadine

(Ref 1): DETAILED CHRONOLOGY

DATE / PROVIDER / OCCURRENCE / PDF REF
XXXXX Health Care
10/02/YYYY – 10/08/YYYY – Hospitalization for hip fracture and the corresponding management
*Reviewer’s comment: Records from 10/02/YYYY to 10/08/YYYY are reviewed and are summarized in brief to showcase the skin condition of the patient before being transferred to XXXXX Kentucky, Louisville and the development of the pressure ulcer
10/02/YYYY – 10/08/YYYY / XXXXX Health Care / Patient presented with a complaint of hip pain for several days; she was supposed to see an Orthopedic surgeon next week but she stepped on her leg and it gave out and she fell to the floor, she was taken to the emergency room and workup revealed left femoral neck fracture. Following this she was admitted for further evaluation. She underwent a left hip hemiarthroplasty. She was briefly admitted to the Intensive Care Unit (ICU) post operatively due to hypotension but the patient normally ran low blood pressures. Dialysis was carried out in the course. She kept doing well and was planned to discharge to XXXXX Kentucky, Louisville for a short acute rehabilitation. Pressure reduction mattress was discontinued at the time of discharge.
Discharge examination:
BP: 87/46, Pulse 99, Temperature: 98.8 °F, Respiration: 16, Weight: 134 lb 4.2 oz, Body Mass Index (BMI): 19.34 kg/m2, SpO2: 99%
General appearance: Alert, cooperative, no distress, appears stated age
Skin: Skin color, texture, turgor normal, no rashes or lesions
All the other system examinations remain unremarkable
Patient on 10/08/YYYY was then discharge to XXXXX Home of Kentucky. / 332-336, 344-356, 371-426, 547, 858-876

(Ref 2): PRESSURE ULCER MATRIX

DATE / PDF REF / SKIN RISK INTERVENTIONS / LABS / WOUND ASSESSMENT/TREATMENT /
/ Repositioning every 2hrs/
Mattress/Continence / Nutrition and Hydration / Plan of Care /
XXXXX Kentucky, Louisville
*Reviewer’s comment: The skin risk interventions carried out, the development of the pressure ulcers and the management of the same from the date of admission on 10/08/YYYY till discharge on 10/28/YYYY is captured in detail below. The other medical conditions of the patient are not included.
10/08/YYYY / 173- 183, 193-205, 70, 42 / Admission assessment and plan of care:
Admitted to the Home. Temperature: 97°, pulse: 85, respiration: 20, BP: 84/46. Resident alert with clear speech and vision with good long term memory. No history of dementia, dehydration. Support provided for Activity of Daily Living (ADLs), Total dependence for Bed mobility – Full staff performance of an activity with no participation by resident for any aspect of the ADL activity (2+persons physical assist). Bed mobility includes how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture support. Incontinent bowel for the last 7 days. Bladder continent.
Weight: 131 lbs.
Skin integrity: Edema. Admitted neither with history of pressure ulcers nor with pressure ulcers. Braden score: 18 (Mild risk for ulcer development)
Turning and repositioning will be initiated: No
Patient aware of need to turn and reposition. Skin assessment weekly. Pressure reduction specialty mattress ordered.
Comorbidities that could place the resident at risk of skin breakdown: Peripheral Vascular Disease (PVD)
Diet order: Regular, thin liquids
10/09/YYYY / 168, 275-276-277, 231-232, 206, 212, 144-145 / @ 0115 hrs: Continent bladder
@ 0845 hrs: Continent bowel and bladder
Pressure relieving and reducing device for chair and bed present
Turning and repositioning done every 2 hrs / Total fluid intake: 240+120+240
Meal :
Breakfast: 75%
Lunch: 75%
Supper: 100% / Pressure area right buttocks – Position off affected areas, pressure reduction mattress.
Area of right buttock – Clean with Normal Saline, applies with Triple Antibiotic Ointment (TAO) cover with dry dressing and secure with paper tape. Twice daily and as needed.
Wound Care to consult. / @ 0115, 0845 hrs: Warm, brown, turgor quick
@ 1132 hrs: Presence of pressure ulcers with skin tears
@ 1425 hrs: Shearing/skin tear 7cm x 5.5 cm/4 cm x 2.5 cm x 0.1 cm red center, no drainage, no odor. Unremarkable periwound
Area of right buttock – Cleansed with Normal Saline, applied with Triple Antibiotic Ointment (TAO) and cover with dry dressing and secured with paper tape. Twice daily and as needed.
10/10/YYYY / 277, 206, 212, 145 / Continent bowel and bladder
Turning and repositioning done every 2 hrs / Total fluid intake: 220+260+360
Meal :
Breakfast: 25%
Lunch: 100%
Supper: 100% / @ 1825 hrs: Warm, brown, turgor quick
Area of right buttock – Cleansed with Normal Saline, applied with Triple Antibiotic Ointment (TAO) and cover with dry dressing and secured with paper tape. Twice daily and as needed.
Wound care Consultation report for right buttock full-thickness skin tear: (Ref: 36-37, 45)
Patient states this has occurred over the last two days or so. She thinks this might have occurred with some shearing when being moved.
Impression: Skin tear, right buttock, full thickness.
Plan: It is unclear whether the surrounding tissues will survive or may slough as well. We will wait for this to demarcate. We recommend SilvaSorb gel after cleansing the area with saline daily with Vaseline gauze or Adaptic and then bordered gauze. We will see her back in this facility in a week’s time. We recommend turning and repositioning to offload the pressure. Her wound is going to have an increased risk associated with it given her current immobilization and her incontinence. Certainly, as I have discussed with her and her family, we will defer the surgical incision management to her primary operative surgeon.
10/11/YYYY / 278-279, 206, 212, 144 / Continent bowel and bladder
Turning and repositioning done every 2 hrs / Total fluid intake: 120+240+240
Meal :
Breakfast: 75%
Lunch: 25%
Supper: 75% / @ 1327 hrs: Warm, brown, turgor quick
Right buttock cleansed with Normal Saline, then SilvaSorb gel then adaptic or Vaseline gauze followed by Bordered gauze placed.
10/12/YYYY / 279, 206-207, 212, 280, 144 / Turning and repositioning done every 2 hrs
Continent bladder and bowel / Total fluid intake: 120+240
Meal :
Breakfast: 25%
Lunch: 50%
Total fluid intake: 120+240
Meal :
Breakfast: 25%
Lunch: 50% / @ 1359 hrs: Warm, brown, turgor quick, skin tears
Right buttock cleansed with Normal Saline, then SilvaSorb gel then adaptic or Vaseline gauze followed by Bordered gauze placed
10/13/YYYY / 207, 212, 280, 144 / Turning and repositioning done every 2 hrs
Continent bladder and bowel / Total fluid intake: 240+120+240
Meal :
Breakfast: 50%
Lunch: 100%
Supper: 100% / @ 1432 hrs: Bruises and abrasions present
Right buttock cleansed with Normal Saline, then SilvaSorb gel then adaptic or Vaseline gauze followed by Bordered gauze placed
10/14/YYYY / 207, 242, 212, 281-282, 144 / Turning and repositioning done every 2 hrs
Continent bladder and bowel / Total fluid intake: 240+120+120
Meal :
Breakfast: 100%
Lunch: 25%
Supper: 100% / Resident had a fall on 10/13/YYYY when was in bathroom and attempted to stand without assistance. / @ 1424 hrs: Warm, brown
Right buttock cleansed with Normal Saline, then SilvaSorb gel then adaptic or Vaseline gauze followed by Bordered gauze placed
10/15/YYYY / 207, 242, 212, 283, 189-190, 168, 48, 144 / Turning and repositioning done every 2 hrs
Continent bladder and bowel / Weight: 137.3 lbs
Total fluid intake: 240+120+120
Meal :
Breakfast, lunch, supper: 100%
Estimated nutrition:
Calories: 1560/day
Protein: 62 gram/day
Fluid: 1560-1872 ml/day
Regular diet order with 75% per oral intake. Continent bladder and bowel. / Order to have no paper tape to buttocks / @ 1312 hrs: Warm, brown
Right buttock cleansed with Normal Saline, then SilvaSorb gel then adaptic or Vaseline gauze followed by Bordered gauze placed
10/16/YYYY / 233, 207-208, 212, 157, 144 / Turning and repositioning done every 2 hrs / Total fluid intake: 240+240+240
Meal :
Breakfast: 100%
Lunch: 50%
Supper: 50% / Measure ulcers weekly treatments as ordered
Measure pressure ulcers weekly, record measurements, description of wounds that is drainage, odor, redness, etc.
Observe for assistance with turn and reposition at least every 2 hrs and as needed. Staff to assist as needed.
Pressure-reducing mattress
Report any redness or open areas to nurse
Weekly skin checks 1/2 side rails x 2 to assist with transfers and mobility
Quarterly risk assessments every 3
months
No paper tape to buttocks
Wound MD consult as needed
Turn and reposition every 2 hrs
ROHO cushion to chair and to take to dialysis
Low air loss mattress
No more than two hours out of bed at any given time ___ dialysis. / @ 0601 hrs: Open areas in buttocks, sheering of skin
Right buttock cleansed with Normal Saline, then SilvaSorb gel then adaptic or Vaseline gauze followed by Bordered gauze placed
10/17/YYYY / 208, 212, 285-286, 48, 145 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair / Total fluid intake: 240+120+240
Meal :
Breakfast: 50%
Lunch: 75%
Supper: 75% / To bilateral buttocks, discontinue current treatment and begin cleanse wounds with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs, then AbsorbentDressing (ABD) pad (No tape). ____ Clean to periwound skin every 12 hrs. Roho cushion, Low Air Loss (LAL) mattress. 2 hrs out of bed at any given time. / @ 1951 hrs: Warm, brown
Cleansed bilateral buttocks wound with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs applied, then AbsorbentDressing (ABD) pad placed. No tape on skin. Applied Microenvironmental Minimal Bactericidal Concentrations (MMBC). to upper wound.
Local wound care report: (Ref: 31)
Right buttock: 7 cm x 5 cm, eschar, unstageable
Left buttock: 3 cm x 2 cm, pale granulation tissue, stage III
Plan: Roho cushion, Low Air Loss (LAL) mattress, Santyl Dakin 1/8th MMBC. See next week
10/18/YYYY / 208, 212, 286, 145 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Total fluid intake: 360+240
Meal :
Breakfast: 50%
Lunch: 50% / Pressure ulcers present
Cleansed bilateral buttocks wound with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs applied, then AbsorbentDressing (ABD) pad placed. No tape on skin. Applied MMBC to upper wound.
10/19/YYYY / 208, 212, 287, 145 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Total fluid intake: 240+120+360
Meal :
Breakfast: 100%
Lunch: 75%
Supper: 50% / Pressure ulcers present
Cleansed bilateral buttocks wound with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs applied, then AbsorbentDressing (ABD) pad placed. No tape on skin. Applied MMBC to upper wound.
10/20/YYYY / 208-209, 212, 288, 145, 148 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Total fluid intake: 120+120
Meal:
Breakfast: 50%
Lunch: 50% / Temperature: 99° / Pressure ulcers present
Cleansed bilateral buttocks wound with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs applied, then AbsorbentDressing (ABD) pad placed. No tape on skin. Applied MMBC to upper wound.
10/21/YYYY / 209, 241, 212, 145 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Weight: 132 lbs (10/18/YYYY), 3.8% weight loss x admit
Total fluid intake: 240+240
Meal :
Breakfast: 100%
Lunch: 100%
Zero signs and symptoms of dehydration problems. / Recommended 90 ml MedPass + twice daily for wound healing / Stage III left buttocks area
Cleansed bilateral buttocks wound with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs applied, then AbsorbentDressing (ABD) pad placed. No tape on skin. Applied MMBC to upper wound.
10/22/YYYY / 209, 234, 212, 240, 145 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Total fluid intake: 240+240+240
Meal :
Breakfast: 50%
Lunch: 50%
Supper: 50% / Sheering skin impairment in the buttocks
Cleansed bilateral buttocks wound with saline, Santyl ointment, 1/8 Dakins wet – moist every 12 hrs applied, then AbsorbentDressing (ABD) pad placed. No tape on skin. Applied MMBC to upper wound.
10/23/YYYY / 209, 212, 291, 145 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Total fluid intake: 240+240
Meal :
Breakfast: 100%
Lunch: 75% / Pressure ulcers present
10/24/YYYY / 209-210, 212, 240, 145, 147 / Turning and repositioning done every 2 hrs
Roho cushion for wheel chair
LAL mattress / Total fluid intake: 240+240+400
Meal :
Breakfast: 50%
Lunch: 50%
Supper: 75% / Temperature: 99.7°
To continue with renal diet related to End Stage Renal Disease (ESRD) with consumption of approximately 50% of meal and 240ml of fluids. / Stage II wound in the bilateral buttock. One black area in middle with beefy red in the edges of wound bed. Other wound bed is beefy red.
Resident wounds: Stage III on left buttocks and unstageable on the right buttocks.