What are these wounds??!
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Hoping someone can help figure out the wounds I'm seeing on a LTC patient of mine because my co-workers and I are completely stumped.
A little bit of background: The patient is a kind of a younger man, in his 60s. TBI that has had some really significant residual effects. He's been residing at the LTC facility where I work for about 6 years. He's very spastic in his movements, has severe swallowing issues, incont. of B&B, can be very resistive and combative towards staff, very poor nutritional status. He's a tall man and is literally skin and bones. Surprisingly he's never had any skin issues despite that fact that he refuses to get out of bed or reposition. Up until a few months ago that is... He first presented with what we thought was a shingles rash across his lower back. He refused medications so we basically let it resolve on it's own. The rash faded and our provider decided it wasn't shingles after all. A short while later the rash came back and extended down his hips and buttocks and up his back. The rash consisted of red scabbed looking circles, the only redness surrounding these spots was from areas where he was scratching. We tried triamcinolone cream which was not effective. Shortly after the strange rash reappeared he developed two ulcers on his coccyx, they were small and perfectly round with 100% slough. They were maybe the size of an eraser head. The provider classified them as pressure ulcers and ordered calcium aliginate and duoderm dressings to be changed every 3 days. He was completely noncompliant with repositioning off the area and would tear off the dressings within an hour of them being applied. He won't wear incont. products and all too often rips the sheets off his bed and lays right in the mattress. At this point I thought that the weird rash was moisture related and decided to try applying zinc over his entire back side. For a few weeks it started to look better. And then it went downhill. The two small ulcers increased in size and became one ulcer right over his coccyx. And one the red circular marks on his hip opened up and is now quite large and 100% eshar. The practitioner changed the diagnosis to terminal ulcers and initially d/c'd all tx since he was noncompliant with keeping a dressing on and the zinc wasn't doing anything. The ulcer over his coccyx is almost to the bone now. And his entire lower-mid back, hips, and buttocks are covered in the same type of ulcers that first presented on his coccyx. They're small and perfectly circular. It honestly looks like someone took a punch biopsy tool to his back! The practitioner ordered new tx, medi-honey and calcium alginate covered with duoderm to the coccyx ulcer and change daily. And triam cream mixed with eucerin over the "dermatitis"
qd. He continues to rip the dressing off and scratches at the ulcer on his hip. The sores on his back look worse every day. I have never in my nursing career seen anything like this, it's actually pretty shocking and disturbing to see. Could these sites all be Kennedy ulcers appearing? I can't even find a comparable pic online that I can post as an example. Anyone have any ideas?