What are these wounds??!

[NurseQT]

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?

[OrganizedChaos, LVN]

It would be difficult to say what they are since we are not there, in front of the patient viewing the wounds.

[NurseQT]

I really wish I could find a picture online of what these ulcers look like so I could post it but no matter how much I've searched online I can't find anything like it.

[Nurse Leigh]

Is his nutritional status being addressed? Peg tube? Likely needs a lot more protein than he's getting. Do you have wound care nurses available?

This just sounds like all his comorbidities + his refusal to participate in care are making a huge mess.

Is he maybe just ready for hospice and comfort measures? And him pulling off dressings is his way of trying to communicate his frustration?

[vampiregirl, BSN, RN]

What a challenging situation!

My only additional thought would be to consider if any fungi/ yeast/ bacteria is hanging out on the mattress since you mentioned that he frequently removes dressings, linen etc. and contributing to the wounds...

Good luck!

[CoffeeRTC, BSN, RN]

I was thinking mattress too! Have you took a culture of the wounds?

[Ladyscrubs]

Could these sites all be Kennedy ulcers appearing?

Wow, I learn so much from this site! So I thought I would pass it on...

http://www.o-wm.com/files/owm/pdfs/Schank_SEPT2.pdf

Kennedy Terminal Ulcer Information and Warning Signs

At first it almost sounded like a Lyme disease rash, but me thinks you may be on to something NurseQT, :up:and as the literature states, it is not due to lack of care, but a blood perfusion problem related to the dying process.

[meanmaryjean, DNP, RN]

Fascinating website! Never heard of this before.

[NurseQT]

Well we're a little bit closer to finding out what is going on with this man's skin! We had one of other providers take a look today, she took one look and said "that is definitely NOT dermatitis!" She really thinks it's something systemic. Her first question was "is he HIV positive", which as far as we know he's not. She gave us some good suggestions to address with his provider since she's not able to write orders for him. One of the biggest ones was to use bleach free linen! She thinks he may be ripping his sheets off his bed because they're too irritating to his skin! She also suggested drawing labs if possible and putting a foley in. She said the ulcers didn't appear to be Kennedy ulcers. They were worse looking today again today, the one on his hip was doubled in size from yesterday and it was apparent he had been scratching at it!

We do have a Wound Nurse but she was just as perplexed as the rest of us!

His nutritional status is beyond poor, but he is "comfort measures only", so anything like a feeding tube aren't an option. He honestly looks like he's a concentration camp survivor, that's how skinny he is! He had been on hospice before but was discharged and when the option was brought up again his guardian declined the referral.

We know we aren't going to heal his wounds but it would be nice to know exactly what is going on so we can appropriately. He's in a lot of pain and refuses PRN MSO4 more then he'll take it. It's heartbreaking to watch, he really just needs to go to sleep.

[BeenThere2012, ASN, RN]

Any treatment for fungal infection been tried?

[Cmahue]

My thoughts were similar...HIV status....also sounds similar to, but much slower than, Ã case of necrotizing fasciatis I saw once on a Native American Reservation. I wonder if that disorder has any slow moving "cousins." Something systemic I agree.

[Anna Flaxis, BSN, RN]

Scurvy?