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?
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.
I've never heard of this before but it makes sense. Its so interesting. I'm quoting a paragraph from your first link.
The skin is an organ that (similar to other organs) canfail, especially as people age. Skin integrity is dependent onthe function of all other organ systems for nutrition, circulation,and immune function.7 Raised temperature, declinein circulation, pressure, and other yet-to-bedetermined causes increase tissue demands on the skin andcan have an impact on skin integrity8; pressure ulcers, atype of skin death, frequently occur in persons with a heavydisease burden, especially those at or near the end of life.9Although the skin is approximately 10% to 15% of totalbody weight, it is known to require 25% to 33% of cardiacoutput. It is no surprise then that the skin in patients onvasopressors that divert blood to major organs for survivalis compromised.
As was said before without pictures it is really difficult to tell. However, as a WOCN nurse I may consider:
1) extensive fungal rash. If he is incontinent of B&B he may definitely need an anti-fungal. You didn't mention his skin color but I have often seen darker skin people with fungal rashes that go undetected because we don't see the "erythema" associated with fungal rashes. The small round circles could be satellite lesions. If it is an extensive fungal rash he may need something more system like diflucan if it is not contraindicated.
2) possibly consider scabies given the fact that they also present as "scabs" and it is getting worse.
3) If it were scabies, a fungal rash, or incontinence associated dermatitis as a primary diagnosis he could be developing pressure ulcers within the area given his debilitated state and immobility.
His primary physician saw him this past week. He said the ulcers are due to a vitamin D or zinc definciancy or a combo of both. Basically because of his extremely poor nutritional health his skin is unable to regenerate, as dead skin cells are sloughed away there are no new skin cells to replace them. Because he is comfort measures only we won't be treating the underlying issues. Just trying to keep him as comfortable as possible which is easier said then done. He's now on fentanyl duragesic as well as PRN MSO4 and lorazepam, which he often times refuses even when he's having pain. Sadly, I think he will be one that's going to linger on for quite some time. :-(
His primary physician saw him this past week. He said the ulcers are due to a vitamin D or zinc definciancy or a combo of both. Basically because of his extremely poor nutritional health his skin is unable to regenerate, as dead skin cells are sloughed away there are no new skin cells to replace them. Because he is comfort measures only we won't be treating the underlying issues. Just trying to keep him as comfortable as possible which is easier said then done. He's now on fentanyl duragesic as well as PRN MSO4 and lorazepam, which he often times refuses even when he's having pain. Sadly, I think he will be one that's going to linger on for quite some time. :-(
Thank you for the update. Sounds very sad...You sound like someone I would want as one of my nurses. He is fortunate to have you.
Nursynursenurse, ADN, RN
114 Posts
I've never heard of this before but it makes sense. Its so interesting. I'm quoting a paragraph from your first link.