Skin Changes at Life's End: Case Reports Protection Status
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by Rick Hall, BA, RN, CWON
Part 3 in a series on Skin Care Changes at Life's End (SCALE) and Kennedy Terminal Ulcers (KTUs).
For part 1, click here. For part 2, click here.

As is often the case in wound care, health care professionals cannot fight what they can't see. In the case of Skin Changes At Life's End (SCALE) and Kennedy Terminal Ulcers (KTUs), education is the first step towards effective management and documentation. Presentations offered to long-term care facilities and other organizations in the states of Kansas and Missouri have made them aware of SCALE and KTUs. Nurses have been taught what to look for and how to report it based on the education provided in these seminars. Teaching in various nursing schools has also enlightened many nurses, CNAs and HHAs in these states on SCALE/KTUs. These trained health care workers are looking for KTUs. It is not uncommon to receive phone calls stating, "I think we have found a KTU."

Patient Case #1: The Implications of SCALE

Mr. A is a home care patient with a pressure ulcer who was recently discharged from the hospital. Shortly after he returned home, he became unresponsive. A visit was made to the patient two days later to access the ulcer.

In a meeting with the HHA prior to visiting the patient, the HHA advised me the ulcer was larger on day two, approximately twice the size. When the ulcer first appeared it looked like a small purple area on the sacrum. This was day three. When we visited the patient and turned him to his side, the area was now five times as large as it was on day one. The wound was purple and red and had a large blister which was intact.

In a meeting with the patient's wife, the condition of her husband's lesion was explained and what the implications were. She was advised her husband probably would not make it to the weekend. He was declining rapidly. She was asked if there was any family who needed to say goodbye and she said her daughter was several hours away. She called her daughter and relayed the information given to her. The daughter was able to make it in to say her goodbyes and her father expired the next day. This is a case where we were able to identify what was happening and educate and prepare the family for the impending death.

Patient Case #2: The Rapid Onset of Kennedy Terminal Ulcers

Ms. B is admitted into a facility where a KTU was discovered in only one and one half hours from her admission. This is the shortest time reported for the development of a KTU. The Director of Nursing and the Assistant Director of Nursing turned the declining resident at noon. At 13:30 the patient was turned again by the same two nurses. They noticed three areas of discoloration on the coccygeal/sacral area, the spine and the right heel. The resident expired at 20:30 that evening, seven hours from the onset of the KTUs.

Patient History
The resident had previously fallen and was sent to the emergency room where x-rays showed no broken bones. Further workup revealed this resident had a deep vein thrombosis extending to her inferior vena cava from her right lower extremity. They also found a pelvic mass that was pressing on a ureter. Ovarian cancer was the diagnosis.

Risks and benefits of Coumadin and Heparin therapy were discussed and a decision was made not to treat with these interventions. The resident was not a candidate for surgery to remove the mass. The patient and family opted for comfort care.

Labs done on this resident at the hospital revealed she had an albumin of 2.7 which is indicative of generalized edema. When albumin is less than 2.8, fluid and platelets could leak from the vessels into the skin, causing it to become stained.

Patient #3: The Opportunity to Educate State Surveyors

It is difficult to capture these ulcers early because they grow so rapidly in size and sometimes in depth. In another patient case, a nurse was fortunate enough to capture a KTU early. Using an E-Z Graph measuring device, she documented two, 0.2cmx0.2cm stage II open areas in the sacrum.

On day two, state surveyors entered the building. They chose this patient to review. When they went to look at the wound it was now a stage III pressure ulcer and mimicked the dressing. The surveyor felt it was the facility's fault for applying the pressure dressing. The Director of Nursing felt it was a KTU. She informed the state surveyor what is was based on the rapid onset and changing appearance of the ulcer; this was not the normal progression of a pressure ulcer. The Director of Nursing was able to educate the state surveyor about development of KTUs versus pressure ulcers and a deficiency was avoided.

Following the patient's progression of the ulcer, on day six it was 10cmx10cm. On day seven the patient expired. On that morning, a presentation was made to the Kansas State Surveyors on wound care and Skin Changes at Life's End and the specific appearance of the KTU. With knowledge of SCALE and KTUs, the wound care provider can glean more information about their patients, and help defend their facility from claims of negligence.

About the Author
Rick Hall is a wound and ostomy educator and consultant for Kaiser Permanente and Helping Hands wound consultant.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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