Major Case

Study:
Kennedy
Terminal
Ulcer/Pressure
Injuries
Kristina Weiser
Literature Review
 Journal Article #1
• Title: Kennedy terminal ulcer and • Journal of Tissue Viability
other skin wounds at the end of life
• Published May 2021
• Authors: Roca-Biosca, Alba; • Integrative literature review
Rubio-Rico, Lourdes, Fernandez,
Maria; Martinez-Castillo, Juan;
Pancorbo-Hidalgo, Pedro; Garcia-
Fernandez, Francisco
 #1- Abstract
• Background: Pressure injuries are a common • Results
issue among geriatric patients, and healthcare
professionals are familiar in how to prevent their • KTUs occur as a result of reduced blood flow
development. However, there is increased due to multiple-organ failure
evidence that some pressure injuries that exist are • Develops within the last few weeks/months of
unavoidable, such as Kennedy Terminal Ulcers. life
• Objective: To evaluate existing literature related • Risk factors: Prescence of other pressure
to the characteristics, risk factors, development, injuries, low weight, loss of appetite, cachexia,
and proper care of Kennedy Terminal Ulcers. reduced mobility, poor nutrition, low albumin.
• Study design: Articles were included that • Characteristics- Black/yellowish in color, usually
presented information on unavoidable skin
on the sacrum or coccyx
injuries that occur at the end of life.
• Conclusion: Further research is needed to determine
the proper method of treatment for KTUs.
 #1- Application to Patient Care
• Identification of risk factors
• Differentiating between KTUs and PIs
• Appearance
• Etiology
• Shift of patient care goals
 Journal Article #2
• Title: Nutritional management of • Published 11/15/18
older hospitalized patients with
• Cross-sectional study design
pressure injuries
• Authors: Eglseer, Doris; Maneula,
Hodl; Lohrmann, Christa
• International Wound Journal
 #2- Abstract
• Background: Development of pressure injuries have • Results
been shown to be a risk factor in older adults due to
incontinence, reduced mobility, and malnutrition. • 36% of patients with pressure injuries were at
risk for malnutrition.
• Objective: To evaluate the interventions put in place
for patients 70 years of age or older with a pressure • 23.4% of patients at risk for pressure injuries
injury as well to assess the association between were at risk for malnutrition.
pressure injuries and malnutrition. • Recommended interventions include high
• Study design: 33 Austrian hospitals and a total of calorie/protein diet and oral nutrition
1,476 patients older than 70 participated. 609 of the supplementation
patients were at risk of developing pressure injuries
and 71 had at least one pressure injury. They were
then screened using the MUST .
 #2- Application to Patient Care
• Nutrition plays an important role in preserving skin and supporting wound
healing
• Increased energy needs (30-35 kcal/kg)
• Increased protein needs (1.2-1.5 g/kg)
• Decreased appetite among older adults
 Journal Article #3
• Title: Factors Affecting Wound • Journal: Ostomy Wound
Healing in Individuals with Management
Pressure Ulcers • Published February 2018
• Authors: Karahan, Azize; • Retrospective study
Abbasoglu, Aysel; Isik, Sevcan;
Cevik, Banu; Saltan, Cigdem; Elbas,
Nalan; Yalili, Ayse
 #3- Abstract
• Background: Pressure injuries have the potential to • Results: The number of participants whose
increase the duration of hospitalization, as well as wounds healed (34) was lower among patients
decrease mobility and overall quality of life. When that:
developing proper wound care plans, it is essential to
identify risk factors that can potentially delay healing. • Had mobility issues
• Objective: To identify factors that may delay or • On enteral/parenteral nutrition
progress wound healing in patients with pressure
injuries. • Braden score </= 12
• Design: 103 patients admitted to a Turkish hospital • Low hemoglobin
over a 4-year time span with Stage 2, 3, and 4 • Longer duration of hospitalization
pressure injuries were evaluated. The data collected
consisted of questions regarding demographic
characteristics, health/disease status, laboratory
values, characteristics of the pressure-ulcer, and
patient-risk status.
 #3- Application to Patient Care
• Risk factors should be considered when treating patients with pressure
injuries to prevent progression and development of other wounds
• Braden Scale monitoring
• Prioritize oral nutrition
• Monitor labs
Case Report
 Introduction to Mr. X
• 74-year-old African American male
• 69 in tall, 187 lb (BMI- 27.8)
• Classified as overweight
• Family history
• Wife with dementia
• Complicated relationship with 3 children
• Admitted to the Tuscaloosa VA long-term care facility in 2017 following a stroke
 Admitting/Current Diagnoses
• Admitting dx: ESRD and vascular dementia with behavioral disturbance
• Current dx: Kidney failure, Kennedy terminal ulcer of the sacrum, stage 3
pressure injury of left heel, left lateral lower leg, and right hip.
• Kennedy ulcer -> 6.5 x 7.5 x 3.5 cm
• Left heel -> 2 x 2 x 0.3 cm
• Left leg -> 6.5 x 4.5 x 0.2 cm
• Right hip -> 3.5 x 2.5 x 1 cm
 Past Medical History
• Chronic heart failure • Gastroparesis due to T2DM
• Chronic periodontitis • Osteoporosis
• COPD • Anemia of chronic renal failure
• GERD • Peripheral vascular disease
• T2DM • Chronic gingivitis
• Dysphagia • Right hemiplegia
 Clinical Course
• On hemodialysis since 2012, had his last session on 9/21/22
• Hemodialysis discontinued due to development of KTU
• Hospice care
• Receiving wound care for comfort and odor control
 Weight/Diet History
• Weight upon admission in 2017- 226.4 lb
• March 2022- 206.2 lb
• June 2022- 181 lb (severe loss)
• October 2022- 176.1 lb
• Diet history- Renal/diabetic
 Diet Information
• Poor appetite with an average intake of 25% of meals
• Poor fluid intake with an average intake of 0-240 mL/day
• Food allergies- nuts, eggs, milk, tomatoes
• No religious/cultural eating habits
• Current diet order- Mechanical
 Estimated Needs
• Energy needs: • Protein needs: 1.2-1.5 g/kg
• 30-35 g/kg- 2,400-2,800 kcal/day • 96-120 g/day
• MSJ x 1.2-1.3- 1,837-2,105 kcal/day • Fluid needs: 30 mL/kg of IB
• 2,190 mL/day
 Nutrition Focused Physical Exam
• 9/25/12 Braden Score- 12
• Mild subcutaneous fat loss- orbital fat pads
• Anasarca- generalized swelling throughout the body
• Edema in feet
• Very few teeth remaining
 Malnutrition Diagnosis
• Severe malnutrition in the context of chronic illness
• <75% average PO intake for over 1 month
• 12% weight loss in 3 months (March-June)
• Classified as severe
• Severe fluid accumulation
• Mild subcutaneous fat loss
 Significant Lab Values
Parameter Normal Value Range Patient’s Value Reason for Abnormality Nutrition Implication
Glucose 70-105 mg/dL 333 mg/dL (H) T2DM Uncontrolled diabetes
Urea Nitrogen 7-18 mg/dL 42 mg/dL (H) CKD stage 5 Kidney failure, dehydration
Creatinine 0.7-1.4 mg/dL 5.75 mg/dL (H) CKD stage 5 Kidney failure, dehydration
Chloride 98-107 mmol/L 97 mmol/L (L) CHF/COPD Dehydration
Hemoglobin A1C <7 (for diabetics) 9.4 (H) T2DM Uncontrolled diabetes
Albumin 3-6.4 g/dL 2.6 g/dL (L) Kidney failure Poor nutrition status, inadequate hydration,
inflammation
GFR >/= 60 10 (L) CKD stage 5 Kidney failure, not related to nutrition
 Significant Lab Values (continued)

Parameter Normal Value Patient’s Value Reason for Nutrition

Range (High or Low) Abnormality Implication
RBC 4.2-5.6 3.23 (L) ESRD, Inadequate PO
malnutrition intake
HGB 13-17 g/dL 9.3 g/dL (L) Hx of anemia of Not related to
chronic renal nutrition
failure
HCT 40-50% 31.2% (L) Hx of anemia of Not related to
chronic renal nutrition
failure
 Medications
Medication Used to treat? Mechanism of Action Nutrition Interactions
Acetaminophen Chronic pain/fever above 100.4 Blocks sensations of pain by inhibiting synthesis Avoid alcohol
of prostaglandins
Bisacodyl suppository Prevents constipation Increases the amount of fluid and salt in the N/A
intestines to stimulate bowel movement.
Glycopyrrolate Controls drooling Decreases stomach acid and saliva production Avoid alcohol

Ondansetron Nausea/vomiting Blocks action of serotonin Avoid grapefruit

Pantoprazole Controls symptoms of GERD Decreases the amount of acid produced by the Can reduce absorption of iron and
stomach. other multivitamins
Atorvastatin Controls Blocks an enzyme called HMG-CoA reductase that Avoid alcohol/grapefruit
cholesterol/triglycerides speeds up the build up of cholesterol in the body.
 Nutrition Risk Factors
PES Statement Goal Intervention Monitoring Evaluation

Increased energy needs (NI- Short-term: Improve PO Provide Nepro and Juven Short-term: Check patient Short-term: Increased average
5.1) related to severe wounds intake to meet increased with meals TID. Both trays after meals to ensure PO intake of meals and
as evidenced by Kennedy energy needs of 2,400-2,800 provide an additional 1,530 consumption of meals and supplements
Terminal Ulcer and stage III kcal/day kcal/day. Juven used to supplements
pressure injuries of the left support wound healing and Long-term: No new wounds
heel, leg, and right hip. Long-term: Consistent to maintain lead body mass. Long-term: Communicate formed for the duration of
average PO intake of 50- with other healthcare patient’s life
75% professionals about patient’s
wound status
Involuntary weight loss (NC- Short-term: Improve PO Provide Nepro TID to Short-term: Monitor Short-term: Increased average
3.2) related to inadequate PO intake to prevent further provide an additional 1,260 patient’s daily PO intake and PO intake of meals and
intake as evidenced by severe weight loss kcal/day. status of appetite supplements
weight loss of 12% in 3
months. Long-term: Maintain current Long-term: Weigh patient Long-term: Weight
weight with no further loss once a week maintenance for the duration
of patient’s life
 Patient and Family Education
• Discuss increased calorie needs
• Continuing Nepro after dialysis was discontinued
• Use of Juven for wound care
• End of life care
• Staff assistance
• Ensuring comfort
• Quality of life
 Prognosis
• Due to Kennedy Terminal Ulcer, it is unlikely that the patient’s health and
nutritional status will improve
• However, nutritional interventions related to wound healing should remain in
place for the duration of life
• Main goal is to ensure Mr. X’s comfort and quality of life during hospice
 References
1. Roca-Biosca A, Rubio-Rico L, De Molina-Fernández MI, Martinez-Castillo JF, Pancorbo-Hidalgo PL, García-Fernández FP. Kennedy terminal ulcer and other skin wounds at
the end of life: An integrative review. J Tissue Viability. 2021;30(2):178-182. doi:10.1016/j.jtv.2021.02.006

2. Eglseer D, Hödl M, Lohrmann C. Nutritional management of older hospitalised patients with pressure injuries.Int Wound J. 2019;16(1):226-232. doi:10.1111/iwj.13016

3. Karahan A, AAbbasoğlu A, Işık SA, et al. Factors Affecting Wound Healing in Individuals With Pressure Ulcers: A RetrospectiveStudy. Ostomy Wound Manage.
2018;64(2):32-39.

4. Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice
Guideline Recommendations. Adv Skin Wound Care. 2020;33(3):123-136. doi:10.1097/01.ASW.0000653144.90739.ad

5. Nahikian-Nelms M. Nutrition Therapy and Pathophysiology. Australia: Cengage; 2020.

6. Charney P, Malone A. Pocket Guide to Nutrition Assessment. Chicago, IL: Academy of Nutrition and Dietetics; 2021.

7. Weerakkody Y. Anasarca: Radiology Reference Article. Radiopaedia Blog RSS. https://radiopaedia.org/articles/anasarca?lang=us. Published August 12, 2022.