ISOFLEX® CASE STUDY Autumn View Nursing HomeMary Ann Huber, RN, ADON

On June 28th a ninety-five year old female resident, Mrs. O. E., was re-admitted to our extended care facility following a brief stayin the local hospital. In 1998, at the time of her initial admission to our facility, her primary diagnosis was severe arterial occlusivedisease. Her vascular condition precipitated an above the knee amputation of her right lower extremity on June 11th 1999. Upon re-admission to us, her skin assessment revealed an unstageable sacral pressure ulcer. Her other medical history is significant foranemia, osteoarthritis, hypertension and chronic obstructive pulmonary disease.

According to our pressure ulcer prevention protocol, we completed a Braden Scale for risk assessment at the time of re-admission.Mrs. O. E. was found to score fourteen. In our resident population, we have designated a threshold often as high risk. At that time,she was placed on our mattress replacement support surface. Since Mrs. O. E. spent approximately four hours out of bed in the chaireach day, she was also provided with a gel chair cushion.

A nutritional consult was ordered, due to a low albumin level of 2.7. Dietary recommendations for a high protein diet wereimplemented because nutrition plays such a vital role in wound healing. Mrs. O. E. also received weekly Vitamin B12 injectionsand daily oral iron supplements.

Within our institution, wound assessments are documented weekly on our standardized skin integrity forms. On June 28t\ the

unstageable sacral pressure ulcer measured 6.4 em X 3.6 em and was covered with yellow/gray eschar. Periwound skin waserythemic. We began topical therapy with Normal Saline cleansings, application of Cleocin T Gel every 4 hours with dry steriledressing. Within three weeks the eschar was lifting at the edges and there was evidence of granulation tissue at the wound edges.By July 20th the surface area of the wound bed measured 3.8 ern X 3.0 ern with clear demarcation of eschar 2.5 em X 2.0 cm.

On August io", six weeks into treatment, the entire wound bed measured 2.5 em X 2.0 cm. Since the eschar had softened andsloughed, we could now measure a depth of 0.4 ern and we determined the wound bed to be a Stage III. We continued with theCleocin T Gel applications, but we changed Mrs. O. E. 's support surface to the ISOFLEX pressure and shear management system.

By August 31st, the wound bed measured 2.0 em X 1.4 ern, the necrotic tissue had sloughed and become stringy and was veryloosely attached. The base of the wound bed was pink with granulation tissue. By September io-, the wound bed was clean withpale pink granulation tissue, no odor and minimal serous drainage. Throughout the next month, the wound continued to decrease insize with epithelialization occurring and contraction of the wound edges. On November 2od

, the wound had progressed to a smalldenuded area measuring 0.3 em X 0.4 ern. No further drainage was noted and no odor or inflammation was present.

A comprehensive pressure ulcer treatment plan was successful in promoting progress to healing of this sacral wound. We kept Mrs.O. E. on her lSOFLEX pressure and shear management system until complete resurfacing of her sacral wound on November 23rd.A pressure ulcer does not heal in isolation. Addressing the needs of the compromised individual who is at risk for pressure ulcerdevelopment or who already has an existing pressure ulcer includes meticulous skin care, nutritional supplementation and pressureand shear management. All components of the plan, including pressure and shear management must be addressed to promotepositive outcomes.

GAYMAR"

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GAYMAR INDUSTRIES. INC.10 Centre DriveOrchard Park, NY 14127-2295

©2000. Gaymar Industries Inc.MAW4599

Natalie Turner, RNGowanda Nursing HomeGowanda, New York

ISOFLEX® Case Study

Mrs. S., an 81 year-old white female,was admitted to the GowandaNursing Home, Gowanda, New

York, on 12/03/99 for a rehabilitation stay,status post a light displaced subcapital femoralneck fracture. The patient had an insertion ofa bipolar hemiarthroplasty of the right hip on11128/99. During surgery, the patient wastransfused with packed red blood cells due tolow hemoglobin. Other diagnoses includecoronary artery disease, hyperlipidemia,urinary incontinence, degenerative arthritis,and hypertension. Current medicationsinclude Zocor", Fosamax", CalciumCarbonate, Methotrexate, and Darvocet" asneeded for pain. Upon admission to thenursing home, the patient was placed on arestorative physical and occupational therapyprogram, with future plans to return home.

The patient was considered high risk forpressure ulcer development due to occasionalurinary and bowel incontinence, decreasedmobility, and poor nutritional intake. Thepatient only consumed 25-40% of her meals,meeting less than her daily body requirements.The patient had experienced a 4 lb. weightloss during the week of hospitalization. Uponadmission to the nursing home, her weightwas 116.5 lbs. (52.95 kg) with a height of 5feet 4 inches. Following a nutritionalassessment, the dietician recommended thatMrs. S. receive TwoCal'!; HN dietarysupplements and Forta" Shakes on a dailybasis.

At the time of admission the patient's skin wasdocumented as intact. On ]2/07/99, twosuperficial open areas were noted on thepatient's left buttock region and a third areawas noted on the coccyx. Dermagram sprayand ointment treatment was started and a gelcushion was applied to her wheelchair. Thesuperficial open areas had progressed to StageIII pressure areas within one week. Thepressure areas remained clean and free fromdrainage. Several topical treatments wereimplemented without success. On 12!l9/99the treatment was changed back toDermagram spray and ointment, protected bya 2x2 gauze and an Opsite dressing.

On 12/23/99, Mrs. S. was placed on anISOFLEX mattress. At this time, theleft upper buttock (outer) pressure

area measured 0.7 ern x 0.4 em, with a 0.1 cmdepth noted. The left upper buttock (inner)pressure area measured 1.7 em x 1 em, with a

depth of 0.2 ern noted. The coccyx areameasured I cm x 0.5 em, The center of theulcers contained a yellowish matter, and thewound edges were slightly reddened with aminimal amount of granulation tissue noted.The pressure areas were monitored on aweekly basis and every week improvementwas noted. On 1113/00, the coccyx pressurearea was completely resurfaced and scartissue was noted at the site. On 1119/00, theleft upper buttock (outer) pressure area wasnoted to be resolved and on 1/27/00, theupper buttock (inner) area was resurfacedwith only slight erythema noted at the site.The ISOFLEX mattress was removed fromthe patient's bed on 2/1/00. All areasremained resurfaced at this point.

The patient stated that the ISO FLEXmattress was comfortable and alsohelped her back pain. The staff was

impressed with the rate of the healingprocess upon the initiation of the ISOFLEXmattress.

CONCLUSIONThe patient's decreased mobility, urinary andbowel incontinence, poor nutritional status,and medical diagnoses constituted her as aprime candidate for pressure ulcerdevelopment. When the pressure areas were

. discovered, treatment was implemented.The ulcers required ongoing treatmentevaluation due to the deterioration of thewounds. It was at the point when theISOFLEX mattress was introduced thatprogress to healing was noted. Weeklyimprovement evidenced by decreaseddimensions and wound resurfacing wasnoted with the ISOFLEX mattress as andintricate part of the treatment plan. Thepatient's mobility improved on a daily basiswith restorative therapy. The nursing staffmonitored the patient on a daily basis toensure repositioning every two hours and thedietary staff closely monitored the intakeand the weight ofthe patient. With all thetreatment modalities in place, the outcomewas positive for both the patient and thestaff.

GAVMAR"

GAYMAR INDUSTRIES, INC.

10 Centre DriveOrchard Park, NY 14127

1 800 828-7341www.gaymar.com

MAW4568©2000. Gaymar Industries, Inc.

Valerie Ryan, RN, CWOCNLevindaleBaltimore, Maryland

ISOFLEX@:A Case Study

Ms.A.B., a resident in along-term care facility,has been with us since

early in 1998. Although shepresented with a myriad of medicalproblems including IDDM, ASeVD,multiple eVA's, progressivedementia as well as a total hipreplacement, she stablized at thetime of admission. She was admittedto the sub-acute unit forrehabilitation, but over time she didnot respond well and sheprogressively became chair bound.Her admission skin assessmentrevealed Stage I pressure ulcers ofboth heels, a Stage II pressure ulceron her trochanter and evidence ofseveral healed wounds on hersacrum. The trochanteric ulcer wenton to resurface.

Though her Norton Scale reflected amoderate risk, the fact that she has aprevious history of ulcerspredisposed her to further sacralbreakdown.

In October, 2000 she experienceddifficulty in swallowing whichnecessitated a G.T. placement forcontinuous tube feedings. Herhealth continued to decline with aUTI and C. difficile for which shewas given Flagyl. On December 5,2000, two Stage III pressure ulcersof the sacrum were documentedmeasuring 2x2 and lxl. Althoughsmall in circumference, the woundsdid have necrotic tissue. Hervulnerable sacrum, the site ofprevious breakdown was showing

the effects of pressure and shear.Recidivism is high in patients withhistory of previous pressuredamage. She was immediatelyplaced on a pressure-reducingoverlay, the Acucair", along withother pressure reducing devices,cushion and boots.

Her tube feedings continued anddespite a pre-albumin of 28.3 shedeveloped an additional Stage IIpressure ulcer of her heel (2xl.5)in January, 2001. While her heelulcer resolved, frequent episodes ofe. difficile made the healing on hersacral ulcers difficult. The ulcerswould rotate through cycles of re-surfacing and opening.

On March 5, she wastransferred from thepressure reducing overlay

to the ISOFLEX® Pressure andShear Management System. Hersacral Stage III pressure ulcersresolved within one week and sheremained stable despite repeatedepisodes of diarrhea and decreasedresponsiveness. The sacral arearemains intact two monthsfollowing placement on theISOFLEX.

GAVMAR"

GAYMAR INDUSTRIES. INC.

10 Centre DriveOrchard Park. NY 14127

1 800 828-7341www.gaymar.com

MAW4997©2001. Gaymar Industries. Inc.

Diane Gronwell, RNMcAulley ResidenceWestern New York

ISOFLEX® Pressure and ShearManagement Support Surface

Mrs.s. is a 77 year oldwoman admitted to a longterm care facility in

Western New York, weighing 114lbs. with a height of 5' 1". Prior to heradmission she had been hospitalizedwith a history of falls. Other medicalhistory included atrial fibrillation,osteoarthritis, osteoporosis,depression, anemia, history of coloncancer, and pilonidal disease.

On April 20, her admission date, itwas noted that Mrs. S. had a StageIII pressure ulcer at the scar site of apilonidal cyst that had been removedat age 17. It measured 2cm long andlcm wide with a depth of 1cm. Thepressure ulcer had no drainage orodor but had some yellow slough.She was placed on a standardhospital mattress, and Intrasite GelBID was ordered. Generally, she haddry skin and multiple ecchymoticareas. She remained in bed 20 to 22hours a day due to back pain and wasout of bed only for meals andPhysical Therapy. Pain was managedwith Lortabs pm and then Vicodinpm. She was able to repositionherself every two hours. With theexception of some stressincontinence, she was continent ofbowel and bladder.

Her risk factors for pressure ulcersincluded poor nutritional intake, analbumin level of 2.9, systemicsteroids, anemia, and a Vitamin BJ 2

deficiency. She was on a regular,NAS diet along with supplementswith and between meals. Multiplevitamins were given daily.

On May 17, the area measured 1.6cmx 0.7cm with a depth ofO.2cm.There was still a small amount of

slough noted in the center of thewound. On May 20, she wasplaced on an ISOFLEX Pressureand Shear Management SupportMattress. In a three week period oftime, the wound measured 0.6cm x0.3cm and had a depth ofO.2cm.Staff reported pink granulationtissue in the wound.

On June 23, she was removed fromthe ISOFLEX Pressure and ShearManagement Support Mattress andadmitted to the hospital fortreatment of atrial fibrillation. Shereturned to the long term carefacility on June 29 and it was notedthat the pressure ulcer hadincreased in length to 0.8cm. Thewidth and depth were unchanged,however the wound again hadslough tissue in the center.

There was no odor ordrainage. She was returnedto the ISO FLEX Pressureand Shear Management

Support Mattress and Intrasite Get'"BID was also reordered. By July 9the pressure ulcer had improved to0.6cm X O.lcm and a depth of 0.1em. The following week it wasdocumented in the chart as a 0.2cm"slit" and on July 20 the pressureulcer was closed. The residentremained on the ISOFLEXPressure and Shear ManagementSupport Surface because she felther back pain was improved withthis mattress since she spent a greatdeal of her day in bed.

On July 27 she was removed fromthe ISOFLEX Pressure and ShearManagement Support Mattress andadmitted to the hospital for nine

days. She retumed on August 4, withthe pressure ulcer open again. Thepressure ulcer now measured 1.7emx O.5cm and a depth ofO.1cm. Theupper wound bed had soft yellowslough and the lower wound bed hadpink granulating tissue. She wasreturned to the ISOFLEX Pressureand Shear Management SupportMattress and Intrasite GelJil BID wasalso reordered. On August 10 thewound measured 1.4cm x O.2cm anda depth ofO.lcm with pinkgranulating tissue. On August 24, itwas closed.

CONCLUSIONThis resident's poor nutritionalstatus, use of systemic steroids, andimmobility made her a poorcandidate for healing. The use of theISOFLEX Pressure and ShearManagement Support Mattress alongwith attentive nursing carecontributed to the positive outcomefor this resident. The opening andclosing of this wound had a directcorrelation between being placed onthe ISOFLEX Pressure and ShearManagement Support Mattress andbeing removed from it.

Treatment Date Range Episode Ulcer Dimensions MeasurementEpisode of Episode Duration Length Width Depth Date

Measurement 1.6 em 0.7 em 0.2 em 5/17/99Prior to ISOFLEX

On ISOFLEX 5/20/99 to 34 days 0.6 em 0.3 em 0.2 em 6/10/996/23/99

Hospitalized 6/23/99 to 6 days(Off ISOFLEX) 6/29/99

6/29/99 to 0.8 em 0.3 em 0.2 em 6/29/99On ISOFLEX 28 days 0.1 em 7/9/997/27/99 0.6 em Ulcer is closed 0.1 em 7/20/99

Hospitalized 7/27/99 to 8 days(Off ISOFLEX) 8/4/99

8/4/99 to 1.7 em 0.5 em 0.1 em 8/4/99On ISOFLEX 20 days 0.2 em 8/10/998/24/99 1.4 em

Ulcer is closed 0.1 em 8/24/99

I GAVMAR" IGAYMAR INDUSTRIES. INC.10 Centre DriveOrchard Park, NY 14127·2295Phone: 1 800828·7341

(716) 662·2551FAX: 1 800993·7890

(716) 662·0748www.gaymar.comMAW4410©1999. Gaymar Industries, Inc.

Effective Treatment: Stage III Pressure UlcerUsing ISOFLE~, a Non-powered Support SuraDonna McMullen RN CWOCN, E.T. Consultants, Inc., Clarksburg, MDThis study was presented at WOCN Conference, 2003

A 78-year-old male was admitted to a long-termcare facility. His medical history included a CVAwith left-sided hemiplegia. He was considered athigh risk for developing a pressure ulcer.

He had:• a Braden score of 13• a Stage I pressure ulcer on left lateral upper back

Initial treatment included facility protocol:• Thick foam mattress / positioning• Nutrition consultation• Appropriate wound treatment

Day 5 the following changes were noted:• Progressed to a Stage III• 100% slough• Switched to ISOFLEX®• Treatment changed to address the slough

Day 12:• Wound decreased in size• 100% granular• Treatment changed to address granulation

Day 19:• Wound closed

Conclusion:Application of the ISOFLEX was clearlyinstrumental in resolving this pressureulcer so quickly.• Resident verbalized comfort on the

ISOFLEX as compared to the previousmattress with easier transfer towheelchair due to the firmer support

• Resident refused to change back tothe facility mattress

• There was a 72% cost savings usingthe ISOFLEX.

ISOFLEX is a registered trademark of Gaymar Industries, Inc.

BIBLIOGRAPHY:• Pressure Ulcer Treatment, Clinical Practice Guidelines Number 15. U.S. Department of Health and

Human Services Public Health Service. Agency for Health Care Policy and Research. Rockville,Maryland. AHCPR Publication No. 95-0653 December 1994

• Bennett L. Kavner D. Lee B, Trainor F. Shear vs. pressure as causative factors in skin blood flowocclusion. Arch. Phys. Med. Rehab. 1979; 60:309-314.

• Rodheaver GT, Stotts NA. Methods for assessing change in pressure ulcer status. Advances in WoundCare 1995; 8:34-6.

MAW5450©2003. Gaymar Industries, Inc.

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Clinical Effectiveness of ISOFLEX*in theTreatment of a Patient with Multiple WoundsRose Marie Boroch, RN EDDCWOCN,E.T.Consultants, Inc., Silver Spring, MDThis study was presented at SAWC 2003, WOCN Conference 2003 and Clinical Symposium 2003

Ms. S'I an 81-year-old women.returned from the hospital withcomfort care orders only.

She had:• a Braden score of 10• a Stage III sacral pressure ulcer with 100% yellow

slough• a Stasis ulcer on right calf• a Stage" pressure ulcer on the right heel

Initial treatment included:• Facility specific wound treatment protocol, including

turning and repositioning• Nutritional consultant• Removal of the standard facility foam mattress and

placement on ISOFLEX

Day 21 the following changes were noted:• All wounds decreased in size• Sacral ulcer had 85% thin yellow slough• Heel ulcer had 100% granular tissue• Right calf was covered with 100% epithelial tissue

Day 36:• Sacral wound decreased in size and 100% granular• Heel wound covered with epithelial tissue• Calf wound remained intact

Day 49:• Sacral wound new epithelial tissue• Heel and calf wounds remained intact

ISOFLEX" Pressure Ulcer Management Support Surface.ISOFLEXis a registered trademark of Gaymar Industries, Inc.

MAW5418©2003. Gaymar Inudstries, Inc.

Conclusion:Of significance, this patienthealed with multiple woundsin different locations and apoor prognosis for healing.

The protocol at this long-termfacility required the rental of alow-air-Ioss mattress. Therewas a 72% cost savingsusing the ISOFLEX.