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array:22 [ "pii" => "S2445147922000327" "issn" => "24451479" "doi" => "10.1016/j.enfcle.2022.03.001" "estado" => "S300" "fechaPublicacion" => "2022-07-01" "aid" => "1967" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2022" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Clin. 2022;32:284-90" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemAnterior" => array:18 [ "pii" => "S2445147922000522" "issn" => "24451479" "doi" => "10.1016/j.enfcle.2022.04.004" "estado" => "S300" "fechaPublicacion" => "2022-07-01" "aid" => "1978" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Clin. 2022;32:279-83" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief Original Article</span>" "titulo" => "Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "279" "paginaFinal" => "283" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eficacia de una intervención educativa en el manejo de un dispositivo de inhalación entre profesionales de enfermería de un servicio de emergencias" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Guadalupe Gracia, Vanesa Romina Ruiz, Bernardo Martínez, María Florencia Grande-Ratti, Germán Federico Mayer" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Guadalupe" "apellidos" => "Gracia" ] 1 => array:2 [ "nombre" => "Vanesa Romina" "apellidos" => "Ruiz" ] 2 => array:2 [ "nombre" => "Bernardo" "apellidos" => "Martínez" ] 3 => array:2 [ "nombre" => "María Florencia" "apellidos" => "Grande-Ratti" ] 4 => array:2 [ "nombre" => "Germán Federico" "apellidos" => "Mayer" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445147922000522?idApp=UINPBA00004N" "url" => "/24451479/0000003200000004/v2_202207230603/S2445147922000522/v2_202207230603/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Nursing care</span>" "titulo" => "Nursing care plan for the Kennedy terminal ulcer patient. Case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "284" "paginaFinal" => "290" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Carmen María Alarcón-Alfonso" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Carmen María" "apellidos" => "Alarcón-Alfonso" "email" => array:1 [ 0 => "carmenalarcon23@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Quemados, Departamento Hospital Universitari i Politècnic la Fe, Valencia, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Plan de cuidados de enfermería de una paciente con úlcera terminal de Kennedy. Caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 559 "Ancho" => 900 "Tamanyo" => 70694 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of the ulcer to category IV within 48 h of detection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The concept of Kennedy’s terminal ulcer (KTU) was described by Karen Lou Kennedy in the late 20th century.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is a tissue lesion of sudden onset and rapid progression seen in people before death, usually bedridden.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its aetiology is unknown, although it is associated with a problem of blood hypoperfusion secondary to the dying process, which causes the pressure exerted on the bony prominences to produce lesions in a shorter period of time.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The differential diagnosis of KTU is difficult to establish because of its similarities to pressure ulcers (PU). However, some authors argue that KTU are more superficial in onset and develop more rapidly in both size and depth compared to PUs.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> They also have defining clinical features, appearing mainly on the sacrum or coccyx, as a bilateral ulcer, shaped like a horseshoe or butterfly, with red, purple, yellow or black colourations and irregular borders.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> KTU starts as a category II ulcer or as a blister that will rapidly progress to category III or IV. Patients with KTU are at increased risk of imminent death.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the treatment of this type of ulcer the main objective is not wound healing. Priority is given to other aspects such as patient comfort and pain control, odour management, preventing the appearance of new ulcers, wound care to avoid complications and helping the family to cope with the situation.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is a certain lack of knowledge about this entity in clinical practice, which prevents its correct detection, management and treatment.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> For this reason, the following clinical case is presented of a patient who developed a terminal Kennedy’s ulcer in the context of Home Care provided by Primary Care. The nursing care provided is presented, describing the diagnoses obtained, the interventions planned and the evaluation of the results.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objectives</span><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to develop an individualised care plan for a patient diagnosed with Kennedy’s terminal ulcer.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Méthod: clinical case history</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Specific patient information</span><p id="par0030" class="elsevierStylePara elsevierViewall">81 year old woman, bedridden with multiple pathologies, being monitored by primary care nurses.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Personal history</span><p id="par0035" class="elsevierStylePara elsevierViewall">Medical history: hypertension, type 2 diabetes mellitus and Alzheimer’s disease, diagnosed in 2013, no surgery or other pathologies. No other family and psychosocial history of interest. She lives at home with her daughter, who is her main caregiver, her son-in-law and her grandson.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Her usual medication is Atenolol 50 mg ev./24 h, Metformin 580 mg ev./24 h and Lorazepam 1 mg ev./12 h.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical findings</span><p id="par0045" class="elsevierStylePara elsevierViewall">A general assessment of the patient was carried out according to Marjory Gordon’s Functional Patterns model and an alteration was detected in all the patterns: a bed-ridden patient with total dependence for basic activities of daily living (ADL) according to the result of 0 points obtained with the Barthel index. She had severe cognitive impairment with a score of 2 on the Mini Mental Lobo scale and severe dementia according to the GDS (Global Deterioration Scale). The risk of PU was high, with 9 points on the Braden scale. The patient presented the same clinical situation as described two years ago.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patient with a previous care plan drawn up for the prevention of PUs, with measures applied such as the use of pressure management surfaces (SPMS), implementation of postural changes and protection of bony prominences, development of a diet for nutritional support, as well as education of the main caregiver and other family members for continuity of care.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The health centre received a notification from the patient’s main caregiver because she had observed a sudden onset lesion in the sacral area.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Following the notification, during an initial visit, the PU risk was reassessed, using the Braden scale, obtaining 8 points, which meant that the high risk of PUs recorded in the patient’s history was maintained. The MUST scale was also used, with a score of more than 2, indicating a high risk of malnutrition, which was already known. A skin examination was performed and a lesion was observed in the sacral area, with partial loss of skin thickness, with the appearance of a superficial crater. The lesion was 3 cm long × 4 cm wide, with no cavities or tunnels, an erythemous bed, perilesional border with slight maceration and irregularity, minimal exudate and no signs of infection. The RESVECH 2.0 index was used to monitor the assessment and evolution of the ulcer. In the first measurement with this index a score of 8 out of 35 was obtained: size between 4 and 16 cm<span class="elsevierStyleSup">2</span> (2 points), involvement of the dermis-epidermis (1 point), diffuse borders (1 point), tissue in the wound bed was epithelial (1 point), there was moisture (0 points), increasing pain (1 point), perilesional erythema (1 point) and increasing temperature (1 point).</p><p id="par0065" class="elsevierStylePara elsevierViewall">A diagnosis of category II pressure ulcer was established and a care plan drawn up based on general and local care: indications to the main caregiver to relieve tissue pressure and prevent the appearance of new lesions through postural changes and protection of other risk areas such as the heels using pressure relief devices; nutritional shakes with higher calorie intake were introduced into the patient’s diet according to medical prescription; local wound relief every 48 h with physiological saline solution was prescribed for cleaning, drying, application of INTRASITE® hydrogel and a secondary dressing of Mepilex® BorderSacrum foam.</p><p id="par0070" class="elsevierStylePara elsevierViewall">After 48 h, a second visit was made for treatment and to assess the evolution of the lesion. The ulcer progressed to category IV (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with complete loss of tissue thickness and perilesional skin, the presence of slough and necrotic tissue, the appearance of cavitations, abundant exudate and a foul odour. The depth of the affected tissue could not be established.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In the second RESVECH 2. 0 treatment, wound area between 16 and 36 cm<span class="elsevierStyleSup">2</span> (3 points), muscle involvement (3 points), damaged edges (3 points), necrotic and sloughy tissue (3 points), presence of exudate leakage (3 points), increasing pain (1 point), perilesional erythema (1 point), perilesional skin oedema (1 point), increasing temperature (1 point), increasing exudate (1 point), purulent exudate (1 point), malodour (1 point) and increasing wound size (1 point). The score obtained was 23 points, which shows the progression and poor evolution of the lesion since the first visit and assessment.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The care plan was modified with a change in the wound dressing, using saline cleansing with light pressure to remove necrotic tissue and slough, drying, AQUACEL® Ag + silver dressing and a secondary dressing of Mepilex® BorderSacrum foam. By medical prescription, oral antibiotic therapy with Ciprofloxacin 500 mg every 12 h was started due to suspicion of ulcer infection.</p><p id="par0085" class="elsevierStylePara elsevierViewall">However, given the rapid and poor evolution and the deterioration of the patient’s general condition, the case was discussed with the rest of the nursing team and the diagnosis was changed to Kennedy’s terminal ulcer.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The case was presented to the medical team and the family was informed of the intention to carry out palliative treatment, without curative purposes, given the terminal situation.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Three days later, the patient was transferred to the emergency department of the reference hospital due to respiratory distress, where she died five hours after admission as a result of cardio-respiratory arrest.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Timeline</span><p id="par0100" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="fig0010"></elsevierMultimedia></p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Therapeutic intervention</span><p id="par0105" class="elsevierStylePara elsevierViewall">This section describes the therapeutic interventions carried out, following a care plan drawn up on the basis of the Nursing Diagnoses identified. The NANDA taxonomy has been used for this purpose. In addition, the expected results and the interventions carried out according to NOC and NIC are described, and the individualised care plan is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The online platform NNNconsult<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> was used for its preparation.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Follow-up and results</span><p id="par0110" class="elsevierStylePara elsevierViewall">The results obtained showed that the nursing interventions carried out were consistent with the real and potential problems of both the patient and her environment. The identification of the lesion and its classification as a Kennedy terminal ulcer allowed the development of activities focused on achieving maximum comfort for the patient and a dignified death. At the same time, the necessary information was provided to the family so that they could participate in decision-making and understand the palliative approach presented to them by the healthcare team.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In addition, the whole family was involved in the care of the patient, reducing the burden on the main caregiver. Finally, the patient died without showing signs of pain, in a calm environment and accompanied by her daughter.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Both the staff involved in the patient’s care and the family were satisfied with the care process.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Kennedy’s terminal ulcer is a type of lesion that can be misdiagnosed as a pressure ulcer, which leads to a poor approach to nursing interventions. They are ulcers associated with the dying process, so their correct identification provides the patient and family with the necessary information to be able to make decisions that facilitate a dignified death, limiting the therapeutic effort.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In this case, a correct initial diagnosis was not made. The lack of knowledge of this clinical entity and the difficulty in diagnosing it is an issue recognised in the literature consulted. The reasons for this include the lack of training of healthcare professionals in ulcers other than PUs, the use of different terms (such as skin changes at the end of life or Trombley-Brennan terminal lesion) to name the lesions that appear in patients at the end of life, which is confusing as they are very similar concepts. Furthermore, information on the aetiology and pathophysiology of KTU is incomplete, and there are no unified diagnostic criteria.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7,9</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Another topic of discussion is whether these ulcers are preventable or not, i.e. whether their occurrence can be prevented. A prevention strategy similar to that of PUs is recommended with the main objective of reducing pressure and friction on bony prominences. To this end, postural changes every 2 h if tolerated, keeping the skin dry and clean, use of pressure relieving devices such as dressings or SPMS9 are recommended. Despite all these measures, KTU can occur due to the patient’s clinical condition and non-modifiable risk factors.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Therefore, an assessment and evaluation of the person’s situation and an individualised care plan with ongoing monitoring and review must be in place before this or any other ulcer can be considered unavoidable.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The therapeutic approach to KTUs should include emotional support and counselling. Carers and families may feel that these ulcers have arisen as a result of medical negligence or inadequate care on their part. This creates feelings of guilt or mistrust. The possibility of imminent death should be explained to both the patient and family members, which facilitates the making of last wishes, improves the subsequent grieving process by allowing them to say goodbye to their loved one, and facilitates proper care planning. Effective pain management should be carried out to help improve the patient’s comfort.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In this case, the ulcer was treated conservatively, without the use of debridement techniques, prioritising good control of pain, odour and exudates.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The family was informed of the poor prognosis, which facilitated decision-making.</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Strengths and limitations</span><p id="par0155" class="elsevierStylePara elsevierViewall">Among the main limitations, it should be noted that it was not possible to reach a consensus with the patient on the interventions to be carried out due to her cognitive impairment. Nor was it possible to evaluate in depth the impact of the care plan developed due to her rapid death. As a strength, it should be noted that this clinical case provides information on the care to be provided in KTU. Given that this type of lesion is unfamiliar to many healthcare professionals, this case may help to improve the diagnosis and management of KTU.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0160" class="elsevierStylePara elsevierViewall">The development of the care plan for the patient with Kennedy’s terminal ulcer made it possible to define realistic objectives, limit the therapeutic effort, focus interventions on pain management, patient comfort, dignified death and support for the family.</p><p id="par0165" class="elsevierStylePara elsevierViewall">This clinical case highlights the need to increase the training of nursing staff and other health professionals in this type of lesions, allowing the development of care plans that favour the correct care of patients.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financing</span><p id="par0170" class="elsevierStylePara elsevierViewall">No funding was required for this study.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical considerations</span><p id="par0175" class="elsevierStylePara elsevierViewall">The image was taken with the consent of the family.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1750057" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1541518" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1750056" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1541519" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objectives" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Méthod: clinical case history" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Specific patient information" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Personal history" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical findings" ] ] ] 7 => array:3 [ "identificador" => "sec0035" "titulo" => "Timeline" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Therapeutic intervention" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Follow-up and results" ] ] ] 8 => array:3 [ "identificador" => "sec0050" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Strengths and limitations" ] ] ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Financing" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Ethical considerations" ] 12 => array:2 [ "identificador" => "xack618188" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-05-29" "fechaAceptado" => "2022-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1541518" "palabras" => array:5 [ 0 => "Kennedy terminal ulcer" 1 => "Palliative care" 2 => "Pressure ulcer" 3 => "Nursing care" 4 => "Case reports" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1541519" "palabras" => array:5 [ 0 => "Úlcera terminal de Kennedy" 1 => "Cuidados paliativos" 2 => "Úlceras por presión" 3 => "Cuidados de enfermería" 4 => "Caso clínico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We present the clinical case report of an 81-year-old bedridden woman with severe cognitive impairment, who initially presented with a category II pressure ulcer in the sacral region. At 48 h, progression to a category IV ulcer was observed. Given the rapid evolution, the characteristics of the lesion and the patient’s condition, a diagnosis of terminal Kennedy ulcer was established. In consensus with the family, a conservative approach was adopted, and the therapeutic effort was limited due to the irreversibility situation. Three days later, the patient died of respiratory failure.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The care plan is developed based on Marjory Gordon’s assessment by patterns, allowing the identification of the patient’s problems, setting realistic outcomes (NOC) and developing nursing interventions (NIC) that lead to a dignified death.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se presenta el caso clínico de una mujer de 81 años con deterioro cognitivo severo y encamada, que presenta inicialmente lesión tipo úlcera por presión de categoría II en región sacra. A las 48 horas, se observa progresión a úlcera de categoría IV. Dada la rápida evolución, las características de la lesión y el estado de la paciente, se establece el diagnóstico de úlcera terminal de Kennedy. En consenso con la familia se realiza un abordaje conservador y se limita el esfuerzo terapéutico debido a la situación de irreversibilidad. Tres días después, la paciente fallece a causa de una insuficiencia respiratoria.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El plan de cuidados se elabora a partir de la valoración por patrones de Marjory Gordon, permitiendo identificar los problemas de la paciente, trazar objetivos (NOC) realistas y desarrollar intervenciones de enfermería (NIC) que conduzcan a una muerte digna.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alarcón-Alfonso CM. Plan de cuidados de enfermería de una paciente con úlcera terminal de Kennedy. Caso clínico. Enferm Clin. 2022;32:284–290.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 559 "Ancho" => 900 "Tamanyo" => 70694 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of the ulcer to category IV within 48 h of detection.</p>" ] ] 1 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: own creation." "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nursing diagnoses (NANDA) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nursing outcomes (NOC) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nursing interventions (NIC) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Impaired skin integrity (00046)</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1001 tissue integrity skin and mucous membranes:</span>110113 skin integrity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">740 bedridden patient care:</span> positioning the patient with correct body alignment, keeping bed linen clean and dry. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1004 nutritional status:</span>100401 nutrient intake, 100402 food intake:</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">3660 wound care:</span> Perform daily wound care. Guideline: cleanse wound with saline, apply silver-impregnated activated charcoal antimicrobial dressing for odour and infection control, polyurethane dressing with silicone coating for exudate management and secondary adhesive dressing for occlusion. Apply zinc oxide barrier cream to protect perilesional skin. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">2316. Medication administration:</span> topical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Acute pain (00132)</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1605 pain control:</span> 160508 uses available resources, 160511 refers to controlled pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">11400 pain management:</span> pain assessment <span class="elsevierStyleItalic">with Pain Assessment in Advanced Dementia scale,</span> explain to the caregiver the prescribed analgesia guidelines and use of rescues, and teach how to recognise signs of pain in the patient. Assess efficacy of analgesia according to objective indicators (agitation, breathing, grimacing).</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">2102 level of pain:</span> 210206 facial expressions of pain, 210221 rubbing the affected area, 210222 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Willingness to improve comfort (00183)</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1214 level of agitation:</span> 121402 restlessness, 121414 clinging trying to remove dressing. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">3540 pressure ulcer prevention:</span> assess the risk of developing pressure ulcers with the Braden scale. A score of 6 is obtained with a result of high risk. Apply postural changes and reduce pressure on bony prominences by means of offloading (heel pads, hydrocolloid dressings or pillows). Application of hyperoxygenated fatty acids in risk areas where the skin is intact. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1307 dignified death:</span> 130716 gradually disconnects from significant others.</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">6482 environmental comfort management:</span> use air fresheners to reduce possible unpleasant odours and use soothing music to create an atmosphere that favours tranquillity. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">5260 agony care:</span> encourage the family to be close to the patient and to accompany her in the final process. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Willingness to improve family coping (00075)</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1300 acceptance of health status:</span> 130010 coping with health situation by the family \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">5270 emotional support</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">1302 coping with problems:</span> 130205 verbalises acceptance of the situation, 130212 uses effective coping strategies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">5290 bereavement support:</span> explain to the family the possible death of the patient during the hospital stay and invite them to express their feelings and say goodbye to the patient before the transfer, since by Covid-19 regulations there could only be one companion in the room. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Willingness to improve decision making (00184)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0906 decision making: 090602 identifies alternatives, 090609 chooses among several alternatives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">5250 decision support:</span> informing the family of the patient’s condition in a clear and concise manner, presenting the therapeutic options and identifying the advantages and disadvantages of each. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Risk of caregiver burnout (00062)</span></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2508 well-being of primary caregiver: <span class="elsevierStyleItalic">250811 family shares caregiving responsibilities, 250812 availability of breaks</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">7040 support for the main caregiver:</span> involve other family members in the care of the patient. Encourage the caregiver to engage in leisure activities to improve stress levels. Telephone consultations to form a support system.</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2203 alterations in family caregiver’s lifestyle: <span class="elsevierStyleItalic">220309 productivity at work</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Individualised care plan.</p>" ] ] 2 => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 2646 "Ancho" => 2508 "Tamanyo" => 628558 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Poliulceración en paciente terminal: úlceras de Kennedy. 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To my mother and brother for their unconditional support.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24451479/0000003200000004/v2_202207230603/S2445147922000327/v2_202207230603/en/main.assets" "Apartado" => array:4 [ "identificador" => "63168" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Nursing care" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24451479/0000003200000004/v2_202207230603/S2445147922000327/v2_202207230603/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445147922000327?idApp=UINPBA00004N" ]
