Roca-Biosca A, Rubio-Rico L, Velasco-Guillen MC, Anguera-Saperas L, et al.
Enfermeria intensiva. Date of publication 2016 Jan 1;volume 27(4):168-172.
1. Enferm Intensiva. 2016 Oct - Dec;27(4):168-172. doi: 10.1016/j.enfi.2016.03.002.
Epub 2016 May 21.
[The adapting of a care plan after Kennedy terminal ulcer diagnosis].
[Article in Spanish]
Roca-Biosca A(1), Rubio-Rico L(2), Velasco-Guillen MC(3), Anguera-Saperas L(4).
Author information:
(1)Universidad Rovira i Virgili, Departamento de Enfermería, Tarragona, España.
Electronic address: alba.roca@urv.cat.
(2)Universidad Rovira i Virgili, Departamento de Enfermería, Tarragona, España.
(3)Hospital Universitari Joan XXIII de Tarragona, Servicio de Medicina Intensiva,
Tarragona, España.
(4)Hospital Universitari Joan XXIII de Tarragona, Unidad de Acogida
Prequirúrgica, Tarragona, España.
Comment in
Enferm Intensiva. 2017 Jul - Sep;28(3):135-136.
A 69 year old man was admitted to the Intensive Care Unit (ICU) from the
Emergency Department due to severe respiratory failure. Due to unsuccessful
non-invasive mechanical ventilation, endotracheal intubation was performed. A
category I ulcer in coccyx was detected 48h after admission. Eight hours later, a
double erythema (the second one darker than the first one) with displacement
between 30-45° over the bony prominence suggested there was a deep tissue injury.
The lesion progressed rapidly during the next 24h. The shape and the rapid
evolution of the injury lead us to diagnose a Kennedy terminal ulcer (KTU). At
72h after the admission, and once the causes of acute decompensation were ruled
out, limitation of life-sustaining treatment was decided. An individualised plan
of care was drawn up with the aim of identifying problems in a patient with KTU
evolving from a critical to a terminal situation. Our overall objectives (NOC)
were to adapt the care plan based on a realistic approach. Nursing interventions
(NIC) included actions such as pain management, conservative treatment of the
injury, agony care and support to help the family to make decisions.CONCLUSION:
The diagnosis of KTU helped the health care team in the decision-making process
when they considered limiting the life support, as well as in the adapting of the
care plan to the actual situation.
Copyright © 2016 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
DOI: 10.1016/j.enfi.2016.03.002
PMID: 27221551 [Indexed for MEDLINE]
