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Saturday, September 21, 2013

Sight, Smell, Texture, & Feeling

DIETETIC INTERNSHIP: Weeks 24 - 25 (of 41)
Spinal Cord Injury: Weeks 24 & 25
The Spinal Cord Injury (SCI) population is a very unique group that ranges from tetraplegia (formerly known as quadriplegia) to paraplegia, with various stages of injury severity (complete v. incomplete) and mobility.  For example, an incomplete tetraplegic patient may walk with a cane or walker, but a complete paraplegia may not be able to turn him/herself in the bed, nor sit up.  Much of this has to do with injury severity.

I spent two weeks working with inpatient and outpatient SCI patients.  VA SCI individuals are frequently inpatient for extremely long durations; I visited with patients that had been inpatient for over 6 months or more!  Many SCI patients are quite healthy in mind, but uncooperative in body.  The injuries that resulted in SCI are far ranging, from a 32 year old enlisted officer that went butt over teakettle while mountain biking, to an older man that fell out of the top bunk of his prison bed.  One can only imagine that compliance to medication, which includes nutrition, is just as varied.  With some near complete immobility, nutrition is the #1 form of medicine… or the #1 form of disease.  

The most common issues are constipation (bad diet + loss of movement and musculature to stimulate peristalsis), hypertension (bad diet), hyperlipidemia (bad diet), diabetes (bad diet, no physical activity), overweight/obesity (bad diet, no physical activity), and pressure ulcers (lying in one position without turning/lack of movement, and significantly increased protein needs for wound healing).

I performed a lot of education to patients regarding all of these issues.  Because of the commonality and severity of the last relentless concern, pressure ulcers, and the nutrition ramifications, I went on Wound Rounds with the Ostomy/Wound Nurse ~4 x week , helping him/her with measurements and recording data.   Wounds are cleaned, measured, staged, and assessed for healing or progression.  Pressure ulcers are a REALLY BIG problem in this population due to immobility and reliance on others for frequent turning, bathing, cleaning, and friction issues.  Essentially, a pressure ulcer can begin to hatch in about 2 hours, and can lead to devastating consequences; this is why most hospitals have protocols for turning patients every 2 hours.

As you might imagine, immobile patients are often lying on their backs, and consequently sacral (lower back) and ischial (“sit bones”) areas receive a lot of constant pressure.  These areas are the most susceptible to pressure ulcers, as are the heels of the feet (lying on the bed, too).  Wounds require a significant amount of additional dietary protein for adequate wound healing, which is where the Registered Dietitian plays a big role: calculating appropriate protein needs for wound patients, providing an adequate quantity on their meal trays and snacks, and counseling patients on why they should consume it, as well as adequate supplemental fluids to metabolize the extra protein.  All of this can be particularly challenging for patients that are ill with poor appetites, have nausea symptoms, and/or cannot feed themselves due to injury severity.  In addition, protein can be provided in several forms to meet needs (meat entrees, beverage supplements, and protein powders), which increases difficulty with compliance, i.e. consuming adequately.

Wounds have several complications that affect our senses:  Sight, Smell, Texture, Feeling.  Here is my Wound Rounds perspective:

As stated, many wounds are on the lower back and buttocks.  This means to access, clean, and measure the wound, the patient must be on his/her side and undressed (It’s a hospital, everyone is wearing fanny-baring gowns!).  At the VA, this means that it is mostly men laying on their side, with full manhood on display:  scrotum, penis, and anus.  Oh yay!  Right, let’s not forget about the wound.  I don’t even know where to begin.  A wound that appears to only have a quarter-size opening can literally host a CAVE under the skin.  This is called undermining, which is measured to understand size and severity.  Sometimes the wound edges and surrounding skin is pink, sometimes white, sometimes bright red.  Always noticeable.  Some of the wounds are *enormous*, larger than the size of one’s hand, and deeper than several inches all the way to the bone/spinal cord.

Have you ever had a bad wound?  What about one that got infected?  Have you smelled it?  It is stomach-turning disgusting.  Wounds of these magnitudes, particularly with significant undermining, are bound to become infected.  During Wound Rounds, the Nurse handed me a pen light and asked me to look up into the wound and report what I saw.  After pressing a man’s buttocks up and around so that I could see the depth of the wound, and examining its internal characteristics, one is bound to be very, very close.  So close that every smell is apparent.  So close that one must consciously hold back the desire to gag at the smell.  And sight.  Unfortunately, it is not necessary to be close to a wound to smell it.  If a patient has a “wound vacuum” on the wound, the entire room smells revolting, which magnifies as you approach the patient bed.  Try interviewing and charting on that patient weekly!

I already talked about undermining.  Now measure it.  How?  Take a long q-tip, you know, the ones that are about 12” long with a cotton swab on only one end?  Put it inside the wound, and poke/slide it around.  Those were my instructions before I did it the first time.  What surprised me was the softness of the tissue.  I barely had to move the q-tip to different areas as I felt it slide over the yielding tissue, pressing gently to find the deepest part of the hidden area.  My first wound had an opening of less than 1” across, but was more than 2.5” deep!

Here’s the thing (thank goodness), these Spinal Cord Injury patients don’t feel any of this palpation.  They don’t feel the wound.  There is minimal to frequently NO feeling below the injury point.  Thank goodness gracious.  I cannot imagine the pain that would accompany these wounds.  Or the associated sometimes required surgery.

Are you ready for Wounds Rounds now?!  Every detail of severity increases the nutritional ramifications associated with healing.  Be thankful for healthy, pressure ulcer-free skin!

I would rather regret the things that I have done than the things that I have not.
Lucille Ball

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