KTU

What is a Kennedy Terminal Ulcer?

A Kennedy Terminal Ulcer is a pressure ulcer some people get as they are dying.

What does a Kennedy Terminal Ulcer look like?

It is can be shaped like a pear.

It is usually on the sacrum.

It can have the colors of red, yellow and black.

The borders of the ulcer are usually irregular.

It has a sudden onset.

The statement you will usually hear is one of the following:

1 “Oh, my gosh, that was not there yesterday.”

2 “I worked Friday, it was not there then, I was off the weekend and when I came back on Monday there it was.

How does a Kennedy Terminal Ulcer progress?

It usually starts out as a blister or a Stage II and rapidly progresses to a Stage III or a Stage IV. In the beginning it almost looks like someone took the patient and put them on a black top driveway and drug their bottom along it. It looks sometimes much like an abrasion. It becomes deeper and starts to turn colors. The colors as a rule start out as a red area then turn to yellow and then black.

How are these different than other pressure ulcers?

They start out larger than other pressure ulcers, are usually more superficial initially and develop rapidly in size and depth.

What kind of treatment is best for a Kennedy Terminal Ulcer?

The treatment for a Kennedy Terminal Ulcer is the same as if would be for any other pressure ulcer. What you see is what you treat. When it is in the blanchable or non blanchable intact skin stage all you need to do is relieve the pressure. When it becomes a Stage II or a partial thickness ulcer a thin film, hydrocolloid, foam or gel could be used. When it is a full thickness wound, Stage III or IV depending on the amount of drainage you could use a hydrocolloid, foam, gel, or calcium alginate if it had a lot of drainage. Usually, these do not have a lot of drainage. If there is slough (yellow tissue) or necrotic tissue (black tissue) you might want to consider a debridement method such as an enzymatic debriding agent, autolytic debridement method (thin film, hydrocolloid) or mechanical debridement method (wet to dry).

What causes a Kennedy Terminal Ulcer?

Further research needs to be done on this subject. However, one idea is it may be a blood perfusion problem exacerbated by the dying process. The skin is an organ, just like the heart, kidneys, lungs and liver. It happens to be the largest of the body organs and is the only one that is on the outside of the body and can reflect what is going on inside the human body. One idea is that as people are approaching the dying process the internal organs may begin to slow down and go into what is thought of as multi-organ failure. This is where all the organs start to slow down and not function as efficiently as previously. No particular symptomatology may be detected except that the skin over bony prominences starts to show effect of pressure in a very short amount of time. Where as turning a patient every two hours may be enough in somewhat of a normal situation it now may cause superficial tissue damage.

Can a Kennedy Terminal Ulcer get better?

Yes, and no.

The majority of them do not. It is something that is generally thought to be terminal. However, it has been known for a patient that was terminal or at the end of life and the patient or family decided they did want intravenous or tube feeding intervention along with other appropriate modalities to change their mind and decide they did want all available interventions. At that point I have known of patients to have this phenomena reversed.

When was a Kennedy Terminal Ulcer first described?

In March of 1989 the National Pressure Ulcer Advisory Panel got together in Washington D.C. to see if they could determine how many pressure ulcers were out there and could you predict who was going to get them. During Karen Lou Kennedy’s talk on the Prevalence of Pressure Ulcers in a Long Term Care Facility the Kennedy Terminal Ulcer was first described.

What age group is this prominent in?

This tends to be a geriatric phenomenon. It does not seem to be prominent in pediatrics. It is reported frequently in hospice patients

What do you mean by the 3:30 syndrome?

In our experience at the Byron Health Center and in many nurses around the country that have shared their experience this tends to be something that comes on quickly, sometimes in a matter of hours. It comes on as little be-be spots that are black. They tend to look like a speck of dirt or dried bowel movement that most care givers tend to try to wash away, finding out it is under the skin and not on the skin. As the hours progress it becomes larger and can in a matter of hours become almost the size of one to many quarters lined up. These almost look like someone colored the skin with a permanent marker. The usual story is when the patient got up in the morning and the skin was looked at it was intact with no discoloration. At 3:30 when some patients are placed back in bed for a nap the skin shows this blackened discoloration. It is then questioned as to why this was not reported before. In questioning the care giver they explain that it was not there when they got them up in the morning and it was not present. The skin is almost always intact and looks almost like a black blood blister. These patients have a history of dying almost within 8-24 hours.

How did it get its name?

It was named after the First Family Nurse Practitioner in Fort Wayne, Indiana who discovered it. In 1977 Karen Lou Kennedy-Evans RN, CS, FNP started working at the Byron Health Center, then a 500 bed Long Term Care facility in Fort Wayne, Indiana. In1983 she started one of the first Skin Care Teams. Records began to be kept and it was in evaluating this data she noticed that some people got pressure ulcers that had a similar look to them (see photos) and two weeks later they were dead. As she looked back over the years of data she collected it became obvious that this was a pattern. This was discussed with the full time physician at the Byron Health Center, Dr. Delores Espino and the medical director, Dr. Stephen Glassley and it was Dr. Stephen Glassley who named it after the nurse that discovered it. Karen left Byron on November 2002 but consults for various companies, a noted lecturer and author of the book Gaymar Pictorial Guide to Pressure Ulcer Assessment.

Why have I not heard of this before?

This is not something that has been known or understood for long. It is a new phenomenon and needs further research to know why this happens. It was first described at the First National Pressure Ulcer Advisory Panel in Washington D.C. in1989. It first appeared in a nursing text book in 1991, the Fundamentals of Nursing, by Kosier, Erb and Olivieri Fourth Edition, 1991 where there are two colored pictures of it in the “Guide to Selected Skin Lesions” section. It also appeared in Decubitus (Now known as Advances in Skin & Wound Care) Vol.2, No.2, May 1989, p.44-45. and has a whole page developed to it in the Gaymar Pictorial Guide to Pressure Ulcer Assessment p.13. Now available for purchase online for $24.95 plus shipping and handling by clicking here.

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