Wound care
resident spending hours in bed each day, there are ample opportunities for the sheets to rub against the body, or for the way someone is lying to put pressure on vulnerable joints. From there, and especially in vulnerable areas like the spine, it’s often just a matter of time before this disrupts the flow of blood through the skin, starving the area of oxygen and nutrients and leading to the formation of an ulcer. In practice, these ulcers can presage a number of serious health problems. While the first two ‘stages’ of an ulcer generally just cause redness and itching of the skin, the third affects the fatty tissue underneath. The fourth and final stage, for its part, can ultimately make tissue die, heightening the risk of infection and even leaving muscle and bone exposed. All told, a shocking 69% of people with stage four ulcers die within 180 days of them forming – which explains Carter’s insistence on calling the condition an ‘injury’. A few decades ago, she stresses, it was “shown very clearly” that neglect in nursing homes caused a lot of pressure ulcers in elderly patients – “and that was avoidable”.
Tossing and turning
This last point – the potential avoidability of pressure ulcers or injuries – really strikes at the heart of the problem. For if a lack of movement, and the pressure that results, can bring about an ulcer, it follows that the opposite is also true. Not that warding off pressure ulcers is simply a matter of prodding patients to shift their weight. In large part, that’s a question of capacity. UK bodies like the National Institute for Clinical Excellence – and its cousins overseas – may boast detailed guidance on offloading weight from patients. But in a country like England, where around 40,000 nursing positions are currently unfilled, finding the time to physically turn hundreds of patients can prove challenging. Special mattresses made out of foam or gel exist to help prevent pressure ulcers, but Carter is sceptical: “I’m not aware of any literature that says those mattresses show superiority over proper offloading by other means.”
She stresses that teaching people outside the average hospital ward about the tell-tale signs of pressure ulcers is one important strategy for prevention. “Primary care physicians get to see pressure ulcers when they’re not being caught in other areas of medicine,” she says. “Those are the ones that do need to start the education process with the patients.”
The blame game Once again, however, simply educating patients about what they can do to defeat pressure ulcers is easier said than done. What, for instance, to do about people in care homes, many of whom suffer
Practical Patient Care /
www.practical-patient-care.com
from dementia and who can’t possibly be expected to move themselves every few hours? “In a sense,” Carter says of these examples, “the patient is going to be their own worst enemy.” Perhaps it makes more sense to focus on longer-term strategies to fight the causes of the disease. We know, after all, that avoiding cigarettes and drinking more fluids can drastically reduce the underlying conditions that promote ulcers, even if pressure is almost always the spark. Just as well, then, that organisations as varied as the Mayo Clinic and the NHS are promoting these healthy lifestyle choices on their websites. As for offloading, Carter emphasises that patients can only be kept safe if hospitals and care homes develop strict protocols for turning them regularly. Especially in a world of chronic staff shortages, she argues managers need to make ward nurses into “stakeholders” and understand exactly how much capacity they have. This spirit of collaboration, must also encompass different institutions. Historically – and especially in the US, where these questions often have a financial angle – hospitals and care homes have tended to blame each other for the emergence of pressure ulcers in patients. “It’s a blame game,” Carter laments. “They’re claiming ‘well it started in your facility, not ours, so it’s not our problem’.” It goes without saying that this approach is not good for patients. Far better, Carter continues, to leave the bickering over responsibility aside in favour of practical medical results. “How do these injuries propagate? How do they initiate? What can we do to prevent them from the very beginning?” All these are eminently reasonable questions.
Yet as so often with pressure ulcers, actually asking them in the real world is far from straightforward. No matter how easy pressure ulcers are to beat in theory, then, they seem destined to worry nurses and patients for many years to come.
Teaching people about the tell-tale signs of pressure ulcers is a key prevention strategy.
2.5 million
Agency for Healthcare Research and Quality
41
The number of people who develop pressure ulcers across the US every 12 months – 700,000 people develop these ulcers in Britain each year.
Artemida-psy/
Shutterstock.com
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