Perspective of Nursing Care from Past to Future by Matron Marley

By Margaret Heale, RN, MSc, CWOCN

Another day at Rose Cottage is over and I am remembering some events and pondering as I wait for my granddaughter to finish work and drop me off home. I have been volunteering here a while now and am getting used to being in a position of watching, listening and not having to react to everything as I am just an outsider helping out. I was a matron though, and the patterns within my brain are such that I must at least ponder at where we are, where we came from and where we are heading. ‘Ahhh,’ you are thinking she is going to bemoan modern nursing and call for a return to the good old days, well you’d be wrong. I am not sure it was all so good and with new blood, new technologies and modern versions of Flo, we will see our Scutari change and develop into a new and exciting place. Well you will, I will join my fellows here at some point and allow you to care and listen.

Continence Assessment: Questions to Ask Clients Upon Admission

So as I wait I ponder. We had a lady admitted today who is 80 years old. She was catheterized when she had her hip operated on and she is a bit big (as in overweight) and hearing impaired. Our facility has a great admissions nurse and she uses some approaches I would never have dreamed of doing. One of the first is to check the new resident she is admitting can actually hear. She has hearing aid batteries and knows how a hearing aid works (fancy that). If there is no hearing aid or it won’t work, she uses a microphone and has the resident wear a headset! The first time I saw how easy this makes the process of admission I kicked myself. Such a very simple thing and I never thought of it.

The other ‘wouldn’t have dreamed of thing’ the admission nurse does is ask a simple set of questions as a continence assessment and horror of horrors, removes the catheters. Occasionally there are specific instruction for use, in which case she comes up with a plan and calls the MD for an order. This particular client today had been re-catheterized before arriving because of constant wetting of her sacral pressure ulcer dressing. I was unpacking her belonging with her when a couple of staff came in to check and reposition her into the armchair from the wheelchair. As they helped her stand one noticed she had a brief on and it was wet from leaking. I disappeared to get supplies for hygiene and give her privacy and off came the brief. As I exited the room the nurse asked me to get an RN and a 10ml syringe. Out came the catheter. The admission nurse came in and explained to her that as she was constipated, the catheter was probably being bypassed due to increased pressure on the bladder. Also apparently when she was re-catheterized someone decided a size increase from a 16 to an 18Fr may stop the leakage. In fact it is more likely to be the cause, as larger catheters irritate the urethra leading to bladder spasms that can cause bypassing.

The Right Size: The Importance of Properly Fitting Catheters Based on Continence Issues

I struggled for years trying to get these two important issues across to staff. Convincing them to remove large catheters and replace them with smaller ones was difficult (initially impossible). I think it is because we tend to think of the urethra as an open tube, forgetting that coaptation is partly why it works to prevent leakage of urine. Introducing a catheter forces the walls apart, irritates the mucous membrane and the bigger the cath the more disruption and irritation. Interestingly our facility tried to get size 12 catheterization packs, but the vendor only does 14, 16 and 18 in inclusive packs. So we use 14s but, actually there are very few catheterized residents. There are probably six residents that use straight cathing for problems with retention. This is so much better than leaving a catheter in place—little counter intuitive but definitely true (WOCN 2009).

I was interim manager on an elderly care ward for a while and learned that the pus draining from the penis of a catheterized man was in fact slough from a pressure ulcer of the bladder neck. This was not unusual at the time, we were using size 18, 20 and 22Fr catheters with 30ml balloons. I remember another man who had the urethral meatus eroded away forming a slit. We removed his catheter and used a condom cath. I had never really seen successful condom cath use till I came to Rose Cottage. Mostly we found ours in among a very wet bed. Here we actually use several different types from a few different companies. The issues I always had was that staff were reluctant to measure, all I had back, way back when, was a washable tape measure. The companies now have a simple semicircular measure which is quick and easy to use, the resident hardly has time to notice. The skin barrier wipe really seems to help and the new materials are so flexible that they do not get displaced so easily. There is still a knack to getting them on correctly though. One trick I passed on was making sure the drainage bag has a little urine left in it. There is an odd suction effect from a fully empty system because of the surface tension

Assessing the New Resident for Previous Pressure-related Injury

The next things that occurred with this new resident shocked me. She stands quite well and I went with the aid to toilet her a couple of hours later. While she transferred with little help, she apologized for needing assistance to the toilet. The nurse aid (a youngster) said “no trouble—you need to get off your pressure ulcer anyway.” The resident said that it wasn’t a pressure ulcer, just a skin tear the nurses at the previous hospital told her she got in the OR. You could have knocked me down with a feather. The wound on her sacrum I knew was a stage IV pressure ulcer that was still debriding. When we put her back to bed she reminded us that she had to lay on her back due to hip precautions. No wonder she had a pressure ulcer. The nursing assistant called the RN and together they showed the woman how she could be off her pressure ulcer by tilting just 20-30 degrees, if laying almost flat (Shea 1975). The importance of pillows and wedges was explained and the RN moved the pillow in the patient’s back higher saying to the aid that putting a pillow onto the damaged area defeated the purpose, which is to offload. I would like to think a follow up call to the referring hospital occurred but I am sure it did not.

It was just a few years back (Oct 2008) that the Center for Medicare and Medicaid Services (CMS) stopped payment for some frontline hospital-acquired conditions and full-thickness pressure ulcers topped the list. It has made a difference to the care we give which is a good thing, though it is a little sad that the impetus for such improvements in care had to come from a regulatory body and not our profession. Maybe the next step should be that the facility that caused the ulcer pays for the care needed to heal it. That would surely keep a few thousand people gainfully employed! We have come a long way with taking responsibility for action and inaction but at transfer across settings it breaks down. We enter all our pressure ulcers into a database and it will soon be possible to find out what percentage of patients with pressure ulcers come to us from which hospitals. The culture of blaming the ER, OR or previous facility is melting away, being fully accountable will be our future. Until then, we will measure and stage, enter and count.

Sources
Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res. 1975;(112):89-100.

Wound, Ostomy and Continence Nurses Society. Indwelling Urinary Catheters: Best Practice for Clinicians.2009.

About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.