Chronic and complex wounds of the lower extremity frequently recur. It is difficult to determine the precise recurrence rate across patients with different lower extremity wound types, including diabetic foot ulcers, arterial ulcers, pressure injuries, and venous ulcers. However, we know that...
Perspective of Nursing Care from Past to Future by Matron Marley
By Margaret Heale, RN, MSc, CWOCN
Well it's me again, Matron Marley. I got in through the door no problem today. My granddaughter dropped me off as she is doing some MDS training. I am feeling more comfortable as a volunteer now that I have visited a few times. When talking to the staff about their wanderer last time I was here and being reminded about the first recliner butt I saw, I wanted to drop back to the past again and tell you why I was so concerned.
I had been aware of Mable, 'the wanderer' from the elderly ward, before starting there, as I got involved when she caught the local bus in her hospital gown. She had since suffered a stroke and as I pointed out last time, she reclined for long periods and was incontinent, which lead to what has become known here as 'recliner butt'. I believe this is a chronic form of moisture associated skin damage, when I first saw it I thought it was going to be a very bad pressure ulcer. Today I will explain why this concerned me so much.
The manager of the ward was on long-term sick leave when the school of nursing withdrew the students and I was placed as interim manager. The students were removed because of a series of events that started with Mable's bus adventure and stroke, then ended with a complaint from a relative. A clinical teacher came to assess the ward and ended up counting pressure ulcers. Eight of 35 patients had more than one deep bedsore on their trunk, some had sacral and bilateral hip sores, and many had ulcers on their heels.
I had been there a week, consumed with staffing levels (a dreadful 'off sick' problem), laundry and a mattress problem. Some of these sores were very large indeed; I have seen nothing like it since. Half of the patients were bedbound! I will not continue to paint the picture because it was grim. I felt I carried the odor from the place with me when I left and my plan was... to survive (preferably with all patients and staff in a better position when my time was up). I began 'rounds' after a few days and could not understand why the first patient to be admitted after I started had a bruise on her sacrum. There was no history of a fall and my worst fears were realized as the days wore on. So now you know why I was so horrified at poor Mable's buttocks: I thought it too was a deep tissue injury. Looking back on it now I appreciate the difference. Mable's purpleish, discoloured buttocks were blanchable and soft, the disparate tiny lesions were superficial and healed quickly. The so-called bruise on the other lady was non-blanching and when pressed it felt firm. Deep tissue injuries may also feel boggy, different from the surrounding area (particularly important for dark skin). Within a week the skin looked scuffed with some peeling and it turned leathery then brown to black eschar formed. I was meant to be improving things and within my first week we had yet another pressure ulcer. As relieved as I was that Mable's buttocks did not ulcerate I still spent many hours pondering the differences. We knew moisture played a role in pressure ulcers but then and for many years we treated them the same. With the great skin protectants, absorbent products that wick moisture away from the skin and the demise of the recliner, such chronic moisture associated skin damage may soon be a thing of the past.
We made many changes to the practices on that ward. All patients who were unable to walk were put on a repositioning schedule and had a skin check on admission, a very new innovation at the time. We discontinued the overuse of laxatives routinely twice a week (laundry problem solved) but it took a very long time to introduce an effective bowel program. We got rid of the 'horse hair' mattresses. I am not sure if they were really horse hair but they were heavy and hard. We stopped 90 degree side turns, positioning back a little (later described as the 30 degree tilt by Shea 19751). It was discovered (almost accidentally) that one of the older auxiliary nurses who was on nights, brought in her own rubbing alcohol and ferociously applied it to red areas. We were convinced this was an important contributing factor when a colleague demonstrated the process. The shear forces created are now known to be very damaging and of course alcohol reduces the natural skin moisturizers that play a role as a barrier and protectant. Early retirement of the nurses aid solved the problem but it was a deeply ingrained routine for many and required some education. The new beds needed to 'save the backs' of the nurses, was a slower process. They had easy-to-adjust back rests and a hydraulic foot pump to change the bed height, state of the art in the 70's. We got big thick mattress overlays, like huge comforters for all patients with ulcers. Most ended up soiled and needed to be thrown out as they didn't launder as well as the company rep said they would. All doughnuts were thrown out as mostly they offload the anus not the coccyx (except in someone very tiny), it was many years before we had a suitable cushion to replace them though.
I did rounds once a week and we managed most of the wounds by cleaning with hydrogen peroxide and dressing with gauze moistened with a form of Dakin's till they were clean. Iodine was another favorite. Once clean we used moist gauze daily and if soiled. Soiling was a major problem and I remember one nurse hand cutting chux to tape over fresh dressings to protect them, it didn't work well. One of the nurses came up with the idea of using an antibiotic powder at the edge to help 'dry the wound up,' all it seemed to do was develop into a goopy mess and irritate the skin. We did use oxygen to dry up superficial wounds and heat lamps (not at the same time). For diabetic foot wounds we applied insulin directly to the wound and a variety of salves and pastes! With pressure ulcers of course it is not the dressing that is important it is prevention with the recognition of risk, pressure reduction using effective support surfaces, offloading, education of caregivers and good manual handling practices. I have always believed 'boosting' patients (and eating in bed) is a major cause of shear and expect this practice will decline as we more successfully focus on prevention.
Recognition by Medicare that some pressure ulcers are not preventable is also a turning point (excuse the pun)2. The Kennedy ulcer is the inevitable consequence of skin failure associated with end of life and not a reflection of inadequate care.
Since that time there is no doubt in my mind things have improved in all elderly care homes. After working there for five years it became a brighter more caring place with a bird and a cat. Residents were dressed for the day not nursed in a hospital gown. The students returned once we were 'restraint free' (back then bed rails and recliner tables were not considered restraints). Very soon after I finished the previous manager returned... as a resident! She had early onset dementia and her family could no longer cope, they thought she would like to be in her own ward but I bet she preferred the one her staff helped to create.
So that is the past, the present is now and all of the above still linger here and there. Staging at last is becoming easier at least in part because the focus is on pressure. Admission skin assessments are taken more seriously (thank you Medicare). The ER and OR are no longer excluded from being able to utilize innovations that make a difference. The NPUAP have collaborated with a bed company to define and delineate support surface terminology and this will make a big difference at the bedside3.
Today in this modern nursing home I am going to help with a dressing not available in my day, negative pressure wound therapy. I will let you know what I think next time. As for the future, you will have to wait, we're not there yet, though I think we may be slipping into it right now!
Levine JM. CMS recognizes the Kennedy Terminal Ulcer in Long-Term Care Hospitals. http://www.jeffreymlevinemd.com/unavoidable-kennedy-ulcer-in-long-term-c.... 7/10/13.
NPUAP. Bear of a Problem: Who Should be Sleeping in Which Bed [webinar]. September 13 2013. https://www.regonline.com/Register/Checkin.aspx?EventID=1273094.
Shea JD. Pressure Sores: Classification and Management. Clinical Orthopaedics Oct 1975. 112 p89-100.
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.