Using Assessment in the Prevention of Medical Device-Related Pressure Ulcers
To read the previous chapter, click here.
by Janis E. Harrison, RN, BSN, CWOCN, CFCN
Monday came with expectations of fixing the problem. It wasn't to be. Daryl was weak and hated the NG tube in his nose and throat. I arrived early at his bedside and waited for the doctor to let us know what the plan of action would be for the blockage problem. I left to use the public restroom and missed the doctor's visit. No one quite new what the plan was when I questioned the staff. So I created my own plan. I made Daryl get out of bed and started walking him in the halls throughout the entire hospital. I did not want him to get any weaker and I wanted to see if the mobility would increase the gastrointestinal motility. He was not happy with me at first but with education and the explanation of why, he was more than willing to try.
Nasogastric Intubation and Pressure Ulcer Development
Days passed, forcing me to raise the question of what we were going to do nutritionally for Daryl. I always seemed to miss the doctor when he made rounds. This left me to question staff and the next thing I knew someone or something was being planned. Without discussion, Daryl was taken to Radiology for a barium swallow to assess motility. Then he was taken to Anesthesia to have a subclavian port placed for TPN nutrition. I felt as though I was conducting his acute medical care and could not get a physician to visit with me regarding the long-term plan.
Another weekend of Physician-On-Call came around and this doctor was extremely rude. Daryl was sound asleep when he came in and "ripped" the NG tube out, causing Daryl to come up swinging and cussing. Daryl had been trained as a Special Forces paramedic which raises his expectations of care, and he was so upset he told the doctor to leave and not return. So, I was back to conducting his care again.
When Monday rolled around we were hoping once again to find a solution to this ever increasing malady. The NG tube had to be replaced, and by this time Daryl had a pressure ulcer starting to cause problems in his nasal passage. I still continued to miss the Doctor on rounds. We discovered there was a pattern. He would always seem to visit Daryl when I left to go to the restroom. We decided to test our theory. I left for the restroom according to pattern but, this time I stood around the corner and watched as the Doctor came out of a little room behind the Nurses Station and went to Daryl's room. I made my way back down the hall and listened at the doorway to hear nothing new was being said. I surprised the doctor as he came out of the room and angrily told him he had to decide what was going to be done for Daryl after three weeks of no output other than an NG and TPN. He took me back into Daryl's room and said we would have to decide on a laparoscopic surgery or go home to die. Wow! What kind of decision was that?
Well it was not laparoscopic: it was open abdominal. This was surgery number three within 30 days. Still no priest, still no anointing, but fortunately we had lots of family support. Daryl was in surgery for several grueling hours and when the surgeon came out to talk to us the Doctor said his small intestine was looped and his gallbladder was bad and he had to move the stoma as the blood supply was compromised due to the adhesions attached to the intestine. He explained it as "trying to separate each strand of spaghetti in a kettle."
After another 10 days in the hospital, a great deal of walking, adding small amounts to his diet and functions beginning to return, we got to go home ending 40 days and 40 nights of hell and high water.
Home – the place where two souls become meshed once again. It was good to be back home with my husband. Or was it?
A Closer Look at Medical Device-Related Pressure Ulcers
Let's think about Medical Device-Related Pressure Ulcers (MDRPU) this month. I have been preparing to speak at a convention regarding this topic and have learned the assessment for MDRPUs is to become a part of our assessment matrix along with the skin assessment and pressure ulcer risk assessment. There is no tool known to predict a pressure ulcer caused by a medical device according to the National Pressure Ulcer Advisory Panel or Barbara Braden, but it would be the extra assessment and care that would assist the nurse in preventing trauma to the tissue under a device.
The most common devices to cause MDRPUs are respiratory related, i.e. tubing, masks, CPAP and BIPAP masks, endotracheal tubes, nasogastric tubes, oxygen saturation monitoring clips on the ears, as well as orthotics such as splints and collars.
Padding and/or moving the device are means to avoid breakdown. Due to the patient condition some devices are not able to be moved or padded. Therapeutic measures are more important to patient health and well-being and the pressure breakdown may be unavoidable.
Using the risk assessment measured to prevent pressure ulcers is a must. If any part of the scale indicates the patient is at risk for skin breakdown due to pressure then the skin under a medical device should be assessed on a frequent schedule.
About the Author
Janis Harrison is the CEO and owner of Harrison WOC Services, LLC, which offers contractual Wound, Ostomy and Continence (WOC) services for hospitals, long-term care facilities and home health across Northeast Nebraska. Harrison has had numerous poster published, is a writer for Advanced Tissue's newsletter and is currently involved in developing health care documentation applications for WoundRight Technologies, LLC.
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.