Heel care for the geriatric patient

[toptastic]

I work at a subacute/LTC facility located within a medical center. Our turnover is rather quick but then so are the pressure sores we find on the heels and/or backsides of our residents. As a group we are rather diligent in our assessments for any and I mean any sort of skin breakdown. I'd like to know how other similar facilities are handling the assessment, prevention and care of actual or potential skin breakdowns. Do you have a specific work sheet to monitor prevention and/or healing. What about what equipment are you using. I would appreciate any and all information given.

[CoffeeRTC, BSN, RN]

I work in LTC and we don't really have a specific form. We have very long term and very short term residents. Admit skin assessment is done and so is the Braden assessment (done on admit and weekly X4 and then quarterly)

On shower days (2 times a week) nurse is to do a head to toe assessment.

[vampiregirl, BSN, RN]

At the facility I work at, we use the Norton Pressure Scale which a assigns a numerical value to the risk the individual has a getting a pressure sore. Based on the number, we request orders for/ implement certain interventions.

We mainly use waffle mattresses or occasionally a rojo mattress, heel protectors or float heels, turn and position q 2 hours in bed, appropriate w/c cushions (as recommended by our therapy dept), reposition q 1 hour in w/c, and weekly skin checks. Depending on their nutritional status, we sometimes pursue supplements (health shakes etc). If we get someone in with wounds, often times we request orders for vitamin C or zinc, usually for 30 days.

All of our residents also have prn orders for a skin barrier cream, which our CNA's are pretty good about applying after every episode of incontinence.

I've also found that not wearing depends when possible if someone does develop skin breakdown on their behind end helps (especially those with breakdown on the coccyx or gluteal folds). The plastic really seems to hold moisture against their skin. Even lying down an hour between meals (with good peri-care and moisture barrier cream when they first lay down) without a brief seems to make a difference.

[CapeCodMermaid, RN]

We use skin prep on intact heels and pressure relieving mattresses. If the heels are boggy, we use heel floats or if the patient says no, pillows.

In Massachusetts we use the Norton Plus score....on admission and then quarterly. Weekly head to toe skin checks by a licensed person and daily skin checks by the CNAs.

[LadyinScrubs, ASN, RN]

I do not work in a SNF or long term facility. When I am not working, I care for a very elderly, frail, bedbound (but able to self transfer to comode) family member who will not turn--she insists on lying on her back. I will reposition with pillows and I find the pillows tossed aside and she is on her back again.

She has been this way for 2+ years. No skin breakdown, etc. I bought a tempurpedic type matress topper for her hospital bed and when she started to show some sacral redness bought a gel memory foam topper.

Everyone is amazed her skin is healthy with no breakdown. Before I bought the tempurpedic type matress toppers, home health wanted to give her an eggcrate type foam matress topper--which was totally unsuitable. While this type of matress topper is far too expensive for long term care, I highly recommend the gel foam product for home care. The gel foam is particularly helpful -->no sacral or heal break down....

[LTCangel, ADN, BSN, LPN]

We do weekly body audits on all residents, use moisture barrier creams, and we have a Wound Care Nurse who checks all the pressure ulcers regullarly and reccomends the type and frequency of dressings needed for decubs. We also have a few residents with wound vacs and they go out to the WC Clinic twice weekly to have their wounds assessed and the wound vac changed. Of course the wound vac can also be changed PRN by us when needed. The CNAs are supposed to carry a small pad around with them and if they see any new skin issues they are supposed to document this and bring it to the nurse so it can then be looked at, measured and a treatment started. It is hard to get some of them to actually use this, they would rather call the nurse in to look. Personally, I don't care as long as they make me aware of an issue. Any new admit gets a complete skin audit with measurements and treatments applied according to our P&P. A consult is also sent to the wound Nurse so she can also look at the wounds and make changes or not. We use a lot of skin prep on red heels and other red places and it really works. Hope this helps. It really takes a team effort to make sure that the resident's skin is looking ok and that any skin issues are addressed and continue to be monitored for healing.