Bed Sores & Contractures

[missjennmb]

I'm a student and in my rotation at a LTC facility. I see a LOT of both of these and cannot help but be confused. I also note that the patients I see are always in the same position every time I go. Admittedly some can move themselves, but not all of them. Are contractures and bed sores the norm and just something to deal with? Do a lot of patients come IN with contractures to the point that you end up with a good percentage of your patients contractured?

I am trying to reconcile what I see in the nursing home with what I learn at school, and my instructors are trying very hard to be "politically correct" in order to not lose their ability to do rotations at this LTC facility. I have also seen patients who are readily eating, who we are told will be getting a feeding tube due to failure to thrive. The entire place smells pretty pungently every time we go, and there is always a lot of that white yeast-like stuff in the folds of their skin every time we do bed baths (we're nursing students, but doing just ADLs this semester).

I am not trying to pass judgement. I know that there is a lot of work to do and never enough people to do it. I just have nothing to compare this to. Is this the norm? Do these things happen even with the best of care and the best of intentions or can we / should we expect something better? Do bedsores just happen no matter what you do? Do contractures just happen? If someone were to work the limbs of patients every single day (as we were taught in school - range of motion exercises) would there still be contractures due perhaps to neurological disorders or some other component that I am not far enough along to understand yet? Do people actually DO range of motion exercises? we are only there in the mornings two days a week, so its possible that things happen that we are not seeing, but I have not seen them done.

Also, some of the food is really terrible, and we have had residents complain about it. We are required to record their intake, and when I've talked to mine, they've said "the grits tasted raw" or "those eggs are nasty" but nobody is ever offered anything other than standard fare of powdered eggs, sausage/bacon & toast (which has been the exact same thing the past 4 times we have gone). One time, the resident complained that the milk was sour, and on checking it, I noticed the expiration date was over a week past due. There are UTIs as well, but being a female, I know those can happen even with the best of intentions at times.

Can anyone please enlighten me about what is the "norm" in a nursing home in regards to these things? Please be gentle if I'm being judgemental (I am not trying... just trying to understand). I really LOVE the elderly that I have met thus far, and if I knew of a place that provided care that didn't leave me going home and worrying about the residents, I would probably be on their doorstep introducing myself in hopes of working there upon graduation.

If this is the norm, what can we do to make it better? What can *I* do to help as I become a nurse and begin my career?

**I'm in my 30s and I think perhaps thats where my pessimism comes from, having had a career and some life experience thus far, but if its possible, I would dive in head first to help make things better

[bookwormom]

I take my sophomore students to a nursing home for their first clinical experience. I consider it to be well run. However, some patients have contractures, even with daily range of motion. I believe that even with good care, contractures may be the inevitable result of some neurological conditions. I rarely see decubiti, unless the person has been admitted from the home or the hospital with them. Sometimes they occur when all the systems are failing.

I'd hold judgement on the feeding tubes (need more background), the "white stuff" (powder?) and the odors (sometimes inevitable, especially if laxatives have been given, although hopefully temporary). Also the food. My students consider the pureed bread and pureed meat gross, but I notice that the residents often scarf it down. Also remember that meals may repeat on a weekly schedule, so the same food is served every Tuesday. Turning may also be on a set schedule, so residents may always be positioned the same way at 8AM every day.

Is the facility trying to address any of your concerns? Powder isn't really recommended; odors can be controlled with agressive approaches. The facility I use gives residents medication to deordorize foul bowel movements and requires all soiled linen to be rinsed before it is put in the laundry barrel. If the food is expired, that is a serious concern the facility should address immediately. You should be able to mention this to the dietary department without any fear of repercussions.

Here's a suggestion that may give you some perspective. Take a look at the last federal inspection results, if it is available. As you may know, for federal reimbursement, all long term care facilities are subject to inspection. As I understand it, the results of that inspection, the violations, and the plans of correction are required to be accessible to residents and visitors. In the facility I use, the inspection results are easily accessible to everyone, including wheelchair users. If they aren't accessible, that's a big warning signal.

The violations I've noted there are relatively minor, such as the temperature of hot food being several degrees less than optimal, or a resident receiving oatmeal on her tray (when her chart says she dislikes oatmeal.) But when I was looking at facilities for my mother in another state, the violations were pretty serious. It can be an eye opener.

You may or may not be working in a facility that gives good care. Try to learn from the experience, and give the residents the best care you can. You should, however, share your concerns with your instructor. You sound like you'll be a great nurse.

[racing-mom4, BSN, RN]

Just like anything else there are good places and bad places...from what you have described your clinical sight does not sound like the optimal place, but we dont know the entire story...the staff may be doing the best they can for what they have avail from mgmt.

As far as the food, studies have been done that shows when given meal options, patients will eat better. Food will not be wasted because the residents can actually chose thier meal thus eat more of it.

If you really want to feel like your making some sort of a difference use that topic for a research paper and then present it to the mgmt of this site. Who knows, maybe given the facts they may change something.

I admire your passion and hope you keep it. I have only been a nurse for a year and I still have that "I love being a nurse feeling"

[missjennmb]

Thank you so much for the feedback. I know the white stuff is not powder as the facility does not allow powder (one of the residents I cared for has complained each time about wanting her powder but that she is not allowed to have it here and I verified that with my instructor) Its not a huge issue, its just that build up of skin tissue when an area is not cleaned and dried on a daily basis (I've seen it on myself on occasion when I've been laid up in bed for a couple of days or not worn a bra or during hotter summer months - I'm a bigger girl) I don't think the food looks bad at all (other than the milk having that expiration date). I guess they just did not like it (or to give the facility the benefit of the doubt, it could just be an excuse on the resident's part because they did not want to eat it I suppose)

Thank you for the insight and the information on how I could learn more. I'll have to look more closely at the bulletin boards etc that are around the facility. I did read one thing about grievances, that was mistyped (I hope! lol) because it said (among the details) if your grievance is unfounded, we will tell you its unfounded, and if its proven, we will tell you its unfounded. I didn't read anything else after that specific posting assuming nothing of import would be up there, if they had posted something with errors and never noticed it.

[CoffeeRTC, BSN, RN]

Okay...that place sounds like the pits. I'm surprised you school would have you there. Normally, they are the "better" facilities.

Smells happen, but should only happen occasionally. (like at changing rounds) If it persists...yeah...problem that might equal poor care.

Sounds like they are not getting baths enough too. Could the powder be a nystantin med powder?

Food...it is hard to please everyone, but...I would eat the food served at our nursing home. By no means is it the Ritz, but it is decent. We do have a list of subs that they can have too.

Contractures....we were just talking about this at work. When I first started over 10 yrs ago...I saw a lot of res with them. Too many. Now days...very little of our res have them. With PT/OT and restorative programs, they are not as common.

Bedsores...Sometimes they are admitted with them or unavoidable. This is a big thing that we keep ontop of. The state looks at those numbers too.

Look online for the facility inspection results. Look at someother facilities in that same area too. That will give you a little peek into what is around you area.

[nightmare, RN]

We don't have bed sore too often,we have a good turning system.Contractures though,when i first started we did not have any but with the advent of 'no lifting' policies residents who were previously 'walked' by two carers/nurses are now hoisted more often.The lack of use of their limbs very soon results in contractures and the visits from the physio service are not often enough to combat these.

[missjennmb]

The lack of use of their limbs very soon results in contractures and the visits from the physio service are not often enough to combat these.

Do you feel like increased physio service (I'm assuming you mean physical therapy/occupational therapy) would be able to reduce the amount of contractures that you are currently seeing?

I had assumed that was a nurse/CNA duty, but thinking on it, for a 96 bed facility, there is one therapy assistant that is there full time, and the OT person is only there two days a week (not sure on the main PT person as I've never seen/met them). I did see them using a Wii the other day which looked fun for the resident though.

I know that as a nurse I need to detatch myself somewhat, but I can't help but thinking "what if this was my mother" every time I meet a resident, and thinking "what would it be worth to me to make her last days better/contracture and bedsore free/good food/etc". Obviously they cannot say "if you give me x amt extra I will make sure your parent gets turned every two hours/gets PT as needed" because that would suggest they were not doing what is necessary for patients who cannot pay that extra bit, but it would be worth it, in my mind.

[CT Pixie, BSN, RN]

Way back years ago when I first started as a CNA I remember there were tons of people with contractures and nasty bed sores. I was mortified since I knew that usually these two things can be stopped with proper positioning and ROM. It took a while, after doing a few admission "body audits" to realize that most were coming into the LTC facility like that. It wasn't that my facility was causing them..thankfully.

Now, years later, I can honestly say I don't recall seeing ANY contractures during my clinicals nor in the facility I work at now. I have seen some grotesque looking bedsores (again all the really bad ones the resident came to us with). My CNA;s are vigilant with turning and positioning! When I first started, I let them know what I expect, the #1 thing I really insisted upon was turning q2 or less!

I can't speak for all places, but the places I've done clinicals at and the facility I work at doesn't have many bed sores and no contractures that I know about.

I only have one pt with a PEG tube and she came to us with it. The majority of my residents eat very well (75-100% of every meal). They rarely complain about the meals, even the people on the puree. I think it has a lot to do with the presentation of the food too. Who wants to eat what looks like a white round ball, an orange ball, and a brown ball? (mashed potatoes, carrots and meatloaf pureed). My facility "dresses" up the plates and foods and the foods are seasoned pretty well.

I understand your concerns but please know that not all facilities are like the one you are doing your clinicals at. But take everything you see, hear, smell etc as a learning opportunity..when you graduate and become a nurse, you will KNOW how you want your residents treated and cared for. You are seeing what sounds like the worst of the LTC, hopefully you will also be exposed to the best (I happened to have done a clinical roatation through the facility I now work at, and from the get-go I loved the facility).

thank you for being concerned about your residents! That what we need, people who see things that are wrong and want to fix them . :)

[nightmare, RN]

We do not have in-house physical therapists,they have to be referred from community health.Although they may teach some of the staff exercises and movements for the residents with contactures,there is not enough staff to be able to work one to one with these residents for any length of time.

[debRN0417]

Bedsores...this one gets me. Many pressure ulcers are hospital acquired and the reason is that most folks are in the hospital for surgery and spend hours in the OR , thus deep tissue injury and there you go! a big fat old pressure sore. Also, I have found that the turning schedule in the hospitals are not as strictly adhered to as in LTC. Most LTC facilities now have great assessment nurses who pick up on this at admission so that the facility does not "Own" that pressure sore. Pressure sores can be unavoiadable, but the facility must be able to show this through the assessment and documentation process, as well as have a care plan which addresses it thoroughly. Smells....transient smells are expected. You can tell the difference between a transient "someone just pood and got changed" and "laying in it for hours"...Food...I have yet to find a facility that everyone thinks the food is wonderful. No matter where you go, it will never please everyone.

Contractures- most facilities have therapists, and restorative nursing. There should not be a high incidence of contractures, unless the person came with them.

[vampiregirl, BSN, RN]

I'm sorry that you had some concerns and frustrations with the nursing home you've visited. I can assure that not all facilities are like that! Actually, the LTC where I am a PRN CNA I applied to work there because it didn't smell when I walked in to pick up an application:)

As for some of your other concerns - the white yeasty stuff, I wonder if maybe the staff is lacking in proper hygeine training. Especially with residents who may appear to be doing their own hygeine. Many times they wash okay, but don't dry real well which is the perfect breeding ground. These are the residents where you can make a difference, if you work with them to teach them.

Try to learn everything you can at this facility, and take the good knowledge with you. LTC so needs nurses who truly care about the elderly. Please don't let this experience change your path if you truly enjoy this population.

[CapeCodMermaid, RN]

"Just like anything else there are good places and bad places...from what you have described your clinical sight does not sound like the optimal place, but we dont know the entire story...the staff may be doing the best they can for what they have avail from mgmt."

Why is it always the management's fault if things aren't done? I provide more than enough supplies and training and oversight for the staff and sometimes they STILL don't do what they are supposed to do. I find many people on here are quick to blame management.

Most pressure sores are avoidable with good skin care, a good mattress or gel pad, good nutrition and basic nursing care. Some, however, are unavoidable.