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

[achot chavi]

Hi, I've read through the thread- and agree with much of what is written- I do believe that ultimately management is responsible for problems- they should be doing a QA eval and finding non compliant staff and replacing them.

Bed sores should not exceed 25% of the patients. In our facility of 200 beds we have only 10 sores (Thank G-d) though we can go as much as 18- some from admissions or post hospitalizations.

Is there a wound care nurse who makes decubiti rounds weekly?

are baths given every other day or daily? Is there a PT program in place to give assistive devices to prevent contractures? Do the CNA'z do T&P Q2H? Are restraints released Q2H? Are the patients treated in a respectful and caring manner? Are the families involved and informed? Is there an in-service director who makes rounds- is in touch with what is going on and taking control? Are the nurses and CNA'z and housekeeping staff doing their jobs or do you see them watching TV?

Is it possible that the "white stuff" u see is cream or zinc oxide? (giving benefit of doubt here)?

If you and your peers feel that your education is better served in another facility- you could -very politely and with as much tact as you can muster- write a (if u want- anonymous) letter to your director of nursing voicing these concerns and requesting an evaluation of the appropriateness of this facility as a learning tool (don't be surprised if it is ignored- but you never know).

You will make a helluva nurse:yeah:- I am proud of your questions and concerns- it shows that you care about your patients quality of life and care!!!

[CoffeeRTC, BSN, RN]

Capecod....when I think management, most of the times I'm refering to the corporate management or sometimes the ADM. We have the best DONs, but most don't stick around because of the upper management and corp politics. A DON can only do so much with what they are given...often times things (budget, staffing etc) is out of their hands.

[CapeCodMermaid, RN]

In Massachusetts if we had a 25% rate of pressure ulcers we would be shut down. And yes, I know about corporations not wanting to spend money, but if you know how to work the system, you usually get what you need.

[noc4senuf]

The "never" rule has now went into effect with the hospitals. Meaning, one of the "nevers" is pressure ulcers and if acquired in the hospital, they will not be paid for the care of it by medicare. So, if you receive someone from the hospital, make sure your documentation of a body assessment is completed within a few hours of admit. Also, if you are sending someone out to the hospital, make sure you also have an up-to-date assessment for the skin done when they leave your facility. The hospitals will start looking to the SNF's for blame.

We have individualized turning programs that are from anywhere 1/2 hours to 2 hours, per regs for individualization. Our pressure ulcers were there on admit. We have the aides doing restorative care on each resident that it is deemed that needs it such as walking, ROM, transfers, etc.

[missjennmb]

This has really turned into such an informative conversation. Thank you so much for all of the thoughts on this subject. My hospital has put a lot of the "never" rules into place as well (I work in a hospital as a secretary while I am in nsg school), but I hadnt realized that it would apply to decubiti/nursing homes as well. I think thats great for the patients/residents, particularly when some of the issues discussed here can become lifelong or life endangering in themselves.

[achot chavi]

In Massachusetts if we had a 25% rate of pressure ulcers we would be shut down. And yes, I know about corporations not wanting to spend money, but if you know how to work the system, you usually get what you need.

If the pressure sores came from admissions or hospitalizations-not in-house- why would they shut you down?

Most of our sores are less than half an inch by half an inch - stage 1 to 2 that heal within a week to ten days with proper care and don't return, but I still categorize them as pressure sores.

We once had a unit that was devoted only to specialized care for bedsores that had a high nurse to patient ratio for this reason. We used treatments that others lacked access to and had a high rate of recovery. Other facilities sent their patients with stubborn pressure sores that didn't heal- to us!! It was a sad day when management decided it wasn't cost effective to keep the unit and closed it.

BTW- I know that when you say "work the system"- you are an honest person- but in my experience (not where I currently live) there are management that put pressure on nurses to lie on documents in order to "work the system". We have to always remember that we put our licenses on the line when we input information on patients records that can be discredited.

As someone wrote- not every pressure sore is avoidable- sometimes internal pressure can cause a sore etc.