leaving patient in bed with wound

KyPinkRN · May 17, 2008

patient has stage 2 wound in perineal area, no tunneling, i would say about 20% slough. edges are firm. very hard to treat this wound because every time he has a bowel movement, dressing has to be changed, and he is diabetic with poor food intake. the unit manager wanted us to sit him in chair no more than 2 hours at a time, so that means right after he has eaten his meal he is to go back to bed. he is a total care and very difficult to take care of. aides have to use a hoyer lift to transfer him and sometimes he tries to fight. cenas are saying he eats better when he is in bed but my worry is he is on pureed diet and honey thick liquid and he has difficulty with swallowing food and his intake is very poor and i'm worried hes going to choke.

i recently had a patient very similar to this but with contractures of his lower ext. it was very hard to even turn him, so he was on a bed that did the turning itself. the problem came when he had a bm which he did often because of his tube feed. he was so contracted it was almost impossible to get all the stool off. they finally wound up doing a colostomy to divert stool from the area. sounds extreme but is sure did work in helping to heal that wound quickly. i was amazed by how fast it actually did heal after it wasn't constantly being inundated with feces. also regranex is awesome stuff.

asoonernurse · May 17, 2008

You do NOT automatically say turn Q2 hours anymore, that logic is gone.

True.

However, I am assuming we are speaking of most LTC facilities, in which the aides rarely have the time for anything more than this. Sorry I failed to make that point clearer. My bad. :nuke:

However, like many things in nursing (and the medical field in general), the "logic" may be gone, but it is still widely practiced. We could certainly get into a discussion (or argument) about the pro's and con's of the old ways versus the cutting edge, but I fail to see how this would help the OP's initial question. Doctors are notorious for doing things the way they were taught, whether the "logic" is gone or not.

A tissue tolerance test is completed and you guide your staff to turn and reposition according to those results.

I'm not sure any of the LVN's I work with know what a tissue tolerance test is, much less how to run one.

Also, when your "staff" consists on 1 or 2 CNA's per hall (about 30 patients each) getting them to do a "turn" on the patients at 7, 9, 11, 1, and 2 would be far more practical than trying to get them to turn patients according to their tissue tolerance tests.

If we had 5 CNA's per hall, then this would be feasible. I'm talking "real world" here, not "according to the book."

If the wound is on the coccyx, then they must be turned side-to-side.

Of course.

There are cushions for the chairs called an isch-dish; these have coccyx cut-outs.

Yes, there are. How well do they work on patients with little to no ROM due to contracture?

Rarely would i leave someone in bed d/t a wound as other issues settle in such as respiratory problems and decreased range of motion.

I agree, but as I said in the beginning, I was making rather large assumptions about a patient I have (and you have) never seen, assessed, or spoken to either the patient himself or his physician.

However, I do agree with much of what you are saying. :yeah:

Good Luck,

Michael

vashtee, RN · May 17, 2008

You do NOT automatically say turn Q2 hours anymore, that logic is gone.

I didn't know this. Can you tell me where I might research this further?

asoonernurse · May 17, 2008

I didn't know this. Can you tell me where I might research this further?

It is not as widely-accepted a theory as noc4senuf makes it sound, Natania.

You might find the odd white paper or journal article on the emergent theory, but only in the wound care community itself will you be able to actually find any substantial information.

At this point, it is theory ONLY. There has not been a sufficient breadth or amount of supportive evidence that it is better (or worse) than turning q2h (which as I mentioned earlier, is still very much practiced in the "real world.")

I, however, lean toward the theory myself. Not all wound are created equally so-to-speak, so why should we treat them equally. Same goes for the "type" of patient.

Would you treat a stage 2 ulcer on a 30-year old non-diabetic male with sufficient nutritional intake in the same fashion as

you would a 76-year old diabetic with insufficient nutritional intake?

I wouldn't.

Good Luck,

Michael

asoonernurse · May 17, 2008

You might check back issues of The Journal of Advanced Wound Care for articles!

Michael

ktwlpn, LPN · May 17, 2008

I'm not sure any of the LVN's I work with know what a tissue tolerance test is, much less how to run one.
QUOTE]
As I understand it there is no standard "tissue tolerance test".Assessment on admission ( also s/p hospitilization or significant change) includes other standardized measurements such as the Braden scale and each residents plan of care must be individualized.In LTC you DO turn/reposition q 2 hours unless the resident requires more frequent turning.-the plan of care should reflect that. That's "tissue tolerance" We have an excellent OT in house and access all types of cushions and mattresses.We do have a stage IV with a wound vac on bedrest at this time.She is on an air mattress and has no range of motion-can't sit on an isch dish at this point.In our facility (if the resident is amenable) bedrest for a set number of days is the best way to prevent an early ulcer from becoming a big problem.

asoonernurse · May 17, 2008

At this time, there is no standard. Many, however are being developed and tested within the Wound Care Community.

However, the Braden Scale, which has been in use for many years, is a checklist used to predict the risk level of a patient to POSSIBLE skin integrity loss, not a tissue tolerance test, which are used on patients who ALREADY have skin integrity issues.

Good Luck,

Michael

As I understand it there is no standard "tissue tolerance test".Assessment on admission ( also s/p hospitilization or significant change) includes other standardized measurements such as the Braden scale and each residents plan of care must be individualized.In LTC you DO turn/reposition q 2 hours unless the resident requires more frequent turning.-the plan of care should reflect that. That's "tissue tolerance" We have an excellent OT in house and access all types of cushions and mattresses.We do have a stage IV with a wound vac on bedrest at this time.She is on an air mattress and has no range of motion-can't sit on an isch dish at this point.In our facility (if the resident is amenable) bedrest for a set number of days is the best way to prevent an early ulcer from becoming a big problem.

noc4senuf · May 18, 2008

It is NOT ok to automatically assume each resident can be turned/repos every 2 hours. A tissue tolerance test needs to be completed starting within the first day of admit in LTC. A pressure ulcer can develop within 2-6 hours. Yes, it is possible in LTC to complete this task more often than Q2hrs. The tissue tolerance testing is a federal requirement by CMS (483.25). If you are not doing this, it will cause you to get a cite for F314. It is not an option. All nurses and CNA's in our facility do know what tissue tolerance testing is and are able to complete one. If the end result is that the resident needs to be turned/repos every one hour or one and 1/2 hours... that is what is done. If they entered your facility with the pressure sore, then you need to show you are doing everything possible to heal it. IF they acquired it after entry into your facility.... you caused it and it is grounds for a cite. It also is not acceptable to allow someone on hospice or dying to acquire a pressure ulcer.

You also need to look at the resident's nutrition and hydration, what are the labs showing for albumin? IS the person getting enough protein? Many different factors are involved.

As for eating in bed, if the person has a swallowing problem and you choose to let them eat in bed, then you better have someone in the room with them the entire timewhile eating as that puts them at risk for aspiration/choking and can cause another citation. You have to weigh what is best for the resident.

Been through all of this..... not just logically but, the law.

noc4senuf · May 18, 2008

UNITE..... when you become a nurse, and then know the regulations.... then you can criticize someone else's knowledge.

CapeCodMermaid, RN · May 18, 2008

UNITE..... when you become a nurse, and then know the regulations.... then you can criticize someone else's knowledge.

I work in Massachusetts and have gone head to head with many a surveyor over wounds and the forms we were using to document. I have also been to many inservices given by WOCN nurses. At no time was I ever told that a tissue tolerance test was required as part of any assessment.

And, as an aside, stating a different opinion is not the same as criticizing.

asoonernurse · May 19, 2008

I apologize noc4senuf, I wasn't aware that only upon state's awarding me the title of nurse will I have attained "knowledge".

Unfortunately, I only have knowledge as an NA (before they became certified), a CNA (lengthy), an EMT and Paramedic (also lengthy). I have also been published.

Also, looking back on the posts, I fail to see where I am "criticizing" anyone...I seem to be going out of my way not to use derogatory language. I am also trying to be as objective as possible while engaging in wound care discussion with peers.

I am glad to see that in your facility a issue tolerance test is completed within the first day of admission for all patients. Unfortunately, as I stated previously, that is an ideal goal that is rarely accomplished 100% of the time in 100% of the facilities in this nation.

In the many, many LTC facilities it has been my privilege (or horror) to work for, the overwhelming majority of them have been woefully understaffed, overworked and underpaid, leading to a state of high turnover and under-performance.

I am also glad to see you can look up Federal Regulations. However, those same regulations that you cite are often overlooked by the state regulators themselves, or easily covered up by staff who know, oftentimes by a prearranged and announced code, that the state in "in the facility."

It is impressive that you have both the time and the available staff to be able to turn your patients "every one hour or one and 1/2 hours..." I rarely see this done, as charge RNs are normally inundated with paperwork and/or visiting physicians, and LVNs have their hands full with Med Administration (and then more paperwork!) CNAs try hard, but are covering way too many patients, especially when they are working short-handed, which, unfortunately seems to be the norm these days.

I commend you and your facility, but I have just not seen this level of staffing and performance you state in any LTC, no matter how hard they try to make it work.

As for the regulations you cite, does the state cite every instance of a developing pressure sore in your facility, as you seem to imply. They do not in mine. I would be curious to find out how many LTC RNs, LVNs and CNAs would say that the state DOES cite the facility for every new pressure sore. I would think administration would try very hard NOT to be sited for ANYTHING, using every trick in the bag to do so.

You do move on to make some outstanding points, however, associating nutrition and the development of pressure ulcers and dysphagia, a common condition in many LTC patients.

Good Luck,

Michael

UNITE..... when you become a nurse, and then know the regulations.... then you can criticize someone else's knowledge.

noc4senuf · May 19, 2008

All I am saying is that F314 is one of the most highly cited regs in the country. Surveyors are asking to see how we establish the tissue tolerance. Also, when case mix review comes in, we need to show how we are determining tissue tolerance.

When I meet with other DON's, they are all doing tissue tolerance testing as it is a regulation, and adjust their care plans accordingly.

Not all residents need to be repos every one hours, some are able to go two hours. I staff with a ratio of CNA's on my LTC floors at 1:8or9 and on the rehab unit of 1:7or8. It all comes down to teamwork and the NCA's working together to accomplish the turning/repos.