Patients who are too unstable to turn

CrabbyPatty · Dec 8, 2010

Does anyone have any suggestions for preventing skin breakdown on a patient that is too unstable to turn? I was moving his arms and legs and tilting the bed hourly at least. And of course, he pooped 3x...of all the patients that you don't want pooping...so he did get turned two times on my shift. When we turned him for his chest xray I was amazed that there wasn't any breakdown yet (after 2 days of laying totally flat) but I'm wondering if you guys have any other suggestions. Logistically, we were not able to get him on a specialized mattress either.
Caroline

I too would love to know what the options are. When I was on orientation, several hours into our shift, I suggested to my preceptor that we turn our vented patient.....as soon as we did, she went into SVT. I never had a situation like that again (thankfully), but I'm guessing that in reality, skin breakdown is a better alternative than death! If there is an answer out there, I'd love to hear it.

sunnycalifRN · Dec 8, 2010

We just had a patient that would desat if you looked at him cross-eyed. So, turning was definitely out. He couldn't be turned for a week and when we finally were able to turn him, he had a stage 3 decub . . . but, he eventually made it out of ICU!

edogs334 · Dec 8, 2010

There was a patient I had when I was still on orientation (or was it when I was off orientation? I forget :uhoh3: - been off for a few months now) that would brady down to the 30's if you turned, suctioned or otherwise stimulated him significantly. I kept Atropine at the bedside and actually had to push 0.5mg once. The attending ordered a Scopolamine patch because evidence has shown it worked- for what reason he didn't really know. Anyways, the Scopolamine actually worked in the sense that he didn't brady down when stimulated- so we were able to turn him more often after the patch was applied.

Darkfield · Dec 8, 2010

If you can't turn them, don't! What is more important, life or skin integrity? If a patient gets a bedsore because you can't turn them because their pressure drops to 60/20 when you touch them, don't turn them. I hate these kind of patients because I feel like a horrible nurse. Turning, positioning and cleaning are absolute basic nursing care and it makes me feel so weird to let that go!

When we have patients on the occilator, we turn them q4, if that, because they are so unstable. And if they have skin breakdown, so be it. Life is more important.

If you have a pt that is really sick but not at a point where they can't be turned, think about getting them on a better mattress, but at some point, without turning, even the best mattresses fail.

meandragonbrett · Dec 8, 2010

When I have a patient I can't turn because of their status I always make sure to get one of the docs to write an order that says "do not turn patient" just so my own management team doesn't come after me when we have a Stage 3 or 4.

Pediatric Critical Care Columnist · Dec 8, 2010

It's usually possible to reposition most of these patients. Turning doesn't have to mean flipping them side to side like a burger. I find that using bolsters and wedges to bank the patient even slightly can mean no deterioration and no ulcer. If you shift their weight gradually from completely supine to slightly banked to the left to slightly more banked to the left and so on, you're redistributing the pressure almost as effectively as turning. Use a draw sheet to ease them off the mattress and allow space to slide the wedge in and they'll hardly notice.

TemperStripe · Dec 8, 2010

This particular case was an incredibly unstable pelvic fracture so the wedge wouldn't have worked because the patient needed to be 100% flat, but I will definitely keep that in mind for the future. I agree with the above poster who mentioned feeling like a bad nurse...I felt the same way! Turning and skin breakdown is 100% nurse-owned and its' always been drilled into my head from day 1...so yes, leaving them flat goes against EVERYTHING I know. But yes, life is more important than skin...no life= no skin, right? Airway, breathing, circulation......skin.

ObtundedRN, BSN, RN · Dec 14, 2010

There was a patient I had when I was still on orientation (or was it when I was off orientation? I forget - been off for a few months now) that would brady down to the 30's if you turned, suctioned or otherwise stimulated him significantly. I kept Atropine at the bedside and actually had to push 0.5mg once. The attending ordered a Scopolamine patch because evidence has shown it worked- for what reason he didn't really know. Anyways, the Scopolamine actually worked in the sense that he didn't brady down when stimulated- so we were able to turn him more often after the patch was applied.

Scopolamine is an anticholinergic, just like atropine. That is why it had some effect for you. Anticholinergics are also used to decrease secretions. Which is why atropine is also used for organophosphate poisonings. You should teach your MD why it works :)

TangoLima · Dec 17, 2010

Our beds have a rotation function built into them. You can set how much of an angle you want to turn the patient and what time interval. I usually always set the bed to 30-degree rotation each 15 minutes on all my patients, and then prop them on pillows as often as I can in addition. For my more unstable patients, I may use 10 or 20 degrees rotation at longer intervals.

Nobody mentioned that here, so I thought I would throw that out.

CrabbyPatty · Dec 17, 2010

Our beds have a rotation function built into them. You can set how much of an angle you want to turn the patient and what time interval. I usually always set the bed to 30-degree rotation each 15 minutes on all my patients, and then prop them on pillows as often as I can in addition. For my more unstable patients, I may use 10 or 20 degrees rotation at longer intervals.
Nobody mentioned that here, so I thought I would throw that out.

Although I feel it's better than nothing, the rotation function on the bed is for pulmonary issues and does not replace turning patients to prevent skin breakdown. At least that's what our management told us after a study at one of our sister hospitals.

ObtundedRN, BSN, RN · Dec 17, 2010

Although I feel it's better than nothing, the rotation function on the bed is for pulmonary issues and does not replace turning patients to prevent skin breakdown. At least that's what our management told us after a study at one of our sister hospitals.

I was about to post the same thing. It is only for pulmonary function. Also helps decrease urinary stasis and prevent fever. But I suppose it is better then nothing.