Pressure sores and geriatic facilities

[TurtleCat]

This is something I've been concerned about recently. I'm a relatively new CNA working in a geriatric group home, and I am curious about the exact causes behind pressure sores and how to prevent them. I am concerned because I've noticed pressure sores in a few of my clients and I'm not sure how they occurred. I have of course reported it to my house manager, who is looking into it. The thing is I want to make sure I'm doing my job properly. From my understanding, if you follow proper precautions and procedures -- repositioning on their side every 2 hours, cleaning thoroughly w/ soap and water after incontinence and changing them, applying barrier creams, etc. the risk of developing skin breakdown and sores should be low. Yet, they have them in spite of the fact that I'm turning and cleaning them every 2 hours. What could be the reason for this? I've thought about it and I've figured out a few factors may be coming into play.

1. This is the obvious one -- I'm not the only one who works there. I'm only there 2 or 3 nights a week, there's only so much I can do as one person and it could easily be that someone else there isn't doing their job. I hate to point fingers but sometimes I worry the day shift isn't caring for them as they should. From the impression I get, they leave them sitting in a chair most of the day and when I come in for the night shift to check them, I'll find myself wondering "Jesus CHRIST, when was the last time these ladies were changed??" They'll either be soaking wet, or were cleaned in such a half-hearted manner that they still smell, have urine or BM residue on them, etc.

2. I fear they might be in the dying process. I know with one lady I was caring for who had a bedsore that wouldn't heal, she was on hospice and passed away shortly afterward. Of course when the body is about to die, it loses its ability to heal and repair itself as normal. Also, what are some of the major causes of pressure sores, aside from not turning or cleaning -- poor circulation, malnutrition and dehydration, right? So if their blood's not circulating properly and they aren't getting proper nourishment from a diminished appetite and food intake, I could see that also contributing to the development and subsequent deterioration of a sore.

So basically, I'm wondering what could contribute to a pressure sore and cause it not to heal even when proper precautions and procedures are followed. I just want to make sure I'm doing my job correctly and that there's nothing I'm missing, because if there is I want to change that and make sure my clients are properly cared for.

[CapeCodMermaid, RN]

Turning and repositioning every 2 hours certainly is a good idea, but not all pressure ulcers can be prevented. Does the person have diabetes? PVD? Anemia? There are many reasons for skin breakdown. Those residents are lucky to have someone as caring as you seem to be on their side.

[NutmeggeRN, BSN]

And sometimes, when you look at a persons butt sideways, it breaks down! just kidding but really, skin is SO fragile breaks down so quickly. Keeping them clean and hydrated, reducing pressure and friction and vigilant monitoring!

[NurseGuyBri]

You better be going to nursing school. Your level of interest and care already says to me that you need to be in charge of making things happen! Thank you for restoring some faith in the nursing force. Great job- and yes, there is a lot more to it. Do some research, google, go to the NPUAP website (just google NPUAP) and you can learn a lot from there. Thanks!

[LemonAide]

I've seen pressure ulcers start 30 minutes after repositioning with end of life care. Thats with a air bed and heel booties.

[nursejenny1310]

Also, research "Kennedy Ulcer". But I agree with the others, sometimes all the prevention in the world wont matter, and I certainly hope you are going on to nursing school!

[chrisrn24]

Also research "Kennedy Ulcer". But I agree with the others, sometimes all the prevention in the world wont matter, and I certainly hope you are going on to nursing school![/quote']

Never heard of that! Thanks for the info!

[jayni87]

Firstly, thanks for the Kennedy Ulcer. I'd never heard of that, so that was a good research project. Also, OP, please go on and become an RN! You obviously care about your patients, you're very literate, and we need more nurses like you!

[ali.nystrom]

Sounds like you are doing your job the best you can. Sometimes other CNA's don't do the job as they are supposed to--and there is nothing you can do about that. I would keep slathering on the butt cream and turning them every 2 hours (at least). That will at least keep them from getting anyworse (hopefully...)

I would bring it up to the charge nurse (or whoever is in charge) if it keeps happening. It is so inappropriate for patients to be treated that way.

[VivaLasViejas, ASN, RN]

It's not always neglect of hygiene and positioning, although that doesn't help matters any. Nutrition is another major concern that comes into play in the formation of pressure ulcers. Many frail elderly simply don't eat well enough to maintain adequate protein stores that help keep skin intact, and we often have to give them things they don't like very much, e.g. ProSource and similar nutritional supplements, multiple types of vitamins etc. in order to prevent breakdown.

The active dying process is another consideration, and I've seen some pretty dramatic skin changes in very short periods of time. In some hospice patients, I've literally seen pressure ulcers that begin as a Stage I on day shift progress to Stage III by the next morning and Stage IV before the day is out. (The patient generally does not live long once the skin starts breaking down like this.) At one of my ALFs, we had a lady who literally got a new pressure ulcer every time we repositioned her. Of course, we were turning/changing every hour or so and as needed, but at that point it was futile---by the time she passed, she had breakdown on every bony prominence. Even her elbows and the tips of her ears.

I echo the sentiments of the other nurses here who have encouraged you to further your education and become a nurse yourself. You have a lot to offer, and it's obvious that you care about the health and comfort of the people you work with. We could use more of your kind of folks in this profession!