Shearing/Pressure Sores in Bariatric Patients

[notanumber]

A&O lady who chooses to stay in bed 90% of the time in fowler's, can make small adjustments in position independently, non-ambulatory, foley cath in situ and continent of bowel, developing sores on both buttocks from what seems to be a combination of shearing and pressure. She insists on having a plain draw sheet as a turn sheet, because the sliders make her 'slide down too far' and I think this has exacerbated the issue. Surrounding skin is always somewhat inflamed, and the skin seems unusually fragile and prone to peeling.

Aside from requesting maybe an alternating pressure mattress from OT, what wound care would you implement? Even my mepilex borders are peeling off strips of dermis. Alldress is a bit better. I want to cover the area with *something* to protect it from shearing and friction. Should I insist about using the slider sheet, even though it means more frequent boosts?

[bgxyrnf, MSN, RN]

I would use the slider, for sure.

Put the bed in slight Trendelenberg to help keep her from sliding down.

Barrier cream can help reduce shearing forces.

And then turn as often as necessary... q30m if need be.

[KatieMI, BSN, MSN, RN]

Most important thing would be using slider or TARP system, air loss mattress (if available), barrier cream and making this lady moving her butt about every 30 min, sharp, during the day and at least every 2 hours at night.

This patient (and her family, if any is there) needs to be spoken with in unequivocal terms. She can "like" or "want" whatever she likes or wants but then she should know what she is palying with. Sepsis, pelvic osteo, PICC line, chronic pain, all the trimmings.

Why she has Foley? Maybe getting her up to pee would break the circle? If she is that bad incapacitated, does the facility has enough staff to manage her needs? If no, if there alternative placements?

[LovingLife123]

How are you turning her and how often? Are you putting pillows under a different side each time you turn? Are you talking about leaving the slide sheet under her? That should not be done.

[notanumber]

I forgot to add - this res is in LTC.

Refuses turning, cannot tolerate any position other than fowler's due to chronic pain and SOB. Sleeps in this position as well (which looks so uncomfortable, but...). It's common practice here to leave sliders on, but good point - I will see if we can get this lady to cooperate with removing it after repositioning (laying supine and rolling are difficult for both her and staff - it's a 2P assist and she requires a boost several times a day). Maybe no slider + air flow mattress, if the res will tolerate change (change is bad and terrible). Foley in place d/t res request and refusing all other measures - not incontinent - full lift but hates lift and refuses. Res has right to refuse care, and this is her home. We always try to find a compromise that will work even if not ideal - e.g. foley.

[beekee]

Whatever you do, document all efforts to turn, interventions tried (and those refused) as well as patient education.

[AceOfHearts<3]

See if you can get a big waffle cushion for her sacrum area. They remind me of chic fila waffle fries, but really redistribute pressure and allow airflow. They can make a big difference and can be used 24/7- whether laying in bed or sitting in a chair. Most people find them pretty comfortable too.