Stege 4 Pressure Ulcers

Long Term Care Columnist / Guide · Mar 29, 2004

Of course it's possible to get stage IV pressure ulcers even when the patient is turned q 2 hrs.......or q 1 hr. I've seen stage II's become stage IV in the course of 24 hours; it's not just a matter of keeping the pt. off the pressure area. There are many, many factors at work in the formation of pressure sores---the pt's nutrition (or lack thereof), the presence of urine or feces in or near the area of breakdown, the general condition of the skin, whether there is underlying infection, diabetes, and the overall condition of the pt are just a few. I've seen dramatic changes in the skin of dying patients especially......one day their skin is intact, and the next day there'll be an open ulcer on the coccyx as the body's systems begin to shut down in preparation for death. (Turning them on a schedule and keeping them off the area of breakdown are more palliative than curative in this instance.)

The best thing to do in the case of a pressure ulcer that continues to worsen is to call the doctor and get orders for a wound consult. These are often done by certified wound care nurses with advanced training in skin issues (they usually are experts in continence and ostomies, as well). When I was in LTC as a resident care manager, I also made sure to get orders for a good multivitamin, Vitamin C, zinc, and protein supplements for any incoming resident with wounds......even if the patient's nutrition isn't good to begin with, this regimen can help.

Hope this information answers some of your questions. :)

longtermcarern · Mar 29, 2004

I saw a nasty stage IV PU at clinical this weekend. There was a lot of talk among the students about neglect in LTC causing this. Is it possible to get these huge ulcers despite 2 hour turning? I hate to point the finger when I really don't know if the LTC personnel were at fault.
Thanks!

do a search for the terminal kennedy ulcer. There is a web site devoted to just this type of ulcer. it is also called the 3oclock ulcer because it is not there at 7am but there at 3pm. happens only in patients that are nearing the end of life.

ktwlpn, LPN · Mar 30, 2004

I saw a nasty stage IV PU at clinical this weekend. There was a lot of talk among the students about neglect in LTC causing this. Is it possible to get these huge ulcers despite 2 hour turning? I hate to point the finger when I really don't know if the LTC personnel were at fault.
Thanks!

Was your clinical in acute care? That patient could have been admitted from home to the LTC with that pressure ulcer or gotten it in the hospital....That kind of neglect is a rarity in LTC around here-we are very closely regulated and monitored...The occurence of a pressure ulcer is a sentinel event-a report has to be made to the state dept of health and believe me they are following up...Too many reports and they see a red flag....We have had several s/p fx hips come back to us from the hospital with pressure ulcers on their heels...I understand that just the time they are in the OR can get that process started and measures are now being taken in the OR to prevent it....Our staff are taught well about skin care and they report every change promptly to us-if we take the appropriate measures stat we can prevent problems...We are very pro-active...In LTC it is all about teaching the cna's and I have an awesome crew on my unit at this time....We also have a certified wound care nurse on staff and many new policies and procedures in force regarding skin care,treatments and nutrition.....It is working well for us....(PS-when my 98 yr old grandmom was in hospital with a hip fx and heart failure someone put knee high ted hose on her and did not take them off for 5 days-the elastic around the top took a band of skin off the complete circumference of both legs-and the wrinkles across the top of both feet caused pressure ulcers...she did not need that pain on top of everything else-that hospital now has added removal ,inspection of the feet and legs and re-application of TED hose to the assessment flow sheet-she was not the first pt this happened too)

CarVsTree · Mar 31, 2004

Was your clinical in acute care? That patient could have been admitted from home to the LTC with that pressure ulcer or gotten it in the hospital....

Yes, clinical was in acute care. Pt. was just admitted for the PU (I think, not my pt.). I do know he was in an Assisted Living Complex with a Skilled Nursing Center. I don't know whether he was living in assisted living or the nursing home section.

Just wondering how out of control these things can get despite nursing interventions.

Thanks everyone for your replies.

gwenith, BSN, RN · Mar 31, 2004

I will add to everyone's replies - for too many years the finger of blame was pointed directly at nurses as the only cause of pressure areas and if you read the literature it still abounds with phrases such as "development of pressure areas are a sign of poor nursing care"

As has already been pointed out there are a multidude of factors cause pressure sores. As well as those already mentioned there is hypoxia and decreased tissue perfusion. Less seen now than previously they are still very important factors in the development of ulcers.

And then there is my favourite "Pressure area development due to otherwise mobile patient acting as a terminal couch potato" The patient who despite no pain or reason to lie in bed does so while treating staff like personal slaves.

CCU NRS · Mar 31, 2004

Of course it's possible to get stage IV pressure ulcers even when the patient is turned q 2 hrs.......or q 1 hr. I've seen stage II's become stage IV in the course of 24 hours; it's not just a matter of keeping the pt. off the pressure area. There are many, many factors at work in the formation of pressure sores---the pt's nutrition (or lack thereof), the presence of urine or feces in or near the area of breakdown, the general condition of the skin, whether there is underlying infection, diabetes, and the overall condition of the pt are just a few. I've seen dramatic changes in the skin of dying patients especially......one day their skin is intact, and the next day there'll be an open ulcer on the coccyx as the body's systems begin to shut down in preparation for death. (Turning them on a schedule and keeping them off the area of breakdown are more palliative than curative in this instance.)
The best thing to do in the case of a pressure ulcer that continues to worsen is to call the doctor and get orders for a wound consult. These are often done by certified wound care nurses with advanced training in skin issues (they usually are experts in continence and ostomies, as well). When I was in LTC as a resident care manager, I also made sure to get orders for a good multivitamin, Vitamin C, zinc, and protein supplements for any incoming resident with wounds......even if the patient's nutrition isn't good to begin with, this regimen can help.
Hope this information answers some of your questions. :)

Completely agree well stated!!!

jkaee · Mar 31, 2004

All the above posts give excellent info on how pressure ulcers start. While it can be the result of poor nursing care, that reason is rarely seen now due to the above mentioned reasons: state regs, inspections, reports to the state, etc. Sometimes, a pressure area is very hard to prevent. A lot of disease processes facilitate the beginning of an open area. And most times, we admit patients from acute care facilities with pressure areas already. In my facility, rarely do we have house acquired pressure areas. They are usually admitted from the hospital with them, due to various reasons.

I'm not bashing hospital nurses, but I also want new RN's and students to realize that LTC nursing is just as complicated and technical as acute care nurses. It's just from a different perspective. And not all facilities leave their residents to die without any care. That's FAR from it. As a matter of fact, in PA where I live, nursing home care is more regulated than the nuclear power plant in our area. That's how strict we are regulated, and we follow these regs. The care in most places I have been is very good, but with staffing the way it is, it is impossible to do everything that needs to be done. The nurses and CNA's work together to prevent pressure areas from forming.

LTC nursing is a very rewarding and demanding field. Don't let one experience keep you from looking into it!

Good luck!

Jennifer

(BTW, the above posts are excellent, exactly what I was thinking!)

Hellllllo Nurse, BSN, RN · Mar 31, 2004

I have seen pts with stage IV pressure sores on all sides of their body.

This is obviously proof that this can happen no matter how often pts are turned.

Meaning- how could a pt get a pressure sore on each hip even if they weren't turned every two hours? For example: If a pt was on their right hip for four hours, then they would be off of their left hip for four hours, but the left hip still develops a sore.

I've seen pts on automatic beds that turn pts every ten minutes still get pressure sores. These students should not just assume that these pts are being neglected in LTC.

Also, many pts are sent to hospitals with intact skin, and come back from the hospitals with bed sores. However, I believe that understaffing, thus, managment is responsible for this, not the nurses.

renerian, BSN, RN · Mar 31, 2004

Yes it can happen despite turning. There are a myriad of comitigating factors I am sure. One being nutrition, meds and all sorts of things.

renerian

CarVsTree · Apr 1, 2004

We just had a lecture on wound care I'm happy to report. On Monday, we're having a wound care specialist nurse (ET?) come in to share some wisdom. I'm looking forward to it.

star77, MSN, RN · Jul 20, 2008

Yes it can happen despite turning. There are a myriad of comitigating factors I am sure. One being nutrition, meds and all sorts of things.
renerian

Definitely. And the fact that now, insurance isn't going to pay for sores acquired in the hospital is going to silence reporting of them.

Sigh.

I found a stage one and a stage two on the same patient on Friday. Got the wound nurse down there, and even though we were trying to turn the Pt, how do you turn a pt onto both sides with an NG tube, a Foley, who's two-days post-op with TWO different organ transplants and in a sh*t-ton of pain? Can turn the pt on one side, but not the other, can get the pt out of bed, for a bit.

I'm just a student, but already I can see how much of a problem the pressure ulcers are. On one hand, there's no excuse. On the other hand, it's tough to keep running around, moving a pt to one side when they're crying in pain.

Thank goodness for our wound nurse, and for the nurses I'm learning from, who are pretty awesome and on top of it - kept that patient moving around as much as they could, even with a full load of very sick people. I have a lot of respect for my teachers.