This Burns My Britches!

[leslie :-D]

My mil was in the hospital around 1 month ago and had an emergency knee replacement. She was quite sick for awhile, as the plastic in her knee from the replacement 12 yrs ago caused a local then systemic infection.

This hospital she was in, has been consistently voted in the top 10 nationwide.

In this hospital, her buttocks and coccyx broke down; by the time she was transferred to a rehab hospital, it was stage III-IV and approx 10cm diameter.

This was totally from her not being repositioned.

When I spoke with the DON in this hospital, I told her how preventable this was.

That day they got her on an air mattress.

The rehab hosp discharged her home last week.

I've been doing the dsgs 1x/day and visiting nurse, 1x/day.

I told the visiting nurse that mil needs aggressive surgical debridement as the tissue is non-viable.

So now the visiting nurse is going to get a plastic surgeon involved.

GRRRRRRRRRRRRR. I am so freakin' upset.

My neighbor, who is a very sick and brittle diabetic, had bil aka because of heel ulcers he got in this very same hospital.

And my mil's roomate in the rehab hospital, also had decubs from this hospital.

How long does it take to reposition a patient??????

What the hell is it with these nurses that just don't get it?

Repositioning a patient has to be one of the easiest yet most effective interventions we can do to prevent skin breakdown, never mind STAGE III-IV DECUBS!!!!!!!

Now I am sure that my mil will be going back to the hospital for surgery to remove all of this necrotic tissue. And she's on oxycontin for pain with only moderate relief. :angryfire

Why does this ignorance exist?

There is no reason for something that takes 1-2 minutes q2-3 hours.

leslie

[caroladybelle, BSN, RN]

In an ICU setting, there are no aides to assist in turning pts. An ICU nurse must round up other busy ICU RN's for assistance in turning. While I know that this is no excuse for the higher incidence of decubs seen in the ICU setting, it is most definately a contributing factor, particularly when there are critical pts going bad all over the place. Never forget your ABC's. And sadly, in a busy ICU, Q2 re-positioning does have to take a backseat to critical care. That's just one more supporting reason that the sooner a pt is stable, the sooner the need for transfer. But a stage III-IV decub occuring in ANY hospital setting is deplorable. :angryfire

Sorry, but I have problems with this.

I work BMT, and carry 4 patients. We do not have aides, most of the time. Those patients require isolation precautions - ALL OF THEM. We may have patients on Bipap ( vent support without the support of sedatives/ET tubes), They may be on tele. They have 3-6 central IV lines with meds/TPN/Tac/ABXs infusing at all times. Many have hourly I/O, hourly blood work. Daily transfusions often with severe reactions d/t sensitization are the norm.

All my patients are pretty critical.

These days, "stable" floor patients have nitro running, insulin gtts, tele, multiple central lines, IV meds, continuous Bipap, IV dopamine/cardizem, ...all things that used to require admission to the unit...and we may have 6-10 patients, frequently without aides.

I routinely go to the units to give Chemo ( on top of carrying my patient load) because only "chemo nurses can give chemo". I write down the required followup care in detail and explain to both the primary nurse/charge nurse what followup is required. and variably receive the patient back in 2-10 days, with mucositis/thrush so severe they have to be on PCA/TPN (oh, good another infection factor), decubes, and inadequate I/O monitoring/maintenance (resulting with deafness, renal failure, hematuria). And yet these are the same standards that I have to adhere to on BMT with 4 patients, and on onco/hemo with 5-10.

We all have critical patients and inadequate staffing/assistance to deal with, floors and units.

[LydiaGreen]

In the nearly four years (three as a student in clinicals) I have been at "my" hospital - I have seen only three patients with decubitus ulcers. One came to us from an LTC facility in another county and two from being cared for at home by family members who were simply overwhelmed and unaware of the risks of skin breakdown. I have never seen a decub result from a stay in our hospital. Why? It simply would NOT be tolerated. Our administration and senior nursing staff have been adamant from day one that decubs are preventable and will NOT be tolerated in this hospital. Meetings are held to determine the most "at risk" patients and they are given the special mattresses. We have only one local LTC and they have similar policies and I have never seen a patient arrive from there with any skin breakdown. Again, this simply would NOT be tolerated.

I have never heard of a "turning mattress" but I think this would give a false sense of security to staff and patients alike.

Sorry about your MIL's discomfort, pain, and unnecessary suffering.

[Surgical Hrt RN]

this is exactly why my blood is boiling.

it should have never gotten to these stages.

there's an opening/hole that is 3cm deep and when i look in it through a flashlight, it is white and hard.....bone?????

and yes, many patients do refuse to be turned because of the pain.

and even when patients have refused, i still have gotten them to consent.

i round up 2-3 cna's and even minimally turn them....slowly, gently and supporting all body parts, especially the areas that are injured.

no matter how busy i've been, i recognize those that are at high risk for breakdown and make it a priority to turn them.

mil's skin broke down in the icu....the nurse had 2 patients.

and dh went there one day with mil's nurse at the desk eating a bagel.

when dh stated that mil was in extreme pain, icu nurse said she'd be in there after break.

and she stayed at that desk for 30 minutes. :angryfire :angryfire :angryfire

i gotta calm down.

nothing burns me up more than this! i am an icu nurse and have been for over 6 years! i would never do this! i have to admit though i have come across quite a few nurses that have! it is disgusting! of course there are times when we are busy and can't get to a room promptly, but sitting at a desk eating a bagel! please!!!!! where was the charge nurse, where was the manager? what a bunch of crap!!!!:angryfire

[Ortho_RN]

Well it's been quit a while since I last posted, but I figure this is a good one to return to. So would you like to mail your license to your BRN via USPS or hand delivery? At least this way, no patient has to suffer, because taking responsibility for that many acutely ill pts is eventually going to lead to some unfortunate situation for your pt and/or possibly you. In fact, I read one study which states going from 4 to 8 pts per nurse increases the risk of dying by 31%. Do with the information as you wish.

Surely there is some sort of way you can legally refuse such an assignment, or take the assignment with the provision that your license isn't hanging on a noose. That way you can promptly spend your next day looking for a new job. I know in TX such protection is called Safe Harbor.

Trust me.. I'm looking for another job... I'm just having to hold out till the end of the month, b/c I have a cruise scheduled and I figured another job wouldn't want to give me that much time off.. So as soon as I come back fromt he cruise, I will be full force in finding something else..

The 9pts days are not all the time, we usually start with 7 or so then with admits, the numbers keep going up, but the staff doesn't get added.... It's really frustrating trust me. We have tried everything, our Unit Manager is worthless.. She always tell us there is noone else.. Well if there isn't then send the patients somewhere else.. There are other floors is that hospital. One of our nurses went to UPPER management about several issues, so hopefully things are gonna get better.. Plus Oct 1, we are merging with a new company called Triad, so they are suppose to change some things

[CCU NRS]

I could not agree more! This is one of theose things that is a must! I also feel that delegating this task is not sufficient, I feel that participation is necessary. I know everybody is busy but you have to check your Pts q2 anyway so time your interventions to coordinate turning with your CNA. This is the only way you can be sure it is being performed unless youi just do it yourself. There are other thing we as nurses can do inside our scope of practice as well. We can advocate for specialty beds/mattresses, we can report early signs if breakdown and request orders for intervention.

http://www.okcnursingtimes.com/specials/newsletter_view.asp?newsid=333&catid=88&active=0&mode=current&count=0

[leslie :-D]

I could not agree more! This is one of theose things that is a must! I also feel that delegating this task is not sufficient, I feel that participation is necessary. I know everybody is busy but you have to check your Pts q2 anyway so time your interventions to coordinate turning with your CNA. This is the only way you can be sure it is being performed unless youi just do it yourself. There are other thing we as nurses can do inside our scope of practice as well. We can advocate for specialty beds/mattresses, we can report early signs if breakdown and request orders for intervention.

http://www.okcnursingtimes.com/specials/newsletter_view.asp?newsid=333&catid=88&active=0&mode=current&count=0

wow ccu, that was an excellent, excellent article.

thank you.

even though it should be a no-brainer, yes?

leslie

[NeuroICURN]

Ok, I'm supposed to be working on some school work (I'm finally trying to finish my BSN ).....but I'm taking a quick break to visit you all! So, this has to be a quick posting.......

I work ICU. Our unit has the lowest rate of skin breakdown in the hospital. Why??? Because all of us make turning a priority!!! And not just turning, we turn and we try to rub their backs and pressure areas with cream a minimum of every 4 hours to get the blood flowing! When skin breaks down it's just another route that allow bacteria, etc. to enter the body...which, in the long run, only adds to your problems with a pt.

However, I do have to say that you have the rare pt. that, no matter how hard you try, will get a red spot, or a little stage 2...but we don't let it get any further than that, we're pretty agressive. Also, if what we're doing doesn't seem to be enough, then we get the skin care RNs involved! I swear, some of these pt's I have like a thousand pillows in bed with them...one under their butt, one under their back, one for each arm, one or two to get the heels (that I've already used skin prep or benzoin on) off the bed, LOL!!!

One more thing that I think we're all forgetting here.....Turning also helps the resp. system!!!!!!!!! And what's more important than keeping those lungs open and being able to move that mucous around so it can be coughed/suctioned out??????

And one final note....in neuro, we do have the rare pt. that is only a once or twice a shift turn....but only because they can't tolerate it for other reasons. I've had pt's that will thyroid storm when you so much as lift their pinky finger. Though these pt's are pretty uncommon, thank goodness!!!

Leslie, I hope your mil finds relief soon and she's lucky she has you to fight on her side!!! Keep us updated on her progress!

[RN92]

some of my inlaws were quite vocal with their concerns.

yet they do not understand the implications of not having a patient turned.

one nurse told my husband that they could not turn her because the operative knee couldn't be moved.

Then shame on the nurses and shame on the system. You should probably go above the DON. Ask for copies of her medical chart. If for no other reason, just to make them nervous. Did they ever debrid her wound? Dsg changes arent going to make much difference if you dont get rid of the dead tissue first. (Im sure you already know this). She is very lucky to have so many involved family members. Many elderly pts have no one. I have visited pts, who's family could care less about them. Let us know how things go.

[CCU NRS]

wow ccu, that was an excellent, excellent article.

thank you.

even though it should be a no-brainer, yes?

leslie

Thank you for the compliment, and yes it should be a no brainer.

[CCU NRS]

some of my inlaws were quite vocal with their concerns.

yet they do not understand the implications of not having a patient turned.

one nurse told my husband that they could not turn her because the operative knee couldn't be moved.

Then shame on the nurses and shame on the system. You should probably go above the DON. Ask for copies of her medical chart. If for no other reason, just to make them nervous. Did they ever debrid her wound? Dsg changes arent going to make much difference if you dont get rid of the dead tissue first. (Im sure you already know this). She is very lucky to have so many involved family members. Many elderly pts have no one. I have visited pts, who's family could care less about them. Let us know how things go.

I am sometimes awed by what I hear from friends and relatives after they have a hospital experience.

I have an uncle that had a CABG recently somewhere in Georgia (no offense to anyone from Georgia)and post procedure they told him he could not use his arms to help support his weight for six weeks! WTH I have people getting out of bed day 2 and using their arms for support every inch of the way!

[nursemary9, BSN, RN]

Hi

This is always one of my top priorities!! TURN; REPOSITION; it only takes a little time.

Why is it such a big thing with me?? Well, when I was 44 yrs. old, I had my first hip replacement; I was on an Ortho floor; Within a day, I had the start of a skin breakdown on my sacral area; WHY?? They didn't move me & I was so out of it I didn't even think about it. As the days went by, no one noticed that I had this & quite frankly, I couldn't see back there, of course so I didn't notice!! DAH!! I was blond at that time!!

So when I got home, DH was taking great care of me & says, by the way, you have quite a bed sore there!! Well, to that time I hadn't really felt much.

Well, then it started to bother me.

Since this was about 15 yrs. ago, we tried a lot of the things that were available at the time--however, it got bigger & bigger despite the fact that I was now up & around. Well, he kept obsessing about it & I finally had him take a polaroid of it & I was amazed at the size--I was also amazed that it caused more pain then the surgery had!! We finally treated it with one of the wound gels that I had gotten a sample of at a seminar & it was gone in a week.

But I learned how important that turning & repositioning is & that skin breakdown can happen VERY quickly.

A few minutes of basic care can prevent months of agony and expense.

Mary Ann