Want to hear from experienced LTC nurses

CoffeeRTC, BSN, RN · Apr 26, 2017

It all depends. Pressure ulcers are preventable. We all know that. In a perfect world with adequate and above average staffing, great food, plenty supplies, restorative nurses where all the residents get the best care, your numbers still might not be 100%. Some residents just decline. The hospice patient that hasn't eaten in days and is in so much pain that the staff decides frequently turning causes too much pain...your in-house aquirred numbers are unavoidable. We all still strive for that number.

Same with skin tears. Accidents happen.

mander · Apr 27, 2017

First of all, there must be some policy you can refer to. It might need revamping.

When we have an uptick of new pressure areas, we put 2 hr turning sheets on all the closets for everyone to sign and do a lot of in servicing. We order labs, involve the dietician, have therapy put in their 2 cents on positioning etc, and do some more in servicing. We have a nurse practitioner that comes in and does skin rounds once a week. We alter care plans and treatments accordingly. Add in some more education from CNAs to unit managers. We found that a lot of nurses were just coming up with their own treatments or using treatments common 10 years ago. We changed out our inventory and came up with some standard materials to use. ( For instance, everyone used to put dermagran on everything. Like, it was Windex from My Big Fat Greek Wedding. We completely removed it and came up with new basic treatments for skin tears vs excoriation vs different stages of pressure areas, hung guides on all the tx carts and tx rooms.)

We just had a pretty good inservice yesterday on pressure ulcers. We are using a tool to determine if it's unavoidable vs avoidable. A big take away from the inservice was to use certified tools to determine risk for PU (Braden or Waterlow, not make up your own)and use treatments that fall in line with current standards of practice (see my dermagran issue). Oh, and after 2-3 years the skin might be 80% of what it once was.

If your pressure area is not improving in a few weeks, a new treatment should be initiated. You need to look at all comorbidities and medications that could affect healing. We like to add a protein supplement for some residents. We started applying skin prep to b/l heels for 14 days after admission on our rehab unit for ALL admissions because we had a few sudden heel areas. We bought a few new cushions specifically for elevating heels. We don't use "heel cups" anymore. We use Herbst boots or use elevate of a pillow. A lot of changes happened in the past year for us.

For skin tears, we can really only use lotion and maybe a geri glove or tube grip to cover. (I know we probably use different terms). We document that skin is fragile or if someone again is on a med that might impact healing. If the resident is resistive to care we might care plan to re approach as necessary, take ID badges off and put into pocket, have maintenance check bedside tables and equipment... And we avoid side rails as much as possible. (I worked at a county owned facility that was recently bought by a private company and we had a huge staff and policy turnover... almost all of our beds had side rails and a lot of older staff had no idea most places got rid of them YEARS ago...)

Your facility might also have to suck it up and pay for some new pressure relieving mattresses. Reevaluate who has what type of mattress- maybe someone who used to roll out of bed no longer is as mobile and her risk for a pressure injury outweighs her risk of falling.

It might be worth it to get some outside help if you really can't get a handle on this. We joined up with another... ugh idk what to call it. They own a lot of facilities and have a lot of resources though. Getting someone to evaluate your processes from admission to discovering a pressure area to tx and prevention might help. Sorry for the rambling, but yes it IS possible to prevent and heal pressure injuries!

CKPM2RN, ASN, EMT-P · Apr 27, 2017

Thanks for the great advice. The facility I'm in does a really great job and a lot of these patients with pressure wounds come to us with them from home, etc. But as I'm watching the co-morbidities do their dirty work (labile blood glucose, arterial and venous issues, patient returning always to preferred position, etc) I feel defeated.

CKPM2RN, ASN, EMT-P · Apr 27, 2017

And overwhelmed. LTC is not for sissies! One RN, 33 patients and it is impossible to give each patient the attention they deserve.

CKPM2RN, ASN, EMT-P · May 18, 2017

UPDATE.

I'm realizing that the super stubborn wounds are on the people who have so many co-morbidities and are so unhealthy to start with and not to mention non-compliant. I have had my spirits lifted by some recent gorgeously healing wounds in a few of our residents.