Pressure Sores 101

One of the most common nursing buzzwords- pressure sores (AKA pressure ulcers). They can be developed by anyone, and in a wide range of places on the body. As nurses (student or not!) it is our responsibility to report, treat and prevent them.

What is a pressure sore?

A pressure sore is an area of skin that has been deprived of oxygen, due to continuous pressure. This prevents the area of skin getting enough blood, causing the skin to “blanch” (become white due to lack of blood flow). This can then develop into varying degrees of tissue damage; ranging from grade 1 to 4 depending on the severity (NHS Stop the Pressure, 2009).

Grade 1-  skin is intact but blanching, may be some heat/oedema as well 

Grade 2- partial thickness skin loss, looks like an abrasion or a blister. 

Grade 3- full thickness skin loss, some fat may be visible. Possible ‘undermining’ or ‘tracking’ as there is usually depth, depending on the location. This depth can sometimes be covered by slough, which needs to be removed before proper grading can take place. 

Grade 4- full thickness tissue loss, with exposed bone or tendon. There tends to be undermining or tracking, depending on the location. 

Where do they crop up?

Areas that have a hard bony prominence are at risk of pressure sores. This is because they have the least amount of skin protecting itself.

What factors lead to a higher risk of pressure sores?

There are many factors that increase the risk of pressure sores:

  • poor circulation – this could be caused by kidney problems, heart diseases or diabetes.
  • reduced/no mobility- it doesn’t have to be long term! even short term loss of mobility (e.g. after an operation) leads to a pressure ulcer risk.
  • friction- this is where good practice comes in. People who transfer frequently between bed-hoist-chair or just bed-chair, and being moved up/down a bed are at risk. This is why we use slide sheets!

How can they be treated?

  • regular re-positioning/ turns are vital! This helps distribute the pressure, and reduce the risk of the pressure sore from getting worse. You must assess whether the patient is able to do this themselves, or if they require help. Asking the patient (if they have capacity) is always best.
  • pressure relieving devices such as airflow mattresses or pressure cushions can be obtained through physiotherapists, occupational therapists, some trusts require nurses to send the referrals (depends on the area).

  • regular cleaning of the area. Special washes can be used such barrier creams or sprays like ‘Sorbaderm’. This is especially useful for pressure sores on the buttocks/sacrum as they are subjected to lots of moisture.
  • dressings! There are a wide range of dressings which can be used on pressure sores, those that have foam are good for extra protection.

 

How can they be prevented?

Similar to the above treatment! Encourage your patient to mobilize frequently (if possible) and explain the reasons why. Those who are at risk will be identified by their Waterlow Score (10+). If in the community and the patient has carers/relatives helping with their care, speak to them and ask them to update you on any concerns re: pressure sores. Completing bodymaps whenever a new patient arrives and update it regularly is also important. This allows you to assess the patient’s skin integrity, and keep an eye on any possible developments.

 

If you have any ideas for another ‘101 guide’, please get in contact via facebook, twitter or email us on enhancingplacement@gmail.com.

 

 

“The doctor says I’m dying”: tough conversations about death

One of my most vivid placement memories was my first conversation with a patient about dying. One afternoon I went to check on Joan (name changed), a lady in a side room on an elderly ward. I was helping her to have a drink when she looked up and said: “the doctor says I’m dying.”

I froze. My stomach turned and my mind started racing, taken aback by a statement I felt totally unprepared to respond to. I had grown fond of Joan and to see her so distressed was upsetting. I felt a sense of panic, worried that I might say the wrong thing.

I knew from the handover that morning that Joan was receiving end of life care and from what the other nurses had said, she was deteriorating and it was unlikely that she would get any better.

Taking a deep breath, I thought back to our communication lectures which covered how to deal with difficult questions. I drew up a chair next to Joan and holding her hand, I asked some straightforward questions like ‘when did you discover that?’ and ‘how does that make you feel?’, trying my best to mask my own anxiety and appear relaxed.

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While I think I started off ok, all of a sudden I panicked; I didn’t know what to say next.  Almost without thinking, I said: “Don’t worry Joan, we’re all doing everything we can to get you better and back to your normal self.”

I immediately felt awful and her face said it all; she knew I was covering. I said it out of a desire to help Joan stay hopeful, optimistic, but in reality it sounded trite, like I was brushing her off and trying to avoid a deeper conversation. I think that it made her feel worse.

Kicking myself, I spoke to my mentor who reassured me that she too struggled with questions like those and some research when I got home that night revealed that I wasn’t alone – apparently it’s common for healthcare professionals to avoid or block difficult questions, particularly about death or dying. I suppose we like to focus on how we can ‘fix’ things and don’t want our patients to lose hope.

Looking back, I wish I’d spent more time with Joan, even just to sit quietly by her side. She may have had more questions that she wanted to ask and as a student nurse, I may not have known the answers but I could have found out on her behalf.

Honesty and courage are such important parts of nursing, especially at the end of someone’s life. Sometimes the best thing we can do is to be there; to listen, answer questions and ease fears – or just to hold someone’s hand and let them know that they are not alone.

Commentary: “If you need anything just use the Buzzer…”

Firstly, I would like to say thank you to Tasha for her thoughts on call buttons. I think this is a very important topic in terms of understanding patient need and attainable levels of comfort.

There is a reasonable amount of research out there exploring patients’ perceptions of the ‘busy nurse’ and how this changes their willingness to ask for support as well as what they value in nurse-patient communication (see McCabe, 2004 for an excellent introduction).

I think it is always worth keeping in mind that what may seem trivial to us might be something that is far from trivial to our patients. Taking your slightly colder water jug scenario – to a mobile individual who can get up to get their own water whenever they want and who feels relatively in good health it may be rather trivial to want colder water. But to a patient who may be feeling nauseous, overheated, uncomfortable and is currently bed bound – that cold water may mean a great deal. I realise that it was a comment made in jest but I also think you hit on something: patients are in an unfamiliar and ultimately uncomfortable environment and this discomfort will manifest itself in different fashions and lead to different patient responses.

Hospital stays take patients out of their own environment and place them in close proximity with other patients at a time when some or none of them may be feeling particularly well. Then to add insult to injury we ask them to do things such as have personal conversations about their care and condition or use a commode with nothing but a thin curtain between them and a dozen other individuals. As much as we try to preserve the dignity of our patients and attend to making their experience positive, I can’t help but think how excruciating I would find being admitted to hospital myself. Add to that the fear of upsetting a nurse who has labelled me as calling ‘unnecessarily’ for an ‘outrageous reason’ when my world has been reduced to revolving around the next mealtime, managing my pain and whether I need the toilet or not.

Of course there will be times when we realise we are dealing with a patient who is calling for an element of attention rather than just water. But maybe that attention is just as important in terms of the nursing care that we can provide. Have I reassured my patient sufficiently? Have I answered all their questions? Have I promised to do things previously and then forgotten and hence lost some of their trust in me as their nurse? Have I fully taken their immediate psychological health into consideration as one of my nursing goals for their care?

I would say that there are things we can do during our not-so-busy moments such as making a point of checking in on them rather than waiting for a call button to ring. That little bit of extra support may alleviate some of their concerns and decrease their use of the call button – thus leaving us in a position where we can trust that if the button goes off we know it will be something more serious.

McCabe, C. (2004) Nurse-patient communication: an exploration of patients’ experiences. Journal of Clinical Nursing, 13(1):41-49.