Zero Tolerance for Bedsores
Bedsores (also called decubitus ulcers, pressure sores, or pressure ulcers) are the breakdown of skin resulting from excessive pressure that cuts off blood circulation. Friction burns also cause ulcerations when nursing personnel drag their patients on the sheets while pulling them up in bed. This subject deserves its own chapter because bedsores are one of the most common complications of hospitalization and exist in every hospital and nursing home.
According to the U.S. Federal Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality), as of 1993, 10 percent of all hospital patients and 25 percent of all nursing home residents develop bedsores during their stay. Empirical data indicate that these percentages are on the rise. Bedsores are usually the result of institutional neglect, and although prevention is difficult, bedsores certainly can be prevented.
Skin ulcers develop from the weight of the body resting on certain areas of the skin for long periods and from unnecessary friction. A primary responsibility of nurses is to relieve that pressure of weight and to avoid the chafing that comes from dragging the patient's buttocks on the sheet. The fact that such a problem persists in every hospital and nursing home tells us that the nursing profession as a whole has not placed a high enough priority on maintaining skin integrity. To that extent, this particular aspect of nursing is an abject failure. Therefore, you will have to learn what duties nurses owe you and your loved ones so you can insist on those services.
My own mother's story illustrates this point and also demonstrates how some interference can really improve the quality of care you receive. My mother, at the age of ninety-one, was living independently. I was visiting her once or twice per week.
One day, about a day before my regular visit, my sister called to tell me that one of Mom's neighbors said she had not seen Mom for three days. Upon learning this, I called the hospital nearest her home and found out that she had had hip surgery because of a fall she'd taken while out walking. Although she gave my name and location to one of the social workers, no one from the hospital called me to tell me that she was there.
The surgery itself was flawless. Unfortunately, within two days after surgery, Mom developed a pressure ulcer on her tailbone (coccyx). Shortly after the doctor transferred her to the rehabilitation floor, the bedsore deteriorated from partial to full-thickness skin erosion (stage I to stage II).
I had asked the nurses repeatedly if she had any skin breakdown. They assured me that she was getting the necessary care and that her skin was fine. They either lied or really did not know about the wound until one of the doctors discovered it. I did not find out about it until the attending physician told me that he had called in a plastic surgeon for a consult to evaluate the bedsore. Even my mother didn't know about the wound until the doctor told her.
Feeling outraged that I had been misinformed, I went to the nursing office and complained to the supervisor. I asked if my mother had been identified as being at risk for bedsores. The supervisor said she would get back to me.
The next day I went back to the nursing office, and the same supervisor told me she had reviewed the chart and that the admitting nurse had identified her as being at risk.
"Was there a plan of prevention?
- Yes. They were to turn her every two hours, improve her nutritional status, and keep her skin clean and dry.
- Did the nurses implement the plan?
- To be honest, the documentation leaves something to be desired.
- What's missing?
- The turning every two hours was not fully documented.
- They left her unattended for several hours at a time, didn't they?
- I cannot disprove that statement from the record.
- Wouldn't you agree that the presence of a pressure sore speaks for itself?
- Nevertheless, I am now concerned with the fact that the wound deteriorated to stage II after she arrived in rehab. I want to know what your nurses are going to do about it. When I first asked them if my mother had any skin problems, they lied to me. Now I still cannot get a straight answer from anyone.
- I will ask the rehab nurse-manager to have a conference with you."
A few minutes later, the rehab nurse-manager came and invited me to his office. His first concern was to tell me that my mother had the bedsore when she arrived on his floor, so it wasn't caused there.
I told him that I was not interested in laying blame, but since he brought it up, my mother's wound had gotten worse after she arrived on his floor. He asked me what I wanted, and I told him that I wanted to know their plan for treating my mother's stage II decubitus ulcer. I asked for an air-flotation mattress, instructions to the staff to turn her every two hours while she was in bed, and meticulous wound care. I also asked him to tell me everything else they intended to do to make sure this wound would not get any worse but instead would heal. He assured me that all the things that I requested were happening and were being documented.
The sad commentary is that in a hospital that enjoys a very fine reputation, my mother would have suffered further deterioration if I had not intervened with a complaint. I also fought for her to remain in the hospital when they wanted to send her out with the wound unresolved. As a result of my speaking to the nursing administration, discharge planner, and attending physicians about the liability they incurred allowing my mother to develop a bedsore, Mom remained there for an additional ten days until the wound healed.
However, in fairness to the nursing staff at this hospital, I must point out that once I brought the problem to their attention, the quality of care became exemplary. From this I learned (from the other side of the fence) that if you voice a legitimate complaint, nursing supervisors and staff would likely rise to the occasion and take immediate corrective measures. Conversely, if you say nothing, chances are one in ten in hospitals and one in four in nursing homes that you or your loved one will suffer the consequences of shameful negligence.
Bedsores may not sound serious, but the loss of skin integrity with even a slight break puts the patient on a slippery slope toward a painful course of deterioration and infection. The skin is a complex organ. One of its primary functions is to shield the rest of the body from a hostile outside world. Bacteria and viruses swarm all over its surface like an army of invaders looking for a breach in the defensive barriers. Once even the slightest breach occurs, the enemy invades and destroys without mercy. In such cases, the nurses, charged with preventing the breakdown, are like sentries who fall asleep at their posts.
The protective barrier function of the skin also works the other way. Thus an ulcer as well results in the loss of body fluids containing precious blood cells, protein, and minerals. The same breach that allows the enemy to invade causes the defending army to lose its weapons and ammunition. For that reason, the slightest skin break can be devastating to one for whom the stress of illness or injury has already strained the immune system.
The principle that I am clarifying here goes to the standard legal definition of the scope of practice of a registered professional nurse that you will find in every state and U.S. territory. "A registered professional nurse diagnoses and treats human responses to existing and potential health problems through such actions and interventions as health counseling, health teaching and actions restorative to life and well-being…." (New York Education Law, Section 169; the balance of this statute refers to administering physician-prescribed regimens and the prohibition against altering any existing course of medical treatment.)
Accordingly, the responsibility of diagnosing the potential for pressure ulcers and providing preventive measures and daily follow up falls exclusively on the registered nurses. First, the admitting nurse must initially assess whether you or your loved one has any risk factors that predispose to pressure ulcers.
Second, the nurses must devise a nursing care plan detailing what preventive action they and their subordinate staff (licensed practical nurses and nurse's aides) must take. If you find out there is a likelihood of forming pressure sores, you have a right to demand that the nurse show you or tell you what the plan is. Once you learn the one method of prevention that works, you will be able to assess whether the nursing care plan is adequate. Anything less is not acceptable because the appearance of even a small bedsore results in a high risk of infection.
Finally, the nurses must follow up daily and document the results of the protective measures. It only takes an hour for the skin to start breaking down. Therefore, early detection of prolonged pressure is paramount.