5 ways to prevent pressure ulcers in nursing homes
Although some bedsores cannot be avoided, most can and should be prevented before they start. Improper planning and care are the principle culprits to the development of bedsores. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Margo Craig, RN from Sentry Legal @legalnurse5 to talk about common interventions that can help prevent the development of bedsores in nursing home residents.
Schenk: Hey out there, welcome back. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: Today we have a very informative episode about a common problem in many nursing homes across the country, and that problem is pressure ulcers, also known as bedsores, wounds that occur oftentimes, not every time, oftentimes as a result of prolonged pressure and weight on a particular part of the body, for example, a heel, the buttocks, shoulder blades, elbow.
Smith: And as opposed to other types of ulcers – there are venous ulcers, there are diabetic ulcers, there are ulcers that are caused by cancerous. We’re talking specifically about one that are…
Smith: That are related to gravity. Gravity is the culprit.
Schenk: Correct. But we don’t do this feat alone. We have an ultra-special guest, a two-time guest. We’ve had this particular guest on Episode 95 back in November of 2018 talking about MBS enforcement. Today we’re talking about pressure ulcers. Who we’ve got, Will?
Smith: We have nurse Margo Craig. She’s a registered nurse and a legal nurse consultant who founded Sentry Medical Legal Services almost over 10 years ago. With over 30 years of nursing experience combined with criminal justice and forensics studies, she’s uniquely equipped to investigate and develop medically-related legal claims for her attorney clients. Her clinical background includes many diverse practice areas with concentrations in long-term care with infusion therapy, labor, delivery, nursery and oncology nursing as well.
Early in her nursing career, Margo was appointed quality assurance director of a large hospital. She was responsible for the development and implementation of ongoing quality assurance activities based on standards established for accreditation by the joint commission and state health department. This experience working with physicians and hospital staff and later in nursing home administration has given her significant insight into the potential for improving the quality and safety of patient care, so she has a very diverse background and we’re very happy to have her on today.
Schenk: Margo, welcome to the show.
Margo: Thank you so much for asking me to join you. It’s a pleasure to be here and discuss this important topic for public health.
Pressure Ulcers are a common danger in nursing homes
Schenk: Yes, ma’am, you hit the nail right on the head. Pressure ulcers, I mean this is just – this is a problem that we see a lot unfortunately. Many of our clients go into nursing homes without skin conditions and they leave with life-threatening skin conditions. So this is good to have an episode dedicated to what pressure ulcers are and how we actually prevent them from ever occurring. So we’re really happy you came here.
But as you know already, our audience is generally composed to family members or residents – excuse me, I always mess that up – families who have someone in a nursing home, a family member in a nursing home. I don’t know why I always get my nouns confused.
So anyways, from a 40,000-foot view, can you tell us what a pressure ulcer is?
What is a pressure ulcer?
Margo: Well a pressure ulcer is sometimes called a bedsore. That’s kind of the history of what we called them when I was growing up, and even some people I’ve talked to lately want to talk about a pressure ulcer, they get this puzzled look, and when I say, “Oh, it’s a bedsore,” they’re like, “Oh, okay.” So our terminology has changed a little bit since we know that pressure’s a component but there are other things that can make the skin break down and all those things kind of go together.
But basically a pressure, what we call pressure injury because it depends on what the original source of the wound is, but a pressure injury is a wound to the skin and underlying tissue that develops from prolonged pressure and reduced blood flow to the skin. So we know the skin’s got to have nutrients and oxygen with good blood flow to stay healthy, and when the pressure is on, that compromises that system.
Schenk: And so we understand you correctly, when you say when a pressure’s on a part of the body, we literally mean the body is applying the pressure as opposed to your arm is laying there and you’ve got a cooler of beer on it or something. We’re literally talking about the pressure points of the body.
Pressure ulcers most commonly occurs over the body’s pressure points
Margo: Right. Body weight causes pressure over prominent bones, so if someone’s laying down, the weight is a little more distributed, but you still can have pressure ulcers for someone who’s laying down. For someone who’s up in a wheelchair, think about all that weight from the upper body pressing down on the tailbone area. The areas that are most frequently affected are the tailbone area, we call the coccyx, the tailbone, the sacrum is part of that whole system, the part of the pelvis that gets skin pinched between the chair or the bed and develops this significant reduction in blood flow, the hip, the elbows, the heels and the shoulder blades are the most common areas, and then it can even happen – I’ve even seen some starting on the bony parts of the spine that can show through on a really thin person, the ankles, knees, head and even the ears.
So any place that you can touch your body and feel a bone, you don’t have to be thin, actually overweight people can have just as much trouble because they have more weight pressing their body against the surface where their bone is creating that tension on the skin.
Schenk: Right. And so due to that pressure, the underlying tissue and muscle has difficulty receiving the blood from the body, which carries nutrients, which carries oxygen, and over time, those tissues and that muscle deteriorates, the wound opens up and you have basically a gaping wound in the skin.
Margo: That’s a very good summary of what actually happens, right.
What are factors leading to pressure ulcer risk?
Schenk: So that is the actual injury. That’s how they kind of develop. In a skilled nursing setting where you have a variety of residents, you’ve got residents that are 500 pounds, you’ve got residents that are 100 pounds and type-2 diabetic, some have cancers, some are 85-years-plus, so you’re dealing with a lot of different variables for the prevention of pressure ulcers. Can you walk us through – the title of the episode is “Five Ways to Prevent Pressure Ulcers,” but I know that there’s probably a lot more than that. Can you walk us through what are some of the principal means, given the variety of people you have in the nursing home, what are some of the basic means that you have to prevent this type of wound?
Margo: Right. Well you describe exactly what you see. There’s a wide range of conditions of people who are in long-term care, and many of them have come from the hospital where their wounds actually got started, so the tool that they use for prevention starts with assessment.
Schenk: That’s a good point.
Margo: So you need to identify risk factors so you can plan on how to prevent them. So we have an assessment requirement by Medicare and Medicaid that regulates nursing homes and tells them it needs to be done on admission, at certain scheduled intervals and with any change in condition. So the assessments are structured to identify the risk factors that should help the staff plan for what to do, but you know, that’s a baseline. That’s a minimum starting point. You really need to use good clinical judgment to find out what’s really the most significant things about a person. Like you said, if you have someone that’s 500 pounds, that’s going to be their biggest challenge is the amount of weight that’s pressing down on their bony prominences, and their circulation is going to be impaired in general because of that. So the tools help us assign a score that will highlight the need and also kind of quantify how significant is it, to what lengths do we need to go to prevent.
Schenk: That makes sense. Now as the first tool being assessment, can you go a little bit into – we sometimes on the show, we talk about the Braden score. Sometimes we talk about other types of assessments. Is there a particular type of assessment that you find that is effective or…
Smith: More reliable or cutting edge?
Schenk: …or you prefer?
What types of assessments are used for pressure ulcers?
Margo: Well I kind of cut my case on Norton, but the most common one is Braden, and they’re both very valid, very commonly used, and all of them pretty much do the same thing. They just help us organize our thoughts and focus in on the most important aspects of prevention. The total score is meaningful. It kind of tells you if you’ve the lowest of the really low score, that’s bad, just like a school – if you get an F, that’s bad.
But it’s a general screen. It’s not specific enough to a resident to be the be all and end all of “Oh, Braden says this, then this is what we need to do.” You’ve really got to look at the individual and all of the things that are going on to make your decisions about planning and prevention.
Schenk: That makes sense. And the assessments, no matter what they are, are taking into account multiple factors, the mental cognition of the patient, the ability for them to move themselves, these types of things, psychological components, like can you walk us through those categories?
Margo: So you want me to talk about the risk factors that have an impact on these?
Schenk: Yeah, sure. Sure. Yeah.
What are common risk factors associated with pressure ulcer development?
Margo: Okay. So the most important one is immobility. And our main goal here is to educate people about how do I know how to help my loved one? How do I know how to intervene if I don’t know anything about pressure ulcers? So you know your loved one best. You know, like in my family, where the elders like to sit in the chair and their crossword puzzles and watch their specific shows and they have a rhythm to their days and that may mean they’re in the same place for four hours because they’re busy. They’ve got stuff to do and they’re not as mobile as they may be because their joints hurt.
So then you have this normal activity level, but as they age, they’re not eating well and so their tissues aren’t tolerating that same length of time in one position. They have decreased sensations or pressure so they’re not moving because they don’t really perceive there’s a problem. And their nutritional status is down.
So you have then, as things progress, you have people who have cognitive problems. Their thinking isn’t like it used to be we can have minor changes from just normal what we used to call hardening of the arteries, but the blood vessels aren’t working as well as they used to either from heart disease or general vessel disease or brain vessel disease. So they’re not making these connections that I need to move. They may have neurological problems with dementia, Parkinson’s, stroke, those kinds of things, or you know in a nursing home, we have people with spinal cord injuries, people who just are no longer as sharp as they were to know to move and possibly physically can’t. So those are the ones most at risk especially if they’re sitting in a wheelchair. So if they can’t significantly change positions on their own, you’ve got to do it for them.
Schenk: That makes sense.
Margo: Those are the ones with the highest levels of risk, but there’s lots of intermediate reasons as well.
Schenk: I got you. So that’s some of the things that you factor into the assessment, and the assessment, as you mentioned, is kind of like the first and best tool to prevent these. So what’s next? What’s number two on the…
Pressure ulcers do not just occur in bed
Smith: Well I want to point out something that she’s talking about that’s important – that this can happen outside of a bed. We call these bedsores, but it’s important for people to remember that that’s just a colloquial term. It can happen anytime.
Schenk: Yeah, and Will and I are guilty of that even though this is our area of the law in the sense that there’s the misconception that bedsores occur only in bed, and there’s a misconception of the fact that just because you have an open wound on your body where there could be some pressure that it is in actuality a pressure wound. So we might be saying bedsore when it’s a vascular ulcer, things like that. So we’re doing a better job of educating the public on those things, but that’s a good point, Will.
Margo: Right. As you said, there are other reasons to develop a wound, and there’s sometimes combination reasons, which is generally what I see in my practice. You’ll have someone that’s diabetic or has severely impaired circulation who also is immobile, and so they’ve got a double whammy. They’re not getting good blood flow from their diseases and they’re also immobile, so their pressure points are breaking down. And then you have the perfect storm because once it starts, it’s super hard to heal those folks, so we really do want to focus on prevention.
Factors other than pressure can help cause pressure ulcers to develop
Smith: Yeah. So what are some things that people can do who have to sit for long periods of time? Like for example, my mother is quadriplegic. She has to sit. She can’t get up and move around. So is it just as simple as shifting your weight, as moving around? Or are there creams that you can use?
Margo: Right. So you know just in general when we’re at home, if we have dry skin, we’re going to put on some type of lotion to help with that, and the elderly, they need that even more, but they also have to be kept really clean without using harsh soaps. So you’ve got people, if they’re immobile, where their skin is against the bedding, there’s probably going to be moisture from just body heat or condensation, and so for those people, like your mother, who are really not able to move, you’ve got to jump in with both feet and get a specialized mattress that allows for air circulation as well as decreased pressure to the bony points. So you get them on a surface that’s going to help support them whether it’s a wheelchair or a bed and keep the skin as clean as possible without scrubbing them down and removing all their own body oils constantly, so it’s a balancing act. Moisturize – and especially for families, you want to inspect those areas.
So I recommend visiting at different times during the day because you’re going to see different levels of care with staffing based on what that particular shift is being asked to accomplish. You’ve got meal time and bath time to consider. You’ve got activities that are happening, group activities. There’s a lot going on at different times of day and you want to make sure that the rhythm of the day is not throw everyone in a wheelchair after breakfast and leaving them there until dinner. So they need to have significant position changes. If they are in a wheelchair, the nursing home needs to develop programs on how to change position. If they’re able to use their arms or shift their weight, they can be leaning over at different times. They can lift up with their hands.
And one of the things I’ve seen, especially within the last several months, maybe it just didn’t register with me before, but a lot of injuries happen from falls, and residents are falling out of their wheelchairs. Well just think about why. Why are they falling out of that wheelchair? They’ve been sitting on their tail and their body tells them, “Get off me. I can’t breathe.” And so they lean forward and out they go.
Smith: Yeah, go ahead.
Repositioning is critical in preventing pressure ulcers
Margo: Well it’s just important even for people who don’t have the thinking ability any longer to reposition themselves. We as caregivers and family members and nursing home staff have to find creative ways to make that happen, and if that means every time you walk down the hall, stop in and say, “Hey, it’s time to lean over,” you know it can be that simple, but it’s got to be intentional and frequent.
Schenk: And so Margo, if I understand you correctly, some of these, of the five ways of preventing, the first one was assessment. Then I believe you mentioned various devices like mattresses to alleviate pressure from one spot for long periods of time. The other one was literally just position changes, which was what you were just talking about. But the other one was preventing moisture. Can you kind of talk about why moisture is dangerous?
Moisture can speed up the development of pressure ulcers
Margo: Well when skin is wet, it rots. I’m sorry, there’s no easy, gentle way to say that. It becomes red. You know when you’ve been in the bath too long, your toes get pruney? Well your bottom gets pruney where your diaper is holding urine against you as well. So wet and urine are the two most common ways that the skin can get spongey and mushy, and that leads to further injury, whether it’s from pressure wounds from scraping and scooting, so keeping it clean and dry and keeping moisture off of it is the best way, especially in the diaper area. When you have urine combined with feces, those two things have a chemical reaction together. It can really burn the skin. So you’ve got to make sure that diaper is changed as soon as there is stool in it and as often as possible when it’s wet.
Schenk: And you mentioned earlier that if you’re going to use moisturizer – or not moisturizer, sorry – if you’re going to clean those areas, nonabrasive ones, like what’s the difference between an abrasive soap, an abrasive cleaner and a nonabrasive one? Why is that important?
What types of soap can be used to clean the skin?
Margo: Well some people react to different soaps. You’ve got to make sure you’ve got a product that isn’t causing a rash, a redness or itching. There are products recommended by manufacturers and vendors to healthcare providers that specifically are designed to be gentle in that way. And just making sure that it’s thorough without being harsh.
Schenk: I see.
Smith: I think another important thing that she’s pointed out is inspection, just checking your loved one out, because I know we’ve had several cases where the family, an individual died of a terrible, terrible bedsore, stage four, and I remember the family saying, “We had never seen that before. We didn’t realize it was there.” So these come in stages. If you’re loved one’s in a long-term care setting, check their body. Look them over. Maybe the staff isn’t doing that.
Margo: Yeah. And if they are, it may not be communicated in a timely manner. And these wounds can develop honestly very quickly. They can go from just what seems like a little bruise to a gaping wound in really just hours to days. So it’s important to inspect, but just think about the invasion of privacy. You have to use discretion. If there’s someone who is alert, you can’t say, “Hey, let me look in your pants.”
So there’s diplomatic ways to partner with the resident, but I think one of the best ways is to help and ask, like, “You seem sweaty. Can I wash your back?” and even just use a wet washcloth, you don’t have to use soap to wash someone’s back. But that gives you a chance to look now from the waist up. Then you can help take someone to the bathroom. A lot of nursing home patients can get up and go to the bathroom but they spend most of their time sitting or laying down. So when you are the one helping them do that, you’re in the room when they’re getting ready to sit on the potty, and you can just glance. You don’t have to be real obvious about it.
And then the heel is another area that family members get surprised by “I didn’t know that was there,” because when they see their loved one, they’re already up and dressed. And so that’s another thing that you can offer to do, come in before it’s time to get dressed and you be the one to see those feet before they’re dressed, or even if you can’t come early, come late, help them get ready for bed, and during that dressing opportunity, that’s when you can see more areas of that exposed skin.
Schenk: That’s smart.
Schenk: So aside from that, what are some other things, Margo, that families can do to help prevent pressure ulcers from developing on their loved ones at nursing homes?
Nutrition and fluid intake is critical to prevent pressure ulcers
Margo: Right. So another important aspect of skin health is nutrition and fluid intake. So a very important part of a good prevention program includes monitoring body weight, labs that will reveal whether or not there’s enough protein in the diet, whether or not there’s enough electrolyte to support good skin health. So that’s something that would happen, I guess we haven’t talked yet about ways families do interact with nursing homes in a team approach. I know in your other broadcast, you’ve talked about these care planning meetings or interdisciplinary team meetings that happen where social workers, dieticians, therapists, nursing aides and nurses get together and talk about – therapists get together and talk about the issues with the families. So that would be a good time to go over the weight, how often are we weighing? You may visibly see weight loss – their face looks thinner, their skin looks drier, mouth looks dry, even as far as there’s no armpit sweat because someone’s so dehydrated they can’t sweat. So there’s – if you pinch the skin and it stays up in a tent instead of quickly returning, that’s going to happen to a certain extent with elderly and sick people, but you know when there’s been a change.
So they’ve got to have adequate intake and dieticians are good at developing interventions. Nursing home staff – not necessarily so good at implementing them, so you’re going to have to stay on top of how much did they take in today. How’ve they been doing this week? Have they been eating all their meals or are they leaving some food? And the best way to do that is to show up at meal time and see if they’re just sitting there staring at that tray instead of eating it.
Schenk: Yeah, make sure that tray has protein on it.
Smith: I mean this clearly happens a lot because there are attorneys like us out here. So it’s a problem.
Schenk: Yeah. And with regard to labs really quickly, Margo, I mean we don’t have to get in the weeds with this, but is it fair to say that you’re looking at blood sugar levels, making sure that if blood sugar levels are high and you think that there is a wound that it’s going to have problems healing?
How does blood sugar affect pressure ulcer healing?
Margo: Well that is part of what we call a basic metabolic panel, and that measures blood sugar, oxygenation, kidney function as well as measures of good nutrition. So it’s all right there in front of you if you know what you’re looking at. Family members often don’t, but the dieticians, everyone I met, are just wonderful educators. And they love for people to ask questions that give them the opportunity to share in understanding what’s really going on.
Schenk: Right. Well great. Well Margo, I’m going to be keeping count, because again, I don’t want to lie to the audience. There’s five ways to prevent pressure ulcers. Number one, assessing the risk. Number one. Number two, you’ve got preventing moisture. Number three, we have the use of devices like mattresses or maybe boot heels. We have number four, physical position changes, so that’s either literally doing it yourself or running past the hallway and saying, “Hey, Mrs. Johnson, roll over for 15 minutes.” And five is the family participation, the family monitoring of all things pressure-related, so nutrition, making sure you’re taking part in the care plans, that type of thing.
Smith: And I think it should be noted – these are not the only…
Schenk: Not the only – we should put a disclaimer out there. These are just five ways.
Margo: Big ones.
Schenk: We’ll have five more next time with Margo.
Margo: Those family members are just incredibly important to inspire nursing homes to pay good attention to their loved ones. If you’re paying good attention to them, you’re going to have good help coming from the staff. And if something happens and you don’t, then you may need to be the one to advocate for getting the consultation with a certified wound nurse or a wound physician because nursing homes have persons allocated to wound care, but they have a lot of other responsibilities, and they’re not as highly trained as wound specialists. So you may need to advocate for that even to the point of making an appointment and providing transportation to make it happen.
Schenk: There you go.
Margo: So be that advocate. Find out what you can about your loved one’s risk factors, what you know is being done, and be part of the solution. Be there. Offer to help. Learn how to turn safely yourself and advocate for nutrition cleanliness and proper skin care.
Schenk: That’s all fantastic information. Margo, if somebody’s out there and wants to get a hold of you, how do they do that?
Margo: I’m just so available. My website is SentryLegalNurse.com and that has all my contact information on it. My email is SentryLegalNurse@gmail.com, and my phone is 256-426-8371. I’d be very happy to help.
Schenk: And also Margo’s one of the few guests we have that has a Twitter handle, and that Twitter handle is @LegalNurse5. So if you’re out there on the Twitterverse, shoot her a tweet.
Margo: Yes. I would love to hear from you.
Schenk: Great. Well thank you so much for coming on the show, Margo. It’s been fantastic having you on again. Maybe in the future, we’ll get you to come back on. You’ll be kind of like a reoccurring guest, like a… We’ll get you on.
Margo: Well I would be so happy to come back. It’s always a pleasure to speak with you and you all are doing such great work to help the public understand what’s going on so we can all be advocating for solutions.
Schenk: Awesome. Well we appreciate you.
Margo: Thank you.
Schenk: Awesome. Thanks, Margo.
Margo: All right, thank you.
Schenk: Bye-bye. Yeah, Margo is fantastic. She definitely knows what she’s doing and I like having her on because she’s very thorough, very good, great information. And just FYI, what was I going to say, June 6th is the anniversary of what?
Smith: Of the Invasion of Normandy.
Schenk: That’s right. Well the Invasion of Normandy on behalf of the Allies, not the Normans.
Smith: Oh, not 1099, the invasion of Norman…
Smith: It’s 1066.
Schenk: But that’s okay. And that’s the Battle of Hastings. That’s the Normans. We completely messed it up because that’s actually the Normans invading England.
Smith: William the Conquerer.
Schenk: Yeah. Battle of Hastings, 1066.
Smith: That’s the beginning of the French-speaking England.
Schenk: That’s right. And the legal system.
Smith: And that’s why we have so many silly words like “thought” where most of the letters are silent.
Schenk: Anyways, a little bit of history for you.
Smith: I think it’s also my niece’s birthday. I think she was born June 6th or June 5th, because I remember thinking, “Oh, that’ll be easy to remember because it’s on D-Day, but apparently I don’t remember if it was on D-Day or before it.
Schenk: Yeah. Anyways, that’s going to conclude this episode of the Nursing Home Abuse Podcast. You can get new episodes every Monday morning wherever you get your podcast or you can watch the podcast on YouTube or on our website, which is NursingHomeAbusePodcast.com. And with that, we will see you next time. See you next time.
Smith: See you next time.