What prevents pressure ulcers from healing?
Pressure ulcers are one of the most common health problems in nursing homes. The Agency for Healthcare Research & Quality (AHRQ) project that over two million seniors will develop pressure ulcers annually. Not all pressure ulcers completely heal, and in fact, can lead to deadly complications. On this week’s episode, nursing home abuse attorneys Rob Schenk and Will Smith welcome Martha Kelso of @woundcareplus to discuss the diagnosis and comorbidities that prevent proper healing of pressure ulcers.
Schenk: Hello out there and welcome back. My name is Rob Schenk and I am your host of this episode of the Nursing Home Abuse Podcast. In this episode, we are going to be talking about the healing of pressure ulcers, namely what are some of the main issues that would prevent a pressure ulcer from healing normally or quickly.
But we don’t do this alone. We have help. And on the episode this week is Martha Kelso. Martha Kelso is a friend of the podcast. This is going to be her third appearance on the show. She appeared on the show way back in May of 2019. We had her talking about prevention of pressure ulcers. Then we had her back not too long ago, Episode 135, which was in November of last year, talking about the staging of pressure ulcers and how the current model of staging might not be the best. But she is an expert in pressure ulcers and we are so happy when she comes on the program to talk about that. But for those that haven’t listened to those episodes, please go and do that. But for those who haven’t, here’s a little bit of info on Martha.
Martha Kelso is the founder and chief executive officer of Wound Care Plus. As a visionary and entrepreneur in the field of mobile medicine, she has operated mobile wound care practices nationwide for many years. She enjoys educating on the art and science of wound healing and how practical solutions apply to healthcare professionals today. Kelso enjoys being a positive change in healthcare, impacting clients suffering from wounds and skin issues of all etiologies.
Kelso’s desire to make healthcare a better place for consumers motivated her desire to form and found Wound Care Plus. In her early career, she was a wound nurse in long-term care, and this past experience has committed Kelso to educate other fellow wound nurses on regulations and national standards of wound healing, thereby empowering the bedside nurse with tools and knowledge. And we are so happy to have her back on the program. Martha, welcome back.
Martha: Hey Rob, good seeing you again. Thank you so much for having me.
Schenk: I appreciate you. As I mentioned at the top just then, this will be your third appearance. We’re so glad you keep coming back. But just before I throw you into the conversation, Martha, I just wanted to remind our audience that we’re going to be not necessarily doing a deep dive but we’re not going to cover the basics of a pressure ulcer. I highly recommend the listeners out there that don’t have an understanding of what a pressure ulcer is or how they develop to go back and listen to Martha’s episode, 118. We covered the basics of what a pressure ulcer is, how they developed, how they’re dangerous, that kind of thing. In this episode, we really want to stick to the intermediate level of talking about how pressure ulcers heal or don’t heal.
So the first question, Martha, is going to be basically what, if any, role does nutrition, what a resident eats, what does that have to do with how or why a pressure ulcer will or will not heal?
How does nutrition affect pressure ulcer healing?
Martha: Sure. So nutrition is an interesting thing. Being a part of the human race – what we put in our mouths can really affect how our body reacts. There’s a medical term now – we call it homeostasis. Our body likes to maintain homeostasis, which means it’s happy, it’s well balanced. So certain things like a high sodium diet can quickly throw us out of homeostasis, cause swelling, cause a metabolic disorder or disturbance. So just in the basic terms, just thinking about that, with nutrition and pressure ulcers, sometimes pressure ulcers are caused from poor nutrition or what we refer to as malnutrition.
And there’s also part of a misnomer out there that overweight or obese people cannot have malnutrition when in fact they can, and oftentimes our obese clientele are the ones that are malnourished because we’re putting not healthy foods into our body, not giving our bodies the nutrients that it needs.
Why is protein important to pressure ulcer healing?
But if somebody said to me, “Hey Martha, here’s five different foods on my mother’s plate, and she has a pressure wound. Which one is most important for her to eat? I know she’s only going to eat 20 percent of her meal. Which one should I reach for first?” My response would be protein because the challenge is, and I’m not a registered dietician, but nationally we recognize that once somebody develops a wound, they need anywhere from three to five times the amount of protein that someone with a wound needs to get the wound to heal. And so sometimes it doesn’t really matter how we get the protein in them, if it’s a supplemental shake or if they’re willing to eat the protein that’s on their plate, but protein I would say is number one. Without the protein, the wound is not going to heal. We can’t develop the building blocks that the body needs to start forming granulation tissue, such as the tissue we need to get the wound to fill in.
Schenk: That’s the connect the dots.
Martha: That’s a long answer, Rob.
Schenk: No, no, you hit it right in the last sentence. I was thinking, “Okay, I get protein, but what does it do?” and that’s exactly right. You’re right. It creates the granulation. It helps rebuild that tissue. Yep. Okay, so protein, important. What else?
Why is hydration important to pressure ulcer healing?
Martha: Same thing with hydration. So if we are dehydrated, we don’t have enough hydration in our body. It’s really hard for our cells to move around and get to where they need to be to start filing in that wound bed, getting that granulation tissue moving, fibroblast, keratinocytes, those are $6 terms, but yet our body needs those growth factors to start filling in. And a dehydrated body, we do not produce of those cells nor is there enough fluid for those cells to move to the wound to start filling in those tissues.
When I was working at the wound center running hyperbaric oxygen chambers, I still remember one of the questions we would always ask was, “Do you smoke?” And they would say, “Yes,” and we would say, “Well one cigarette negates the effect of hyperbaric oxygen.” And at the time, we’re talking 10 years ago, one hyperbaric treatment could be as much as $1,300. And I would say, “That’s a really expensive cigarette.” But you think about when you smoke, it robs the body of the oxygen molecules we need to form granulation tissue. And so smoking is a really big thing. If you smoke and you want to heal, you’ve got to put down the cigarettes. You’ve got to put down the nicotine.
Schenk: I think that there’s a very, I mean, knowledge deficiency in that area. You would be surprised at how many people, especially in the state of Georgia, I feel like if you go into South Georgia, everybody’s smoking, but just the knowledge gap in that – “Well I understand that I don’t want to get emphysema or lung cancer, but I’m going to take that risk.” It is having an effect on your body other than emphysema and lung cancer. It’s preventing your wound from healing. There’s a big misconception about that, or lack of knowledge on it.
Why does smoking cigarettes affect pressure ulcer healing?
Martha: So smoking is definitely one of those things we can mitigate. Sometimes with wounds, there are things we can’t mitigate. We can’t eliminate some of the barriers. And so those are things we can focus on for a medical standpoint, but some barriers that we can eliminate, let’s do that. So if you are chair-ridden, you’re in a wheelchair all day or you’re in bed all day and you have the capability of getting up, do it because the more you get off your bottom, your derriere, the more blood can restore.
Martha: There are other things like…
Schenk: Well with regard to nutrition, you mention protein as being good. You mention being hydrated, so making sure that oxygen is getting in there. What about – is there anything that’s bad in terms of nutrition, like for example, what’s your understanding about sugar or blood sugar levels?
Why does blood sugar levels affect pressure ulcer healing?
Martha: Yeah, blood sugar levels, once they get out of control, obviously impair everything from our vision to our kidneys to the body’s ability to absorb. So when people are hyperglycemic, they have too much sugar in their body, it blows our body out of that state of homeostasis or well-being, of balance, and the cells, the body’s cells cannot utilize the nutrients that are there because there are too much sugars preventing the body from doing what it needs to do just to absorb our regular nutrients. And so we talk about managing blood sugars, but even in a wound care world, prediabetes still acts like diabetes. It still negatively impairs the microvascular blood flow and still negatively impairs our ability to absorb nutrients. So if you know that you’re prediabetic and you can do things now to turn that around, whether that’s diet, exercise, everything in moderation, now’s the time to do it. Otherwise you’re going to be treated for a wound at some point in your lifetime if you choose not to.
Schenk: Right. So we talked a little bit about nutrition. We’ve talked about definitely not smoking – not smoking at least for wound care but just in general, can you talk about – it’s funny because you mentioned hydration, but let’s talk about moisture on the body and incontinence, like these seem to me to be big problems with the inability of a wound to heal. Can you tell me why that’s the case?
How does moisture on the skin prevent pressure ulcers from healing?
Martha: Sure. Anytime – I always think about people who love to soak in a bathtub. I’m one of those people. I love to soak in a bathtub. But when I get out, I have the wrinkling effect, like I call it the bathtub effect, and my skin’s pruny. And what that does is decreases my skin’s resistance to be resilient. So when people have perpetual moisture on their skin, like perpetual moisture decreases the skin’s ability to fight back against external forces like pressure. Additionally, when skin is too moist, it increases sheering or friction because your skin is sticking to whatever object you’re trying to move away from.
So urine, in and of itself, increases moisture around the skin, which means it decreases the skin’s ability to stay strong. It also allows other things to creep in like bacteria or fungus. Fungus loves to grow in dark, warm and moist environments, which is what happens when we’re incontinent in our briefs, our pants create dark, warm, moist environments.
Martha: And then if you’re incontinent of feces, feces also have an acidic component to it, and we know there’s bacteria in our stool, usually e. coli or enterococcus. There’s bacteria in our gut that helps us break down food, which means there’s also bacteria in our stool that our gut produces. When you add bacteria and acidity to our skin on top of moisture, it helps erode the skin.
Schenk: Yeah, and I think perspiration is also a – what’s the word I’m looking for? – a cause of moisture on the body.
Martha: Moisture contributor.
Schenk: Yeah, exactly. So it’s any type of moisture, regardless of whether it is from incontinence or from sweating or from baths, these are not good in terms of either preventing wounds or causing it to heal.
Schenk: So what about – you mentioned diabetes a little bit. Can you talk about other disease or medical conditions that would inherently cause or inherently prevent a pressure ulcer from healing properly?
What medical conditions prohibit a pressure ulcer from healing quickly?
Martha: Well there’s a lot. That’s a long conversation. The current national standard is if they have two or more comorbid medical conditions at the same time, the risk in skin failure skyrockets. So for example, they have a thyroid disorder and high blood pressure – that’s two. So your risk for skin failure goes up significantly. If you have LPD and osteosclerosis or arterial disease, that’s two – your risk goes sky high. And then you think about somebody who might have numerous – they had a stroke, they have kidney disease, they have diabetes, they have dementia – the more diagnoses you add, the greater the chance of risk of skin failure, whether it’s through pressure or other disease factors is enormous.
Schenk: So the overarching idea is that whatever inhibits blood flow or whatever inhibits your body to carry the nutrients it needs in the blood, those are the risk factors in terms of comorbidities.
Martha: Correct, or maintaining homeostasis. For example, someone with thyroid disorder, the thyroid, of course, gives off hormones that helps regulate our body, so if the thyroid is diseased, it’s not going to regulate our body as well. People with gallbladder disease, it doesn’t regulate your nutrients as well when it passes through your digestive system. So really any medical disease or condition that alters our state of homeostasis elevates the risk of skin breakdown, whether that’s through pressure or some other disease process.
Schenk: Speaking of that then, what does the role of a resident’s mental capacity play in the healing of a wound or a prevention of the wound?
Does mental cognition of the resident matter?
Martha: People that have Alzheimer’s dementia, for example, I used to run an Alzheimer’s dementia building when I was director of nursing, and they may not have the capacity to understand, “This is supper, I need to eat now. My body is hungry.” The disease process alters the way we not only think, but the way that we move, the decisions that we make. So if a resident is alert and oriented but maybe has schizophrenia, they may not be making the best choices to help heal wounds or prevent wounds from healing. Sometimes those choices lead up to the fact that we do have a wound. But when somebody is mentally incapacitated, they have a durable power of attorney, a healthcare proxy that speaks for them and is able to help make those decisions, but when somebody is mentally incapacitated, it is a challenge to keep them from breaking down, whether that is through nutrition or the decision to, “Man, my butt’s hurting. I really need to move now,” or “My doctor told me I need to have compression stockings. I’m going to choose to put those on every day.” Maybe they choose not to or they’re resistant to it.
Schenk: Right. So I guess the overarching idea on that is that when you have an individual who cannot cooperate in their care, that obviously makes caring more difficult.
Martha: Correct. And sometimes they look to the wound specialist or the nursing home staff to kind of forgive all the sins of the past, so to speak. “I made poor choices by smoking for 40 years, but now I have a wound and you need to fix it.” And oftentimes we can’t because you’ve smoked for 40 years and you now have major inclusions, major inclusive disease. So it goes back to that not all wounds are healable, and in order to get a wound to heal, the stars really do have to align and we do have to mitigate as many issues as we can, but we cannot always get rid of every issue out there that’s preventing the wound from healing.
Martha: So having that open discussion, being really honest about what’s going on with the wound, how did we get this wound, what is keeping the wound from healing and what do we do about it?
Schenk: Exactly. And actually that brings up a good topic there. Can you talk about – we call it noncompliance – the resident is not going along with the basics of the care plan. Kind of – I guess other than saying, “Okay, that’s your decision,” what can we done, if anything, when you have a resident that maybe doesn’t want to be turned every two hours? How does that affect the care plan?
What can a nursing home do about non-compliance from the resident?
Martha: I think sometimes it goes back to really defining what the goal is. So Rob, let’s pretend you have a wound and I’m going to say, “Rob, what is your goal with this wound?” “Well my goal is to heal it.” “Okay, Rob. One of the things that’s keeping your wound from healing is your smoking and you are drinking a can of regular pop every day and you’re diabetic.”
Schenk: And as you say that, I’m holding up, I’m actually holding up my can of Coke Zero that I’ve been drinking this episode.
Martha: Yeah. “And so if you goal is to heal this wound, I need you to stop smoking and I need you to put down your regular can of pop.” And Rob’s going to look at me and say, “Martha, I’ve smoked for 40 years. I don’t want to quit smoking. I love it. It’s my one joy throughout the day.” That’s fine. Then I’m going to look at you and say, “Rob, I’m okay with that. It’s your body. But then the goal should not be to heal your wound because I’m not magic. It’s a partnership between the two of us. So in which case, I need to move your wound to be really a palliative wound, because your goal is really to keep smoking, not to heal your wound.” So that’s one thing. “But if your goal is to really heal the wound and you’re willing to quit smoking and eat the diet prescribed and quit drinking your regular pop for the day so we can manage your diabetes, now that’s a reasonable goal. That we can do.” So instead of charting you down as noncompliant because you won’t quit smoking, I really need to move your goal, change your care plan so to speak.
Schenk: That makes sense.
Martha: Sometimes the noncompliance is due to fear. “I had compression stockings in the past and they hurt me.” Okay, but it’s 2019. We have a lot of different compression stockings out there now that are more comfortable. And so sometimes it’s really asking, “Why are you not wanting to do what I’ve prescribed?” It’s not, “I’m the doctor, you’re going to do what I say.” It is, “You’re the patient. You’re in control. So how do I help move that needle to where we want it to be so that we have the same goal?”
Schenk: Right. So that makes perfect sense because you’ll see a chart and it’ll say, “Resident refused to be turned.” Well okay, why? Is it because their shoulder hurts and the CNA that does that is jerking it too hard? So you never know. But I think that’s an appropriate and reasonable viewpoint of noncompliance in the resident is, “Okay, you want to keep smoking. You’re putting a nail in the coffin then, so we’re going to move the concept of what we’re even doing here to you want to maintain your dignity and keeping smoking – okay, that doesn’t go hand-in-hand with healing this wound.” Because in the literature on this, I think, I can’t remember if it’s CMS or – they went from a pressure ulcer being a never event to now kind of, “All right, that’s not true. Not every single one of these pressure ulcers is avoidable based on whatever is happening with your body or your life choices.”
Martha: Right. And we are dealing with an extraordinarily sick population in the elderly because it is 2019 and we are keeping people alive much, much longer than we used to with conditions that 15 years ago, they wouldn’t survive from. Now they do because we have better medications, better treatments, better medical interventions, so they are still alive. We are dealing with an incredibly sick population.
Schenk: Right. Our ability to keep someone alive is not catching up to our ability to care for them in those later years, it’s kind of like football where we made all the pads and the gear such that a man can run as fast as he can at the other guy and not hurt him, but we haven’t realized how to make them safe in the long run of now they’re getting brain damage.
Schenk: Okay, so with that in mind, I guess it’s not impossible for you to be able to – it’s not – a pressure ulcer isn’t a death sentence.
Is it possible for a pressure ulcer to heal? Yes.
Schenk: However, taken in these other factors, it can be harder to heal, or in some instances, the resident, him or herself, have made it impossible to heal.
Martha: Well I think not all wounds, and not just pressure, but not all wounds can be healed. So sometimes our goal is to keep them from getting worse or keep them from getting infected if we can. So it’s not that – I don’t know, 30 years ago, you couldn’t live with a wound. 2019, you can live with a wound and live for many years with a wound. So even on wounds that are not healable, it doesn’t mean that we’re writing them off and saying, “Well good luck to you. We’ll work on your funeral arrangements here in just a few weeks.”
Martha: They can live with a wound if their body is able to continue going. I will say there are medications that also delay wound healing. There are some medications that create wounds. And so hydroxyurea, for example, is a medication that can cause wounds. I’ve treated two cases personally. One was sickle cell ulcer around the ankle and we were not able to take them off the hydroxyurea, because they were going into full-blown sickle cell crisis and would most likely die. The other one I had was over the Achilles heel area and she had pre-leukemia. The challenge is if we take her off the hydroxyurea, she’s going to go into full-blown leukemia. So you leave them on the hydroxyurea but you know you’ll most likely never heal that wound and the wound may get worse, but at least they still live. They don’t go into full-blown sickle cell, they don’t go into full-blown leukemia.
There are some medications that delay wound healing, prednisone being one of them. There’s some medications that encourage wound healing, and there’s an entire list of those. This nurse actually did a PubMed lit review and published them all in one document. It’s called – and I’m going to paraphrase, but it’s basically the Pharmacological Impact of Medications on Wound Healing.
Schenk: That makes sense. I’ll have to research that and get that URL on the screen for people to read.
Schenk: Because that’s a component that we haven’t talked about is how medications can delay healing or prevent it or enhance it.
Martha: Correct. You would need a PharmD for that podcast, Rob.
Schenk: I think that would be above everybody’s pay grade on that one except for that PharmD. But Martha, I really appreciate you coming on the podcast for a third time. You’re a true friend of this podcast and again, your episodes are always – look, pressure ulcers are one of the reasons we get a lot of our phone calls, so the more that we can educate our audience, particularly here in Georgia about the causes, the preventions, what families can do to help the nursing home – go in and tell Grandma and smack the cigarette out of her hand – the better off we are as a community. So we really appreciate you coming on so often to talk with us about that.
Martha: Yeah, I appreciate it. Thank you for giving us the voice and chance to educate on pressure ulcers and other wound types also. This is very important.
Schenk: There you go.
Martha: Good talking to you. Thank you, Rob.
Schenk: You as well. Thanks a lot. Always great to have Martha on the show talking about pressure ulcers. She is just so knowledgeable about the subject and is always a great resource. Her episodes are always some of our most listened to episodes. We are breaking records when we have her on, getting on them ratings.
But at any rate, happy new year I guess is in order. This is our first episode of the new year. Hope your 2020 has started off great. I know ours is. We’re looking forward to bringing you many episodes of the Nursing Home Abuse Podcast this year as we move into almost our third year. I believe our next episode will actually be our third year anniversary, so it’s interesting that we’ve been doing this this long.
But that’s actually going to conclude this episode. We’re happy that you made it this far. You can check out new episodes of the Nursing Home Abuse Podcast every other week, bi-monthly as they say, on YouTube, our website, which is NursingHomeAbusePodcast.com, or wherever you get your podcasts from. And with that, we will see you next time.