The important nursing role in bedsore prevention

 

Nurses sometimes ignore the standardized tools in place to identify at-risk patients, and to prevent and treat pressure injuries

 
May 29, 2017

In my career as a Houston medical malpractice attorney, I have represented numerous clients who were seriously injured as a result of pressure ulcers.

Pressure ulcers are also known as bedsores or decubitus ulcers. The National Pressure Ulcer Advisory Panel defines them as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Bedsores sometimes may be present with intact skin, but also commonly are very painful open ulcers.

The pressure injury staging scale

The standard of care requires doctors and nurses to identify, and document in the medical records, pressure injuries according to a staging system that is based on the degree of tissue damage.

Stage I Pressure Injury: Non-blanchable erythema of intact skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage II Pressure Injury: Partial thickness skin loss with exposed dermis. Wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum filled blister. Adipose and deeper tissues are not visible.

Stage III Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.  Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. 

Stage IV Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.  This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.  The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.

Bedsores can develop quickly

You might expect that many of the cases that I have handled involved bedsores that developed in elderly patients in a hospital, nursing home, or rehabilitation facility. What may surprise you, though, is that there is a surprising number of younger patients who develop bedsores when they have to be immobile, or stay in bed, following an orthopedic surgery or other procedure.

Research has shown that the damage to the skin and underlying tissue, located under bony prominences, can occur in the first hour and up to four to six hours after pressure loading.

Standardized nursing pressure injury prevention tools

The standard requires nurses taking care of bedridden patients to be competent in pressure ulcer prevention, recognition, and treatment. And hospitals, nursing homes, and rehabilitation facilities must provide a reliable standardized tool for nurses to identify those patients at risk for pressure ulcer development and to prevent them from getting bedsores.

One of the most widely used and accepted standardized tools for pressure sore identification and prevention is the Braden Risk Assessment Scale. The Braden Scale helps nurses identify patients at risk for bedsores, using six factors.

The standard of care requires nurses to use the Braden Scale, or a similar standardized tool, at admission to the facility, at specified intervals (usually the nursing shift change), and when there is a change in the patient’s condition.

The areas assessed by the Braden Scale include Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. A score of 23 is the highest score possible, which reflects no risk identified. Those patients that score lower are at a higher risk for skin breakdown. The Braden Scale states that patients with a score of 16 or less are considered to be at high risk for developing pressure ulcers.

Nurses are also required to assess contributory factors. For example, emergency admission to the hospital, failure of multiple organ systems (liver, kidney, heart, lungs, etc.), and an altered level of consciousness are all indicators that the patient is at high risk for pressure ulcer development and measures should be put into place to prevent skin breakdown.

Every time the nursing staff assesses a patient’s skin integrity and Braden Scale, it should be documented in the medical record. This allows a continuity of care, meaning that later shifts of nurses and doctors will be able to tell if the patient’s condition is getting better, worse, or staying the same.

Preventing bedsores

If a patient is at-risk for developing a pressure injury, the standard of care requires the nursing staff to do a skin inspection once per shift, to keep compromised areas clean and dry, and to document findings in the medical records. If there is no doctor’s order for this type of assessment, a nurse has an independent duty to advocate on the patient’s behalf to get an order. This will ensure that future nurses taking care of the patient will perform the important task of skin checks.

When a patient is bedridden or immobilized, nurses need to make sure that all bony prominences, like the hips, buttocks area, and heels are protected. Such measures would include placement of pillows and heel protectors to keep the patient’s heels protected. 

In many circumstances, when a patient has a high risk of developing pressure sores, the nursing staff needs to advocate for a specialized bed, such as an alternating air pressure mattress, to preserve skin integrity.

Another important nursing responsibility is to reposition the patient at frequent intervals, to relieve weight bearing on the same spots.

What you can do

I have met with countless family members who were shocked to find out that their loves ones developed serious pressure injuries in a hospital, nursing home, or rehab facility, despite the fact that they visited them daily.

Even though experts agree that the best way to handle pressure sores is to prevent them from developing in the first place, in my experience, the level of care provided at many facilities is seriously lacking.

Most people do not realize how quickly pressure sores can develop, but now you do. And you also know what nurses should be doing to prevent them.

You can use this information to increase your safety or the well-being or your loved one, by asking questions and paying close attention to the nursing care.

Upon admission, politely ask your nurses about their findings on your risk for a pressure injury. Discuss with your nurses and doctors what preventive measures they will be using in your care.

Make sure that your bony prominences are padded with pillows or protected with other devices. The areas that are particularly prone to bedsores include the buttocks/hip area and heels.

Pay attention to how often the nurses are repositioning you. If you are bedridden, it is dangerous to your skin integrity to be left in the same position too long.

Finally, although it may feel a bit immodest, if you are bedridden and immobile for a period of time, I recommend having a family member or friend check your heels and buttocks area every now and them to make sure a pressure sore has not developed.

We are here to help

At Painter Law Firm, our Texas medical malpractice lawyers have experience in handling pressure injury, or bedsore, cases involving a variety of facilities, patient ages, and conditions. If you have been seriously injured, call us at 281-580-8800, for a free consultation.

Robert Painter

Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.

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