A pressure ulcer, also known as a “decubitus ulcer” or bedsore, is a wound caused by–as the name implies–pressure applied to the skin and soft tissues, usually over a prominent bony structure. These wounds are especially worrisome in older patients whose circulation may be poor, and who may be bedridden or have limited mobility. While they can be successfully treated if they are found early, more advanced wounds are likely to be life threatening, especially in vulnerable patient groups, like the elderly. In cases where the wound is very advanced, it is often fatal.
The seriousness of these wounds, and the fact that wound healing is slow or impossible in some patients, makes prevention a major influence in patient outcomes. Pressure ulcers are prevented by moving a patient regularly, every 2 hours at least. Seems like an easy thing to do, right? Maybe. As you may remember from my bio, if you read it, I worked for a short time during college in an Alzheimer’s facility, as a Certified Nurse’s Aide (CNA). One of my most important tasks each day was to make sure that my patients were regularly moved into new but comfortable resting positions, to prevent the formation (or exacerbation) of decubitus ulcers or bedsores. If someone had been lying on his left side, for instance, we might turn him to his right side, or onto his back. For some patients, we might get them up from their chair and help them walk a lap around the nurse’s station before putting them back in the chair or to bed for a nap. In theory it’s easy enough, but dementia patients can be very challenging. Maybe Mr. Smith doesn’t recognize me today and stubbornly decides he does not want to do as I ask of him–and maybe as soon as I leave the room, he returns to his left side despite my efforts to give that side a break. Maybe the other CNA on my unit called in sick and we’re understaffed–and maybe my patients have to wait 3 or 4 hours before I can get in to turn them.
There are a number of reasons why pressure ulcers may develop in immobile patients, diabetics, or patients with stagnant blood flow (e.g., venous stasis or peripheral artery disease “PAD”). Most of them, however, can be prevented with adequate care. When inadequate or substandard care results in a wound of this sort, it might be appropriate to talk to a lawyer. Bedsores are among the leading causes of death for immobile patients, and they don’t just happen in nursing homes. There are plenty of cases of pressure ulcers that develop in the acute-care hospital setting, too.
Some patients are a pressure sore waiting to happen–they are immobile, perhaps not cooperative with care, have poor circulation and/or impaired ability to heal–diabetics are an example. Many serious and deadly decubitus ulcers have come into the world on the heel of a diabetic foot. Regardless of how challenging a patient may be, the most important thing to remember–for caregivers and patients alike–is that difficult patients need MORE care, not less. It is never acceptable for a facility to ‘give up’ on repositioning a patient because the patient might be combative or confused. If one CNA can’t manage it, add another, or move the patient to a place where he can be observed from the nurse’s station, so that when he rolls back to the position he likes the best, someone can be there ready to intercept him. There are also a number of specialty beds, chairs, and cushions that are specifically designed to help prevent these wounds, and these can be of great help in difficult cases. Pressure mattresses are not an alternative to patient repositioning, but they are a tool that can be used as part of a patient care plan to prevent injury.
Older patients, especially those with Alzheimer’s or other forms of dementia, can be a steep challenge to care for. If you’re a caregiver and you wanted an easy job, maybe you ought to try working with other patient populations. Difficult patients require more from their caregivers, but it can be very rewarding to work with patients who demand your best effort.