Editorial
Pressure sores: the result of bad nursing? F
or many years nurses have carried a burden of guilt for pressure sores as they are often felt to symbolize a failure of care. While medical staff abdicate responsi bility, nurses tend to deny the problem: ‘We only have pressure sores here when the patient comes in with them'. Everyone is so keen to cast blame on everyone else that no one considers the actual cause of the sore. Many factors influence the development of pressure sores. These can be divided into extrinsic factors, such as pressure, friction and shear, and intrinsic factors, such as reduced mobility and poor nutritional status. When a patient develops a pressure sore it is important to de termine the precise cause. If the individual is at short term risk, it may only be an isolated event, but in cases of long-term risk, there is the possibility of repetitive injury. Short-term risk can be illustrated by the example of a patient who returns from the operating theatre with bruising over the sacrum. Operating tables undeniably create high interface pressures over the bony prominences, and yet not all patients undergoing sur gery develop pressure sores. The risk of pressure sore development is increased in the presence of certain fac tors, e.g. surgery lasting several hours, a heavy blood loss and a period of hypotension. However, once re covered from the surgery and from the pressure sore, the patient is no longer at risk. An example of a patient at long-term risk might be that of a tetraplegic who has been assessed for suitable bedding and seating before discharge from a younger disabled unit. When readmitted for respite care, it is noted that he has a small pressure sore at the junction of his thigh and buttock; an unusual position for a such a sore. Upon investigation, it is discovered that he had previously persuaded his carer to exchange his wheel chair cushion for a wooden board and a thin piece of foam. The board had subsequently caused pressure on the back of his thigh which he had been unable to feel. The offending articles were removed and he was given further education. However, the ongoing nature of his disability means that the risk of pressure sores develop ing in the future, as a result of other factors, has not been eliminated. Identification of causative factors can lead to improv ed prevention. A survey by Dealey (unpublished data, 1988) in a hospital for the elderly found that 38% of pressure sores were on the buttocks. Their cause was related to sitting rather than lying. Dealey et al (1991) investigated the state of the armchairs provided in the hospital and found that only 23% were in good condi tion. Further research identified suitable replacement chairs, the use of which produced a reduction in pressure
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sores in general and sores on the buttocks in particular. Many hospitals are adopting effective prevention pol icies. Any plan of care should consider the length of time for which the patient will be at risk. If the risk continues after discharge into the community, suitable plans must be made. Pressure sores are costly to both the patient and the health service. Take the example of Mary, a 60-year-old woman with severe rheumatoid disease, who is wheel chair bound and unable to move herself. While an inpa tient she was cared for on a sophisticated pressure-re lieving mattress and was turned regularly; she did not get pressure sores. When she went home, the district nurse was only able to provide a hollow-core, fibre pad and Mary spent over 10 hours in bed without being turned. As a result, she developed a severe pressure sore and was subsequently readmitted to another hospital. While the sore was healing, various pieces of equipment were tested to establish the most appropriate support system for Mary. Once this was established, the fre quency of turning at night was gradually reduced until she could safely be left all night. The pressure sore heal ed without complication. Mary was discharged home with a mattress that was thought to fulfil her needs; she has had no further prob lems. The cost of the mattress was £450, which may seem expensive until weighed against the cost of treating her sore: £22 000 for her 132-day hospital stay. If a suit able discharge plan had been made by the first hospital, this money could have been saved. Since the Audit Commission (1991) has suggested that pressure sore incidence should be used as one of the markers of quality of care, such sores are likely to have a much higher profile. Indeed, many purchasers of healthcare are requesting details of their incidence. This situation provides nurses with the opportunity to take the lead in the multidisciplinary team to establish the actual causes of pressure sores in individual cases and to develop suitable prevention plans. Carol Dealey Clinical Nurse Specialist in Tissue Viability Queen Elizabeth and Moseley Hall Hospitals Birmingham
Audit Commission (1991) The Virtue of Patients: Making the Best Use o f Ward Nursing Resources. The Audit Commission for Local Authorities and the National Health Service in England and Wales, London Dealey C, Earwaker T, Eden L (1991) Arc your patients sitting com fortably? J Tissue Viability 1: 36-9
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.127.145.240 on November 21, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved. British InnrnalnfNiirsinC. 1992.Voi l.N o 15
Pressure sores: the result of bad nursing? F
or many years nurses have carried a burden of guilt for pressure sores as they are often felt to symbolize a failure of care. While medical staff abdicate responsi bility, nurses tend to deny the problem: ‘We only have pressure sores here when the patient comes in with them'. Everyone is so keen to cast blame on everyone else that no one considers the actual cause of the sore. Many factors influence the development of pressure sores. These can be divided into extrinsic factors, such as pressure, friction and shear, and intrinsic factors, such as reduced mobility and poor nutritional status. When a patient develops a pressure sore it is important to de termine the precise cause. If the individual is at short term risk, it may only be an isolated event, but in cases of long-term risk, there is the possibility of repetitive injury. Short-term risk can be illustrated by the example of a patient who returns from the operating theatre with bruising over the sacrum. Operating tables undeniably create high interface pressures over the bony prominences, and yet not all patients undergoing sur gery develop pressure sores. The risk of pressure sore development is increased in the presence of certain fac tors, e.g. surgery lasting several hours, a heavy blood loss and a period of hypotension. However, once re covered from the surgery and from the pressure sore, the patient is no longer at risk. An example of a patient at long-term risk might be that of a tetraplegic who has been assessed for suitable bedding and seating before discharge from a younger disabled unit. When readmitted for respite care, it is noted that he has a small pressure sore at the junction of his thigh and buttock; an unusual position for a such a sore. Upon investigation, it is discovered that he had previously persuaded his carer to exchange his wheel chair cushion for a wooden board and a thin piece of foam. The board had subsequently caused pressure on the back of his thigh which he had been unable to feel. The offending articles were removed and he was given further education. However, the ongoing nature of his disability means that the risk of pressure sores develop ing in the future, as a result of other factors, has not been eliminated. Identification of causative factors can lead to improv ed prevention. A survey by Dealey (unpublished data, 1988) in a hospital for the elderly found that 38% of pressure sores were on the buttocks. Their cause was related to sitting rather than lying. Dealey et al (1991) investigated the state of the armchairs provided in the hospital and found that only 23% were in good condi tion. Further research identified suitable replacement chairs, the use of which produced a reduction in pressure
748
sores in general and sores on the buttocks in particular. Many hospitals are adopting effective prevention pol icies. Any plan of care should consider the length of time for which the patient will be at risk. If the risk continues after discharge into the community, suitable plans must be made. Pressure sores are costly to both the patient and the health service. Take the example of Mary, a 60-year-old woman with severe rheumatoid disease, who is wheel chair bound and unable to move herself. While an inpa tient she was cared for on a sophisticated pressure-re lieving mattress and was turned regularly; she did not get pressure sores. When she went home, the district nurse was only able to provide a hollow-core, fibre pad and Mary spent over 10 hours in bed without being turned. As a result, she developed a severe pressure sore and was subsequently readmitted to another hospital. While the sore was healing, various pieces of equipment were tested to establish the most appropriate support system for Mary. Once this was established, the fre quency of turning at night was gradually reduced until she could safely be left all night. The pressure sore heal ed without complication. Mary was discharged home with a mattress that was thought to fulfil her needs; she has had no further prob lems. The cost of the mattress was £450, which may seem expensive until weighed against the cost of treating her sore: £22 000 for her 132-day hospital stay. If a suit able discharge plan had been made by the first hospital, this money could have been saved. Since the Audit Commission (1991) has suggested that pressure sore incidence should be used as one of the markers of quality of care, such sores are likely to have a much higher profile. Indeed, many purchasers of healthcare are requesting details of their incidence. This situation provides nurses with the opportunity to take the lead in the multidisciplinary team to establish the actual causes of pressure sores in individual cases and to develop suitable prevention plans. Carol Dealey Clinical Nurse Specialist in Tissue Viability Queen Elizabeth and Moseley Hall Hospitals Birmingham
Audit Commission (1991) The Virtue of Patients: Making the Best Use o f Ward Nursing Resources. The Audit Commission for Local Authorities and the National Health Service in England and Wales, London Dealey C, Earwaker T, Eden L (1991) Arc your patients sitting com fortably? J Tissue Viability 1: 36-9
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 129.127.145.240 on November 21, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved. British InnrnalnfNiirsinC. 1992.Voi l.N o 15
