I have seen this article floating around Facebook and other social media platforms – I have so many objections to what is said in this article that I had to respond with a post !
This article contends that the standard of care for turning bed bound patients is abuse during the night as it disturbs patients. It also goes on to say that using an alternating pressure mattress is all that you need to prevent pressure sores.
Positioning and skin breakdown prevention is a lot of what we do at Gaitway of Charlotte. We know an awful lot about this and while we take care of all types of patients, bed bound and hospice patients need the most help with skin management.
Skin breakdown is caused by a multitude of factors – addressing those factors is an important step. Knowing your breakdown “risk” is key in managing a patient and their skin. ( Braden scale).
Skin breakdown occurs when you have limited nutrition and blood supply to an area of skin. Just like any other organ, skin requires nutrition, hydration and a good blood supply. Skin cells become compressed when you lie in a particular position. This compression results in the available blood supply being limited to that particular area. If you do not move, that compression will eventually lead to cell death and thus breakdown. You can see this easily by picking up a glass. Look through the inside of the glass and look at your fingertips – you will see that your finger tips appear bleached – this is what is looks like when you lie in bed. It is easy to understand why “bony prominences” are such a concern for pressure.
How quickly that cell death happens is dependent on a number of things:
1: Overall nutrition of the patient with adequate protein intake as well as overall caloric needs must be met on a daily basis – this can be difficult with older folks that don’t like to eat and have a poor appetite. Factors such as ill fitting dentures, confusion, prescription diets and taste preferences are all hard to handle in a nursing home environment.
2. Hydration: if a patient is chronically dehydrated the skin will demonstrate poor turgor and be come very dry – dry skin is more at risk than healthy skin.
3. Swelling: when a skin cell is swollen – the chances of it breaking down are much higher. When the cell is swollen is already has a limited blood supply and does not tolerate pressure of any kind – something as simple as a heavy blanket can cause blisters on very swollen skin.
4. Immobility: in a perfect world everyone would have a custom seating system that allowed supportive out of bed positioning with perfectly prescribed cushions and be able to be “tilted” every hour to avoid skin breakdown without any disturbance. Normal adults change position frequently while sleeping and do so without disturbing sleep. However, someone who is unable to change their own position has to be moved to avoid breakdown – certainly having a special mattress will help reduce the amount of breakdown but it will still happen in high risk patients.
5. Incontinence: irritation from frequent loose stools and urination exacerbates all skin breakdown on the problem sites around the pelvis and back. keeping skin clean, moisturized and dry is a constant struggle for anyone who is bed bound.
6. Caregiver touch. Human touch is a very big part of being a caregiver – having the human interaction while being turned and checked on at night is , in my opinion, an important thing.
7. Skin sensation: it is well documented in the literature that insensate skin ( skin without sensation) is at higher risk for breakdown. This includes patients with spinal cord injuries such as paraplegia and quadriplegia, stroke and multiple sclerosis.
So – in closing… with everything that we do as members of the medical profession we always need to consider burden v benefit of patient care. Suffering from skin breakdown is very painful, can lead to serious sepsis and death – its not a small issue to deal with and IS A PRIORITY.
But with all things – when the benefit v burden question becomes a severe burden then conversations regarding the plan of care need to be addressed. If turning is very painful – are we addressing pain control ? If someone is breaking down with regular turns – are we addressing their nutrition and hydration – is the skin well oxygenated and moisturized ? In the case of a hospice patient I am all for reducing the burden, however I would still maintain that turning is the last thing you eliminate. Turns also involve human touch, checking for soiled sheets and these things remain a paramount even at the end of life.
If you have questions about positioning, skin care or management of the complicated patient – please do not hesitate to reach out to us on
1. 833. GAITWAY where someone will take your call.
Be informed … be well !