Caring for Pressure Sores in Elderly People with Circulatory Problems from Long-Term Diabetes, in Nursing Homes
Pressure sores are tears or ulcerations in the skin, that occur typically in the lower half of the body over ‘bony prominences’ that support the weight of the body during lying, standing, and sitting. The most typical areas that the elderly are prone to developing pressure sores include the heel, lower legs and feet, and lower back. The majority of pressure sores occur in people aged 70 or over through age-related health and lifestyle factors associated with the elderly.
a) What physical care needs do such elderly people tend to have?
Damage to the skin leading to pressure sores can cause wounds of varying degrees of severity, which have the potential to become infected. Physical care through wound treatment is thus essential and so effective co-working with medical staff colleagues like the community nurses will be very important for nursing home to manage. Prescribed medications to counteract infections and topical locations in order to aid healing are all part of the care routine for those with existing pressure sores. Also within wound treatment, dressings and bandages will need to be changed according to the patients care plan in order to minimize potential for infection.
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Physical care routines for elderly patients in nursing homes residential care can also involve taking actions in order to minimize the risk from pressures, as well as helping residents in wound treatment as outlined above. As diabetes will often incur the symptom of more frequent need for urination, incontinence may be particularly problematic as dampness in clothing, or in bed sheets etc, is likely to cause skin irritation and thus increases the risk from pressure sore. Physical care thus needs to involve frequent toilet visits, changes to sanitary hygiene products like pads, and changing bed clothes when necessary. Avoiding plastic bed padding is also preferable as plastic will trap dampness between the skin and the plastic and so could increase irritation.
Foot care is a very important physical need that elderly diabetic patients will often require help with. Due to changes to the body’s circulatory system and reducing ability of the skin to heal and renew itself (turnover of epidermis can reduce by 50% in older age), once minor foot problems like in-grown toe-nails or blisters can lead to infections and potentially gangrene (in some instances requiring amputation). Ensuring patients / residents are wearing well fitting footwear and that toe-nails are kept short should be completed by staff. This risk from pressure sores is also increased by the reduction in sensitivity that aged-skin possesses – elderly patients simply may not be able to feel that skin ulcers or pressure sores are developing until they are well advanced, and so more difficult to treat, and for the body to heal. Therefore regular checks and skin assessment in risk areas on the body such as the feet should make up an important part of the care routine for elderly patients, who may not be able to do these checks themselves, or who may not have enough skin sensitivity to be aware of these problems as they occur.
b) Why do such elderly people develop bed sores?
Pressure sores (also known as bed sores) will come about through changes in the skin associated with ageing, severely restricted movement, and when there the body has circulatory problems and the health outcomes associated with poor circulation. Those older patients with diabetes particularly, will often experience circulatory problems, which are then compounded by the restricted movement and general reduction in mobility involved within the aging process, which puts repeated or prolonged pressure on certain points of the skin causing wear and tear that the body is unable to cope with.
Elderly patients in general are susceptible to skin damage and pressure sores through the changes to their skin that make it thinner (dermal thickness can decrease by 20%) and weaker as they get older. These processes include the ‘loss of subcutaneous tissue, diminished pain perception, decreased cell mediated immunity, slowed wound healing, and the altered barrier properties of aged skin. These biological changes to the skin have the medical implications that the body’s local inflammatory responses will diminish which slows the healing process, and sensory loss in the skin may follow. These are particular factors that expose the elderly to pressure sores.
In conjunction to the risk from age-related skin changes, the high number of elderly patients who have diabetes means that compromised circulatory systems can put people at even higher risk. This happens because diabetes affects the body’s ability to effectively regulate blood as the high levels of glucose that remain in the blood begin to damage the blood vessels, and it is this process that begins to inhibit circulation of blood around the body. Over time, poor circulation can have the effect where limb extremities begin to suffer and will start to change in the sensation they arouse – a feeling that is particularly common is tingling in the lower legs and feet. A change in sensation especially within the legs can be indicative of worsening circulation which can have serious implications if a pressure sore occurs. Poor circulation compromises the healing process meaning it takes longer for wounds to heal, and leave people more susceptible to developing infections and potentially gangrene. Change in sensation is also often coupled with sensory loss, where by people may be unable to feel when they have a pressure sore, and so wounds may be left untreated for some time if not regularly checked by self or others.
The restricted movement which many elderly people in care homes experience also puts them at risk. Prolonged sitting or lying for people who have difficulty walking or who are bed-bound are those that are in the highest risk group. Hip-fractures, neurological disease paralysis from conditions such as stroke are common within elderly populations and so should be monitored accordingly. Strokes are often a problem for those with diabetes due to the damage that high levels of glucose causes to blood vessels, which can eventually begin to exert on the arteries, so elderly diabetic patients may suffer immobilization and sensation loss resulting from both strokes and poorer general circulation from the diabetes.
c) Describe one Clinical Skill necessary to meet the relevant physical care need(s) of the patients. Describe how this skill would be applied.
Devising a repositioning (regular turning) schedule may help to alleviate the stress on certain areas of the skin for those with restricted mobility or with general immobilization. As mentioned previously, elderly diabetic patients are likely to suffer poor circulation which can lead to change in skin sensation and eventually sensory loss over some areas of skin. Through this process people may sit or lie for much longer periods of time, or be unable to move at all; so increasing the stress placed on set areas of skin – younger adults for instance typically shift their body weight every 15 minutes, even whilst asleep.
Physical care should thus include assessing the repositioning needs of individual patients or residents – some documents discuss a 2-hour turning schedule as a bench mark. The time needed between movements and turning of the body may however be greater for those at higher risk of pressure sores, such as though who have severe mobility restriction or immobilization; those who have existing wounds, those on sedating medications (and therefore may reduce their movements according to when on medication and when not. Also factors like whether special mattresses or support surfaces are being used will affect the rate at which people will need to be repositioned. Skin inspection should also determine the repositioning needs of individual patient needs.
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Physical care routines should therefore apply repositioning by alternating residents / patients between sitting, standing, lying; particularly whether people can engage in physical activities during the day. Short walks, encouraging movement or moving residents between different rooms within residential care (such as between communal lounges, gardens conservatories etc) where possible will provide health benefits as well as reducing relief from pressure sores by shifting body weight through movement and activity. For those with severe immobilisation or those who are bed bound, rotating body weight for lying on back to sitting in bed etc should be maintained along with regular small shifts in body movement (adjusting pillow position, angle at which sitting). Written repositioning schedules are also good practice in places of residence (such as nursing homes) where multiple caring staff will be applying the turning and repositioning of the patient – this will help to ensure that the devised schedule of movements is followed.
d) Supporting literature
Pandya, N. (2003) ‘Diabetes management in long-term-care’ Caring for the Ages
Vol. 4 No. 2 p21-24
Richens, Y. Stephens F. Bick, D. Morrell, C. Loftus-Hills, A. Duff, L. (2003) ‘Pressure ulcer risk assessment and prevention: Improving practice, improving care’ Clinical practice Guidelines, Royal College of Nursing.
Vohra, R. & McCollum, C (1994) ‘Fortnightly Review: Pressure Sores’ British Medical Journal Vol. 309 p853 – 857
Zulkowski, K (2003) ‘Protecting your patient’s aging skin’ Nursing
Nuffield Institute for Health & NHS Centre for reviews and dissemination (1995) ‘The prevention and treatment of pressure sores: How useful are the measures for scoring peoples risk of developing a pressure sore?’ Effective Healthcare Bulletin
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