By Thomas A. Sharon, R.N., M.P.H. (Nursing & Patient Safety Expert, Life Care Plan, Medical Evidence Analysis, Medical Record Review, Legal Nurse Consultant, Litigation Support)

Who is at Risk for Bedsores?

In making the assessment, your admitting nurse must determine whether anyone or more of the following risk factors exist:

spinal cord paralysis
stroke
nervous system disease
poor circulation
diabetes
confined to bed
altered level of consciousness
confusion
bladder incontinence
bowel incontinence
diarrhea
anemia
dehydration
malnutrition
obesity
emaciation
reduced mobility (traction or body cast)

The usual procedure is to assign a value of 1 to each risk factor and add up those that exist. The totals then translate to one of the three levels of risk as follows: 0 to 6 indicates low risk, 7 to 13 indicates moderate risk, 14 to 18 indicates high risk. The parts of the body that are susceptible to pressure ulcers are the heels, ankles, knees, buttocks, tailbone, lower spine, shoulder blades, ears, and back of the head.

Why Bedsores Occur

Bedsores most often develop when continuous pressure closes off the microscopic blood vessels (capillaries) that deliver oxygen and nutrients to the skin cells. The surface skin cells in the affected area experience a buildup of metabolic waste and then die. Once a cell dies, it bursts and the fluid causes swelling in the surrounding area. This makes the blood circulation even worse. It takes as little as one hour from the start of pressure until the initial signs of skin damage appear. The nurse must relieve the pressure at no more than two hour intervals by turning the patient and providing meticulous skin care. The skin care consists of keeping the pressure points clean and dry and massaging those areas at least once every eight hours. Washing and drying reduce the amount of surface bacteria, and massaging increases the blood circulation. The failure to provide these basic nursing services is the underlying cause of all bedsores. Since hospital nurses neglect tasks 10 percent of the time, you as the patient or family member have to pay attention and speak up if these tasks aren’t being done and documented. It is difficult to understand why the need to maintain skin integrity is being neglected on such a large scale. While there is no legitimate excuse, one possible explanation is that most hospital staff nurses are overworked and in a perpetual state of exhaustion. While each nurse is accountable for individual negligence, we need to examine the culpability of hospital executives who fail to provide the fiscal management necessary to generate reasonable working conditions and maintain adequate staffing.

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Skin ulcerations also occur because of friction caused by dragging the patient’s buttocks on the sheet. This happens because nursing personnel pull their patients up in bed by their arms rather than using a drawsheet (a small-sized bedsheet that nurses use like a sling to move the patient in the bed). This may be a common practice, but it is, nonetheless, bad for the patient and, so, is unacceptable.

If you or your loved one is entering the hospital with any of the risk factors listed earlier, tell the admitting nurse that you want to be sure that no bedsores develop and you will be watching and hold nursing staff and the hospital accountable if there is any skin breakdown. You need to be resolute and firm because the effect of bedsores is usually quite damaging. The same negligence that caused the wounds to develop will likely allow them to worsen. The case history that follows is not pretty, but it’s important for you to realize that bedsores are not trivial and it’s critical that you be vigilant.

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Dorothy was a thirty-nine-year-old mother of four. She had diabetes and she was obese, weighing about three hundred pounds. The physician in the Medicaid clinic that she attended admitted her to the hospital because she had a wound that wasn’t healing on the inner aspect of her left thigh. Two weeks earlier, Dorothy had outpatient surgery at the clinic to remove a cyst. The wound became infected while Dorothy was having her usual problem of keeping her blood sugar under control because of the nature of her diabetic condition. High blood sugar causes infections to become worse and also slows the healing process.

After three weeks in the hospital, Dorothy spiked a fever at 103°F. She became lethargic. The blood culture showed that she was septic (had bacteria in the blood), and a culture of her wound showed the same bacteria. The sensitivity tests showed that this bug was resistant to most of the available antibiotics. The course of treatment was long and arduous – it took three months. During this time, Dorothy was delirious and bedridden. She became incontinent of feces (meaning that she was unable to control her bowel movements). She had enough risk factors to classify her as a high risk for bedsores.

Dorothy’s sister and children visited her every day. The sister and her eldest child, her eighteen-year-old son, knew that she was not getting adequate nursing care and started taking photographs. They always found her lying flat on her back with excrement in her bed. When Dorothy had a bowel movement, the nursing staff would usually let her lie in it for about four hours before cleaning her up. Her family complained to the nurses on the floor and got little or no response.

As you may have guessed, Dorothy developed a wound, which started as an area of redness, turned white, and then started to break down. First, there was fatty tissue exposed with weeping of clear fluid. Then infection set in. Next, the deterioration continued until the muscle was showing through. There was dead tissue with copious amounts of coffee-colored pus draining. Finally, there was exposed bone with osteomyelitis (infection of the bone).

Although the thigh wound healed, Dorothy died of overwhelming infection from the pressure ulcer. Her sister and eldest child might have been able to save Dorothy’s life if they had known how to assert themselves with the hospital hierarchy and even the department of health, if necessary. There were many opportunities to stop the worsening of her condition during the first two months of hospitalization. What Dorothy needed was diligent basic nursing care.

• Hospital Acquired Conditions