Sleep deprivation resulting from repositioning and waking without consent is unacceptable, is a form of abuse, and may contribute to a cognitive decline in the elderly. If patients are allowed to sleep and only repositioned when awake, staff workload is reduced, manual handling injuries are minimized and consequently the risk of skin tears, an added problem in the elderly who have tissue-paper like skin, is decreased.

The Pressure Ulcer Prevention Guidelines are lengthy and complex for care staff to read, are not evidence-based and will, more likely than not, fail to prevent pressure ulcers in residential aged care facilities.

LINKS

Nodec A mattress

Sharp, C. A., & Campbell, J (2022). Preventing pressure ulcers in aged care by auditing, and changing, work practices. Asian Journal of Medical Sciences, 13(4), 191-195. DOI:10.3126/ajms.v13i4.41855

Sharp, C. A. (2022). Do clinical practice guidelines for the prevention of pressure ulcers really prevent pressure ulcers? An analysis of the guidelines. Asian Journal of Medical Sciences, 13(6). doi: https://doi.org/10.3126/ajms.v13i6.43030

Patients are often repeatedly woken when being repositioned during that 24-hour period. This repositioning regime is often, if not always, carried out without informed consent.

One rare complication of eye surgery is sympathetic ophthalmia, where an operation performed on one eye can cause loss of vision in the other eye. The estimated chance of this occurring because of eye surgery was cited in the High Court case as about 1 in 14,000 cases. The key issue to informed consent is whether the patient, if informed of this 1 in 14,000 risks of sympathetic ophthalmia with the chance of losing the eye opposite the eye being operated upon, would have refused the surgery as being too risky in her case' (Mazur, 2013).

LINKS

Mazur, D. J (2013). Informed Consent in the Twenty-First Century: What It Is, What It Isn't, and Future Challenges in Informed Consent and Shared Decision Making. Sociology Compass, 7(9), 762-774. doi:10.1111/soc4.12067

Doc Malik interviewing Anna de Buisserat

Preventing pressure ulcers has traditionally involved repositioning patients every two hours to relieve pressure on any part of the body sandwiched between the bony skeleton and mattress, or chair.

Understanding that repositioning wakes patients resulting in sleep deprivation is my significant original contribution to knowledge. In addition, patients are not provided with information about repositioning and their staff will more likely than not fail to give them a choice about being repositioned, yet they should.

Repositioning bed-bound patients is a major manual handling task that puts patients at risk of skin tears and nurses at risk of back injury.

Sharp, C.A. & Campbell J. Preventing Pressure Ulcers In Aged Care By Auditing, And Changing, Work Practices. AJMS vol 13 No 4 1 April (2022)

Exton-Smith, A. N., & Sherwin, R. W (1961a). The prevention of pressure sores significance of spontaneous bodily movements. The Lancet, 278(7212), 1124-1126. doi: http://dx.doi.org/10.1016/S0140-6736(61)91033-9

When I was researching the literature on two-hourly repositioning, studying the scientific papers, learning how pressure ulcers developed, searching for solutions to prevent pressure ulcers, I decided to find out what happens when we reposition patients; specifically, what transpires deep in the body tissues, unseen.

Knowing how to prevent pressure ulcers it became imperative to learn what happens when patients are repositioned every two hours.

Sharp CA and McLaws M-L. A discourse on pressure ulcer physiology: the implications of repositioning and staging. http://www.worldwidewounds.com/2005 /october /Sharp/Discourse-On-Pressure-Ulcer-Physiology.html

For decades, aged care facility residents at risk of pressure ulcers have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week. Yet, pressure ulcers still develop.

We used a cross-sectional survey of eighty randomly selected medical records of residents aged ≥ 65 years from eight Australian Residential Aged Care Facilities to determine the number of residents at risk of PUs, the use of two-hourly repositioning, and the presence of pressure ulcers in the last week of life.

Despite 91 per cent (73/80) of residents identified as being at risk of PUs and repositioned two-hourly 24/7, 34 per cent (25/73) died with one or more pressure ulcers.

Sharp, C.A., Schulz Moore, J.S. & McLaws, ML. Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?. Bioethical Inquiry 16, 17–34 (2019). https://doi.org/10.1007/s11673-018-9892-3

Caterpillars have spikes that they use as a defence mechanism to deter predators. The spikes are very painful if stood on. I talk about treating toddlers who have stood on caterpillars as well as treating children with gravel rash after falling off their bikes.

This podcast will teach you how to remove hundreds of spikes from the feet, and how to treat gravel rash with Duoderm, a favourite hydrocolloid dressing.

Sharp CA and White R.

Pressure Ulcer Risk Assessment: Do we need a 'golden hour?'

Journal of wound care vol 24, no 3, march 2015

Letter to the Editor

Screening patients on admission using rapid clinical judgement, focusing on immobility, the only evidence based risk factor for pressure ulcer development,6 is the fastest way to determine risk. Interventions could then be provided immediately and pressure ulcers prevented. Accordingly reducing delays in screening for pressure ulcer risk and providing pressure relief within the first 'golden hour' must henceforth be considered as the foundation of pressure ulcer prevention. It is unconscionable to delay assessment for up to eight hours.

I knew that pressure ulcers were caused by immobility and the survey showed that many nurses knew that too. They were not using official risk assessment tools but rather their own clinical judgement to screen for risk; and they were right. Nevertheless, it took writing this paper to prove that no risk screening tools could do a better job that nurses using their own knowledge and experience to determine who was at risk. Unanimously nurses wanted to simply focus on mobility; immobility being the only risk factor nurses need to focus on. Because there is no evidence that some of the risk screening tools are better than nurses' clinical judgement (Pancorbo-Hidalgo et al., 2006) it seems sensible to focus on immobility. I believe care staff in residential aged care facilities, many whose first language is not English, will find it very easy to screen using clinical judgement whereas trying to read, and score, a numerical tool such as the Waterlow or Braden, written in English, is time-consuming. Sharp CA and McLaws M-L "Estimating the risk of pressure ulcer development: is it truly evidence-based?

Unusual heel pressure ulcers in ambulant patients

Case Studies and listen to the following episode on screening and how to use professional judgement in screening.

www.thewoundcentre.com

Tinea is a fungal skin infection that can be spread by skin to skin contact. It may be picked up in swimming baths, from floors and cubicles. Tinea is commonly seen on the feet but can affect the groin, scalp and beneath the breasts. Tinea is also known as ringworm but there are no worms.When dressing after a shower, put the patient's socks on before underwear. That way you are not dragging fungi from the toes to the groin. Let your care staff know to dry well between the patient's toes and put socks on before underwear. Check inside the patient's shoes. They may need new shoes. Notify a senior manager and the GP. They may recommend a fungal powder. Please don't use creams. They are a 'slip and fall' risk.