1950-nurses-photoWelcome to the Nurse’s Corner!

This is a new category in this blog that I’m hoping draws some interest.  Here I’ll share experiences,  tips, tricks and ideas for those that are nurses, caregivers, inquisitive family members, patients or just someone who finds it interesting!  Topic suggestions are always welcome, encouraged and potentially begged for!

Skin Care & Pressure Ulcer Prevention

During our 6 months at home on hospice we fought hard to prevent skin breakdown for Gram.  During her brief stay in the nursing home we had an incident where I was unavailable for several days due to my work schedule, during that time Gram developed a large pressure ulcer on the bottom of her left heel.  We knew coming home that skin care was going to be a challenge!

The Foundations!  The Mattress

To lay a good foundation (literally) we added a 2.5″ memory foam topper to the the mattress that Hospice provided with the hospital bed.  We found that this did not create any issues with the height of the bed rails – Gram however, was rarely one to try to climb out of bed!  (She more often tried to climb back into it).  The foam topper was also nice during the winter months as it held a bit more heat preventing Gram from feeling cold.

The memory foam worked like a charm and we were able to get her existing pressure sore on her heel cleared up pretty quickly without using booties and such that Gram didn’t like.  (I can’t sleep with socks on either!  I don’t blame her!)   However, as we started to near the warmer months, cooling became an issue.  The topper held the heat, ideal in cold, the absolute worst idea when it’s hot.  To combat this we tried cooling pads and increased turning but she was still getting too hot too often.   We ended up adding a thin air mattress designed to prevent bedsores on top of the memory foam and the mattress.  The plastic of the air mattress provided a barrier to the heat exchange between body and the memory foam.  Alternating degrees of inflation also changed pressure points thereby working to reduce risk of skin break down.

Bathing & Cleaning

We quickly found after coming home, that in our eagerness to prevent infection and keep things clean, we were washing with soap too often!  Daily bed baths (Gram was bathing at home only a few times a week) stripped the oils from her skin leaving itching and rashes.   We quickly changed most bathing to warm water only, using soap only on critical areas and to the whole body twice a week.  We changed clothing daily (more often as needed) and bedding every 2 days.  All laundry was done in Hot Hot water (I know a plumber who turns the water heater way up for me) with a non-scented detergent and fabric softener.

We also chose to use cloth pads for underneath Gram, disposable briefs, disposable wipes for frequent cleaning and wash cloths and soap for bed baths.  In an effort to not be doing laundry constantly we did choose the ease and convenience of some disposable products, I still feel however that the disposable “chux pad” underneath a patient are prone to wrinkles and bunching that cause increased likelihood of pressure wounds.  (Besides, the rustle when you move, who wants to hear that when they turn over in bed!)

Itching Issues

To get the itching and rashes cleared up we tried everything; lotions, powders, medicated powders, cortisone, menthol, you name it, we tried it.  I even threatened to put her hands in oven mitts and duct tape them. When I say Gram and I went a round or two fighting over her scratching, it does not do it justice.  (I understood of course, nothing is worse that a perpetual itch – but as her nurse, it was undermining everything I was trying to fix!) Nothing was working however, and Gram was actively scratching her skin off daily.

With the huge issue that itching was for us, we quickly learned that an ounce of prevention is worth a pound of cure.  We made sure that we kept her fingernails and toe nails filed and cut reasonably short to reduce the potential for skin tearing while scratching.  (Alternative – see previous options about oven mitt use.)

Cooling

Through the summer months we added a portable fan, a ceiling fan and eventually an air conditioner to create a cooler, more comfortable atmosphere and prevent skin breakdown.  The removal of humidity from the air was a huge factor in reducing her break down risk and improving both our moods!

Coconut Oil! A Lifesaver!

Sweat and warm moist bodies present great opportunities for infection and fungal growth unfortunately.  (Wonder coconut-oil-on-the-dailywhy hospitals are so cold?  No, actually that’s just to keep the staff awake.) Add to that open skin due to scratching and you’ll find yourself in a rather dangerous position.  (Note – Use of morphine at this time also complicated the itching – morphine is known for having itching as a side effect) Benadryl was quickly ruled out as an option to help the itching as a single 12.5mg oral dose would cause profound sedation for 12-24 hours.  I researched tons of alternative medications and therapies, and while weighing my options I pulled a jar of coconut oil down from the cupboard.  I started mixing in peppermint essential oil and massaging it into the areas of itching and rash.  In a few days we were starting to see substantial improvement!  For sensitive areas or areas without itching we would use just the coconut oil  as a moisturizer.  Over time we found that coconut oil was usually our best option for most anything skin related.  We even used it as a barrier cream and to prevent fungal infection under the breasts and in the armpits and groin.

Other Interventions

We did use skin adhesive on her heels to prevent any pressure sore development toward the end when perfusion was decreased.  We also found that toward the end we used calmoseptine (an over the counter barimagesrier cream) and Butt Paste for perineal area excoriation.  (When urine becomes concentrate due to dehydration and lack of water intake, it becomes extremely acidic and quickly can irritate skin).  I found tenting her blankets over her lower extremities and good use of the leg elevation options on the hospital bed also helped to limit damage from pressure on the skin.  We also used extensive massage to encourage blood flow.  Ice packs were used for especially nasty incidents of itching – applying the ice pack to the area for 10-15 minutes reduced itching without scratching.  (Well, depending on Gram’s mood…sometimes she just HAD to scratch that itch!).

While turning a patient is most always a recommended treatment in hospital care for reducing risk of pressure ulcer, it can become a tricky subject at home on hospice care.  Gram didn’t WANT to turn, she preferred to be on her back the great majority of the time, and so, to a good degree we let her.  (Her journey, her choices.  We found ways to try to mitigate the damage.)

Choice!

In all our interventions the bottom line was Gram’s choice.  (okay, occasionally I had veto power, but that was pretty rare!)  If she didn’t like a solution we found, then it wasn’t the solution, we had to keep looking for something better that suited her.  Clinically, scheduled turning, booties on the feet, pressure releases, barrier creams and regiments of medication are acceptable answers, but we all know that if a patient doesn’t want to comply then at the end of the day it’s a losing battle.  In hospice it becomes all that much more important to tailor the treatment to the patient – they’re trying to live out the end of the life with dignity, choice and comfort.  Thinking outside the box, trying new things and being open to other solutions is a vital part of skin care (and any care) at end of life.

The Cliff Notes Version:

  • Consider your sleeping surface – too hard, too soft, too warm, too cold?  Buff it up with memory foam, air mattress or both!
  • Keep the room cool, add fans, air conditioners or use ice packs and cooling sheets as needed.
  • Careful not to wash with soap too often due to stripping oils.
  • Use gentle cleaning products including soap, shampoo, laundry detergent & softener.
  • Choose disposable vs. reusable supplies for both economy and effect!
  • Coconut oil works as an anti-fungal, barrier cream, itch reducer, moisturizer and so much more!  Plus it smells yummy!  Essential oils can be added!
  • Use Skin adhesive on areas of soft skin (heels, elbows, tailbone, etc) to add an extra layer of protection against sheering and pressure wounds.
  • Keep nails (fingers and toes) clipped to prevent accidental or unintentional skin breakage.
  • Think outside the box – try things that work for you!
  • Respect their right to choose – while tough love is sometimes necessary, the great majority of chosen interventions should be agreeable to the patient.