Pressure ulcers back in the day

Pressure ulcers seemed to be few and far between in the early 1980’s although that is probably my rose- tinted glasses talking. As mentioned before routine back rounds were the norm in all adult wards, when each patient was visited at least every two hours to be stood, walked, toileted or re-positioned. The news that vigorous rubbing of pressure areas can cause friction damage or possibly rupture the micro-circulation hadn’t hit us yet and we were still frantically rubbing those hips, heels and bottoms in the belief that it would bring the blood supply back into the oxygen starved tissues. There is of course something about the regularity of visits to the patients and the activity of walking, toilet and turning that, in itself, is a great way of relieving pressure, but heaven knows how many were prevented and how many were caused by our ‘helpful’ intervention.

I’ve mentioned bed cradles, pleated sheets and monkey poles before but that’s not all we had. Alternating pressure mattresses were not in wide use (if at all) but we did have a simple ripple mattress which overlay the basic hospital mattress. The ripple mattress ran on a little motor but that was as sophisticated as it got at

A modern ripple mattress

St.Albans City Hospital. There were none of the weight sensitive mattresses that we have now, nor the all-important lowering of pressure under the heels or the rapid deflation switch for CPR (you cannot do effective chest compressions on an air mattress). The cover of the mattress had a limited stretch to it didn't contour to the patient in the way that today’s highly flexible three way stretch materials do.

The mattress underneath, usually the standard NHS foam mattress by that time, had a marbled pink cover over it with a zip along the side and end. This cover had a really limited stretch to it and in time became infamous for its ability to create a rigid ‘hammock’ for the patient to lie on. This meant that instead of flexing to the patient’s shape and allow the body to sink into the foam underneath the cover stayed fairly rigid, suspending the patient (as in a hammock) above the foam. The hammock effect creates higher pressures over bony prominences instead of dispersing them by increasing the body’s surface area contact with the foam.

The other problem with the cover was that it wasn’t very good at preventing body fluids from soaking through to the foam underneath (partly because the mattresses weren’t replaced often but mainly because they weren’t effectively waterproofed). This problem became more apparent when the use of plastic overs and draw sheets to protect the middle of the bed reduced, thus removing an important additional layer of protection from the mattress cover (they went for good reason, the draw sheets were rough on the skin and the plastic under layer caused the patient to sweat). Many early tissue viability nurses (and infection control nurses) will remember unzipping the mattress to check the foam inside only to find large stained patches in the centre of the mattress. And the stains weren’t all on the inside either, often there would be large, dark stains on the cover itself, an odorous reminder of some previous occupants trauma and distress. Many tissue viability nurses, myself included, would take photos of these mattresses to shock management into getting them replaced.

Nowadays we can buy mattress covers that are very sophisticated in their ability to conform to body shape along with providing excellent waterproofing. High spec products will also have neatly concealed zips to prevent fluids getting into the foam through the zip area although mattresses still need replacing regularly to ensure maximum benefit. As to the foams today, they are also much more sophisticated. Even a basic mattress should be able to offer some pressure re-distribution, whilst the more advanced ones are really effective in spreading load and giving comfort. The memory foams will bounce back into shape too unlike their ancestors which would flatten, or ‘bottom out’, after months of heavy use leaving the patient as good as sitting on the hard metal bed base. Not good for pressure areas and so uncomfortable for the patient.

Something else we used a lot of in the 80’s was sheepskin; sheepskin bootees, sheepskin overlays and

elbow protectors. Real sheepskin products are very absorbent (think sheep in the rain on a mountain side) and soft to touch but the type we used was synthetic and usually been through the hospital laundry so many times it was horribly lumpy. Not comfortable at all and certainly no good for protecting the skin from pressure.

Another lumpy product was the fibre filled overlay which sat over the base mattress and was supposed to offer the patient comfort and pressure reduction. Again, the frequent visits to the laundry meant these products were far from comfortable and today’s at risk patient is more likely to be nursed on an alternating air pressure mattress which will provide pressure reduction on a cyclical basis or a low air loss mattress which will provide a constant low interface pressure between skin and mattress surface.

In earlier times water filled mattresses were used for pressure reduction although by the time I trained they

had been mostly replaced by the ripple mattress. The principle of water flotation remained of interest to the 1980’s nurse though and many who were around at the time will recall filling surgical gloves with water, tying the end like a balloon and balancing the heel on it. This precarious device was difficult to position and although the principle was reasonable enough (minimise and disperse the interface pressure) it was unlikely that it did any good. Particularly when people taped the glove to the foot, the glove leaked, the glove was over or under filled, or filled with water that was very hot or very cold, the foot moved, there was a skin reaction to the latex (I think they all had latex in them then)….

 

One final item that I recall was the ‘doughnut’ or ring cushion. Here the principle was to rest the heel or bottom onto a ring shaped object in-order to relieve pressure in the centre. The seating rings were usually made of foam and the heel ones we usually made ourselves but I can’t recall how (hoping it will come back
to me or perhaps someone will give my memory a nudge). In later years it was suggested that the inner ring could in fact exert a line of pressure around the vulnerable skin area thereby further reducing the supply of blood to the area. We haven’t recommended them for many years because of this but only this week a student asked me about them because she had seen one in practice and I then found several styles for sale in a medical supplies catalogue. Either the evidence isn’t clear enough or the message just hasn’t got through on this one!

Despite all this, as I said at the start we did not seem to have so many pressure ulcers as we do today. But then our patients had longer to recover in hospital, there were fewer high dependency patients because survival rates weren’t so good nor surgery so complex. We had more hands on nurses because we students were part of the ward team and we had that back-round, checking skin condition regularly and re-positioning routinely. We had fewer older patients than today and we were not struggling to provide care within a context of constant pressure on costs, staff and beds. However, this was all set to change, as we moved toward individualised nursing care in the 1980’s what we gained on the one hand (holistic patient focused care) we lost on the other with task orientated nursing care thrown out the window along with the certainty that all the fundamental caring tasks that every patient needed were getting done. Today nurses are trying to re-dress the balance without losing the great strides the profession has made in terms of providing patient-centred, holistic, nurse led care.

Still the 1980’s were a time of great innovation and the pioneers of pressure care were set to really shake things up. Click here to hear Pam Hibbs talking about her ground breaking work at Hackney Hospital in the late 1980’s http://health.hackneysociety.org/page_id__142_path__0p10p43p.aspx ). She and many others started to question why pressure ulcers were on the increase and look at what could be done about it. It was Pam Hibbs who famously said that 95% of all pressure ulcers could be prevented. Its a mantra that many nurses have taken up again today and whilst pressure damage is not the sole province of the nurse, there is no doubt that nurses are supremely well placed to lead on eradicating this problem for the vast majority of patients.

Next week: Moving to the QEII and working as a student in Theatres

Nightingale wards and Nelson's Inhalers

Previously I mentioned the ward sister who called everybody Sweetie Pie regardless of age, race or gender. It made me think back to the ward she ran (and I use that word loosely) which was a single storey medical ward in one of the oldest buildings in the hospital. The ward was set out in ‘Nightingale’ fashion with beds down either side the length of the ward and a Sister’s office at one end with a sluice at the other. All the patients were male aside from the occasional female patient in a side-room when beds were short elsewhere. Just like ITU the ward relied on oxygen and air tanks for its many chest patients and much time was spend manoeuvring these tanks around the bed areas.
The biggest tanks sat shoulder high and were caged in wheeled metal trolleys (as they are now) with a big metal bar on the side for a handle. Moving the tanks meant tipping the cage back on to its two wheels, holding the weight steady and pushing or pulling the trolley into position. There was no more bed space then than there is now and it was an awkward business working in such a limited area; the tanks were heavy and the cold, hard metal of the cage painful if knocked into. Moving around the patient to wash them or provide mouth care, meant working around the tank, the bedside table, the locker and the bed itself. There might also be cot sides, a bed cradle and a monkey pole on the bed (for the patient to lift themselves up with) to contend with.

In every hospital that I’ve worked in since, space has been a problem in wards and side rooms alike. Only recently I was in a side room in a modern hospital and the patient needed a hoist to move from bed to chair. The space limitation of the room (which only had the bare necessities in) was as much a risk to the patient and ourselves as the actual moving procedure we were carrying out. Whilst there is guidance on minimum bed space even now it would seem not all hospitals meet this http://www.informedesign.org/Rs_detail.aspx?rsId=3555

Caring for medical patents can be hard on the back, with patients often highly dependent on the nursing staff to wash, feed, toilet and move them. Having said that, male medical wards had the distinct advantage over female medical wards because the men could use a urine bottle whilst the women always had to be lifted onto a bed pan or commode (the ‘she wee’ hadn’t been invented yet!).

Personally, I liked the variety of working in medicine and I loved the sense of involvement with the patients because they were often in for longer than the surgical ones. Despite the Ward Sister’s out of date approach to nursing (she wore a frilly white cap, sat in the office for long periods of time, fawned over the doctors, avoided the patients and went to the hairdressers on Friday afternoon during shift time) it was a friendly ward and I learned a lot about all round nursing care. At home now I have a Nelson’s Inhaler (bought second hand) which still smells of tincture of benzoin (Friar’s Balsam), one sniff of which takes me back thirty years. They were brilliant for ‘chesty’ patients; we would put a teaspoon of tincture in the china inhaler, add boiled water, sit it in a deep plastic tray and pack around with towels. Then the patient would lean over the inhaler and put the mouthpiece in his mouth and gently inhale. Very soothing and worked a treat.

One advantage of the Nightingale ward was the sense of camaraderie that sometimes developed between patients. Although it is a very public space to be ill in, patients can also see and speak to each-other easily, they can see where the nurses are and they have a sense of the ward routine and activities so there is less risk of isolation. Privacy and dignity was not easy to achieve though and having your bowels open on a commode with just a thin bit of curtain between you and the man in the next bed either side (plus their family if you chose to go between 2pm-4pm or 7pm-8pm) must have caused many a bout of constipation.

The curtains round the beds would rarely stay closed. If the curtains went to be laundered the replacement ones were never long enough or wide enough. No disposable curtains back then either. Nor were there any duvet covers as there are in some wards now. Every bed was made properly with sheet corners folded in and top sheets folded back to show approximately 12 inches of white over the blue bedspread (blue because it was the men’s ward; the women had pink of course). When we made the beds we would put a central pleat in the top sheet to ensure some looseness over the patient’s feet because tight sheets over the foot cause pressure damage and foot drop.

Now, pressure damage, that’s something I will definitely be coming back to…