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Nursing home not saying this? My mom has been in and out of hospitals and nursing home sub-acute wing for 3 weeks.

Yesterday we received a phone call from nurse asking if mom can sign a paper to bring in a wound doctor because she has an "open wound" on her butt. Said she was scratching it.

Mom has a sling on her broken arm and a broken pelvis. She has been drugged up for pain with morphine and dilautin. I cannot imagine how she reached around her body and "scratched her butt" due to her condition. I am thinking the nursing home is saying this to cover themselves for her getting bedsore.

I haven't seen her put in different positions much at all which could have to due with her arm in sling and pelvis which were so extremely painful.

I have a meeting with the staff and want to address this situation. Opinions?

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Make sure the facility has a plan to do a skin assessment daily, or at least every other day. Sorry if I am overwhelming you with suggestions. You could print my suggestions and take them to the director of nursing. They should inspect the skin on her hips and buttock, tailbone, heels, elbows, and back and shoulders.
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Talk to her physical therapist. Patients with hip problems will often be in physical therapy. Make sure they are not doing excercises that will increase her risk of pressure ulcers. Therapy that involves sliding the heel directly on a board will cause friction on the heel and increase the risk of heel ulcer.
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I would also recommend keeping the head of her bed down or just slightly elevated unless there is really a medical reason it needs to up. Having the head of a hospital be up causes a shear force in the bottom area. This shear force contributes to pressure ulcers.
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Try to work with the care facility at this point to help to prevent pressure sores or prevent them from getting worse. You can follow the chain of command if ne cessary, ie go to the administrator an/or director of nursing to get your mom the care she needs. If necessary, you can call 1-800-medicare and ask to talk to the CQI for your area. You can file a quality of care complaint with the medicare CQI if necessary. Unfortunately, you can't turn back the clock, you can only go forward. Try to be kind to the direct care staff. I know this can be very difficult, but working with them in a kind yet assertive manner is the best way to get the care needed for your mom. This is really a system problem within the organization, and common in many healthcare organizations. The staff are probably doing the best they can with the knowledge, training, and staffing resources and workload that they have. They probably have not received enough education on preventing pressure ulcers and probably have very heavy workloads. You should make it clear that you expect her to be repositioned. You may need to communicate with your mother and let her know how important it is that she be repositioned. She may not want to be repositioned because of pain, but she probably doesn't understand the risk for pressure ulcers or how serious the complications of a pressure ulcer can be. If she absolutely refuses to be repositioned, it becomes even more important to have a high quality alternating pressure mattress. But the mattress really should be in addition to repositioning, not in place of it.
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Your mom will also be at very high risk for pressure ulcers on the heel and there are VERY simple measures that can prevent this. Please try to prevent this because the complications can be extremely serious. Have them put a pillow under her calf muscle. The heel should be floating on air. The back of the heel should not be touching either the bed or the pillow, there should be a space between the bed and the heel. Reposition the pillow or try a different pillow if needed but don't let the heel touch the bed. If this keeps the heel off the bed great. If not, they could try ordering a high density foam heel lift device from span America that would go behind her calf.
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One suggestion to help keep her on a turning schedule. Make a pie chart that looks like a clock. Lets says she has been laying on her back all of the time and that is the area that needs the relief (you will have to clarify is this is true but I suspect it is.) The clock will have one pie piece for 12-3. It will say that she should be on her right side during that time. The next piece will be on the clock from 3-6. This will say she should be on her left side during that time. Keep going til you have a 12 hour clock. Color the pie pieces in different colors and place the chart at the head of her bed. Each time a caregiver comes in they will have a visual reminder to check and see if she is in the correct postion for that time or needs to be respositioned. They can look at the chart, then look at the actual time, and reposition her if necessary. It will also help to put a paper on her door and mark off the time and initial it when they reposition her. That way staff can easily check if she has been turned or needs to be turned. And you can check as well. Be patient if they don't do it exactly every three hours to the second. Sometimes it might be 4 hours.But they should be consistent. She should be getting repositioned 3 times in a 12 hour peiord.
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Turning is important but can be difficult because people in pain often have one position that is most comfortable. Sometimes they don't want to be repositioned. Even turning just slightly from side to side can be helpful. She doesn't have to be all of the way on her side, even 15-20 degrees can be helpful. They can put a pillow or wedge under the buttock that is up to help support it. She should be able to tilt slightly to the side, even with a foam wedge secured between her legs for hip stabilization.
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Your mom is certainly at high risk for pressure ulcers, whether she actually has one or not. You should take some urgent measures to help relieve pressure. One suggestion I would have is to have the care facility rent an alternating pressure mattress. This would have a pump with a control unit that goes at the foot of the bed and makes some noise. Note I did say rent because the cost of buying a truly good mattress would be in the thousands of dollars, so at this point they want to rent. The care facility should pay for this because medicare does require them to pay the cost of treating pressure ulcers that are acquired in their facility. Even if she doesn't have an ulcer, certainly they would want to prevent one in the a very high risk patient.
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First of all take a look at it with your own eyes and as pam suggests take pictures and keep for comparison. Going to the health dept is your choice but unless the NH has many signs of inadequate care perhaps hold off on that.
getting a wound care nurse in would be an excellent more.
The other thing to be really concerned about is proper cleaning after a bowel movement. That means getting right down to the anus with a wet washcloth or wipe and getting the cream right down there. Apart from the obvious reasons if feces is not properly cleaned off the area becomes extremely sore and itchy. It is possible this happened and she did in fact scratch down there because she could not stand the itch. Check her fingernails! (Personal experience - the best teacher)
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Phew, she's been given Morphine AND Dilaudid? She probably does not know that she's making matters worse with the bed sore. That's some strong stuff right there!!
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It's very possible that it could be a bedsore, they're very common among older people. What can cause them in people of various ages is when the mattress you're sleeping on causes pressure points and lack of circulation to that pressure point. You can wake with a sharp burning pain in that area when the blood has not been able to circulate very well because of the mattress underneath you. This is why having the right mattress that doesn't cause pressure points is vital.
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I am a care giver for my wife and now dealing with this issue. The problem originated from the stiff stitching in a commode type sling used with an overhead lift. Bacitracin, Xeroform, Vaseline and soft gauze pads helped initially, also an Allevyn butterfly bandage but now that the wound seems dry a barrier cream is working better. I take pictures every day to monitor progress and have a nurse visit twice a week.

My wife has been bedridden for almost 6 years and this is her first bedsore problem. I believe the use of a high density foam mattress is what prevented other types of bedsores. Incidentally, I also use without problems a full body mesh sling to help raise my wife off the bed to re position her up the bed and change the sheets.
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Bed sores can develop anytime someone is laying on back, pitting pressure on the sacrim, or buttocks area, and in you mothers case, it may be very difficult to reposition her due to the pelvic fracture. The sooner you gey help from wound care the better, as these types of sores can get out of control and grow really fast, even overnight, and can get deep under the skin to the bone, as ferris pointed out. At this stage, they are very difficult to treat! It will take persistence to heal, and to prevent it's return, probably for the rest of her life, as these tend to reoccur. Always check her behind, every day, and with bathing. Once healed, a good barrier cream will be nessesary! Good luck!
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My Mom had a open wound on and off on her hindend for the last couple of years she was alive.I took good care of her and kept her clean,but she was incontinent and wet her depends and as soon as it would heal,a new spot would appear.The best thing that helpedher were dermagram patches and Medihoney.It took constant daily effort on it for sure.The heating pad didn't help either,I'm sure on that area but it was a comfort to her.I'm sorry you are having to deal with this...it's a tough one.Good Luck and take care,Lu
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Ditto what everyone said, except for calling the health department. Mobility - or lack there of -, age, and skin fragility all play a factor. My mom has had a couple of bed sores over the years. A week ago one of her in-home helpers noticed the redness starting right at the tailbone. Sure enough I could see one starting. Regular cleansing with a good skin integrity product, then applying a bandage with padding can stop the formation. But if there's an actual break in the skin, a wound nurse should be involved. I agree with ferris1 - be glad they brought it to your attention and are calling in the wound nurse. Side note: it just amazes me how quickly these can develop even in people at home with some mobility. For future reference someone should be checking her skin regularly, particularly at pressure points - heels and elbows included, although they typically form in the hip/bottom area. Good luck!
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I know someone who was getting very good care at home and got a bedsore. They were placed in a nursing home to try to help and it didn't. Sustained treatment did not seem to help, so it's not always someone's fault when they occur.
I have read that if there are a lot of medical issues, it's not uncommon to get them.

Dtrinfl2, is your mother on Hospice?
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As a nurse, positions are normally re-positioned every two hours, however, having a fractured pelvis requires the patient to remain stabilized with a V-block between one's legs. Lying in that position would create a decubi (pressure sore) on the sacrum area. You only mention one arm in a sling. Does she have another arm? She could still reach her buttocks with that arm/hand. Also, being heavily medicated she might be having hallucinations. My suggestion would be to bring in the wound doctor because you don't want the tissue exposed down to the bone (which I have seen). Not good...Also, stop trying to find fault with nursing staff/home which is probably doing the best for your mother since you chose them.
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All the above is good advice, and wound care very important. Just so you know, bed sores can be very easy to get. I have had 3 joint replacements in the past 6 months and developed a nasty one within two days of the first hospitalization - common with harder mattresses, plus I was on my back, and weigh less than when previously in the hospital. Nurses applied a protective ointment and special patch, and used foam wedges to alter my position a bit at regular intervals. It took a couple weeks to heal, but knowing how easily it can occur prepared me for the next two hospital stays. Getting mobile helped, too, and hopefully your mom will heal quickly and be up and about soon. Best wishes!
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I'd keep the meeting as friendly as possible but make it clear that you are wondering about bed sores (which could be a possibility for sure). The idea of not using protective cream, as Bonniepages mentioned also makes sense. Certainly a wound doctor is a good call so I give the NH credit for that. Some would ignore it. Make it plain you expect that this won't happen again.

Good luck to you and your mom,
Carol
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My Mom got hers by staying overnigjt in urinales dispers WITHOUT triple paste aceran protector. It doesn't necessarily have to be from not moving. And my mom is at home with me 24 /7. I just stopped using it for one week when she had her rectum exposed.
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Go, take pictures with your cell phone. Report the bedsore to the health department.
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