VOL: 98, ISSUE: 48, PAGE NO: 54
Irene Broadbent, RGN, Dip. Higher Ed. in Nursing Studies, acting deputy manager, Elizabeth Lodge, Barnes Hospital, LondonMrs Smith has been resident on a continuing care ward for approximately six years. She was originally admitted after a left cerebral vascular accident that resulted in a right-sided hemiplegia. She is dysphasic but appears to understand much of what is said to her, and she is continent of urine and faeces, using facial expressions and body gestures to communicate her needs. In recent years her weight has increased from 63kg to 83kg and she is now chairbound, following a recent leg fracture.
Mrs Smith has been resident on a continuing care ward for approximately six years. She was originally admitted after a left cerebral vascular accident that resulted in a right-sided hemiplegia. She is dysphasic but appears to understand much of what is said to her, and she is continent of urine and faeces, using facial expressions and body gestures to communicate her needs. In recent years her weight has increased from 63kg to 83kg and she is now chairbound, following a recent leg fracture.
Over the past year several of her lower teeth have become loose, and she is careful in her choice of food, but her upper denture fits well. Mrs Smith is comfortable lying on an alternating pressure-relieving overlay mattress at night. During the daytime she sits on a static foam wheelchair cushion. She has several grade two pressure ulcers on her left buttock that have failed to heal properly over the past year and also some broken areas on the rear of her upper left thigh. I suspected that inadequate seating was the problem, in combination with her weight.
A variety of different wound dressings had been applied to the buttocks during the course of the past three months without success. A hydrocolloid dressing had resulted in some improvement. Unfortunately, the edges tended to roll up, and even though Hess (2000) recommends hydrocolloid dressings with thinner edges these were also unsuccessful. Mrs Smith frequently removed them when she was in bed, causing repeated replacement. A transparent film dressing was a little more successful but, due to the positioning of the wounds, this often rolled up. A quick-drying film spray was attempted instead, but Mrs Smith found this extremely irritating. We eventually decided to continue to use a transparent film dressing.
Following a visit to a local wheelchair assessment centre, I decided to carry out an assessment of Mrs Smith's seating needs. This was to ascertain whether or not the wheelchair was affecting the healing of her pressure ulcers. I was aware of her nutritional difficulties and had already referred her to the dietitian and dentist. Poor nutrition is only one of many documented factors contributing to the delayed healing of pressure ulcers (Wells, 1994). Phillips (1999) points out that a full assessment can identify the initial cause of a problem when multiple causative factors are present.
Mrs Smith sits in his wheelchair from 8 am to 6 pm, and usually makes four requests for the toilet, when she is hoisted over a commode. It is acknowledged that the night-time benefits of a pressure-reducing mattress are frequently undone in the day by the use of ordinary chairs for patients at risk of skin breakdown (Cooper, 1998).
The seating assessment criteria given to me by the wheelchair assessment centre appear to be supported by other authors (Collins, 1999). The assessment criteria are listed in Box 1.
An assessment using this criteria revealed that Mrs Smith spends approximately 10 hours a day in her wheelchair, has dry skin and a right hemiplegia which makes it difficult for her to sit upright at times. She is now overweight and so all transfers are carried out using a hoist, but she has the ability to wriggle her bottom back in the chair a little. The hoist sling is not removed from underneath her between transfers. While the staff are aware that this might hamper the effectiveness of any pressure-reducing cushion, it is outweighed by the difficulty replacing the sling underneath her successfully. Mrs Smith's mobility is not expected to improve.
The wheelchair she is currently using is one of a pool but is kept exclusively for her. The seat is wide enough to accommodate her large size, but the cushion is unyielding. The footplates are missing, causing incorrect body posture, as her feet cannot sustain any of her body weight. The staff have compromised by using a footstool to support her feet and legs, making her appear to be comfortable. However, she tends to fall asleep, resting her head on her hand, as she has no support for her head in the wheelchair. She has used this particular wheelchair for over three years, with uncomfortable trials of others.
This gathering of general information about Mrs Smith would, at first, not appear relevant to her pressure sores. However, as Miller (1999) points out, wounds are a result of a cause that needs to be investigated.
It appeared that Mrs Smith's wheelchair was, indeed, affecting the healing of her pressure ulcers. It altered her posture, offered little comfort and encouraged pressure on vulnerable areas.
On reflection, the assessment suggested that she might be better seated in a high-backed, winged armchair with pressure-reducing seating. The ward has recently purchased such chairs, but Mrs Smith had been stereotyped as a wheelchair-bound resident. When she weighed a lot less staff could seat her in an ordinary armchair. However, transfers became increasingly difficult as her weight increased. Consequently, staff chose to leave her in the wheelchair without considering other options.
However, it is possible to hoist her from the wheelchair to an armchair. Her toileting needs are not so frequent that they cause problems for the staff, and the wings of the armchair would offer support when Mrs Smith wished to rest. A dynamic, pressure-reducing cushion could aid the healing of her ulcers, complementing her dynamic mattress overlay.
I felt I had to try different seating for Mr Smith, with the intention of improving her comfort and skin condition. I was concerned that there might be initial resistance from the staff, who might view the transfers from wheelchair to armchair as extra work. However, they agreed to this plan of care.
Mrs Smith's pressure ulcer was monitored daily for signs of improvement or deterioration. Her general comfort was observed by monitoring her posture and temperament. It was necessary to have on-going staff discussions, patient evaluation and reassessment, and the patient's agreement with the plan.
Two months later, Mrs Smith had intact, although still delicate, skin surfaces with no sign of pressure ulcers. She was, however, not completely comfortable in the armchair, and a slightly larger one had to be considered.
Reflecting back on this assessment, I am pleased that I utilised new information acquired from a visit to the wheelchair assessment centre in a practical way for the comfort and treatment of a resident.