De guideline in de eerste lijn Op zoek naar tips Diégo Backaert
Dit is: o
o
o
Een beginnende decubitus stadium 1 Een beginnende decubitus stadium 2 Een bijtwonde
1
Aandachtspunten
Dit is: o Een beginnende decubitus stadium 1 o Een beginnende decubitus stadium 2 o Een bijtwonde
* Voeding * Hygiëne * Drukpunten * Risico bepaling * Communicatie * Huidtoestand * Juiste materiaal * Pijn * Observatie * Preventie * Wisselhouding * Dossier invullen
2
Gebrek aan preventie Studie U Gent 2008 in RVT’s:
Meer dan 65% van de decubitusletsels waren graad één Ontstaan: 70,7% op de eigen afdeling. Gemiddeld 41% van de bewoners waren risicopatiënt Slechts 5,5% van de risicopatiënten kreeg adequate preventie 28% kreeg helemaal geen preventie Gemiddelde kennis van 28,7%.
Wondheling bij verlamde persoon eist: * Kennis * Ondersteuning (literatuur & wetenschap * Doorzettingsvermogen * Creativiteit * Geduld * Portie geluk
Principes van preventie 1. Steunoppervlak (Gelijkmatige spreiding) vergroten door in matras/ kussen te zakken 2. Vermindering duur zelfde houding 3. Continuïteit geven
Wisselhouding Passieve met schuim, Opgeblazen met motor
Om de 4uur op visco-elastische matras * beter dan op een gewone matras om de 2u * even goed als een alternerende matras (zonder wisselhouding) Frequentere wisselhouding leidt niet tot betere resultaten (2u zij + 4u rug: niet minder decubitus dan 4u)
3
Zijlig 30° rechts SemiFowler 30°
SemiFowler 30°
30°
Zijligging 30°
Zijlig 30° links
111° 131°
2
1
Zwevende hielen
Onvoldoende effectief
4
Special case Nevada USA
Verlamd en wonde = Geen revalidatie terugbetaald
5
Dear all, Sorry to hear all this misery. I’ll try to do my best in English to give some advice. First of all, this is a shearing/ moisturized wound. Mostly caused by traction. So the first thing to do is to avoid traction on the skin. A towel to glide is very useful (don’t know the exact name). for exemple: Further it is very important to protect the healthy skin with a barrier. (also for Intertrigo) In your case, I’d prefer a silicon ointment like a Aldanex (Biologiq) or a ProShield Plus (Healthpoint). This will prohibit the Matrix Metalloproteinases (the enzymes coming out of your moisture, urine, faces…..) to irritate your skin. A fine hygiene first, and then the protection. I do not recommend the flammazine nor the topical use of antibiotics, because this oxidates with the air and will cause a film on your wound. You’ll get resistency to MRSA or other bacteria’s. The adaptic is very useful but can be replaced by Cuticell Contact or a Mepitel One. The tegaderm gives striping and skin tears: be aware! You must also avoid the microclimate: too much moisture and closed up under a tegaderm. If you want a super absorbing bandage: look for the Sorbion or the Mextra, or the Vlivasorb. Sorbion takes most of the moisture and is probably not asking to change this every day. It will be difficult to apply these bandages with the use of your skinprotector. The best way to lay down is first lay down completely, then get the knees up, then your head en not to get to much pressure on your heels.
Repositioning on your side in 30° is also necessary: The best way to sit and have the least traction are these: You must not forget that a paralyzed person has only 30% left of its circulation. This means that these persons will have a high risk to develop severe wounds. An alternating mattress is also a necessity, if it’s one with big cells of not less then 10 or 11 cm diameter. Nevertheless, this wounds will normally get cured…. with some time, protection and nutrition. Especially proteins are very important. Here we use Protifar supplements, or Cubitan drinks to cure faster. And afterwards, prevention will be the issue to follow. The skintag you mentioned can be cauterized away. I propose to cure first the other wounds It must be frustrating to hear some people say they can’t do anymore….. there is always hope…. So, congrats to all people who are helping you, and keep up the spirit !! Some products can be bought under another name, but if you ask, I’m sure you will find them. There is also an international guideline available on: http://www.epuap.org/wp-content/uploads/2010/10/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAPPPPIA-16Oct2014.pdf or some nice information on: http://rnao.ca/bpg/guidelines/assessment-and-management-stage-i-iv-pressure-ulcers I hope I’ve given you some help to solve this problem. Greetings, Let me know if I can help.
Greetings, Diego,
I have waited on writing to you because I was hoping to have more information on our actions, based, of course, on your excellent recommendations, however, some things we have been able to change and others we are waiting for, so a thank you and update is certainly in order sans postponement.
I am sure I am speaking for everyone that knows and loves Danny when I say we are very very grateful to you for taking the time to help. I suspect the amount of time you spent on the email is more than the time his own doctors here give him when he gets a chance to see one. Thank you so much for your kind heart.
It was such a relief to hear your ideas. I have always had the determination to get this cleared up, but as you probably know from Marina, I am not a nurse. I am actually a designer and book editor and I have been using techniques taught from home health nurses here! So there has been much for me to learn and though I actively seek solutions, Marina may have also told you how badly broken the medical system in the United States is, and the most needy are the most neglected. Shameful.
The few things you recommended that I WAS able to put into action immediately (angle in bed, type of ointment and wound bandages, repositioning, etc.) have already given a good result, as you can see from the attached photo. I have ordered the ointment ProShield Plus and the Cuticell bandages, and they should be here within the next week.
I am not sure what material the sheet in your photo is, but I know what it does and I will be able to find that material in a store that sells fabric. So far, I have been unable to find one that helps reduce friction/traction in any way from the medical supply stores here and on the USA Internet. But I know what it does, so I will find it. I need to take a drive to an adjacent town to find that so it is also ahead, and in the meantime, I am using satin pillow cases! Satin sheets never stay on the bed, so...? :0)
We have put dietary changes in action as well and Danny is having a supplementary protein drink each day that has the ingredients close to the ones you recommend. You were right that not all of the products are available here, but I do know how to find substitutes based on the ingredients lists given. I am also finding a lot of excellent information from the website links from you.
I am very excited to see the results of the new regimen you outlined. We plan on following your instructions, as close as possible, to the exclusion of any other method, and I will be updating you on our progress.
At the risk of repeating myself...thank you from the bottom of my heart. I will never forget your kindness, and when we are relocated to Belgium perhaps I will be able to help you in some way. That is my hope.
In gratitude to you, and also to Marina, for holding us in your hearts,
Bonnie
6
Hahaha I'm not sure that's such a good idea - showing a photo first! Maybe you read your emails during lunch! ;0) These Americans HATE healing anything! If you heal, they cannot charge you money anymore! I am saying that because I think you would be surprised at what gymnastics I have done to FIND the cream! The ProShield company has been BACK-ORDERED for months, literally. Finally, I found a case of twelve tubes at a medical supply house in New York City, so I have made that purchase and will have it here on Friday. Hurray! I have been using the Cuticells and they are wonderful! Since the very first day, I have not had one incident where his skin was pulled away at the shearing area. He has not had a bleed in over a week, and he told me the pain is almost gone! We have also adjusted his position in bed and have been moving him as you described and it's really improved. Actually, a miracle! As for the cream, I have been using a cream that I found that had many of the ingredients that the ProShield has, and none of the ones that the failed creams have. It's close, and it seems to be helping. I think you can see from the photo that his skin is less "angry" looking, which is what it seems like when it's bright red and very painful to the touch. It looks good, doesn't it? Again, Diégo, thank you for your time and thoughts and most particularly for your kindness. You were right when you said it is discouraging to have the medical professionals say they cannot help. You turned that all upside down for us! I will continue updates. Thank you!!! Sincerely, Bonnie
I finally was able to get the ProShieldPlus cream - the last two tubes in the entire United States it appears (though Healthpoint says they will have it readily available after 15 Aug), so I am using it sparingly. I also found a cream that is very similar in ingredients and the biggest difference seems to be the 1% zinc oxide that is in it. It has been a good substitute for the ProShieldPlus until it arrived, and it is surprisingly easy to remove when cleansing.
I see that the Cuticells are okay for up to five days, but Danny's routine is daily. I cannot imagine the mess he would have if we waited even two days between changing his padding and bandages! He's a big man and he sweats a lot and if there is one thing I have learned it is to keep the area as dry as possible.
Oh, Diego, I am still so glad you stepped up for us and so glad Marina spoke with you on our behalf! It has not only helped me get Danny's bottom on the right track to healing, but it has given me hope and courage.
Last week, the health care nurse that treated Danny for over a year, wanted to come by to see his condition. I called the company and told them she is not welcome here...not so much because everything she told me to do to help Danny was wrong - I can forgive ignorance - but because she told me it could not be healed. I think crushing hope in the caregiver, whether it is a professionally trained nurse or a wife that is trying to take care of her husband, is inappropriate.
They sent a different nurse out and she had the picture of Danny's behind from the original file - how his bottom looked when the hospital released him to my care and she was stunned by the progress. She asked if I would give her the information that you gave me, as she has several patients with the same type of problem. I am hoping you are okay with me doing that. I will not send a copy of it without your permission, however. Please let me know if I can send that along to her. You MAY be changing the face of wound care in the Carson Valley of Nevada! :0)
Danny is back receiving physical therapy twice a week for 45 minutes and you would be shocked at what we have had to go through to get that. It's not often an incomplete quadriplegic is able to walk, and if they can, they should receive the physical therapy to do so. They have allowed him 18 visits. I am already in the process of submitting the paperwork to continue his medical help, as it is a constant struggle here.
Not to switch our focus, but some background information might interest you. I have rheumatoid arthritis, fibromyalgia, a bleeding ulcer and panic attacks. The ulcer and panic attacks started after four years of battling for Danny on my own. There is very little advocacy here as far as receiving help navigating the system, and I believe with all my heart that I must get Danny back to Belgium. If we stay here, he will be gone in two years and who knows what will happen with me? By the end of the day, I am lucky if I c an hold my dinner fork to eat. Seriously. I have been battling the system here for over three years to receive disability payments because I am technically and literally (at times, totally) disabled. Taking care of Danny is pretty much ALL I do. It's all I have the energy to do. This system here is wearing us both down and we are exhausted! If we come to Belgium, he is reunited with his family that he loves very much (and I love the ones I have met in person as well as via skype), he can receive the medical treatment he needs and I believe he can live another 30 years! So, that is our plan. Leaving here is a long, complicated process but we are always moving forward towards our goal.
It's getting us there that is the problem and though you didn't ask for all this information, this is why you are playing such a HUGE part in our lives and goals. We cannot afford to have him flown in an actual hospital bed (it is about $18,000 USD for him alone and he would have to leave me and our dogs here!), plus he wants to be somewhat mobile when he comes home. The airlines will not take him if he cannot transfer from his wheelchair to a plane seat and back, etc. So, first we have to heal the buttocks so we can accelerate his physical therapy, so he can make that move.
This is why I cannot thank you enough. Because I believe this country is going to kill him by denying him the medical care he needs, and I believe if that happens, my heart will just stop beating.
Have a wonderful week and please let me know if I can share the information in your original email to me. I will edit out the personal comments and leave in the information about your business. Yes?
Best regards,
Bonnie and Danny
7
I.A.D.
Behandeling * droog leggen * kwalitatief incontinentiemateriaal * patiënt laten verwittigen bij gevoel van vocht, stoelgang * blaassonde * regelmatig toiletbezoek * wisselhouding (combinatieletsels) * gepaste verbandkeuze * zo nodig: infectie behandelen
•
Gekenmerkt door irritatie en ontsteking van de huid
•
Doorlaatbaarheid van de huid verhoogt, barrière valt weg
•
Gestegen pH verhoogt risico bacteriegroei
•
Fysische irritatie door wrijving naast chemische irritatie
Specifieke vorm: intertrigo of smetten * = Beschadiging van de huid in de plooien * Oorzaak: huid-op-huid contact (oksel, lies, borsten, bilnaad, …) * Huidlagen bewegen tegen elkaar : oppervlakkige beschadiging * Warmte,vocht en gebrek aan luchtcirculatie * Verweking, barrière weg en mogelijke infectie
8
Frailty • Frailty of kwetsbaarheid is een syndroomdiagnose voor ouderen en voorspelt de toegenomen kans op functionele achteruitgang • Ouderen verschillen onderling sterk op het gebied van ziektelast, functionele beperkingen en in afhankelijkheid • De huidige zorgverlening herkent de vermindering van lichaamsgewicht, spierkracht, mobiliteit, cognitie, sociale achteruitgang op hogere leeftijd niet als alarmsignaal, en denkt eerder dat het door de ouderdom komt.
♦ ENERGIE
♦ genezing wonden/ litteken
– Suikers – Vetten * 25-35 kcal/kg/dag
♦ activiteitsverhoging
*♦Protéinen PROTEINES : 1 à 1,5gr/kg/dag ♦ Nieuwe cellen aanmaken * Suikers : 50-60% ARGININE ♦ Stimulatie circulatie *♦Vetten : 35% * Water : 1 ml/kcal/dag ♦ Immuunweerstand stijgen ♦ Verwerking proteine stijgen
♦ ZN, VIT.A, C, E
♦ herstel van de wonde ♦ antioxydant
De oudere van morgen
Factoren die beïnvloeden:
* pH liefst 5,5, bij wonde: staphylococ en streptococ binnen, vocht buiten. * Lotion is 80% water, vaseline sluit af, best indifferente zalven (=emolients bv paraffinum perliquidum 60-80 mPas/1liter fles) * Best crème of zalf met ureum 10% * Beste geen uierzalven (AB)
* Medicatie * Natuurlijke veroudering, perkamenthuid * Ziekten (atopisch eczeem, psoriasis, ichtyosis, diabetes, nierinsufficiëntie, couperoze,…. * Verminderde mobiliteit * ….
9
Er is heel veel mogelijk in de eerstelijn als we volgende punten in acht nemen: Juiste patiënt Juiste kennis Juiste team Juiste verband Juiste gebruik
Een preventie procedure maken Omschrijving Voorkomen van decubitus door preventie. Een goede preventie is gestoeld op 6 pijlers: 1) de risico’s op het ontwikkelen van decubitus 2) de drukpunten inspecteren 3) druk verminderen door het toepassen van wisselhouding en het gebruik van hulpmiddelen 4) schuifkrachten voorkomen 5) een goede huidverzorging 6) voeding en vocht op punt stellen
Indicaties – Maximaal vermijden van decubitus, vooral bij patiënten met gedaalde mobiliteit, in een slechte algemene toestand, ... – Alertheid bij de medewerkers in het voorkomen en/of signaleren van decubitus. – Een uniforme aanpak in het nemen van preventiemaatregelen. Contra-indicaties – De bewoner is te ziek om wisselhouding en/of andere hulpmiddelen toe te passen.
Complicaties – Er treedt een decubituswonde op ondanks de genomen preventiemaatregelen. – Door de preventiemaatregelen krijgt men andere zorgproblemen bij de bewoner.
NORTON <14
Benodigdheden – – – – – –
decubitusschaal om te observeren alternatingmatras positioneringskussens een aangepaste zetel vocht- en voedingsbalans voedingssupplementen
BRADEN <18
10
Werkwijze – – – – – – – • • • •
Aandachtspunten bepalen Alle benodigdheden verzamelen Handen wassen Privacy bewaken Communicatie met de patiënt: wat hij gaat voelen of niet voelen Periodiek invullen van decubitusschaal bij risico op decubitus. Al naargelang de score hulpmiddelen gebruiken: alternatingmatras drukverdelend kussen wisselhouding positioneringskussen.
– Voedingsrisico nagaan; indien de bewoner geen volwaardige maaltijd meer inneemt, dan een alternatief zoeken; zorgen dat hij voldoende drinkt. – Comfort nastreven – De handen wassen – Indien materiaal gebruikt, opruimen. – Zorgvuldig rapporteren en aftekenen in het zorgdossier Aandachtspunten – Een goede visuele controle is de basis van alle preventie
– Bijkomende druk op de verschillende drukpunten vermijden. – Observatie van elk drukpunt bij de verzorging Bij niet wegdrukbare roodheid moet de preventie worden opgestart of geïntensifieerd – Patiënt verplaatsen en niet verschuiven – Aangepaste houding in rug- en zijligging – Onderuit zakken in bed of zetel vermijden – Goede huidhygiëne: neutrale zeep; hydraterende crème; huidplooien droog; geen talk; tijdig materiaal verversen en de huid beschermen; kledij gladstrijken; plooien vermijden; geen vreemde voorwerpen in bed; de huid deppen
Observaties – Nauwgezette en nauwkeurige dagelijkse observatie – Screening via een decubitusschaal – Wisselhouding. – Goede vocht- en voedselinname Frequentie Afhankelijk van het soort maatregel dat genomen wordt en de ernst van de situatie.
11
