Care home nurse Sandra Hambett reflects on how she dealt with a seemingly intractable case involving a resident who had developed pressure sores but refused painkillers that would have helped her treat them.
I work for South-West based care, housing and support provider Brunelcare as a staff nurse at Glastonbury Care Home, and was recently posed a real challenge by one of the residents under my care.
He is 79 years old and suffers from Parkinson’s disease, and, as a result, has severe contractures of the fingers and hands. As a result of the contractures, large pressure sores developed between the fingers. The sores were extreme and very painful; infections became prevalent and started to spread through the hand.
What made this case exceptionally challenging for us was that the resident refused to take any form of painkiller. This had been a lifelong belief of the gentleman, which had to be respected. But with the refusal of painkillers it was impossible to open the fingers to dress the sores as the pain would have been excruciating for the gentleman. The situation was serious as, if left untreated, septicaemia was likely to set in
I approached many professionals who formed a working group on how best to tackle the issue, including three GPs from the local surgery, a Parkinson’s nurse specialist and the occupational therapy department of the local hospital. Whilst, under normal circumstances a splint could have been used to separate the fingers this was not possible given the severity of the contractures. I also contacted Parkinson’s UK for advice; however, in all its dealings, it had not come across such a case before.
All medication was looked at that could help to release the contractures; however, for various reasons, including the adverse interaction with Parkinson’s medicine, nothing was suitable. We investigated new-to-market dressings but they were all deemed to be too bulky to insert between fingers that were secured together so tightly that only a paper thin dressing could be used.
It was obviously important to inform the resident of what was happening, and what may happen, so I took a lot of time to fully explain the situation and the importance of treating it. The gentleman eventually agreed to a limited amount of anti-inflammatory painkillers during the infection stage. This ultimately resulted in a slight release between the fingers to enable a thin dressing to be inserted; the sore eventually healed and the infection cleared completely after two months. At all times, we were fully respectful of the gentleman’s choice regarding treatment and adapted a difficult situation to a positive outcome.
The ongoing problem was how to ensure the hands were cleaned effectively. This is an issue with many patients, who have suffered strokes, have contractures of the fingers, or limited mobility in their hand joints due to degenerative joint disease. The nurses at Glastonbury Care Home, however, have created an effective solution, simply using clean plastic bags filled with water; these can be moved to the patient and directly to the hands and arms, so even when a patient can’t straighten their joints the water receptacle is totally moveable allowing effective cleaning in a comfortable manner. It has been a really, simple, but effective solution to a difficult problem.
Thankfully, this is a rare case but one to be aware of, the CQC recently performed an unannounced compliance visit and this case was shared with them. The inspector was very impressed in the proactive action taken, and that choice of the patient was always paramount in every decision.
I have never seen such a severe case as this before, it was heart wrenching to see how tight the contractures became and how intensely the infection took hold. This gentleman is such a lovely man and I was determined, from both a professional, but also personal perspective, to eradicate the sores and infection to enable him a better quality of life. It took a lot of time but we succeeded.
Do you have a similar case?
Contact Glastonbury Care Home for advice on 01458 836800.