Treatment: Consistency in care too often missing
Martie L. Moore, RN, MAOM, CPHQ
My parents have a friend who's struggling with a foot ulceration from diabetes. Recently, I had a chance to learn more about what she goes through. While she has managed her diabetes fairly well, she did not understand how diabetes impacts her body. She bought and wore shoes that caused pressure on an affected foot. Because of her diabetes, she lost sensation and couldn't feel the damage to a foot until it was inflamed, infected or had an open area.
She sent me some photos and we discussed them over a conference call with her primary care physician. Together, we determined how best to care for the area. When I called to check on her, details about her foot and pain were varied and inconsistent. In working with the team that was caring for her, it became clear there was not a standard method of assessment for both the wound and her pain management.
We worked together to introduce the Pressure Ulcer Scale for Healing or PUSH tool. The PUSH tool was developed by the National Pressure Ulcer Advisory Panel as a method to monitor healing ulcers. It helped us in having a standardized tool with common language to determine how well she was healing.
Utilizing a standardized tool for wound healing guides the plan of care and communication among those caring for her. It also helps the family become more comfortable and confident about the healing of her ulceration.
When it comes to pain assessment, it's a little more difficult to establish a standardized process. Because of a past insult to her brain, she had some impairment in her cognitive ability. When asked if she had pain, she would say “yes.” When asked to give pain a number, it would be a 2 (not much pain) or 10 (worst pain ever).
In working with her care team, we talked about what they were assessing instead of a number being assigned for pain management. Surprisingly, we learned that the number had no meaning to her. When we mapped out her behaviors, we saw patterns occurring around pain. She was alone in her room away from others when she was in pain. When ambulating, she grimaced and moaned. Utilizing OTC pain management tools, we were able to manage her pain by observation of nonverbal behaviors and a checklist of items to have done to manage pain on a consistent level.
By utilizing both the wound healing tool and behavioral assessment, we were able to get her back to her favorite activities, including Wednesday Bingo. Most importantly, we were able to help address and heal her foot ulcer.
I worked with a team of dedicated and caring individuals. What surprised me was the lack of standardized assessment available to them to utilize in her care. Without a standardized tool, care became fragmented. It was also confusing to understand wound response to treatment. Every day, I see how much we as caregivers must move toward reducing variation by utilizing evidenced based tools for both assessment and communication of care.
Martie Moore is the Chief Nursing Officer for Medline Industries Inc.