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Small steps can help to avoid big problems

© St. Petersburg Times
published May 28, 2002

As a care manager-nurse consultant for the elderly, I often find many health problems that could have been prevented.

The common scenario is the elderly person who has too many assets to be placed in a nursing home but not enough money to pay for private custodial care. So this person moves close to family for support or may even move in with a son or daughter. But these family members often are not trained caregivers, and their lack of knowledge can cause problems such as contracture of muscles, malnutrition and pressure sores, all of which feed on each other.

The "sandwich generation," and that usually means a daughter who has responsibility for caregiving, needs to become more educated and knowledgeable about problems their elderly relatives face.

For the immobile elderly, a big and costly problem is pressure sores. Many measures can be taken to prevent these sores; some suggestions follow: First, determine if the person is at risk for skin breakdown. Risk factors must be identified, so a care plan can be established. The care plan should be made clear to all members of the family so the plan is followed.

Second, keep the individual walking as much as possible. If the person needs assistance and/or assistive devices, provide these tools.

If the person is bedridden or chairbound, make sure you have a wheelchair cushion or a mattress that offers pressure reduction or pressure relief. A person is at greater risk for pressure sores if he or she sits for long periods of time.

Also make sure the individual has good body posture and alignment. A chairbound person should change position about every 15 minutes. If the person has the upper body strength and is able, he or she may be instructed how to do wheelchair pushups.

Bedridden people must be turned and repositioned off of bony prominences at least every two hours. Unless it is against medical advice, keep the bed at a 30-degree angle to avoid friction and shearing on the coccyx area. Make sure the person's heels are off the mattress, called flotation of the heels. If the bedridden person needs to be taken out of bed, lift instead of drag the person in the bed linen.

The name of the game is to keep the individual moving. If the person needs assistance with moving extremities, perform range of motion exercises to avoid contractures, which increase the risk of developing pressure sores. A caregiver may need some assistance from a physical therapist in the development of a care plan and for instruction in the proper way to perform range of motion exercises.

If the person has a problem with moisture as a result of incontinence, wound drainage or perspiration, try to obtain a support surface that will allow air to flow across the skin. Do not use any doughnut-shaped or ring products. These reduce blood flow to an even wider area and can cause a bigger problem.

Good nutrition and adequate fluid intake are integral components of a care plan for the prevention of pressure sores. The person should eat a well-balanced diet that includes all four basic food groups. It is important for the caregiver to monitor the intake of all foods and fluids. If intake is questionable, you may need to consult a registered dietitian and/or the primary care physician. If a person is not receiving the appropriate amount of calories, the body will break down glycogen, fat reserves and the body's proteins for energy.

A low albumin level can make medications toxic. Drugs bind to plasma proteins such as albumin, and a drug that has so bound is in its inactive state. In addition, the portion of the drug not bound to albumin is in its active form. Therefore, if the person has a low albumin level, more drug is circulating in its active form, leading to increased drug actions. This may cause increased sedation, which boosts the risk for pressure sores. Another danger of low albumin is the increased potential for skin breakdown.

If you suspect the person you are taking care of is malnourished, consult the primary care physician. Have blood tests done and try to find out why the person's calorie intake is low before a bigger problem develops.

The caregiver must look at the individual's body, head to toe, at least weekly to see if there are any areas of skin breakdown. If there is an area of concern, act promptly. Consult your physician. Do not massage any area of concern, which could reduce blood flow and cause tissue damage.

Do not assume that incontinence is a normal part of aging. Find out why the individual is incontinent. Once you have done this, a care plan can be developed. If the incontinence is irreversible, make sure the individual is changed at least every two hours to avoid skin breakdown. Gentle washing with a nonalkaline cleansing agent is best. Plastic and paper linen savers should never be placed next to the individual's skin because they hold moisture and can irritate the skin. If the person has dry skin, don't promote frequent bathing. This will only remove the natural barriers and increase dryness. Keep the skin moisturized. If you use a liquid barrier, make sure to fan the area to assure complete dryness.

Taking care of an elderly person with multiple problems can be challenging and overwhelming, and it is always best to educate yourself to prevent problems. Get some help when you can, but if that is not possible, I hope these tips will help you be a responsible caregiver for your loved one.

Debra L. Crum, registered nurse, has more than 20 years' experience in the nursing profession. She owns Forerunner Medical Consultants Inc. and specializes in private case management for the geriatric population. Her e-mail address is

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