Under pressure

In 1861, Florence Nightingale, who was perhaps the first nurse researcher to focus on the care of the skin and prevention of pressure injuries, wrote “The amount of relief and comfort experienced by the sick after the skin has been carefully washed and dried, is one of the commonest observations made at a sick bed”.

While the profession of nursing has evolved, these wise words have remained as relevant today as they were for Florence and those she cared for during the Crimean War more than 150 years ago.

Although the skin is the largest and most visible organ of the human body, we are just beginning to understand how to prevent and manage wounds.

But what we do know is that pressure injuries are a major concern.

The hardest to heal

Today is Stop Pressure Injury Day, and there are good reasons to manage pressure wounds effectively. International data suggest that the condition affects up to 32 per cent of aged care residents and locally the condition costs our healthcare system an estimated $A983 million a year.

But younger people can also develop chronic wounds from unmanaged diabetes and vascular disease.

The care of the skin, and prevention and management of wounds, is quintessentially nursing.

Across all healthcare settings, with patients journeying from the cradle to the grave, nurses assess the skin, develop care plans and provide treatment that prevents skin injury, heals wounds and prevent wounds from re-occurring.

Nurses commonly deal with the wounds that are the hardest to heal, including pressure injuries – often called bed sores.

These ‘chronic wounds’ are physically disfiguring, cause pain and suffering, are expensive to treat and can affect many areas of quality of life.

The role of the nurse in wound care is unparalleled, given the frequent and specialised treatment that wounds require. But patients also need support and care to be able to deal with the physical, emotional, social, financial and lifestyle challenges that this condition can present.

My earlier research found that people affected commonly report that their wound is painful, causes distress, disrupts many day-to-day activities and costs them a lot of money.

But, historically, chronic wounds have been largely hidden in the broader community.

The covid risk of skin injury

2020 is the World Health Organisation’s International Year of the Nurse and Midwife, however, it’s also the year we’ve seen community awareness of chronic wounds elevated to an unprecedented level.

The arrival of the coronavirus pandemic this year has seen emerging evidence of the detrimental effect of COVID-19 on the skin of the critically ill.

Patients in intensive care are often put into a prone or face-down position to help with their breathing, but this comes with risks of developing facial pressure ulcers as well as sores on other weight-bearing areas of the body.

There’s emerging evidence of the development of unusual and unexpected pressure injuries among patients who have COVID-19, for example, in areas not exposed to direct pressure. There have been various reports of ‘COVID toes’ – purple or blue areas of skin that may be mistaken for pressure injuries.

And nurses, who have tirelessly cared for COVID-19 patients, have been constantly exposed to the risk of skin injury associated with the prolonged use of personal protective equipment (PPE) like face masks.

While COVID-19 drew attention to hospital care, chronic wounds also have a severe impact on our elderly.

Earlier this year, the Australian Royal Commission into Aged Care Quality and Safety highlighted, perhaps in more detail perhaps than ever before, the plight of older Australians affected by chronic wounds.

Not only did the Interim Report of the Royal Commission find “inadequate prevention and management of wounds, sometimes leading to septicaemia and death” but the personal experience of those affected serves as a warning.

One informal carer of an aged care resident who had a leg ulcer said in evidence “[I cannot] unhear her cries or unsee what I saw.” In fact, the Commission’s interim report lists chronic wound care as the first listed major quality and safety issue identified.

More to be done

Although Florence Nightingale summed up the importance of skin care more than half a century ago, there is in fact much still to learn about the skin and how to prevent and treat wounds.

Our nurse-led pressure injury research, funded by the Victorian Medical Research Acceleration Fund 2020, aims to implement and evaluate remote expert nurse consultation for prevention and management of pressure injuries in residential aged care.

We will establish an accessible effective approach to nurse-led wound management in aged care and generate evidence to inform how to sustain practice change, on a large scale, in the future.

While 2020 has thrust the vital role of nurses into the spotlight, there’s still more to be done when it comes to understanding and prioritising the importance of skin heath and the role of nurses in the prevention and management of wounds.

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