Home care after hip surgery: a stage 1 pressure injury, a catheter on the floor and a fever

What the lesion is. A 3 cm red area over the sacrum that does not blanch when pressed, with skin still intact, is a stage 1 pressure injury. It is not a rash and it must not be rubbed or massaged - massage on non-blanching skin damages tissue that is already ischaemic. In a 70-year-old diabetic who is immobile for 18–20 hours and incontinent, this is a high-risk combination and stage 1 can progress to an open wound within days. Waiting 12 days is not a safe option.

Plan and rationale:

• Reposition every 2 hours in bed, day and night, using a 30° lateral tilt with pillows; avoid lying directly on the operated hip and check the surgeon's weight-bearing instructions. Two-hourly turning keeps any one area below the capillary closing pressure for a limited period.
• Limit shear: keep the head of the bed at 30° or less when she is not eating, and lift rather than drag her up the bed.
• Offload heels with a pillow under the calves; heels are the second most common site.
• Moisture management: clean with lukewarm water and a mild cleanser after every stool, pat dry, and apply a barrier cream. Prolonged moisture macerates skin and multiplies friction damage.
• Do not use powder in the fold, rubber rings or doughnut cushions.
• Nutrition and glucose: adequate protein (about 1.2 g/kg if kidney function allows), vitamin C and zinc, with better glycaemic control; 160 mg/dL fasting impairs healing.
• Document: mark the site on a body map, measure and photograph it, and reassess daily.

Refer to the doctor or a nurse within 24–48 hours, not at the next scheduled visit.

Errors visible:

1. The bag rests on the floor. The floor is a reservoir of organisms; the outlet touches it and contamination travels back up the tubing.
2. The bag is nearly full. Stasis allows bacteria to multiply, and backflow of urine into the bladder is possible.
3. The tubing loops down and lies on the floor, kinked or dependent, so drainage is obstructed and urine pools in the loop.

Correct practice:

• Hang the bag below the level of the bladder but off the floor, with tubing free of kinks and dependent loops.
• Empty when it is half to two-thirds full or at least every 8 hours, into a separate clean container, never into the toilet directly from the tap, and clean the outlet afterwards.
• Hand hygiene before and after any contact with the catheter or bag; the caregiver should be taught this explicitly.
• Routine meatal care with soap and water once daily; no antiseptic creams or routine antibiotics.
• Maintain a closed system, secure the catheter to the thigh to prevent traction, and give 1.5–2 litres of fluid a day unless the doctor has restricted it.
• Question whether the catheter is still needed. Ten days in, with no clear indication recorded, a trial without catheter should be discussed with the doctor - the single most effective way to prevent catheter-associated infection.

Signs of infection: fever, chills, cloudy or foul-smelling urine, suprapubic or flank pain, new confusion in an elderly person. Cloudy, smelly urine alone does not always mean infection, but cloudy urine plus two days of fever in a diabetic is significant. A urine culture should be taken before any antibiotic is started, and she should be seen the same day.

Same-day referral:

• Fever with a catheter - possible urinary tract infection or pyelonephritis, and a diabetic with 160 mg/dL fasting glucose can deteriorate quickly.
• Stage 1 pressure injury in an immobile diabetic - needs a professional skin assessment now, not in 12 days.
• New faecal incontinence in an older adult - may signal faecal impaction with overflow, a neurological change, or infection; it needs examination.
• Poorly controlled glucose, which slows wound healing and raises infection risk.

Organising care:

1. Telephone the treating doctor or the community health nurse today; request a home visit or an early clinic appointment, and ask for a urine culture.
2. Keep a written temperature chart and a turning chart at the bedside so the daughter-in-law and son share the load - the son can take the night turns on a fixed rota.
3. Put the essentials in one tray: clean cloths, mild cleanser, barrier cream, gloves, a clean container for emptying the bag.
4. Raise the catheter bag onto a stand today.

Teaching the daughter-in-law, using teach-back:

• Hand hygiene before and after every contact, and why.
• Turning every two hours, using the pillow technique, demonstrated and then repeated back by her.
• Perineal cleaning front to back after each stool, patting dry, applying the barrier cream.
• Catheter bag handling and the signs that mean call the doctor.
• Warning signs for immediate hospital attendance: fever above 38.5 °C, breathlessness, confusion, no urine output, or a wound that opens or discharges.

Give the instructions in writing in Hindi, with a phone number, and record who was taught and when.