Pressure ulcer is defined as localized areas of breakdown of skin and underlying tissues caused by pressure, shear, friction, or a combination of these. They can occur in all situations where subjects are subjected to sustained mechanical loads, but are particularly common in those who are infirm and bedridden, wheelchair bound, or wearing a prosthesis or orthosis. These usually result from local breakdown of skin and soft tissue as a result of compression or shear between a bony prominence and external surface ( Lyder CH., 2003).
They usually develop on the lower half of the body, two-thirds around the pelvis and a third on the lower limbs, with particularly having predilection for appendages in the lower extremities such as heels and toes (National Pressure Ulcer Advisory Panel, 1989). As is evident, elderly persons are particularly prone to develop these ulcers, especially the age group above 70. Those who had had surgeries for fracture hip or those who had sustained spinal injuries are particularly prone to develop such ulcers. Interestingly, inadequate and inappropriate nursing care in the inpatient setting has been implicated in the aetiopathogenesis of this disease condition, since statistically the prevalence of pressure ulcers is the maximum among inpatients of the hospital population of this age group.
This can be as high as more than 70% in the elderly in-patients with orthopaedic problems (Baumgarten M et al., 2003). The incidence per se is 1% to 5%. However, in patients who are confined to bed or to a chair due to their primary diseases, the incidence rises to almost 8%. The picture in the long-term healthcare facilities are poorer, since up to 25% of these patients may develop pressure ulcers.
There is another significant implication of these data, since pressure ulceration in elderly patients is associated with a five-fold increase in mortality, and in-hospital mortality is in the range of 25% to 33% (Voss AC, Bender SA, Ferguson ML, et al., 2005). As can be conceived, these ulcers are painful, difficult to treat, and represent a burden to the community in terms of healthcare and finances (Iglesias C et al., 2006).
Background and Literature Review
To date, attempts to prevent pressure ulcers have not led to a significant reduction of the problem. It is widely established that this is at least partly due to the limited fundamental knowledge related to the aetiology of this clinical condition. Thus a research can be designed to study the factors involved in its causation particularly focused as to whether changing position of the patient every 2 hours would lead to improvement of outcome in this category of the patients (Graves N, Birrell F, Whitby M., 2003). To be able to do so, a thorough literature review has been undertaken. This literature review is an important part of this research since the findings would be utilized to create a plan for nursing care of these patients so the outcomes can be altered based on evidence-based practice (Gordon MD, Gottschlich MM, Helvig EI, et al., 2004).
In the study by Pokorny, Koldjeski, and Swanson in 2003, the authors acknowledge the prevalence of pressure ulcers in the hospital settings to be a major problem, particularly in older persons, debilitated persons, and persons with immobility. The authors recognized prolonged pressure and compression of tissues as major contributing factors to the development of pressure ulcers. Pathologically, they cause occlusion of blood vessels due to external pressure and endothelial damage in the microcirculation to such an extent that the damaged tissue area cannot remove toxic cellular materials and excess fluids.
Therefore, small relative changes in pressure might distort the tissue and occlude microcirculation leading to necrosis instantaneously. This study design accommodated repeated interventions in the form of therapeutic nursing interventions (Whitfield MD et al., 2000). The authors concluded that development and progression of pressure ulcers are events that can be altered by nursing care. The outcome in the study group altered towards a positive direction in that it depends in large part on frequent clinical assessments and consistently applied nursing interventions in the form of change of posture every 2 hours. The authors, however, acknowledge that there is debate ongoing as to whether all pressure ulcers are preventable in this manner or not (Pokorny, M.E., Koldjeski, D., and Swanson, M., 2003).
In the study done by De Laat et al published in 2005, the authors did an extensive literature review to demonstrate that many studies have shown that the measures taken to prevent or treat pressure ulcers vary greatly and that compliance with existing guidelines are inadequate. In this study in order to bridge the gap, the authors wanted to determine the effects of implementation of a hospital guideline for pressure ulcer care (Kaltenhaler E, Whitfield MD,Walters SJ, Akehurst RL, Paisley S., 2001). The intervention in this study was implementation of a new ulcer care policy. Adequate prevention schedule included repositioning of the patients in pressure ulcer patients or patients at high risk of developing pressure ulcer.
Encouragement to change position and in certain cases, if necessary, assistance to repositioning had to be confirmed by patient or nurse. The criteria for adequate care were set in such a manner that if only one of such measures was present, preventative care was adjudged to be adequate. If no such measures were present, prevention was judged to be inadequate. The authors concluded that this study demonstrated that the implementation of a guideline for pressure ulcer care results in a significant decrease in pressure ulcer incidence.
Another aspect of the study is that the authors developed this intervention depending on the indisputable proposition that turning patients at high risk of pressure ulcer is indisputable. Therefore, it can be proclaimed as the standard part of the basic nursing care, and every nurse must have knowledge about this. The interval between two body positions is defined as 2 hours (De Laat, E. H. et al., 2006).
In a systemic review by Reddy, Gill, and Rochon in 2006, the author review extensively literatures that study prevention of pressure ulcers. The pressure ulcer prevention protocols contain many interventions, but patient repositioning is a mainstay in most pressure ulcer prevention protocols.
These often recommend turning patients every 2 hours. The authors recognize the aim of repositioning to be reducing or eliminating interface pressures and thereby maintaining the essential microcirculation to regions of the body at risk for pressure ulcers. However, the authors could identify only two studies that specifically evaluated repositioning strategies (Reddy, M., Gill, S.S., and Rochon, P.A., 2006).
This indicates that there is dearth of literature specifically on this topic, and therefore, it would be worthwhile to undertake an intervention research with the hypothesis that adequate preventative strategy in high-risk patients would involve nursing care that consists of a standard of evidence-based practice that includes awareness and application of two-hourly repositioning of the patients those are admitted to the hospitals with diagnoses that pose high risk of development of pressure ulcers.
P (Patient Population) = Bedridden patients
I (Intervention) = Turning every 2 hours
C (Comparison Intervention) = Not turning patients at all
O (Outcome) = Turning patients every 2 hours prevents pressure ulcers
Research Utilization Model
The Stetler research utilization model is known as the Practitioner-Oriented Model and will be used to guide this study. The five steps in Stetlers model lend themselves easily to this study.
Pressure ulcers represent a common but potentially preventable condition seen most often in high-risk populations such as elderly patients and those with physical impairments. A variety of treatment and preventive measures have been proposed, and there seems to be a lack of consensus as to which would be the basic standards.
Purpose of the Study
The presence of pressure ulcers is a marker of poor overall prognosis and is a known cause of premature mortality. It poses a great economic burden both on the state and the client, but the fact remains that it can be prevented in many cases, and a targeted preventive approach may prove to be less costly that that is focused on treatment of established ulcer. Repositioning the patient can prove to be an essential nursing care tool, and this study examines this proposition to be implemented in a structured care plan.
Sample Size and Characteristics
The sample would comprise of 88 US citizens admitted in a US Hospital of different age groups ranging from 65 to 82.
Interventions and Methodology
The patients will be allocated randomly to two different groups of 44 each. The trained nurses will be allocated to individual patients. The patients who will be given repositioning as a preventative management will be termed as group A. The other group of patients where no reposition would be given as a management strategy would be termed as group B.
All the nurses will be allocated different groups of patients randomly, and all the nurses would be trained on repositioning techniques, the importance of two-hourly reposition on bed for high risk patients, and the physiological and pathological background of pressure ulceration. The physical examination will be done with a tool, and the all the nurses will be provided guidance and training to assess patients as to whether they have evidence of healing or development of pressure ulcers. The nurses would enter data in the format given to them.
This study would be using a quantitative descriptive design using a convenience sampling.
The instrument that would be used in assessing patients is known as Skin Classification Scale from Nixon et al. (Nixon J et al., 2005) Grade 0 will be indicated by no skin changes. Grade 1a will be indicated by redness to skin that blanches. Grade 1b would be indicated by nonblanching redness to skin. Grade 2 would indicate partial-thickness wound involving epidermis or dermis only.
A full-thickness wound involving subcutaneous tissue would mean grade 3. Grade 4 pressure ulcer would indicate full-thickness wound involving subcutaneous tissue to muscle or bone. Grade 5 pressure ulcer would be indicated by a black eschar. All the participants would be assessed on a twice daily basis about the high-risk areas for presence, absence, grading, improvement, deterioration of the pressure points, ulcers, or sores, and the findings will be recorded (Papanikolaou P, Clark M, Lyne PA., 2002).
The collected data will be analyzed to generate the findings. The comparison of the two group of patients will be done with a multivariate analysis, and the effect of the intervention, a two-hourly repositioning on group A patients can be compared with group A in terms of development of pressure ulcers.
The methodological quality of randomized controlled trials evaluating interventions to prevent pressure ulcers is suboptimal since there is a descriptive element in it. These studies, however, provide valuable information on which to base recommendations for effective approaches to prevent pressure ulcers. Several guidelines on the prevention of pressure ulcers have been developed, and this study, likewise, would be able to provide guidelines to the nurses about the evidence-based approach to prevent pressure ulceration.
Recommendations from this research include further research to support two-hourly repositioning for high-risk individuals and incorporating the findings in a guideline. Other recommendations may include acceptance of the fact that repositioning is the mainstay of prevention, but comparison with other strategies are needed to show if one has advantage over another strategy.
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