Literature review paper
Pressure ulcers
Prevention and Treatment of Pressure Ulcers
Introduction
Pressure ulcer is a serious health problem that causes immobility, pain, and suffering, as well as high hospital costs to the elderly. A point to note is that the prevalence of pressure ulcers is high in adult yet preventing pressure ulcers remains a challenge. The National Pressure Ulcer Advisory Plan defines a pressure ulcer as an injury that is localized on skin because of friction. The formation of pressure ulcers occurs due to mechanical loading. The increased pressure results in tissue hypoperfusion, and tissue impairment. The magnitude of pressure and the pressure duration increased damage. Patients who are vulnerable to pressure ulcers are immobile patients who are found in geriatric clinics, retirement homes, home environments, and intensive care units. The main purpose of this paper is to focus on pressure ulcer prevention since this remains a big challenge. There is a disagreement concerning the preventability of pressure ulcers. Note that there is wide range of measures recommended for the prevention of pressure ulcers but there is no strong evidence that the recommended measures reduce pressure ulcers. There are two major methods of prevention; frequent manual repositioning and the active support surface. Repositioning means placing patients in a different body position after every 2 or 4 hours so that the pressure can be alleviated or redistributed. On the other hand, the active support surface is the use of pressure relieving devices such as mattresses that can shift pressure to other areas.
PICO QUESTION
Does alternating pressure support surface compared to patient repositioning prevent pressure ulcers in older adults?
PICO
Population- the elderly
Intervention-Patient repositioning
Comparison-active support surface/ pressure air mattress
Outcome-prevent pressure ulcers
Search history
In the literature review about preventing pressure ulcers, the PICO question which has four elements (population, intervention, comparison, and outcome) helped in searching the right sources. I used the EBSCO Research database and clicked article, and Scholarly Peer-Reviewed Journals with keywords: pressure ulcer, pressure ulcer prevention, patient repositioning, alternating pressure air mattress, and pressure ulcers in geriatrics. I also clicked the published date and selected sources, which were published between 2006-2019. I also selected detailed sources and after viewing the details, I selected 10 quality sources.
Scope and Significance of the problem
Pressure ulcer is a serious issue that has negative impacts on patients, and the healthcare system. Patients experience pain that restricts them from engaging in physical and social activities. Nursing homes suffer from financial costs, which increase because of prolonged hospitalization and severe cases that require more resources (Malbrain et al.2010). It is important to understand that health and social policies have created residential homes for older people, and these homes are either government-subsidized or private. They offer care and attention to older people. Research has found that older people in these facilities are likely to develop pressure ulcers due to factors such as immobility, being inactive, being in an unconscious state, among other factors (Malbrain et al.2010). These factors contribute to comorbidity conditions such as renal disorder, cardiac, and others, which increase pressure ulcers. In an acute care setting, the prevalence is 0 to 12% and in the critical care setting, the prevalence is 24.3% to 53.4%, whereas in an elderly care setting the prevalence is 1.9 to 59% (Ebi rt al.2019). These prevalence are influenced by factors such as friction, lack of positioning, prolonged hospitalization, among other factors. For example in Germany, 400,000 people suffer from pressure ulcers. The patients who suffer from pressure ulcers in geriatric clinics, retirement homes, and home environments are 10%, 30% and 20% respectfully (Pickenbrock et al.2017). A study conducted in Ethiopia reported that in all settings, the cost of treatment ranges from 2.65 € to 87.57€. Another study conducted in Germany reported that the cost of treating pressure ulcers is 50,000 (Pickenbrock et al.2017). For an individual patient to treat pressure ulcer in the U.S, he or she will spend over $17 billion (Peterson et al.2013). An important point to note that pressure ulcer does not only contribute to pain and suffering but it negatively impacts the economy given that in 2010, Netherlands spent 1% for the health budget. Besides, pressure ulcers contribute to morbidity mortality. The worse thing is that Medicare does not cover health expenses for stage 3 and 4 of pressure ulcers (Rich et al.2011). This is because, the clinical guidelines have several measures to prevent ulcers. The major recommendation is manual repositioning every 2 hours. However, this recommendation had not been effectively implemented in healthcare settings. Failure to adhere has been influenced by the argument that patients need active support surface. Focusing on the significance of the problem, nurses will benefit from this literature review by gaining knowledge of pressure ulcers and in specific on the areas of prevention.
Significant to nursing
The topic 'prevention of pressure ulcers' is significant to nurses in that nurses have a primary responsibility to monitor the skin of the patient to prevent the ulcers. Thus, they should know the condition, the risk factors, and prevention. Some studies show that in some healthcare settings, nurses have poor knowledge of pressure ulcers (Ebi et al, 2019). This is very dangerous give that pressure ulcers increase morbidity and mortality, and it has economic and social negative impacts. Thus, the literature review is designed to help the nurses improve pressure ulcer knowledge and minimize the risk. In the nursing home, it is the role and responsibility of nurses to conduct routine skin inspection and look for signs of pressure damage such as blisters, swelling, scratches, and others. They should ensure that patients have healthy skin by preventing skin damage using measures such as regular movement and support surface (Ebi et al, 2019). This review will help nurses learn the importance of changing the position after the recommended time or frequently. The literature view also talks about support surfaces and this is very important to nursing in that they will learn an alternative method of providing support and comfort such as bed mattresses or other products.
Personal connection to the problem
I am interested in the topic of pressure ulcers in that when I visit the older adults at the long-term care facilities, I find elderly hospitalized patients with pain and suffering due to pressure ulcers. I see families struggle with hospital bills since the treatment cost is very high. I also learn that the majority of the elderly suffer from pressure ulcers due to immobilization, advanced age, pressure, friction, among other factors (Demarré et al. 2013). In this literature review, I believe that hospitals should utilize this knowledge and implement alternating pressure surface to minimize tissue damage. I learn that the hospitals have been using patient repositioning but it also important to try support surfaces such as foam mattresses as they will redistribute the pressure. Pressure ulcers can indeed be avoided but healthcare professionals should increase knowledge, and more importantly come up with prevention programs to make a big difference in elder lives. I believe that older adults need interpersonal qualities such as caring about them, showing them care on time, giving them quality care, and being honesty and kind to them (Demarré et al. 2013). These qualities will help them develop social and psychological wellness.
Outline
Synthesis of Evidence
Pressure ulcer prevention using specialist support surface is evidenced by;
- Pressure redistributing support systems prevent pressure ulcers by redistributing pressure.
- Patient repositioning is a hazardous activity in that some critically ill patients have ventilator tubing, and intravenous lines and the movement may interfere with skin (Malbrain et al.2010)
- It is difficult to reposition critically ill patients due to hemodynamic. Thus, the support surface will reduce the pressure ulcer risk through pressure redistribution (Black et al.2012).
- Placing patients at the pressure-reducing mattress and turning them at unequal time intervals prevent pressure ulcers (Vanderwee et al.2007).
- For-profit private residential care homes should improve care and reduce the occurrence of pressure ulcers by using prevention materials such as pressure-relieving mattresses, employ adequate manpower, and offer training for pressure ulcer prevention (Kwong et al.2016)
- Low-Pressure air mattress prevents severe pressure ulcers (Kwong et al.2016).
Patient repositioning
- Patient repositioning should be the standard of care. Repositioning should be done at every 2 hours or nurses should monitor intervals to minimize risk. (Peterson et al.2013)
- Bedbound patients should be repositioned after every 2 hours (Rich et al. 2011
Nurse training
- Nurses failure to prevent pressure ulcers due to lack of adequate knowledge and lack of pressure-relieving devices
- Nurses need knowledge and pressure-relieving devices (Ebi et al.2019).
- Placing support material is the best way to prevent pressure ulcers since the material such as the dynamic mattress will align the body parts (Pickenbrock et al.2017).
- Improve the life of informal caregivers and hence prevent pressure ulcers
- Eliminate factors that increase the levels of burden such as the lack of financial remuneration, and lack of experience (Rodrigues et al.2016).
Critique of Evidence
Malbrain et al.2010)
- Small pilot study
- Error reduction
- Various research designs
Vanderwee et al. 2007
- Randomized controlled trial
- No bias (vanderwee)
Kwong et al.2016
- Randomized controlled trial
- Large sample size
Kwong et al. 2016
- Evidence-based approach
- Action research study
Rodrigues et a. 2016
- Quantitative variables
- Qualitative variables
- Correctional analysis of variables
- Multivariate techniques
Black et al. 2012
- Small sample size
- Failure to enroll in the sample size
Ebi et al.2019
- Failure to complete the knowledge questionnaire
- Participates did not follow instructions
Peterson et al.2013
- Observational study
- Long period (2007 to 2009)
- Larger sample size
Demarré et al. 2013)
- Randomized Controlled Trial
- Use of pooled database
Rich et al, 2011
- Lack of evidence to support frequent repositioning
Gaps in the Evidence
Black et al. 2012
- Use larger samples to get reliable result
Ebi et al.2019
- Be objective during the questionnaire
- Ensure the questions focus on the topic
- Avoid misleading question
- Ask short questions
Rich et al, 201
- Use a randomized controlled trial to compare groups and yield best results
Comparison to your Practice
- The information from the article is similar to my practice
- The prevalence of pressure ulcers is indeed high in long-term care facilities than in other facilities such as home care. Older people are a vulnerable population especially those in a long-term care facility.
- I have evidence that elderly people who use support systems such as foam mattresses relieve pressure ulcers.
- Repositioning is also used in nursing homes but I have seen challenges associated with how often to reposition and which position is the best
- I look forward to understand the best alternating pressure mattresses between low-air loss mattresses and air-fluidized mattresses. This will help use the best mattresses in long-term care facilities.
- However, regardless of the mattresses, the articles have agreed that pressure-redistributing mattresses reduce the risk of pressure ulcers
- I highly agree that pressure ulcers can be prevented since I have seen people recovering by using support surfaces.
Conclusion
- Studies indicate that pressure ulcer is a healthy issue and healthcare professionals need to use the right prevention strategy.
- The repositioning has been the common method but current evidence report that repositioning is limited and therefore nursing homes should shift to support surface.
- An alternating pressure air mattress is effective for a patient with pain on movement.
- Note that some patients cannot be turned and therefore pressure reduction devices will cause a pressure reduction
References
Malbrain, M., Hendriks, B., Wijnands, P., Denie, D., Jans, A., Vanpellicom, J., & De Keulenaer,
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alternating pressure mattresses in the prevention and treatment of pressure ulcers
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Vanderwee, K., Grypdonck, M. H. F., De Bacquer, D., & Defloor, T. (2007). Effectiveness of
turning with unequal time intervals on the incidence of pressure ulcer lesions. Journal of
advanced nursing, 57(1), 59-68.
Kwong, E. W. Y., Lee, P. H., & Yeung, K. M. (2016). Study protocol of a cluster randomized
controlled trial evaluating the efficacy of a comprehensive pressure ulcer prevention
programme for private for-profit nursing homes. BMC geriatrics, 16(1), 20.
Kwong, E. W., Hung, M. S., & Woo, K. (2016). Improvement of pressure ulcer prevention care
in private for-profit residential care homes: an action research study. BMC
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Rodrigues, A. M., Ferreira, P. L., & Ferré‐Grau, C. (2016). Providing informal home care for
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Black, J., Berke, C., & Urzendowski, G. (2012). Pressure ulcer incidence and progression in
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Ebi, W. E., Hirko, G. F., & Mijena, D. A. (2019). Nurses’ knowledge to pressure ulcer
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Pickenbrock, H., Ludwig, V. U., & Zapf, A. (2017). Support pressure distribution for positioning
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Peterson, M. J., Gravenstein, N., Schwab, W. K., van Oostrom, J. H., & Caruso, L. J. (2013).
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Rich, S. E., Margolis, D., Shardell, M., Hawkes, W. G., Miller, R. R., Amr, S., & Baumgarten,
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Demarré, L., Verhaeghe, S., Van Hecke, A., Grypdonck, M., Clays, E., Vanderwee, K., &
Beeckman, D. (2013). The effectiveness of three types of alternating pressure air
mattresses in the prevention of pressure ulcers in Belgian hospitals. Research in
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