Pressure Ulcers as a Topic for Nursing Research & Project

Introduction

The number of people who develop ulcers annually around the world is more than one million. “The assumed prevalence of pressure ulcers in skilled-care and nursing homes is 10.9%, 4.39% in-home care whereas acute care has 10% of the cases. In hospitals, the prevalence ranges from 2.69% to 28.9%” (Guyton &Hall, 2000). It is estimated that more than one million people get pressure ulcers every year (Guyton &Hall, 2000). “Pressure ulcers are associated with increased medical complications, death or infections” (Guyton &Hall, 2000). It affects the life of a patient negatively by reducing its quality of health. There are approximately 60000 annual patient fatalities due to difficulties associated with pressure ulcers (Guyton &Hall, 2000).

Background

A pressure ulcer is also called bedsores, pressure sore, tropic sore, or decubitus ulcer. It is described as an “ischemic necrosis and ulceration of tissues that overly a bony prominence” (Hawrthone & Redmond, 1999). “This body part must have been exposed to long hours of pressure against an object like wheelchairs, beds, splint or cast” (Bickley & Szilagyi, 2003). “The result is a mutilation of the skin integrity that is related to prolonged and unrelieved pressure” (Hawrthone & Redmond, 1999).

This situation is imminent in persons who have low or no sensation, are emaciated, depilated, bedridden or paralyzed. A patient who has a problem with urinary or fecal incontinence, fewer movement options, reduced sensory awareness or poor diet has increased chances of getting pressure ulcers. “Tissues over the Ischia, sacrum, external malleo, greater trochanters and heels are the most susceptible. Pressure ulcers can also affect muscles and bones” (Bryan-Brown, 2006).

Reduction and prevention of pressure ulcers is a healthcare priority in providing care for patients. Among healthy, immobilized individuals, impaired skin problems might not be a problem. However, it might have potentially serious and debilitating effects in bedridden patients. Quick identification and management of high-risk patients and their risk factors is a vital tool in the avoidance of pressure ulcers. “The key problem in treating the pressure ulcers is that it is like an iceberg, small surface that can be seen with an extensive base that cannot be known from a simple look” (Bryan-Brown, 2006). There is no proper method or procedure to determine the extent of depression and damage on the tissue. “Therefore, the nurses are required to use surgical treatment for more advanced ulcers. In case fat and muscle is involved, surgical debridement is required” (Bryan-Brown, 2006).

Dislodgment of bone joints is necessary if the tissue is to be surgically detached because necrotic tissue can enhance growth of pathogens and delay the healing process (Kozia &Erb, 2004). This paper seeks to identify the best medical practice that can be of importance in “prescribing, surveying the real or actual practice, and instituting measures that are aimed at improving the standards of prescription identified in standards” (Kozia &Erb, 2004). The tool to be employed in this study will involve the audit tool which will be used to collect data on variables. The variables would include mattresses, length of stay, reposition provided to patients in the various wards. Some of the wards include: “orthopedic, geriatric or medical ward, recovery room that deals with patients who have a high risk of developing a pressure ulcer and one that is meant for postoperative stay” (Kozia &Erb, 2004). “Data on accompanying medical conditions like diabetes, incontinence, peripheral vascular diseases and heart insufficiency is also included” (Kozia & Erb, 2004).

Importance of the study

It is necessary to improve the risk evaluation and avoidance by executing the instruction recommendations. This would help in protecting patients from developing the medical problem. The study shall propose an intervention programme whose implementation will be based on the results from the project. The program will supplement the existing basic health care practice. It would be applied to patients confined to bed including those who are more susceptible to pressure ulcers (Kozier &Erb, 2004).

Evidence-based pressure ulcer prevention and treatment

This is commonly referred to us evidence based nursing. Other practitioners refer to it as evidence based medicine. It is the explicit, conscientious, and judicious medical practice that employ the use of current best evidence in making key decision regarding care of the patients.

  1. Part of this practice requires the incorporation of personal expertise in clinical medicine by a nurse or physician. The expert should be able to produce external clinical verification data from organized research and individual patient inclinations.
  2. It has been indicated in various research work that when clinical care is dependent on facts as opposed to tradition or common sense, the patient’s outcome are at least 228% better.

There are a number of instruments that can be used to assess the risk of one developing pressure ulcers in healthcare institutions. The preventive treatments are sometimes expensive and; therefore, patients who have little risk for developing the pressure ulcers are spared from undergoing through the process and the related risk of complications.

“The main nursing concerns are the treatment and prevention of pressure ulcers” (Guyton & Hall, 2000). The incidence of such cases in a facility shows the quality of care the nurses give to the patients. The program of ulcers prevention that is guided by risk assessment has been recommended by health bodies. It simultaneously reduces the incidences of ulcer patients in a medical facility by approximately 60%. It also reduces the costs of preventing the occurrence at the same time (Guyton & Hall, 2000).

Advice on nutrition was observed to result in reduced cases of pressure ulcers. The Evidence-based practice suggests that having a nutritional consultation is beneficial. It enables the staff to be sensitized that the elderly are at high risk of developing pressure ulcers hence need for close care. The intercessions for decreasing and curing pressure ulcers in nursing homes and hospitals can be assesses by ascertaining the patient’s reaction to therapies administered by the nurse. It can also be done by ascertaining whether the project managers’ goals were attained.

Research Question

“Are health care staff and directors implementing risk assessment and prevention strategies meant to reduce the level of pressure ulcer in healthcare facilities?”

Research aims and objectives

Aims

To review the research material that relates to prevention of ulcers in nursing facilities

To determine the implementation of risk assessment programs in preventing pressure ulcers

To enhance risk assessment of pressure ulcers and its prevention in view of the guideline recommendations

Research Objectives

  1. To develop an implementation and dissemination strategy that would accompany the guideline recommendations
  2. To audit care offered in nursing facilities to patients with pressure ulcers using risk assessment and prevention guidelines
  3. To make quality recommendations that can be applied for further research based on the outcomes of the study.

Literature Review

“Extrinsic and intrinsic factors increase the severity of pressure ulcers” (McCaffery & Pasero, 1999). Intrinsic factors involve the patient’s loss of pressure and pain sensations that would alert or prompt him to change position and release the pressure. Disuse atrophy, anemia, malnutrition, and other infections are vital factors that contribute to pressure ulcers. The extent at which the ulcer develops depends on the force exerted and the duration. “Prevention is the best treatment for pressure ulcers” (McCaffery & Pasero, 1999). In order to cover potential pressure sites, the nurse is required to develop a window in the cast (Hawthorne & Redmond, 1999).

Skin inspection is also essential to check pressure points. Trauma or erythema should be examined a minimum of one time every day. Mobile or immobile who are able and their families are required to know the day to day visual procedure of examining the skin a palpation sites for signs of ulcer development. It is necessary to have exquisite skin care applied to areas that are neurological damaged. This would prevent secondary infections and maceration. The affected spots should be kept dry and clean at all time to prevent possible maceration (Hawthorne & Redmond, 1999).

The nurse duty is to prevent pressure ulcers when caring for patients. This is not limited to immobile patients only. “Skin impairments may not be a problem to an immobilized patient who is healthy enough but a serious and devastating problem to depilated or ill patients” (Marieb, 2004). Acknowledging the threats for every patient helps in preventing the occurrence of pressure ulcers. Doctors recommend a well-balanced diet when treating pressure ulcers. It should have high in protein contents. “Anemia as a severe condition may require blood transfusions” (Marieb, 2004). “Therefore, threatened pressure sores should include all the above prophylactic measures in order to prevent tissue necrosis. The sore should be left dry, exposed and free from pressure” (Marieb, 2004).

Design

The design adopted was aimed at enhancing the quality of health care in health facilities. Clinical audits have become popular tools that are geared towards changing the behavior in healthcare and enhancing the quality of care offered.

Healthcare systems have employed the use of clinical audits in assessing the quality of their services. The mode of describing care is through an organized evaluation of a series of patient’s experiences at the facility. The information is mostly acquired from close assessment of medical records and charts that are meant for documentation of certain, clinical measures. There is inconsistent proof as to whether clinical audits are more successful in influencing the service providers’ behavior, yet it is still widely used to assess performance.

Sampling Procedure

Due to the short time frame the project had an advisory panel will make a decision on choosing the sites that would be used to provide substantial patient numbers to permit development in practices to be identified between the audits. The sites that were chosen include “those that provided geriatrics, orthopedic or medical care to groups that have a high risk of developing pressure ulcers” (Marieb, 2004). “A sample was selected from these sites. This being an audit project, approval by the ethics committee would not be required” (Marieb, 2004). The hospital sites that would be used in the study would, however, provide a confirmation of their willingness to be involved.

Audit Criterion

The practitioner who has sufficient and suitable skill and understanding should embark on the first evaluation and provide a documented report of the results. “The grade of the health care professional or the nurse would be recorded for the audit purposes” (Marieb, 2004).

Dissemination and implementation

The evidence provided from the study informed the dissemination and implementation strategy that was undertaken. It showed the advice of the site link staff and nurses from various medical areas. This guaranteed that the approach adopted exhibited best verification that would develop a form of alteration, and promote local adoption of the guideline. Dissemination process involved identifying the nurses from each clinical discipline that would help the clinical staff undertaking the project. “The nurse would also assist with the audits by ensuring that every member of the facility has a copy of project proposal, summaries of the guidelines suggested and quarterly newsletters” (Marieb, 2004).

Implementation and Data Collection

“Every senior member of staff was given a resource pack of the clinical area to be audited” (Marieb, 2004). This resource pack contained the evidence-based guidelines. “The site link directors of nursing and the nurses site links, and copies containing of the guidelines for auditing” (Marieb, 2004). The project manager is supposed to direct education meetings at every site, with the help of the designated site link nurse, after the first audit. The manager used the European Pressure Ulcer Panel tools to ensure standardization of pressure ulcer grading. At the end of the exercise, each site would be required to highlight clinical areas that met the inclusion criteria, besides planning the periods when the project manager would undertake the audit one. Second audit will be undertaken at each site six months later (Marieb, 2004).

Development of Audit Tools

“Audit tools to be developed will be for the clinical area and the patient” (Guyton & Hall, 2000). They will be designed using suggestions from the audit protocol recommended by the panel of directors. The development tools would include;

  1. The criteria should be based on facts and prioritized based on the results of the patient and quality of the data presented.
  2. The implemented methods should be quantifiable and suitable to the medical or clinical setting and
  3. The audit procedures will be obtained from the audit instructions provided. Consultation with the advisory board will them follow to confirm the details.

Conclusion

“The teams should understand that patient safety is the primary factor during their stay at the hospital, before, during and after each medical procedure undertaken” (Baker & Fraser, 1995). In order to comprehend the justification of preventive strategies, a comprehensive understanding of the epidemiology is essential as it should be dependent on satisfactory surveillance methodologies. It would help to demonstrate effective prevention and treatment of pressure ulcers.

Auditing is a primary factor due to the pervasiveness of pressure ulcer development, in spite of the clinical protocols that are put in place. The evaluation and control of risks associated with pressure ulcers can be improved by the execution of guideline recommendations. Such recommendations are attributed to “accurate and timely documentation of risk, adequate care planning and the provision and review of appropriate equipment involved” (Baker & Fraser, 1995).

References

Baker, R. & Fraser, R. (1995). Development of Review Criteria: Linking Guidelines and Assessment of Quality, 61(5), 223-275.

Bickley, L. & Szilagyi, P. (2003). Bates’ Guide to Physical Examination: Historical Taking, 25(1), 87-96.

Bryan-Brown, C. W. (2006). Evidence-Based Practice is Wonderful. American Journal of Critical Care, 83, 34.

Guyton, A & Hall, J. (2000). Textbook of Medical Physiology, 98(2), 12-23.

Hawthorne, J. & Redmond K. (1999). Pain: Causes and Management. 54(7), 100-122.

Kozier, B. & Erb, G. (2004). Fundamentals of Nursing: Concepts, Process, and Practice, 34(3), 36-65.

McCaffery, M. & Pasero, C. (1999). Pain: Clinical Manual, 45(7), 102-107.

Marieb, E. (2004) Essentials of Human Anatomy and Physiology, 34(4), 45-71)

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