Eliminating the Development of Pressure Ulcers. A Review of the Literature. Laura Kraszewski

Transcription

1 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS Eliminating the Development of Pressure Ulcers A Review of the Literature Laura Kraszewski Author Note This paper was prepared for English 321, taught by Nathan Garrelts.

2 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 2 Abstract Pressure ulcers are common incidences in any type of patient setting. Research has been done to figure out whether they can be completely avoided or not. This literature review explains multiple different articles, diving into each major point of pressure ulcers and incidence, prevention, and treatment. This paper discusses many different approaches to prevention, and the focus of wound treatments that are being instituted in the last few years. This papers goal is to review literature about different aspects of pressure ulcer prevention and support the fact that pressure ulcer incidence can be zero.

3 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 3 A PrU [pressure ulcer] is a type of wound that results in visible changes in blood supply to dermal and supporting tissue, usually from compression over a bony prominence. The damage can vary from nonblanchable erythema of intact skin to a crater into the muscle and, at times, exposure of the bone (Thompson, 2005, p.423). Development of a pressure ulcer on a patient is something every nurse dreads. One pressure ulcer can not only cost millions of dollars to treat, but can also be a gateway to dangerous infection for a patient. Preventing these types of wounds is something that every institution, whether it is a hospital, nursing home, or adult foster care, must strive to prevent. The following are questions that can be addressed to consider whether pressure ulcers can be completely eliminated as a risk to a patient: 1. What are the main causes of pressure ulcers? 2. How can they be prevented? 3. What aids in the healing of a pressure ulcer? Pressure ulcer development effects care on many levels. What I hope to answer in my review of literature is whether nurses and patients will ever be able to totally eliminate the risk of pressure ulcer development in any patient care setting. What are the main causes of pressure ulcers? Multiple studies have been completed to define what one reason pressure ulcers form. Jenkins and O Neal conducted a Pressure Ulcer Prevalence study in 2009 to determine what may be the top contributing factors to producing a pressure ulcer. They included: 1. Braden score 1 <18 1 A Braden score is a score derived from totaling an assessment of factors regarding patient s movement, continent status, and skin integrity.

4 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 4 2. Incontinence (urinary and/or fecal) 3. Albumin 2 levels of <3 4. Fragile skin 5. Bedbound activity level (Jenkins, p. 558). These are results from a prevalence study that was conducted in three medical-surgical units done in quarterly rounds on predetermined days. The information obtained in this study is very useful: it helps to define what we need to assess about a patient in order to assist with prevention of pressure ulcer development (Jenkins, p.559). Another study that was conducted, specific to incontinence, shows that Fecal incontinence, in fact, has been found to hasten the development of PrU s [Pressure Ulcers]. It is not surprising, then that an individual with fecal incontinence is 22 times more likely to develop a PrU than an individual without this condition (Thompson, 2005, p.422). This study s results show that patients skin that is untreated, or under moisturized, as a preventive measure have a much higher incidence with not only obtaining a pressure ulcer. Once a patient has an ulcer, it deteriorates quickly. The most obvious factor in creating a pressure ulcer is direct pressure to specific areas of the body for a prolonged period. This causes tissue death. Springle and Sonenblum s (2011) article briefly discusses how the damaging effects of pressure are related to both its magnitude and duration (p. 203). There is not a lot of conclusive date from this article regarding incidence of pressure ulcers. 2 Albumin is a liver and kidney enzyme that assists with determining nutrition status.

5 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 5 Collectively, these articles help us determine that direct pressure to any bony area of a body for a prolonged period of time, incontinence, and poor skin and nutritional status all contribute to the incidence of pressure ulcers. The question now is: how can they be prevented? How can pressure ulcers be prevented? A simple way to assist with pressure ulcer prevention is to off load pressure from one pressure point to another, since consistent pressure to a specific area can create a tissue injury. Springle and Sonenblum illustrate how this concept works: Redistribution of Pressure Rationale for Interventions Pressure Ulcer Etiology Tissue Load Magnitude and Duration Interventions: Support, Surfaces Positioning, Devices Posture Interventions: Repositioning, Weight Shifting, Active Surfaces Note: From Sprigle, S., & Sonenblum, S. (2011, p.204). Preventing Pressure Ulcers: The Goal is Zero by Duncan (2007), discusses the fact that pressure ulcer incidence should be zero and that prevention is simple. Pressure ulcer prevention entails two major steps: identifying patients at risk and reliably implementing prevention

6 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 6 strategies for all patients identified as at risk (p. 605). She goes on to further explain that there are six main prevention techniques that exist from pressure ulcer admission assessment on all patients to minimizing pressure (p.605). Pressure ulcers are developed because of surfaces that patients lay on. Patients come in contact with many different surfaces. In Moysidis et al (2011). article Prevention of pressure ulcer: interaction of body characteristic and different mattresses three different mattresses were studied: standard hospital foam mattress, foam mattress, and a low pressure device used as a mattress (p. 578). This article discusses that while body mass and distribution of weight play a role, the main result is that Higher specification foam mattresses and constant low pressure devices show similar IP [interface pressure], but constant low pressure devices show a wider pressure distribution (p. 583) concluding that when given a choice to keep a patient on one of these three beds, the best choice seems to be the constant low pressure device. The limitations of this study are that there were a small number of participants, but the conclusions this article draws are beneficial for hospitals when they are assessing what mattresses to purchase. Occasionally the system in which data that is collected to track pressure ulcers and their incidence/prevention fails. In Prevention of Nosocomial Pressure Ulcers, the authors discuss how a good system needs to be in place to track pressure ulcers before they can accurately treat them and prevent them. This article continues to give an example of what they describe as a 3 prong approach (Stoetling et al., 2007, p.382) where the participants (1) developed a PU [pressure ulcer] Tracking Form to help identify and manage high risk patients; (2) develop a cadre of nursing staff to serve as Unit Champions on their respective units; and (3) implemented individual case reviews of all patients who developed nosocomial PU (Stoetling. 2007, p.382). This was done to provide a more accurate documentation of incidence and resolution, as well as

7 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 7 to track whether current treatment protocols were effective. The only limitation is that the use of this approach isn t guaranteed: meaning it s only a good system if it s used appropriately by caregivers. What aids in the healing of a pressure ulcer? Nutritional supplements can aid the healing of a pressure ulcer. Van Anholt et al. article titled Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients researches the effects of added nutrition and wound healing. This article examines wound measurements after providing supplemental oral nutrition to non-malnourished patients for 8 weeks (vananholt et al., 201, p.867). The results show that wounds decreased and that the supplements actually helped. Another aspect of wound healing is pain control. Pain control cascades many aspects to wound care. If a patient s pain is under control, they are more likely to allow dressing changes to be done. Clean dressings equal less chance of infection. In Langemo et al. article Topical Anesthesia for Pressure Ulcer Treatment the topic is whether or not to use topical pain medications for pressure ulcers (Langemo, 2008, p.364). It is further discussed that the local gel anesthetic could be injected into hydrocolloid dressings, thus making a moist wound environment and aiding directly in healing the wound (Langemo, 2008, p.366). A systematic review of the use of hydrocolloids in the treatment of pressures by Heyneman et al. examines how effective hydrocolloid dressings are for pressure ulcer treatment. Hydrocolloid dressings are bandages that are self-sticking to a wound. They promote a moist wound environment, which is the best environment for wound healing. This article examined all different types of wound care regimens and concluded that hydrocolloids were the safest, most

8 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 8 cost effective pressure ulcer treatment ( Heyneman et al., 2008, p.1171). The only limitation found was the effect of wound bed characteristics has to be studied more in depth (Heyneman et al., 2008, p.1171). Overall, copious amounts of research has been completed to examine prevalence, prevention, and treatment of pressure ulcers. The common denominator in this research is that the outcomes and strategies are only as good as what is practiced. In other words, until nurses and caregivers treat patients in a preventive manner, there will still be incidence of pressure ulcers. Can the prevalence be zero? Yes it can but only when patients are proactively cared for.

9 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 9 References Duncan, K. (2007). 5 Million Lives Campaign. Preventing pressure ulcers: the goal is zero. Joint Commission Journal On Quality & Patient Safety, 33(10), Heyneman, A., Beele, H., Vanderwee, K., & Defloor, T. (2008). A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. Journal Of Clinical Nursing, 17(9), Jenkins, M., & O'Neal, E. (2010). Pressure ulcer prevalence and incidence in acute care. Advances In Skin & Wound Care, 23(12), doi: /01.asw c1 Langemo, D., Thompson, P., Hanson, D., Anderson, J., & Hunter, S. (2008). Research forum. Topical anesthesia for pressure ulcer treatment. Advances In Skin & Wound Care, 21(8), 364 Moysidis, T., Niebel, W., Bartsch, K., Maier, I., Lehmann, N., Nonnemacher, M., & Kroeger, K. (2011). Prevention of pressure ulcer: interaction of body characteristics and different mattresses. International Wound Journal, 8(6), doi: /j x x Sprigle, S., & Sonenblum, S. (2011). Assessing evidence supporting redistribution of pressure for pressure ulcer prevention: A review. Journal Of Rehabilitation Research & Development, 48(3), doi: /jrrd

10 ELIMINATING THE DEVELOPMENT OF PRESSURE ULCERS 10 Stoelting, J., McKenna, L., Taggart, E., Mottar, R., Jeffers, B., & Wendler, M. (2007). Prevention of nosocomial pressure ulcers: a process improvement project. Journal Of Wound, Ostomy & Continence Nursing, 34(4), Thompson, P., Langemo, D., Anderson, J., Hanson, D., & Hunter, S. (2005). Skin care protocols for pressure ulcers and incontinence in long-term care: a quasi-experimental study. Advances In Skin & Wound Care, 18(8), van Anholt, R., Sobotka, L., Meijer, E., Heyman, H., Groen, H., Topinková, E., &... Schols, J. (2010). Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition, 26(9), doi: /j.nut