Abstract
One of the main challenges facing diverse healthcare settings is the development of evidence-based nursing. The incidence and prevalence rates of pressure ulcers, combined with the cost of treatment, have proven to be a huge burden to the existing healthcare system. According to studies and research that have been carried out, the increment in nursing time is bound to rise up to 50% on treatment of pressure ulcers. Despite the ever-increasing evidence-based guidelines and treatment measures for pressure ulcers, lack of empirical evidence is related to the effectiveness that is associated with implementation strategies. This, therefore, indicates the crucial impact of support implementation of evidence-based practice in relation to pressure ulcers. This research paper seeks to define pressure ulcers in relation to methodology, intervention measures, the outcomes related to intervention measures, and the overall perspective in relationship to evidence-based research.
Introduction
A pressure ulcer is a condition that affects the skin and is caused by constant pressure applied on the skin thus resulting in skin breakdown. The pressure that is applied against the skin is attributed to minimal blood flow to that particular area of the skin hence affected tissues die. According to studies conducted, pressure ulcers are regarded to be a complex clinical problem. Evidence of practice has been acquired currently in the various medical practitioners’ fields of nutrition, nursing as well as rehabilitation (Gordon et al, 2004, par 1). Despite the fact that pressure ulcers primarily result from sustained mechanical loading subjected to the soft body tissues, the measure of preventing the pressure ulcers by singularly reducing the loading degree still remains to be an uphill task. Over the years numerous efforts have emerged in a bid to attain an effective way of determining as well as reducing surface pressures (Bader et al, 2005, p. 3).
Review of the Literature
Intervention
Pressure ulcers are regarded as one of the health conditions that require a lot of attention. It is a health condition that requires tracking especially in hospitals in terms of its incidents as well as outcomes of interventions. The incorporation of an interdisciplinary wound team is essential especially if it is comprised of nurses and physicians. Intervention measures are to be undertaken through evaluation of patients with pressure ulcers and planning of institutional care. The incidence and prevention data is crucial in ascertaining the effect of treatment intervention measures.
During the process of using evidence-based medicine concepts to find a solution to pressure ulcers, studies have been conducted and data retrieved from medical records. Wireless thigh monitors used in determining positioning posture and direct observation of the resident are strategies that have been incorporated with the aim of making use of quality indicators as a basis for good care (Lyer, 2006, p. 743). In addition to this, nutritional intervention and basic ulcer care are considered to be some of the intervention measures pertaining to the treatment of pressure ulcers. According to studies, causes of pressure ulcers are regarded as multivariate. This tends to indicate that prevention measures of the ulcers will be more elusive. In addition to this, comprehensive protocols have undergone evaluation in both the hospital and long-term care setting but still, pressure ulcer development still remains to be a challenge (Archbold et al, 2002, p. 44).
Comparison Between Nutrition Intervention and Basic Pressure Ulcer Care
In basic ulcer care, positioning of the resident is considered to be one of the measures that are incorporated in the basics of pressure ulcer care. A resident who has a pressure ulcer condition ought to be positioned frequently through the use of good posture and good body mechanics. According to the majority of the clinicians, it is recommended that a position change is crucial for dependent residents who are associated with sitting, sleeping, or reclining chair postures. Even though wheelchairs are useful for transporting residents, they are attributed to limiting repositioning options thus increasing the levels of pressure ulcer development. Systematic studies are essential in the validation of risk factors that are associated with pressure ulcers. Potential intervention is therefore intertwined with the systematic studies for the sole aim of preventing pressure ulcers (Pignolo et al, 2008, p. 152).
Upon admission, all individuals should be screened to discover nutritional problems that may contribute to the development of pressure ulcers. Proteins are essential and should be provided at levels that create a nitrogen balance that is positive. The recommended rate is “1.25-1.5grams of protein/kg body weight.” Adequate hydration can be encouraged by ingesting or receiving more fluids. This is essential especially to residents who experience fluid losses in terms of fever, diarrhea, and vomiting. According to Maklebust and Sieggreen, “early identification of malnutrition and subsequent intervention can alter the healing trajectory of patients with wounds.” An individualized nutritional plan is to be adapted as there are no formulas that apply to all patients. In the nutritional intervention process, the first step entails nutritional assessment (Maklebust and Sieggreen, 2001, p.92).
Treatment
Local wound treatment and a critical review of the patient’s care plan for preventing pressure ulcers are crucial in controlling the development of pressure ulcers. Pressure ulcers sores that have undergone stages I and II tend to heal within a couple of weeks to a few months, provided conservative care and appropriate overall care are administered. On the other hand, pressure sores that have reached stages III and IV are difficult to attend to in terms of treatment measures. By the time a pressure ulcer wound reaches stages III and IV, the wound would have extended into the fat tissue through the skin layer. This calls for appropriate medical attention. To make matters worse, when a pressure ulcer wound is considered to be in stage IV, the wound will have broken down and thus extend to the bone or muscle. Full-thickness wounds are attributed to the loss of both the epithelium and the dermis. This, therefore, calls for comprehensive treatment measures besides just wound dressing. The usual and most effective treatment for a pressure ulcer wound that has progressed through the four stages is surgery, which incorporates skin grafts and skin flaps.
Some of the factors that are attributed to the influence of nursing as well as the quality of life of the patient include: treatment of the pain, condition of the skin and the cost-effective associated with wound care. It is through the nursing staff’s competence, skills and motivation that preventive and treatment measures can succeed (Romanelli et al, 2006, p. 7).
Nutrition and Prostat
According to Bales and Ritchie, wound healing is in one way or the other intricately associated with nutrition. Low levels of protein calories in humans are required for alteration of tissue regeneration. Over the years controversy has raged on whether poor nutritional status is a factor that causes development of pressure ulcers. Studies have gone on to suggest that patients whose appetite is between 3-4, have less chances of pressure ulcer development as opposed to patients with poor appetite (Doyle et al, 2005, p. 629). In critically ill patients, the role of nutrition therapy is to attenuate the patient’s metabolic response that results from stress or injury. This indicates that nutrition therapy that is incorporated in the treatment measures of a patient with pressure ulcers seeks to treat as well as prevent nutrient deficiencies and to avoid complications that pertain to nutrition delivery.
On achieving these objectives, the patient should have improved in terms of the outcomes expected. Although nutrition therapy is regarded as one of the integral pillars of a patient’s standard care, the evidence that is attributed to the assessment of nutritional status as well as the route, timing, and appropriate substrate is limited, especially in medical patients. One of the major questions that have created room for discussion pertains to the amount or dose of nutrition that is needed. This is because it has been ascertained that overfeeding as well as underfeeding are both attributed to deleterious effects for the patient; hence, these actions should be done away with or avoided. According to recent studies, the majority of the pressure ulcers patients do not meet the standards required in terms of nutrition.
Evidence attained points out that pressure ulcers are correlated positively with malnutrition. In studies conducted only two of the studies involved artificial nutrition. In the randomized control trial that was conducted, a number of 140 subjects who had high pressure ulcer risk were involved (Berger et al, 2007, p. 758).
Basic Pressure Ulcer Dressing
Basic pressure ulcer dressing is one of the treatment measures that tackle the wound treatment. Scientists and researchers have explored almost every different kind of concoction in an effort to heal pressure ulcers. In the various stages that are attributed to pressure ulcers, wound dressing is used for cleaning and moistening the ulcer base as well as maintaining dryness to the peri-ulcer skin. The dressing of the wound is mainly dictated by the wound’s characteristics. It is through the dressings that the physiological integrity of the wound is maintained. The dressing is attributed to keeping the ulcer tissue moist as well as maintaining dryness of the intact skin (Bergstorm et al, 1994, p. 53). According to published studies, remarkable wound healing is recorded as one of the outcomes that pertain to tropical dressing of the pressure ulcer wound among elderly patients. The dressing is supposed to provide a healing environment for the wound. According to the basis of the indirect evidence attained, experts tend to think that the dressing process should incorporate cleaning the wound with saline (Rosenthal et al, 2006, p. 528).
Outcome
Various processes are involved in healing pressure ulcers. A number of studies have tested the role that nutrition plays with respect to the healing rate of pressure ulcers. Low energy and protein intake, low hemoglobin levels, and low body weight have all been suggested to contribute to the development of pressure ulcers. Studies have been concluded that ingesting a high protein diet is one of numerous ways by which to foster pressure ulcer healing (Morison, 1994, p. 197). The recommended protein intake for pressure ulcers patients is 1.25-1.5g/kg per day. Nonetheless, the amount to be administered to the patient is supposed to be adjusted in accordance with the patient’s condition and weight, as well as with the presence of other diseases in the patient and the severity of the ulcers. Studies have indicated that several factors play a major role in time in pressure ulcer outcome. In addition to this ulcer severity is more essential as compared to ulcer site in determination of the ulcer outcome (Levin et al, 2008, p. 5).
A study conducted by Horn et al. (2004), which incorporated a total of 1,524 residents, sought to investigate resident and facility treatment that is attributed to the advancement of pressure ulcers in long-term care residents. The 1,524 residents stemmed from ninety-five different long-term care facilities. The data obtained from each and every resident consisted of such resident characteristics as nutritional factors, demographics, and medical history; treatment characteristics, such as nutritional interventions and strategies pertaining to pressure management; and outcomes. The results indicated that 71% (1,081 subjects) of the total subjects did not acquire pressure ulcers during the 12-week study period. The remaining 21% of the subjects (443 subjects) developed pressure ulcers. An increased probability of acquiring pressure ulcers was attributed to the presence of a history of pressure ulcers, drastic weight loss, and oral problems associated with eating. A decreased probability of developing pressure ulcers was attributed to such characteristics as nutritional intervention and being a new resident (Horn et al., 2004, para. 5).
Methodology
In home care and acute care nursing homes, pressure ulcers are sometimes regarded to be a costly as well as a common problem. In terms of incidence, the percentage is between 2.7-29.5 percent. Prevalence in this research setting has varied from 3.5-29.5 percent. This is in accordance to the 24 hours time that was set in ascertaining the prevalence of pressure ulcers. In development of the guideline on the basis of scientific based support, vast review of the information attained from the consultants and literature focused on pressure ulcers were considered. Nutritional intervention was considered in comparison to basic pressure ulcer care. The information attained in the consideration of these interventions was attained from medical practitioners (clinicians) and literature based on pressure ulcers. The intent of the research is to comprehend or understand the difference brought about by nutrition intervention and treatment measures involved when dealing with pressure ulcers health condition. Scientific evidence and benefits associated with the two interventions were examined using the criteria of examining the patients that have developed the pressure ulcer health condition. Not only are the benefits of the interventions considered but also the risk factors that are involved. Dressing is one of the treatment measures that were considered in the research.
The research incorporated a number of facilities that included nursing homes. The pressure ulcers guidelines that were attained revolved around: assessment, ulcer care and treatment, and interventions. Planning treatment is attributed to be founded on the basis of assessment of an individual who possess the pressure ulcers health condition. In the assessment location, size and stage of the pressure ulcer was identified to be crucial. The assessment was carried out at least once per week. The number of assessment times was bound to increase in relation to patient’s general condition or in case the pressure ulcers demands for reassessment and treatment plan reevaluation.
Nutritional assessment is one of the crucial components in a treatment program involving pressure ulcers. It is essential that pressures ulcers patients’ ought to undergo nutritional assessment. Researches that have been conducted indicate that the stage involved in pressure ulcer in one way or the other correlate with nutritional deficits severity. Malnutrition, according to the research was in one way or the other related to pressure ulcer’s development. In the individual assessment, other factors such as demographic and wound were also recorded. One nutritional assessment is crucial at least in every 3 months time.
In relation to the dressing of the wound, the research’s information was attained from medical practitioners (clinicians), who dress the pressure ulcer wound by keeping it moist and at the same time ensuring the surrounding skin that is intact is dry. Data forms used in recording the findings of the study were collected for the sole reason of recording the attained data in a data base entry for analysis and generation of reports.
Discussion
To implement evidence-based guidance, it is crucial for medical practitioners to comprehend the surroundings in which they work. According to research, pressure ulcers are a major burden because they reduce the quality of life for patients as well as their families. The estimates of the incidence of pressure ulcers as well as their prevalence indicate variations in terms of grade and definition. Currently, the presence of pressure ulcers is attributed to a two- to four-fold increase in risk of death in elderly patients who are admitted to the intensive care unit. The damage associated with pressure ulcers is attributed to various factors, including shear forces, friction, pressure, and moisture (Royal College of Nursing, 2005, p. 26). In terms of nutrition treatment, the available evidence-based research is limited. This calls for appropriate clinical judgment from each and every clinician (Dorner, 2009, Para 5).
Conclusion
Pressure ulcers are defined by many different names. The damage caused by this condition arises from a combination of various factors. In addition to this, pressures ulcers can develop in any part of the body, although in adults the damage mainly occurs in bony areas, e.g., the sacrum. In regard to children, the affected area is likely to be around the occipital areas. Progression of pressure ulcers is divided into four stages. People with spinal injuries and impaired mobility, pregnant women, and old people are more likely to develop them. Patient assessment is attributed for an interactive as well as ongoing approach. It is crucial that the residents who require baseline skin assessment be identified for the sole purpose of determining if a resident is a low risk or does possess a high risk for pressure ulcers. However, dressing change are alone does not heal the wound, proper nutrition is required to increase albumin level and improve BMI. Individual resident risk assessment is regarded as a dynamic as well as an ongoing process that is based on key prognosis factors, the response to pressure and prognosis by the resident’s skin; specialty based knowledge as well as clinical experience.
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