Pressure Ulcer: Review

Abstract

One of the main challenges facing diverse health-care 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 on the existing health-care system. According to studies and research that have been carried out, the increment in nursing time is bound to rise more than 50% on the 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 supporting the implementation of evidence-based practice in relation to pressure ulcers. This research paper seeks to define pressure ulcers in relationship to methodology, intervention measures, the outcomes related to intervention measures, and the overall perspective in relationship to evidence-based research.

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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 based practice has been utilized in the field of nutrition, nursing as well as rehabilitation by the various medical practitioners’ (Gordon et al, 2004, par 1). Over the years numerous efforts have emerged in a bid to achieve an effective way of determining, as well as reducing, surface pressures (Bader et al., 2005, p. 3.

Methodology

In home care and acute care nursing homes, pressure ulcers are sometimes regarded as a costly as well as a common problem. In terms of incidence, the percentage is between 2.7% and 29.5%. Prevalence in this research setting has varied from 3.5% to 29.5%. This is in accordance with the 24 hours time limit that has been set for ascertaining the prevalence of pressure ulcers. In developing guidelines on the basis of science-based support, a vast amount of information that focused on pressure ulcers gathered from consultants and the literature was considered. Nutritional intervention was considered as compared to basic pressure ulcer care.

The information for the consideration of these interventions was derived from medical practitioners (clinicians) and literature based on pressure ulcers. The intent of the research was to comprehend or understand the differences achieved by nutritional intervention and the treatment measures involved when dealing with the condition of pressure ulcers. Scientific evidence and the benefits associated with two interventions were examined using the criteria of an examination of patients who have developed pressure ulcers. Not only were the benefits of the interventions considered but also the risk factors that were involved. The research incorporated surveys conducted in health care facilities and nursing homes. The incidence as well as the prevalence levels was crucial in recording of data. Age, grade of pressure ulcer and type of treatment were also considered as crucial factors in the research. An extensive internet based research was undertaken for the sole purpose of addressing the medical question regarding pressure ulcers. Apart from the use of credible books in the research, the web was used in attaining credible sources that were both closed as well as open. The following databases were explored extensively in a bid to explore the research question.

  • PubMed
  • Medscape
  • National Institute for Health and Clinical Excellence (Nice. Org.Uk)

National Pressure Ulcer Advisory Panel (NPUAP):

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  • Maastricht University databases (unimaas.nl)
  • ACP Journal club
  • TRIP database

MEDLINE (1966 to week 16, 2011), Healthstar (1975 to March 2011) and EMBASE (1974 to week 16, 2011) were the other subsequent databases that were used to attain information for the research question. In the research the following search terms were explored: COPD, bronchodilator, exacerbation, chronic obstructive, albuterol, regular , pulmonary disease, PRN and frequency. The quality of information attained in the various research sources differed and thus the evidence attained was classified into three groups: 1(randomized control trials), 2 (information from experts-books) and 3 (other evidence attained).

According to two prevalence surveys that were conducted in relation to pressure ulcers in Germany in the year 2001 and 2002, data was attained from 15 nursing homes and 51 hospitals. The number of subject participants was 11, 584 patients. Dressing usage was reviewed according to the evidence level and in relation to its consistent. The prevalence rates of pressure ulcers were 10.6%-13.2% and 60% of the patients had Grade 1 pressure ulcer. The results in the nursing home indicated consistency of the dressing selection with current evidence of 6.8% and 27.8% of grade 1 and grade 2 respectively. Despite the fact of strong evidence that supports dressing usage leading moist wound healing, the research indicated that nearly half of the grade 3 and 4 ulcers did not receive this treatment (Helberg et al, 2006 p 1).

The research incorporated a number of healthcare facilities, including nursing homes. The pressure ulcers guidelines that were developed revolved around assessment, ulcer care and treatment, and interventions. Treatment planning is founded on the basis of an assessment of an individual who possesses pressure ulcers. In this assessment, the location, size, and wound stage of the pressure ulcer was identified as crucial. The assessment was conducted once in week. The number of assessments was increased in relation to the patient’s general condition, especially if the severity of the pressure ulcers demanded a reassessment or a reevaluation of the treatment plan.

Nutritional assessment is also one of the crucial components in a treatment program involving pressure ulcers. The general consensus attributes nutrition in terms of its crucial role it plays in a comprehensive care plan that pertains with the treatment as well as the prevention of pressure ulcers. According to the study of 1524 residents that was undertaken in 95 nursing facilities, pressure ulcers was documented to be high in terms of incidence in relation to increase in age. According to the detailed characteristics and the treatment measures of pressure ulcer that were researched by the National Pressure Ulcer Long Term Care Study (NPULS), the subjects of the study included 2,420 adult participants from nursing homes. The period stipulated were not less than 14 days and the participants had to have a high risk of attaining pressure ulcers. According to the outcome of the results attained, over 50% of the residents that participated in the study lost weight of up to 5% during the entire 12 week period. 45.6% of the subject participants were recorded down to be underweight (“defined as a BMI of 22 or less”). A bigger percentage of the weight loss was however documented in residents that had recently experienced pressure ulcers (Dorner et al, 2009, p. 2). Severity of malnutrition is attributed to low serum albumin level as well as total lymphocyte count, which is associated to severity of pressure ulcers (Morrison, 1994, p. 196). It is essential that pressure ulcer patients undergo a nutritional assessment. Past research has indicated that the stage of pressure ulcers, in one way or another, is correlated with severe nutritional deficits. Malnutrition, according to the research, was related to the development of pressure ulcers. In individual assessments, other factors, such as demographics and wound, were also recorded. It is crucial to conduct a nutritional assessment at least every three months. Data forms used to record the findings of the study were collected for the sole reason of recording the data derived from the research in a database for analysis and generation of reports.

Review of the Literature

Intervention

Pressure ulcers are regarded as one of the health conditions that require intensive attention. It is a health condition that requires tracking, especially in hospitals, in terms of its incidences, as well as outcomes, of interventions. Incorporation of an interdisciplinary wound team is essential. 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.

In 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 to determine 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 treatment of pressure ulcers. According to various studies, causes of pressure ulcers are regarded as multivariate. This tends to indicate that prevention measures for pressure ulcers will be more elusive. In addition to this, comprehensive protocols have undergone evaluation in both hospitals and long-term care settings, but pressure ulcer development still remains to be a challenge (Archbold et al., 2002, p 44

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Comparison between Nutrition Intervention and Basic Pressure Ulcer Care

In basic ulcer care, positioning of the resident is considered to be the primary measure incorporated in the basics of the pressure ulcer care. A resident who has the pressure ulcer condition ought to be positioned frequently through use of good posture and good body mechanics. According to majority of the clinicians, it is recommended that a position change is crucial for dependent residents who are associated to sitting, sleeping or reclining chair postures.

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 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 (Maklebust and Sieggreen, 2001, p.92).

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 nutritional intervention process, the first step entails nutritional assessment (Maklebust and Sieggreen, 2001, p.92). However, there are no randomized controlled studies or large analyses to support these conclusions regarding the importance of nutrition and hydration. Physiologic theories provide the underpinnings for these recommendations, which are of yet untested by evidence-based methodologies.

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. 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 a 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 (Feldman, 1994, par 10).

Nutrition and Prostat

According to Bales and Ritchie, pressure ulcer healing is, in one way or another, 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 the development of pressure ulcers. Studies have gone on to suggest that patients whose appetite is good are 3-4 times less probable to have pressure ulcer, 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 into the treatment measures of a patient with pressure ulcers seeks to treat, as well as to prevent, nutrient deficiencies and to avoid complications that pertain to nutrition delivery.

When these objectives are achieved, the patient should have improved in terms of the outcome 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 pertains to the amount or dose of nutrition that is needed. This is because it has been ascertained that overfeeding, as well as underfeeding, can both cause deleterious effects for the patient; hence, these actions should be done away with or avoided. According to recent studies, the majority of pressure ulcer patients do not meet the standards required in terms of nutrition.

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Evidence gathered so far points out that pressure ulcer are correlated positively with malnutrition (Berger et al., 2007, p. 758). Among various studies that have been conducted, only two of the studies involved artificial nutrition. In a randomized control trial that was conducted, 140 subjects who had high pressure ulcer risk were involved. The subject intervention group was fed with standard diet in the hospital as part of the treatment measure. In addition to this, the NGT feeding was administered at night. The comparison group on the other hand was administered with hospital diet alone. On comparing the two groups, no significant difference was noted. Chernoff et al (cited in Berger et al., 2007, p. 758) made use of the artificial nutrition in randomized controlled trials (RCT) that involved 12 pressure ulcers patients that were tube-feeders. The focus was on the protein intake and not the tube feeding (Berger et al., 2007, p. 758).

Basic Skin Care Only

Basic pressure ulcer dressing is one of the treatment measures that tackle this wound treatment. Scientists and researchers have explored nearly 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 used to keeping the ulcer tissue moist, as well as to maintain the dryness of the intact skin (Bergstrom et al., 1994, p. 53). According to published studies, remarkable wound healing is recorded as one of the outcomes that pertain to topical dressing of pressure ulcer wounds among elderly patients. The dressing is supposed to provide a healing environment for the wound. On the basis of the indirect evidence found, experts tend to think that the dressing process should incorporate cleaning the wound with a saline solution (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 as contributors to pressure ulcer development. Ingesting a high protein diet is one of numerous ways by which to foster pressure ulcer healing (Morison, 1994, p. 197). In a study that was conducted in 2008 at a long-term acute hospital (LTAC), a total of 68 subjects participated (Tempest et al, 2010, p. 1). These participants had demonstrated delayed healing of the wound and skin breakdown. The study indicated that protein malnutrition is one of the factors that are attributed to delay wound healing. This is in terms of decreasing and deposition of wound strength. Diminishing of immune function also takes place through protein malnutrition. By diminishing the immune function, the patient would be prone to wound infection thus contributing to delay healing (Tempest et al, 2010, p. 3). The recommended protein intake for pressure ulcer patients is 1.25-1.5 g/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 pressure ulcer outcome. In addition to this, the severity of the ulcer is a more essential factor than the ulcer site in determining 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).

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. There are various factors that are associated with the damage caused by pressure ulcers. Some of these factors include friction, moisture, pressure, and shear forces (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. In terms of structuring nutrition assessment as well as intervention clinical guidelines, evidence based research results are crucial. The impact of nutrition is positive in terms of quality of life; hence, early nutrition interventions are appropriate in the prevention of under nutrition, which is regarded as a risk of pressure ulcer development as well as delayed healing. In summation nutrition intervention has been identified as a crucial systemic factor in the healing rate of pressure ulcers. The relationship that exists between pressure ulcers and nutrition is more of integral relationship as it underscores the crucial role of effective provision of nutrition for the sole aim of wound healing.

References

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Bader, D., Bouten, C. and Colin, D. (2005). Pressure Ulcer Research: Current and Future Perspectives. Berlin: Springer-Verlag Science Berlin Heidelberg.

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Doyle, D., Hanks, G. and Cherny, N. I. (2005). Oxford textbook of palliative medicine. NY: Oxford University Press Inc

Gordon, M.D., Gottschlich, M.M., Helviq, E.L., Marvin, J. A. and Richard. R.L. (2004). “Review of evidenced-based practice for the prevention of pressure sores in burn patients.” Texas: Shriners Hospitals for Children, Galveston.

Helberg, D. et al. (2006). Treatment of Pressure Ulcers: Results of a Study Comparing

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Levin. M. E., O’Neal, L. W., Bowker, H. J. and Pfeifer, M. A. (2008). Levin and O’Neal’s The Diabetic Foot. PA: MOSBY ELSEVIER.

Lyer, P. W. (2006). Nursing home litigation: investigation and case preparation. AZ: Lawyers & Judges Publishing Company, Inc.

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