Evidence Based Practice for Pressure Ulcers
Introduction
Every day, health care professional — nurses, physicians, respiratory therapists, and others — confront difficult questions about caring for patients – acutely ill or not. Health care professionals want to know how to interpret a diagnostic test accurately, how to predict the prognosis of a specific patient, how to identify the comparative effectiveness of 2 therapeutic interventions, and how to compare the costs of their various options. Health care professionals, the public, and policy makers all need to know the most effective care — from a clinical and cost perspective — for a patient hospitalized in any health care setting. Increasingly, the answers to these questions are found in the guidelines that have evolved from systematic research.
Each health care professional is challenged to stay familiar with new information regarding health care concerns in order to provide the highest quality of patient care. Evidence-based practice is therefore important in the health care field. Evidence-based practice is defined as the integration of best systematic research evidence with clinical expertise and patient values.
Pressure ulcers continue to present a major health care problem not only for hospitalized older adults but for other immobilized individuals. The predictions and prevention of pressure ulcers is therefore a top priority in the health care field. It is of extreme significance that processes of quality care related to pressure ulcer prediction and prevention be instituted as part of the development of the plan of acre to predict and prevent the incidence of pressure ulcer development. This paper will focus on evidence-based practice for pressure ulcers.
Healthcare professionals in all patient care settings, not only those involve with patients that have pressure ulcers, must therefore pursue knowledge by taking the time to review research and practice findings, critique research studies, and discuss with colleagues the implications when new knowledge is not integrated into practice.
Background of the medical condition
Pressure ulcer is most commonly known as bedsore. Other names for it include pressure sore, decubitus ulcer and trophic ulcer. It is an ischemic necrosis and ulceration of tissues overlying a bony prominence which has been subjected to prolonged pressure against an external object like a bed, wheelchair, cast or splint for example (2003). The condition results to impaired skin integrity related to unrelieved, prolonged pressure (2004).
Such a condition is seen most frequently in patients who have diminished or absent sensation, or are debilitated, emaciated, paralyzed, or otherwise long bedridden. Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition can therefore be at risk for pressure ulcer development. Tissues over the sacrum, ischia, greater trochanters, external malleoli, and heels are especially susceptible but other sites may be involved, depending on the patient’s position. Pressure ulcers can affect not only superficial tissues, but also muscle and bone.
Both intrinsic and extrinsic factors precipitate pressure ulcers. Intrinsic factors include loss of pain and pressure sensations that ordinarily prompt the patient to shift position and relieve the pressure, and the thinness of fat and muscle padding between bony weight-bearing prominences and the skin. Disuse atrophy, malnutrition, anemia, and infection play contributory roles. The most important of the extrinsic factors is pressure. Its force and duration directly determine the extent of the ulcer. Pressure severe enough to impair local circulation can occur within hours of an immobilized patient, causing local tissue anoxia that progresses, if unrelieved, to necrosis of the skin and subcutaneous tissues.
The best treatment for pressure ulcers is prevention. Pressure on sensitive areas must be relieved. Unless a full-flotation bed such as a water bed is used, providing even distribution of the patient’s weight. If the patient is using braces or plaster casts, a protective padding at bony prominences should be used under braces or plaster casts, and a window in the cast should be cut over potential pressure sites.
Skin inspection is also important. Pressure points should be checked for erythema or trauma at least once/day in an adequate light. Able patients, mobile or immobile, and their families must be taught a routine of daily visual inspection and palpation of sites for potential ulcer formation. Exquisite skin care for neurologically damaged parts is necessary to prevent maceration and secondary infection. Maintaining cleanliness and dryness helps to prevent maceration.
The prevention of pressure ulcers is a priority in caring for patients and is not limited to patients with restrictions in mobility. Impaired skin integrity may not be a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients. Prompt identification of the high-risk patients and their risk factors aids in prevention of pressure ulcers.
A well-balanced diet, high in protein, is important in the treatment of pressure ulcers. Blood transfusions may be needed for anemia. Threatened pressure sores require energetic use of all the above mentioned prophylactic measures to prevent tissue necrosis. The area should be kept exposed, free from pressure, and dry.
The major problem in treating pressure ulcer is that the ulcer is like an iceberg, a small visible surface with an extensive unknown base, and there is no good method of determining the extent of tissue damage.
More advanced ulcers require surgical treatment. Surgical debridement and closure is required for fat and muscle involvement. Affected bone tissue requires surgical removal; disarticulation of joint may be needed. Necrotic tissue can promote pathogen growth and delay healing, so it should be removed. An exception may be eschar or necrotic tissue on a heel ulcer because an open heel wound can easily become infected and lead to osteomyelitis. Several debridement methods are available; the choice depends on the amount of necrotic tissue, absence or presence of infection, patient preferences, and economic considerations ( 2006).
Types & hierarchies of evidence
Evidence-based practice, which is often referred to as evidence-based nursing or evidence-based medicine, is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. (1) It involves integrating the individual clinical expertise of the physician or nurse with the best available external clinical evidence from systematic research and individual patient preferences. (2) Research shows that patients’ outcomes are at least 28% better when clinical care is based on evidence rather than tradition or common sense (2006). The following paragraphs would discuss health care practices and interventions on pressure ulcers which are evidence-based and are widely used in health care settings today.
A major aspect of nursing care is the maintenance of skin integrity. Consistent, planned skin care interventions are critical to ensuring high quality of care (2004). Nurses constantly observe their patient’s skin for breaks or impaired skin integrity. Impaired skin integrity occurs from prolonged pressure, irritation of the skin, or immobility, leading to the development of pressure ulcers. Nursing care interventions aimed at the prevention, assessment and treatment of pressure ulcers should be based on research (2004) or evidence-based practice.
There are several instruments for assessing patients who are at high risk for developing a pressure ulcer. Patients with little risk for pressure ulcer development are spared the unnecessary and sometimes costly preventive treatments and the related risk of complications.
Prevention and treatment of pressure ulcers are major nursing priorities. The incidence of pressure ulcers in a facility or agency is an important indicator of quality of care. There is evidence that a program of prevention guided by risk assessment can simultaneously reduce the institutional incidence of pressure ulcers by as much as 60% and bring down the costs of prevention at the same time (2004).
Evidence-based practice shows that lack of documentation of patients at risk demonstrates the need for hospitals to increase prediction and prevention strategies. Use of a risk scale can provide triggers to plan care to decrease risk factors.
As a predictive measure, individuals should be assessed for risk of pressure ulcer development upon admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities (2004). Pressure ulcer risk assessment should be done systematically.
Evidence-based practice also shows that extended stays of over 7 days increase the risk of pressure ulcer development ( 2001). Nurses must therefore remain vigilant in the prevention of pressure ulcers in patients with longer hospital stays.
Evidence-based practice shows that the use of care practices such as daily skin assessment, use of pressure-relief surfaces and objective risk assessment measures, such as the Braden scale, identified at risk patients and reduce evidence of pressure ulcers ( 2001). The Braden scale was developed based on risk factors in a nursing home population. It is highly reliable when used to identify patients at greatest risk for pressure ulcers. It is also the most commonly used assessment scale for pressure ulcer ( 2004).
Evidence-based practice also shows that the use of nutritional consultation was associated with decreased incidence of pressure ulcers, suggesting a nutritional consultation may sensitize the staff that the older adult is at risk for pressure ulcer development ( 2001).
Nursing interventions for reducing and treating pressure ulcers are evaluated by determining the patient’s response to nursing therapies and by determining whether each goal was achieved. To evaluate outcomes and responses to patient care, the nurse measures the effectiveness of interventions. The optimal outcomes are to prevent injury to the skin and tissues, reduce injury to the skin and underlying tissues, and restore skin integrity (2004). The care of a patient with a pressure ulcer requires a multidisciplinary team approach.
There is a strong relationship between nutritional status and pressure ulcer development, yet nutrition is an area often overlooked by clinicians in pressure ulcer care. Nutrition, including adequate hydration, plays an important role in pressure ulcer prevention and healing, and is critical in maintaining tissue integrity. Patients defined as malnourished at hospital admission are twice as likely to develop pressure ulcers as well-nourished patients. Therefore, nurses and dietitians should work together to assess the patient’s nutritional and hydration status and ensure that these factors are addressed in the patient’s care plan (2000).
Pressure ulcers, regardless of their origin, represent negative outcomes for patients. These negative outcomes may include pain, additional treatments and surgery, longer hospital stays, disfigurement or scarring, increased morbidity; and increased costs. Although all negative outcomes are of concern, a hospital-acquired pressure ulcer can result in increased cost of treatment, patient dissatisfaction with care, and a potential litigious situation ( 2005).
The search process
There are many reliable web-based resources that provide health care professionals with links to evidence-based education. For this particular paper, a variety of web-based sources are used among others. The University of York Centre for evidence-based nursing is an example of a website that provides links to evidence-based education and practice information (). In fact, the website was used in order to find articles containing evidence-based information for pressure ulcers.
An online library called Highbeam () was also used to find articles and other reading materials that provide information regarding evidence-based practice of pressure ulcers. Search results from the website using the keywords “pressure ulcer” generated more that a thousand written articles that contain the word “pressure ulcer.” These articles are really published written articles that were encoded into computers for easier access to readers.
Books were also used to find anything about evidence-based practice for pressure ulcers. These books are mostly nursing books, the titles of which are written in the references section at the end of this paper. These books have proved quite helpful in providing information on the kind of nursing interventions that are used for patients with pressure ulcers and risk assessments for all patients in general.
Problems with evidence-based research/practice
Despite increased focus on evidence-based practice in recent years, information is lacking about utilization of research findings for evidence-based practice among nurses in some rural areas. Many studies on research utilization in the past have been conducted in urban settings. The farther one ventures away from large urban medical centers, the less one hears about research utilization activities for evidence-based practice in nursing. If nursing is to be truly an evidence-based profession, improving utilization of research findings in clinical practice not only must remain within urban-based large hospitals but also must be part of nursing practice in any geographic location (2004).
Sometimes, there is a lack of evidence based practice used in the intervention for pressure ulcers. Strategies are therefore needed to help these specifis nurses to integrate evidence-based guidelines in their practice, specifically on pressure ulcers which is the topic of this paper. There is much evidence to suggest that pressure ulcer rates significantly lower with the use of evidence-based practice.
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