Pressure Ulcer Pain Management - Dissertation Example

?PRESSURE ULCER PAIN MANAGEMENT Table of Contents 0. Introduction 1 Background of the Study 2 2. Aim and Purpose of the Study 3 2.0. RelatedLiterature 4 3.0. Methodology 6 3.1. Sampling Design 6 3.2. Instrumentation 8 3.3. Validity and Reliability 9 3.4. Data Collection Procedure 10 3.5. Data Analysis 12 4.0. References 13 5.0. Appendices 14 5.1. Appendix 1: Proposed Research Instrument 14 5.2. Appendix 2: Coding Guide 15 1.0. Introduction A pressure ulcer is a type of lesion caused by unrelieved pressure, mostly on bony prominences. The combined pressure and friction breaks down the skin and underlying tissues. Pressure ulcers are commonly found on the lower portion of the body, with the heel and sacrum as the most frequent sites (Lippincott, Williams, & Wilkins 2009). Depending on the nature of the pressure ulcer, common treatments include relieving pressure, restoring circulation, and resolution or management of related disorders. However, prevention still remains as the most potent intervention which significantly reduces the chances of undergoing excruciating long-term therapy (Lippincott, Williams, & Wilkins 2009). Effective prevention measures include risk identification, pressure reduction, nutritional assessment, bed rest monitoring, and preservation of skin integrity. In cases of existing pressure ulcers, treatment options include: pressure reduction either by repositioning the patient or by using devices such as beds, mattresses, overlays, and cushions; use of topical ointments; wound cleansing; debridement; and use of dressings to promote wound healing (Lippincott, Williams, & Wilkins 2009). The proper assessment of pressure ulcers is crucial in the determining risk of developing pressure ulcers and provision of appropriate interventions. The Braden Scale is used to determine characteristics present in pressure ulcers. This tool evaluates a patient’s condition in terms of: (1) sensory perception; (2) moisture; (3) activity, (4) mobility, (5) nutrition, and (6) friction and shear (Prevention Plus LLC 2009). The Pressure Ulcer Staging System is a tool developed by the National Pressure Ulcer Advisory Panel and the Agency for Health Care Policy and Research to facilitate the assessment of pressure sore characteristics. It categorizes pressure ulcers according to characteristics observed in the lesion (Lippincott, Williams, & Wilkins 2009). Allen (2011) emphasized the role of pain assessment and treatment as a crucial part of pressure ulcer prevention and management. However, the assessment of patient pain does present some challenges since the sensation of pain is an individual perception. Any indication of pain is considered a valid pain response and patients can experience pain in varying frequency and intensity. In addition, patients may associate pain with movement, infection, or during treatments such as dressing changes and debridement procedures. On the other hand, there may be isolated cases where patients do not report any pain. 1.1. Background of the Study Pain is never ending problem for most patients with pressure ulcers (Caplan 2009; Allen, 2011). Despite advanced improvement in pressure ulcer (PU) care, the condition continues to be a national and international health care problem, resulting in a decreased quality of life, both physically and emotionally, unnecessary suffering, and even death. Research over the past decade has largely focused on the assessment and healing of pressure ulcers, for example, the introduction of standardized risk assessment tools, which are used for the prevention, staging and management of PUs. Despite, all of these measures there is still a dearth of research in relation to the prevention and management of pressure ulcer pain. The impetus for this proposed study comes from the researcher’s personal motivation to search and examine recent evidence-based research addressing pressure ulcer pain, including the factors contributing to the pain, the psychological and social impact of continuous pressure ulcer pain, pain at dressing change and to ascertain the complexities of the pain experienced by patients. 1.2. Aim and Purpose of the Study The aim of this research proposal is to investigate from the nursing viewpoint the current practice pertaining to the management of pressure ulcer pain. Meanwhile, the purpose of the study is to: (1) describe the knowledge base of nurses in this researcher’s health care organisation; and (2) identify current practices in relation to the management of pressure ulcer pain. The knowledge base will be described grounded on the responses in the survey proper. Significant differences in the pain management scheme among the nurses will be evaluated in terms of the respondents’ age, gender and experience. On the other hand, current practices in pressure ulcer pain management will be identified based on generalisations arrived at from the nurses’ responses. These generalisations will be compared to current practiced identified from recent literature, if any. 2.0. Related Literature A preliminary survey of recent literature uncovered the following data regarding the management of pressure ulcer pain: The regular quantification of pain by the patient during visits is an important aspect of pain management regimens for pressure ulcers. Functional outcomes are evaluated through the use of a Verbal Analogue Score, wound healing graph, and wound data sheet. Effective pain control ensures the reduction of pain-related morbidity, as well as proper cleaning and dressing of the wound to facilitate healing. Since patients may feel varying types and degrees of pain, pain control should be performed even when the patient does not feel pain in the affected area (Rooke, McLeskey & Reves 2008). Pressure ulcers are categorized as chronic wounds due to the physiological impairment associated with wound healing. This is widely evident on elderly patients wherein age and its associated comorbidities affect the ability of the body to heal itself. In patients with diabetes, chronic wounds account for more than half of total amputation cases (Rooke, McLeskey & Reves 2008). Hutchinson and Sleeper (2010) warned against the inappropriate use of antibiotics for pressure ulcers, indicating that systemic antibiotics should only be used in cases of elevated fever, elevated white blood cell count, and redness/swelling of surrounding tissue. Moreover, it is also recommended that the use of topical antibiotics should be avoided. The treatment of elderly patients with pressure ulcer involves the consideration of factors which could affect the effectiveness of wound healing interventions. For example, the use of certain medications should be avoided or closely monitored such as glucocorticoids, sedative/hypnotics, opioids, antipsychotics, tricyclic antidepressants, and antihypertensives. Situations involving these medication classes call for the involvement of a pharmacist (Hutchinson & Sleeper 2010). Sussman (2007) identified several contributing factors to pressure ulcer pain which include: pressure, friction, shear, moisture, periulcer irritation, nutrition, deep infection, nerve irritation/damage, and muscle spasms. Pressure can cause pain when the force applied to the skin and underlying tissues inhibit blood flow. Meanwhile, friction and shear created by a patient’s movement over a surface may damage skin or disrupt wound healing. Moisture caused by sweat, stool, urine, or wound drainage can cause skin damage or infection. In addition, exposure to moisture can increase pain induced by periulcer irritation. In terms of nutrition, a patient with low muscle mass can exacerbate pain and impair wound healing. In addition, infections, involuntary muscle spasms, and nerve irritation/damage could amplify the pain experienced by patients (Sussman 2007). 3.0. Methodology The proposed study will employ mixed research methodology with the quantitative strand as the dominant technique. The qualitative strand serves as a supplement for the quantitative strand primarily for the purpose of triangulation. Mixed methods designs integrate quantitative and qualitative approaches in a single study (Tashakkori & Teddlie, 2003). In this study, sequential mixed design will be employed. In a sequential mixed method design, “the distinguishing feature ... is that the second strand of the study emerges as a result of, or in response to, the findings of the first phase” (p. 687). The qualitative strand of the study will be structured based on the findings of the survey in the form of an interview. An interview guide will be structured based on the results of the quantitative strand. 3.1. Sampling Design The proposed study will utilise a total enumeration sample of registered nurses working in a 90-bed medical unit in the institutional locale of the proposed study. The research locale is a company owned health care facility with a bed capacity of 800. The health care facility serves company-operated and privately contracted hospitals catering to employees, their dependants and the local population. A total of 150 bedside nurses will participate as respondents of the study. Of the 150 nurses, a random sample of 120 nurses will participate in the survey (the quantitative strand) while the remaining 30 nurses will participate in the interview (qualitative strand). The random sample size for the survey participants was computed using a web-based sample size calculator based on the following parameters: (1) 5% margin of error (2) 95% confidence level (3) population of 150 registered nurses and (4) response distribution of 50%. The minimum required sample size from the calculation was 109. However, 10% or 11 respondents were added for contingency purposes just in case the one or more questionnaires will be voided, unretrieved or the respondent disagrees to participate in the study. Hence a total of 120 respondents will be involved in the survey. These 120 respondents will be selected through a random sampling procedure where the ID numbers and corresponding names of the 150 nurses will be encoded in MS Excel (2003) in the first two columns in no particular order. In a random sample, each of the 150 nurses have equal chances of being selected as respondent (Black, 2010). Randomisation will be performed by automatically assigning random numbers in the third column using the random number generator of MS Excel, typing the syntax: =randbetween(100, 999) and pressing the Enter button. The random numbers generated will then be sorted from highest to lowest and the nurses in the highest 120 positions will be requested to voluntarily participate in the survey. The rest of the 30 nurses who were not selected to participate in the survey will comprise the respondents for the qualitative interviews. 3.2. Instrumentation The main data collection instrument in this study will be the survey questionnaire. Mitchell and Jolley (2011) maintained that the primary advantage of a survey is that it is a relatively less expensive method of data gathering and that results of a large sample can be retrieved within a short time. However, its disadvantage lies in the accuracy of the responses. Hence, an inaccurate self-report, like in this study will result in poor construct reliability. This issue will, however, be taken care of by triangulating the survey results with existing literature and the secondary instrument – an interview (Mitchell and Jolley, 2011). The survey questionnaire which will consist of two parts: respondent profile and pressure ulcer pain management practices. Under respondent profile, the following variables will be considered: gender, age, and nursing experience in years. Under pressure ulcer pain management practices, application of four practices among the nurse-respondents will be examined: (1) administration of regular pain medication to the patients; (2) routine administration of pain medication prior to change of dressing; (3) routine administration of pain medication prior to debridement, or other nursing interventions; and (4) perception of a problem in the health care centre as to pain management for patients suffering from pressure ulcers. The second part of the questionnaire will elicit responses in the form of a five-point Likert scale interpreted as follows: Interpretation Scale for the Pressure Ulcer Pain Management Practices Numerical Descriptor Statistical Limits Qualitative Descriptor Responses indicated in the Survey Questionnaire Extent of Respondents’ Knowledge Base in the Management of Pressure Ulcer Pain 1 1.00 – 1.49 Almost never true Excellent 2 1.50 – 2.49 Seldom true Very Good 3 2.50 – 3.49 Occasionally true Good 4 3.50 - 4.49 Frequently true Fair 5 4.50 – 5.00 Almost always true Poor 3.3. Validity and Reliability The survey instrument will undergo pilot-testing among 5 registered nurses in another unit of the same health care facility or in a comparable health care institution, preferably one which typically handles pain management such in critical care or surgical unit. During the pilot study, comments from the five nurse-respondents about the survey such as their ease in understanding and answering the questionnaire, as well as their overall impression of the survey itself, will serve as inputs for the enhancement of the research instrument. Only the second part of the questionnaire will be administered for pilot testing. The survey questionnaire will be further enhanced prior to submission for face and content validation to two or more experts in the areas of nursing research and pain management. Validation of a research instrument refers to a measure which is said to accurately reflect the concept or construct which is being measured. Face validation evaluates how an instrument appears at face-value. Meanwhile, content validity refers to the extent to which a construct cover the range of meanings included within a concept or construct (Babbie, 2010). On the other hand, Multon and Coleman (2010) define internal consistency as a measure of the homogeneity of the items. The duo maintained that Cronbach alpha is recognised as the most widely used evaluator of internal consistency reliability. In this study, the internal consistency of the survey instrument will be ascertained using the responses in the pilot test. The responses will be encoded in the software SPSS Statistics (2008) Version 17 for reliability analysis. Black (1998) declared that the satisfactory values of Cronbach alpha ranges from 0.85 to 0.95. A Cronbach alpha of at least 0.85 will be considered reliable. 3.4. Data Collection Procedure Data for the survey and the interview will be collection in the following manner: 1. Permission will be sought from the management of the health care institution for the pilot testing of the research instrument and subsequent administration of the primary and secondary instruments to the 150 respondents. 2. After permission is secures, five registered nurses from the critical care or surgery units will be selected through purposive sampling to answer part 2 of the research questionnaire for the pilot-testing. The respondents will be requested to sign informed consent forms as evidence that they were informed about the details of the study and that they wish to participate voluntarily. 3. The instrument will be submitted for reliability and validity assessment. Approval from the experts who will be requested to perform the face and content validation will indicate that the survey instrument is valid. Additionally, a Cronbach alpha of at least 0.85 will indicate that the research instrument has internal consistency reliability and ready for administration. 4. The survey questionnaire will be administered to a random sampling of 120 registered nurses. The questionnaires will be distributed to the identified nurses on the medical unit by the hospital internal mail system. Once the questionnaire is completed, it will be placed in a secure, locked post-box on the unit for collection by the researches. The respondents will be given one month to complete the questionnaire. The nurses will also be given an option to withdraw anytime from the study. Respondents will be requested to sign informed consent forms after the details of the study have been explained to them. The respondents will also be given a photocopy of the signed informed consent forms. 5. Retrieved questionnaires will be processed using a coding guide to translate textual data from the questionnaire to numerical data ready for encoding into a data matrix using MS Excel (2003). The data matrix will comprise the respondents as horizontal rows and their respective coded responses in columns. The data matrix will be inputted into the software SPSS (2008) for data analysis. Only the researcher will have access to the results of the survey. This data will be kept in a computerised database and password protected. 6. For triangulation, closed questions will be formulated based on the findings and the resulting interview guide will be the basis in the interview of the 30 remaining respondents. The interviewees will also be requested to sign the informed consent forms based on the procedure outlined in no. (4). 3.5. Data Analysis Data obtained from the quantitative strand of this study will be statistically analysed as follows. All inferential statistics will be carried using non-directional or two-tailed analysis and a 0.05 level of significance. All statistical analysis will be carried using the software Statistical Package for the Social Sciences or SPSS Version 17 (2008). Data from the first part of the instrument will be statistically treated using frequency and percentage distributions. On the other hand, data from the second part of the questionnaire will be analysed using the simple mean and the interpretation scale provided under section 3.2. Significant difference in the extent of knowledge base among the respondents will be analysed using independent samples t-test and one-way analysis of variance. All inferential statistics will be performed using non-directional or two-tailed analysis and 0.05 level of significance. Further analysis of the findings will be carried out using the findings of the qualitative strand (the interview) and existing literature on the current practices in pressure ulcer pain management. 4.0. References Allen, JE 2011, Nursing home federal requirements: Guidelines to surveyors and survey protocols, Springer, New York. Babbie, E (2010) The practice of social research, 12th ed, Wadsworth / Cengage Learning, Belmont, CA. Black, PJ (1998), Testing: Friend or foe? Theory and practice of assessment and testing, Falmer Press, GBR. Black, K (2010) Business statistics for contemporary decision making, 6th ed, Wiley & Sons, Hoboken, NJ. Caplan, LR 2009, Caplan’s stroke: A clinical approach, 4th edn, Saunders / Elsevier, Philadelphia, PA. Hutchinson, LC & Sleeper, RB 2010, Fundamentals of geriatric pharmacotherapy: An evidence-based approach, American Society of Health-System Pharmacists, Bethesda, MD. Lippincott, Williams & Wilkins 2009, Lippincotts’ nursing procedure, Lippincott, Williams & Wilkins, Ambler, PA. Mitchell, ML & Jolley, JM 2010, Research design explained, 7th edn, Wadsworth / Cengage Learning, Belmont, CA. Multon, KD & Coleman, JSM (2010), Coefficient alpha, in NJ Salkind, eds, Encyclopedia of research design vol. 1, Sage Publications, Thousand Oaks, CA, 159-162. Prevention Plus LLC 2009, Braden Scale for Predicting Pressure Sore Risk, viewed 25 July 2011, . Rooke, GA, McLeskey, CH & Reves, JG (eds) 2008, Geriatric anaesthesiology, Springer, New York. Sussman, C 2007, Wound care: A collaborative practice manual, Lippincott, Williams & Wilkins, Philadephia, PA. Tashakkori, A & C Teddlie (2003) Handbook of mixed methods in social and behavioural research, Sage Publications, Thousand Oaks, CA. 5.0. Appendices 5.1. Appendix 1: Proposed Research Instrument Please provide the information being requested by marking the appropriate response or writing your response on the space provided for. Part 1: Respondent’s Profile Profile Variable Categories 1 Gender Female ? Male ? - - 2 Age 21 – 30 years old ? 31 – 40 years old ? 41 – 50 years old ? 51 years and above ? 3 Nursing Experience < 1 year ? 1 – 3 years ? 4 – 6 years ? 7 years or more ? Part 2: Practices in Peptic Ulcer Pain Management Please use the following Likert scale to rate yourself in this part of the survey by marking the box which you believe most closely represents your feelings about each statement. 5 4 3 2 1 Almost Always True Frequently True Occasionally True Seldom True Almost Never True Practices in Peptic Ulcer Pain Management ALMOST ALWAYS TRUE FREQUENTLY TRUE OCCASIONALLY TRUE SELDOM TRUE ALMOST NEVER TRUE 1. I administer regular pain medication to the patients every 4 or 6 hours or as directed by the attending physician. ? ? ? ? ? 2. I routinely administer pain medication to the patients prior to change of dressing. ? ? ? ? ? 3. I routinely administer pain medication to the patients prior to debridement ? ? ? ? ? 4. I routinely administer pain medication to the patients prior to other nursing interventions such as attending to patient personal hygiene, repositioning or mobilisation ? ? ? ? ? 5. I believe there is a problem in the health care centre about pain management for patients suffering from pressure ulcer. ? ? ? ? ? 5.2. Appendix 2: Coding Guide Note: The coding scheme for this questionnaire is highlighted in red font. Part 1: Respondent’s Profile Profile Variable Categories 1 Gender Female (1) ? Male (2) ? - - 2 Age 21 – 30 years old (1) ? 31 – 40 years old (2) ? 41 – 50 years old (3) ? 51 years and above (4) ? 3 Nursing Experience < 1 year (1) ? 1 – 3 years (2) ? 4 – 6 years (3) ? 7 years or more (4) ? Part 2: Practices in Peptic Ulcer Pain Management 5 4 3 2 1 Almost Always True Frequently True Occasionally True Seldom True Almost Never True Practices in Peptic Ulcer Pain Management ALMOST ALWAYS TRUE FREQUENTLY TRUE OCCASIONALLY TRUE SELDOM TRUE ALMOST NEVER TRUE 1. I administer regular pain medication to the patients every 4 or 6 hours or as directed by the attending physician. ? (1) ? (2) ? (3) ? (4) ? (5) 2. I routinely administer pain medication to the patients prior to change of dressing. ? (1) ? (2) ? (3) ? (4) ? (5) 3. I routinely administer pain medication to the patients prior to debridement ? (1) ? (2) ? (3) ? (4) ? (5) 4. I routinely administer pain medication to the patients prior to other nursing interventions such as attending to patient personal hygiene, repositioning or mobilisation ? (1) ? (2) ? (3) ? (4) ? (5) 5. I believe there is a problem in the health care centre about pain management for patients suffering from pressure ulcer. ? (5) ? (4) ? (3) ? (2) ? (1) Read More