Pressure as a Global Health Care Problem - Essay Example

? Pressure Sore Management in Adult Patients Introduction Pressure sores, bed sores, decubitus ulcers and pressure ulcers are different terms for the same challenge that nursing professionals have faced from centuries in the care of their patients. Ayello et al 2008, p.254, give the definition of pressure sores provided by the National Pressure Ulcer Advisory Panel through their 2007 consensus conference as, “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction”. Pressure sores have remained a global health care program even to this day. There are several factors that contribute to the development of pressure sores. However, there is limited clarity on the exact influence of these factors on the development of pressure. Furthermore, just as there are different terms for the same health care challenge there are a wide range of interventions that have been used over a long period of time in the management of pressure sore, with some even extending into the exotic in the form of magic potions, as the search for the right intervention in the management of pressure sores carries on (Ayello et al, 2008). The body of knowledge on pressure sores currently has expanded into a large volume of literature that is used as evidence in developing intervention strategies for pressure sores. Yet, quite often the value of the evidence received from research on pressure sores is quite often undermined by the poor research design, with particular emphasis on methodically sound empirical investigations and randomized controlled studies. This has hampered the expanding of the right understanding of pressure sores and the taking of correct informed decisions in the management of pressure sores (Ponto, 2005). The true incidence and prevalence of pressure sores also remains a puzzle. Pressure sores do not constitute a reportable health event in every health care environment and so the data available on the incidence and prevalence cannot be taken as a correct picture. Irrespective of this impediment pressure sores remain a serious health challenge in all countries around the world (Ayello et al, 2008). 2. Importance of Pressure Sores to Adult Nursing More than hundred risk factors have been associated with the development of pressure sores. These risk factors are classified under different heads consisting of medical diagnoses, co-morbidities and earlier medical episodes, patient demographics that include advanced age, anthropometric status, physiological status, nutritional status, functional status, psychological status, social behaviour and quality of nursing care. From the perspective of the importance of pressure sores to adult nursing two key aspects stand out in the risk factors associated with pressure sores. The first aspect is that many of the risk factors associated with the development of pressure sores can be found in a large proportion of the adult population in society, with particular emphasis on the elderly segment. The second is the inclusion of the quality of nursing care in the risk factors for the development of pressure sores, with the obvious implication that when nursing care is deficient or lacks the proper care elements, there are enhanced chances in the pressure sores overwhelming the nursing care provided to increase the negative outcomes for the patients (Bergstrom, 2005). In the upkeep of the health of society there is the need for greater emphasis in adult nursing, which stems from the rising trends in the elderly segment of population. Developments in the field of medical science have resulted in increased longevity of life, which is an important factor in the elderly population segment becoming the fastest growing segment of population. In 1980 the United Nations (UN) had forecasted that the number of elderly individuals above the age of 65 around the world would rise to 760 million in 2025. By 1999 the UN was forced to change the estimates of the elderly population above the age of 65 to 817 million in 2025, which was an increase of nearly 8% over its 1980 estimate (National Research Council, 2001). Moving closer home the census conducted in 2001 in the United Kingdom shows that the elderly population above the age of 65 in rural areas of the United Kingdom was 18% and in urban areas of the United Kingdom it was 13% of the total population (House of Commons Health Committee, 2006). The increase in the adult population in the United Kingdom has reflected in the increased demands in health care requirements of the adult population. Reporting on the hospital activity trends in 2009-2010 in the United Kingdom, the Health and Social Care Information Centre of the National Health Service (NHS) states a bigger proportion of hospital activity in the adult population in the country. The overall hospital stays show a rise of 38%. However in the age group of 75 years in 2009-2010 was 66% and in the age group 60 to 74 years was 50% above the 1999-2000 figures for hospital stays, which is much higher than the national average (The Health and Social Care Information Centre, 2011). The implications of these statistics for nursing is that there will be greater demands for nursing care from the adult segments of population, with emphasis on the elderly segments and given that advanced age heightens the risk for pressure sores, there will be greater expectancy from society for nursing care to cope with the challenge of the prevention and management of pressure sores. There is general acceptance that prolonged pressure arising from the weight of the body on muscles and skin, particularly over bony prominences leads to the occlusion of blood vessels in the area. This occlusion of blood vessels leads to impediments in the availability of essential nutrients to the tissues in the area, resulting in death of the tissues and necrosis. Studies conducted on laboratory animals and humans have pointed to higher tolerance without the development of pressure sores in the case of loss pressure over longer periods, while high pressure results in the development of pressure sores in much shorter periods of times. Studies have also pointed to the muscles in the area under pressure being more sensitive to the pressure than the skin in the area. There is no definite measure of the amount of pressure that leads to the development pressure sores, as the integrity of the concerned tissue is a strong influencing factor in the development of pressure sores. In other words we are looking at a combination of sustained pressure on muscle and skin of poor integrity leading to the quicker development of pressure sores and are the core factors in challenges of pressure sores for adult nursing (Bergstrom, 2005). The elderly population makes up a significant proportion of the population that are at high risk for the development of pressure ulcers, which can be elucidated from the risk factors associated with development of pressure ulcers. Diebold, Fanning-Harding and Hanson, 2009, p.501, make this clearer in real terms by showing us that the prevalence of pressure sores in older adults in acute care settings ranges from 3-11%, while in long term facilities the prevalence of pressure sores rises to 24% and in the community it is 17%. A significant statistic in this regard is that once a person gets affected by a pressure sore the chances of recurrences are ten fold the original probability of getting a pressure sore (Diebold, Fanning-Harding & Hanson, 2009). The question then arises as to why the older adult population is more prone to pressure sores. Two factors need to be considered to answer this question. The first factor is that the older adult population is more prone to suffer from co-morbidities that confine them to the bed for longer periods of time. In combination with this is the factor of the changes that are associated with the skin from the processes of aging. The skin gets thinner as a part of the aging process with less presence of collagen and moisture. In addition, the ability of the skin in an older adult to act as barrier to invading pathogens is impaired, raising the probability of infections in the right situations. The ability to combat such infections in an older adult is reduced due to the reduction of blood flow and nutrient availability in the dermis region, resulting in any infection taking a long time to be controlled. The thinner skin also makes for higher risk of injuries from shear or friction that can contribute to the development of pressure sores (Diebold, Fanning-Harding & Hanson, 2009). Experiences of nursing professionals in various health care settings highlight the issue of pressure sores. Irrespective of the patient care environment of acute care, long-term care and home care settings, pressure ulcers present a significant problem, because of the quantum of nursing care required during the patient’s stay and the increase in health care costs from the development of pressure sores (Siem et al, 2008). In long term care facilities there is high prevalence pressure sore, thus posing a significant health problem in long term care settings. In the U.S.A nearly 9% of patients in long term care facilities develop pressure ulcers (Lyder, 2008). Connor et al, 2010, p. 294, investigating the pre-operative and intra-operative variables that are predictive of the development of pressure ulcers in the surgical environment recommend that nursing professionals use aggressive pressure sore preventive measures in all surgical patients with particular emphasis on patients at risk for pressure ulcers including the older adult population. 3. Models of Pressure Ulcer Physiology In the traditional top to down model in the development of pressure sores pressure resulting from any surface like a mattress or chair is transmitted and the damage is believed to originate at the skin and gradually proceeding to the subcutaneous fat and muscle and finally to the bone. The newer bottom to top model however hypothesis that the pressure ulcer development actually begins deeper down in the tissues near the bone and are the result of increased pressure causing damage to skeletal muscles, subcutaneous fat and blood vessels. It is only subsequently that the skin is affected and becomes visible (Sharp & McLaws, 2005). Traditionally three major risk factors have been associated with the development of pressure sores, namely pressure, friction and shear. In the two models of the development of pressure sores taken up the development of pressure sores is believed to stem from the combination of these three risk factors and other causal factors that include ischaemia as a result of pressure that is unrelieved., the duration of the pressure, the frequency of the pressure, tissue shearing that all bring about tissue necrosis. The top to down model suffers from the criticism that it is not convincing as the sole construct for the development of pressure sores, as it does not take into account the possible development of pressure ulcers as hypothesized in the bottom to top model and ischaemia reperfusion injury. However, it still remains an important model for nursing professionals, as it is based on this model that assessment of tissue damage and its depth and patients at risk for pressure sores is done. The bottom to top model is lacking in two aspects in that it is difficult to assess the beginning of internal injury deep down in the tissues and like the top down model fails to consider ischaemia reperfusion injury. Therefore it may be more relevant to look at the development of pressure sores as a combination of these two models and ischaemia reperfusion injury in what could be termed as the middle model, wherein tissue damage in the development of pressure sores could originate at any point between and including the skin surface and the bony interface on a concurrent or haphazard basis to result in a pressure sore (Sharp & McLaws, 2005). Skin appearance assessment is the most used method to identify the development of tissue trauma. This is a valuable indicator for tissue trauma, but is based on the perspective that the development of pressure ulcer progresses stage wise. However, evidence from studies suggest that the development of pressure sores need be a stage wise development and that deep ulcers can develop deep down and proceed upwards. Thus, though a visible assessment of skin integrity is an important tool in finding out the development of pressure sores, the lack of redness of the skin does not rule out the possibility or risk of an ulcer that deep down, which is comes from indisputable evidence from animals and human organ studies. These lacunae in the assessment of the development of pressure sores can be removed only from further studies and evidence for supportive measures to assess the risk of pressure sores developing deep down without signs at the skin surface, for the prevention and management techniques employed by nursing professionals in pressure sores to be really effective (Sharp & McLaws, 2005). 4. Critique of the Two Studies The first study taken up for a critique is by Diane Smith and Shirley Waugh ‘An Assessment of Registered Nurses Knowledge of Pressure Ulcer Prevention and Treatment’. The study has the aims of assessing the knowledge of pressure ulcer risk and prevention, pressure ulcer staging and wound description and the barriers perceived by nurses to the provision of effective pressure ulcer prevention and treatment. The authors themselves admit limitations in terms of low response rate, short time frame, lack of diversity in sample from hospital nurses and inaccuracy in the nurses’ recall of exposure to education materials. Moving beyond these limitations, it is necessary to point out that the setting was in the acute care of the health care environment, when statistics of the prevalence of pressure sores mark out the lower prevalence of pressure sores. This lower prevalence can be put down to the shorter duration of patient stay in acute care and to the probable higher knowledge levels of registered nurses in acute care settings. Thus, the finding of the study may not be relevant to the other hospital and community care nursing professionals. The study is focused on the knowledge levels of the registered nurses and not in the transference of this knowledge into actual nursing practice. The study may thus be more useful to nursing educators and administrators, rather than to an actual understanding of pressure sores prevention and management practices in the health care environment. To understand the behaviour and practice of nurses in the prevention and management of pressure sores in acute care settings an unobtrusive observational methodology would have been more useful (Polit & Beck, 2008). Nevertheless the study uses the Pieper Pressure Ulcer Knowledge Test to bring out the current state of the knowledge of prevention and management of pressure ulcers among RNs. The study demonstrates clearly that there is lack of enhancement of nursing knowledge on the prevention and management of pressure ulcers among nursing professionals for more than a decade and emphasis the need for correction in this aspect for improving the quality of nursing care to improve the prevention and management of pressure sores for better outcomes to patients. McCormack and McCance 2010, p. 41 define professional competence within the Person-Centered Nursing Framework of nursing practice as “the knowledge and skills of the nurse to make decisions and prioritize care, and includes competence in relation to physical and technical aspects of care”. In the case of the prevention and management of pressure sores, taking this framework into consideration there is lack of competence in RNs in physical and technical aspects of patient care due to the lack of knowledge that translates into barriers for the nurses and poor outcomes for the patients. Repositioning of patients is a commonly practiced pressure sore prevention technique to relieve sustained pressure. This technique is recommended by the Royal College of Nursing as part of the pressure sore prevention measures (Bick & Stephens, 2001). Vanderwee et al, 2006, in their study ‘Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions’, attempt to expand the body of knowledge on repositioning as a technique in the prevention of pressure sores, as there is a deficit in the body of knowledge on the topic. The importance of this study to adult nursing lies in its focus on the elderly in nursing homes and the timing of the repositioning, attempting to evince any advantage in repositioning more frequently every two hours in comparison to a more delayed repositioning every four hours. The study suffers from a small sample size. Nevertheless as this is an exploratory study meant to point direction for further studies it is a useful study. It uses an experimental design well suited for the comparison of the two techniques (Polit & Beck, 2008). The first technique involves repositioning every two hours in a lateral position and four hours in a supine position, while the second technique involves repositioning every four hours. The study found that the more frequent repositioning does not prevent the development of pressure sores in any less measure than repositioning every four hours. This study points to a four hour repositioning being an adequate repositioning strategy in the prevention of pressure sores and this may help nursing professionals to reduce their work load in terms of rime devoted to repositioning in the adult population to prevent pressure sores. However, careful use of this evidence is required. In the first place there is the need for more confirmatory evidence through wider studies on the topic and furthermore, given the personalized nature of nursing practice and the possibility of more person focused nursing care to avoid pressure sores. 5. Conclusion The physiology of pressure sores still lacks clarity and there remain controversies over the prevention and management strategies for pressure sores. Nursing practice is strongly associated with the prevention and management of pressure sores and hence adult patient outcomes hinge on the knowledge and skill levels among nursing professionals, as this segment of population is at high risk for the development of pressure sores at acute care, long term care and community care levels. Yet, there is evidence that there has been poor enhancement in the upgrading of knowledge and skills among RNs in the prevention and management of pressure sores. This act as a barrier in the effective prevention and management of pressure sorer, with RNs lacking confidence in the role to play and also in educating patients and care givers in preventing pressure sores. More studies and evidence is forthcoming to improve the techniques in the prevention and management of pressure sores. However the new evidence will probe useless, unless RNs show the will and motivation to acquire this knowledge and improve their skills for better outcomes to the adult patient population. There is also the need for more research on how to improve the motivation of RNs in enhancing their knowledge and skills in the prevention and management of pressure sores, as also more evidence in efficient strategies for nursing professionals to employ in the prevention and management of pressure sores. (Word Count – 3153) Literary references Ayello, E. A., Baranoski, S., Lyder, C. H. & Cuddigan, J. 2008, ‘Pressure Ulcers’ in Wound Care Essentials: Practice Principles, Second Edition, eds. Sharon Baranoski & Elizabeth, A. Ayello, Lippincott, Williams & Wilkins, Ambler, PA, pp.254-286. Bergstrom, N. 2005, ‘Patients at Risk for Pressure Ulcers and Evidence-Based Care’ in Pressure Ulcer Research: Current and Future Perspectives, eds. D. Bader, C. Bouten, D. Colin & C. Oomens, Springer, Berlin, pp. 35-50. Bick, D & Stephens, F. 2001, ‘Pressure Ulcer Risk Assessment and Prevention: Report of a National Audit Pilot Project’, Royal College of Nursing [Online] Available at: http://www.rcn.org.uk/__data/assets/word_doc/0006/109842/pressure_ulcer_audit_pilot_project.doc (Accessed January 7, 2011). Connor, T., Sledge, A. J., Bryant-Wiersema, Stamm, L & Potter, P. 2010. ‘Identification of Pre-operative and Intra-operative Variables Predictive of Pressure Ulcer Development in Patients Undergoing Urologic Surgical Procedures’, Urologic Nursing, vol.30, no.5, pp.289-295. Diebold, C., Fanning-Harding, F. & Hanson, P. 2009, ‘Management of Common Problems’ in Gerontological Nursing: Competencies for care, Second Edition, ed. Kriste L. Mauk, Jones and Bartlett Publishers, Sudbury, MA, pp. 454-529. House of Commons Health Committee. 2006, NHS Deficits: 2005-2006, Second Volume, The Stationery Office, London. Lyder, C. H. 2008, ‘Implications of Pressure Ulcers and Its Relation to Federal Tag 314’, Annals of Long-Term Care [Online] Available at: http://www.annalsoflongtermcare.com/article/5552 (Accessed January 7, 2011). McCormack, B. & McCance, T. 2010, Person-Centered Nursing: Theory and Practice, John Wiley & Sons, West Sussex, UK. National Research Council. 2001, Preparing for an Aging World: The Case for Cross-National Research, National Academy Press, Washington. Polit, D. F. & Beck, C. T. 2008, Nursing Research: Generating and Assessing Evidence for Nursing Practice, Eighth Edition, Lippincott Williams & Wilkins, Philadelphia, PA. Ponto, M. 2005, ‘Maintaining Healthy Skin’ in Nursing Older People, Third Edition, eds. Sally, J. Redfern & Fiona, M. Ross, Churchill Livingstone, London, pp.431-464. Sharp, C. A. & McLaws, M. 2005, ‘A discourse on pressure ulcer physiology: the implications of repositioning and staging’, World Wide Wounds [Online] Available at: http://www.worldwidewounds.com/2005/october/Sharp/Discourse-On-Pressure-Ulcer-Physiology.html (Accessed January 7, 2011). Siem, C. A., Wipka-Tevis, D. D., Rantz, M. J. & Popejoy, L. L. 2008, ‘Skin Assessment and Pressure Ulcer Care in Hospital-based Skilled Nursing Facilities’ Ostomy Wound Management [Online] Available at: http://www.o-wm.com/article/1758 (Accessed January 7, 2011). Smith, D. & Waugh, S. 2009, An Assessment of Registered Nurses' Knowledge of Pressure Ulcers Prevention and Treatment, The Kansas Nurse, vol.84, no.1, The Health and Social Care Information Centre. 2011, ‘Elderly people account for bigger proportion of NHS hospital activity every year, report shows’, NHS [Online] Available at: http://www.ic.nhs.uk/news-and-events/news/elderly-people-account-for-bigger-proportion-of-nhs-hospital-activity-every-year-report-shows (Accessed January 7, 2011). Vanderwee, K., Grypdonck, D. H. F., De Bacquer, D. & Defloor, T. 2006, ‘Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions’, Journal of Advanced Nursing, vol.57, no.1, pp.59-68. Read More