Strategies for Preventing Pressure Sores in Adult Patients - Assignment Example

Practice Based Question: “In the Hospital Setting, What are the Most Effective Management Strategies for Preventing Pressure Sores in Adult Patients”Rationale and Practice Based Question A degenerative change of skin and underlying tissues leading to lesions of varying degrees caused by pressure and shear force is known as pressure ulcer. Patients in ICU are at high risk of such ulcers due to limitations in their mobility. Treatment of pressure ulcers, therefore, is a primary concern in ICU. The development of pressure sores is very likely with the high risk critically ill patients despite being nursed on different kinds of pressure-relieving devices- mattress or beds. The longer the patient is on the bed the more likely pressure sores will develop. This problem is a critical issue for bedridden patients and their healthcare providers, as pressure sores are painful, difficult to treat and are often associated with complications such as infection that may become life-threatening if systemic infection develops. For these reasons, it is essential to develop and critically evaluate new preventive approaches designed to reduce the incidence of pressure sores in this patient population and also to implement early stage interventions to promote rapid healing once these sores develop in order to prevent further patient discomfort and serious medical complications. This practice based question explores research studies conducted in this critical care area that were designed to address this healthcare issue. A total of six clinical research studies is presented. All but one are prospective randomized trials of patients at high rsk for the development of pressure sores. Four of these studies explore preventive approaches, whereas two of the clinical studies examine early intervention strategies that may control and correct this medical issue as it arises to prevent further complications. Each of these studies involved clinical research on high risk patients to assess several different prevention and management approaches to the problem of pressure sores. These research studies will be reviewed, compared and critically assessed in regard to their potential applications to this medical problem. Search Strategy Evidence-based practice requires the ability to conduct relevant data searches as an integral part of the process of incorporating research into practice. Therefore, a critical component of EBP is the development of the skills needed to conduct relevant and appropriate database inquiries that will facilitate the retrieval of important research finding that may have direct application to patient care procedures and protocols (Fitzpatrick, 2004). For the purpose of researching this topic the databases used included CINHAL, Medicine and BNI (Dale, 2006). Each of these databases contains many journals that address issues in medicine and healthcare practice. CINAHL (Cumulative Index to Nursing & Allied Health Literature) was used as a primary source for retrieving research articles that addressed this topic. In addition, the BNI database was used because it combines several searches to narrow the focus and retrieve articles that are most relevant to the precise research area. In order to utilize these search tools effectively, it is necessary to identify the most appropriate and relevant search terms (Sharkey, 2005). These can then be combined to improve the focus of the search in order to obtain information most relevant to the search topic. For this topic, “pressure” “ulcer” “sore” were primary search terms used to narrow the focus to the specific topic of pressure sores. Additional relevant search terms were “research” and “ clinical”. Additional search terms were ”prevention” “prospective” “trial” that were combined to retrieve data relevant to research clinical trials on prevention of pressure sores. When these search terms were used in BNI and CINAHL databases, many prospective study articles relevant to this topic were retrieved. The titles were scanned; from these a group of about 20 papers was selected. The abstracts were reviewed. Based on this information, a final selection of 6 research journal articles recently were selected and reviewed for this paper. Comparison of Research Findings and Methodology The first group of studies reviewed here addresses different preventive approaches to the development of pressure sores. Vanderwee et al. (2006) and Theaker et al (2005) conducted prospective, randomised controlled, unblinded clinical trials to assess interventionist preventive approaches. The Vandervee study evaluated whether turning patients using unequal time intervals (side position for two hours and back position for 4 hours) reduced pressure ulcers compared with four hourly positional changes Theaker et al. (2005) assessed the effectiveness of the Hill-Rom Duo mattress and the KCI TheraPulse on reducing the development of pressure sores. A study weakness involved the fact that only 235 participants were included in the Vanderwee study and only 62 subjects in the Theaker study. A major difference between the experimental design was that the Theaker study included a control group that received no altered preventive regimen. The data collection in the latter study was more quantiatative. The Lowthain scale was used to classify and determine the early clinical signs and severity of the pressure sore. Rigorous statistical evaluations were conducted in both clinical Both studies employed the Mann-Whitney U-test; student t-test; Fisher’s exact test; Logistic regression analysis and Kaplan-Meier survival analysis The Theaker study also used McNemars, Chi-squared analysis, and anova testing. The research results of the Vandervee trial showed that 20 patients (16.4%) in the experimental group compared with 24 patients (21.2%) in the control group, developed pressure ulcers. Fisher’s exact test (P=0.40) showed no statistical significance between the two groups. The Theaker study also did not show a statistically significant difference between the incidence of pressure sores in the experimental versis control group. Chi-squared analysis showed (p= 0.35) showing that there is no statistical significance between either device. A quantitative study by Saleh et al (2008) was carried out to determine whether the use of risk assessment scales (RAS) reduced the incidences of pressure ulcers. The study design was different from the Theaker and Vandervee studies, in that this trial used pre test - post test design, which reports a change in outcome following a change in intervention. This assessment design doesn’t confidently state the change occurred due to a change in intervention, which reduces rigour (Gerrish & Lacey 2006. Other similarities involve the use of a prospective, randomized approach. The Braden score was the RAS tool used in the study. Data collection was less quantitative than in the Theaker study. It involved only patient observation. Less rigorous statistical methods were used to evaluate the significance of the data than in either the Vanderwee or Theaker studies. Using Chi square analysis the pre test (p=0.90) and post test (p=0.38) results there was no significant difference between the three groups. Verbelen (2007) adopted a quantitative study to examine whether the wound healing properties of polarised light are effective in preventing pressure ulcers in an adult intensive care unit. The study design was similar to the Theaker study in that utilized a quantitative approach, in which participants were randomly allocated to either treatment or control group. Sample size was lower than either the Vandervee or the Theaker trials; the treatment group enrolled 13 and a control group of only 10 patients,which represents a major weakness of the study. As in the Theaker and Vandervee trials, quantitative assessment tools were used to evaluate the incidence and severity of pressure sores in the control and experimental groups. Gradation of pressure ulcers was done using a system similar to EPUAP gradation. Statistical assessment was not as rigorous as in the Theaker, Vandervee or Saleh trials and involved primarily the Mann-Whitney Test. Results showed that treatment with polarised light was significantly better in preventing pressure ulcers of grades II and beyond. However, there was no statistically significant difference between the groups Another group of research studies was designed to explore clinical approaches to the treatment of pressure sores. A major difference in these studies was that their primary goal was treatment based rather than preventive. Gupta et al (2009) used a randomized double blind control trial to assess the effectiveness of pulsed electromagnetic field therapy (PEMF) to stimulate the production of growth factors in healing of pressure ulcers in patients with neurological disorders. The study design was similar to the above-cited trials in that it was a randomized prospective trial that included a control and an experimental group. A major difference in the experimental design was that this study was double-blinded. The Randomised double blind controlled trial that was used in this study was preferable as it is suited for concluding the effectiveness of an intervention and also eliminates biases (Polit et al 2010). A major weakness of this study as with the Verbalen trial was the small sample size of 12 in-patients.. Such a small sample size can also jeopardise result validity. Quantitative assessments of wound healing parameters were used in this study as in the Verbalen study. These involved the Bates Jensen Wound Assessment Tool (BJWAT) and ulcer staging by National Pressure Ulcer Advisory Panel (NPUAOP). Similar statistical tools were used as in the Verbalen and Gupta trials. The data were analysed using the Mann- Whitney U test for comparing the results between the two groups and the Wilcoxon signed rank test to compare within the groups. There was significant healing shown in both groups but when compared there was no significant difference as to which aided healing better (P= 0.0361). The Bergstrom study (2005) contrasts all the others in that it was a retrospective rather than a prospective trial designed to evaluate whether patient characteristics, the wound and treatment parameters influenced the healing of pressure ulcers in long term care residents. The study identified two factors: the use of moist as opposed to dry dressings, and adequate nutritional support. A major advantage of this study was that it was multi-centered (95 hospitals) and included a large sample size (882), the largest by far of any study reviewed here. Convenience sampling was used, which is not a rigourous method of sampling, but was only type of sampling appropriate to a retrospective study of this type. Application to Practice and Future Research Neither the Vanderwee or Theaker studies produced statistically significant results; thus, practice changes involving implementation of these preventive approaches would not be indicated at this time. The studies suffered from small sample sizes. It is possible that larger scale prospective trials might yield significant results that could have practical preventive application. The Saleh et al (2008) study produced no statistically significant differences in the incidence of pressure sores, suggesting that the implementation of the Braden scale, used in this study, is not warranted at this time. . Results of the Verbelen study showed that treatment with polarised light may be useful in preventing pressure ulcers. The study was limited by the extremely small sample size. A larger scale trial should be carried out to determine whether this preventive approach should be considered. Gupta et al (2009) assessed the effectiveness of pulsed electromagnetic field therapy (PEMF). It did not yield a significant difference between control and experimental groups. Further research is needed as the study sample size was too small to be statistically significant. The retrospective study by Bergstrom conclusions were that the use of moist dressings and supportive nutritional approaches correlated with improved healing. These approaches should be considered for implementation. References Bergstrom, N., Horn, S., Smout, R., Bender, S., Ferguson, M., Taler, G., Sauer, A., Sharkey, S. and Voss, A. (2005) The National Pressure Ulcer Long Term Care Study:Outcomes of Pressure Ulcer Treatments in Long Term Care Dale, A.E. (2006) Determining guiding principles for evidence-based practice. Nursing Standard; 20: 25, 41-46. Fitzpatrick, J. (2004) How to… surf the internet. Nursing Times; 100: 10, 46-47. Glassman, K.S. (2004) Developing information literacy. In Fitzpatrick, J.J., Montgomery, K.S. (eds) Internet for Nursing Research: A Guide to Strategies, Skills and resources. New York, NY: Springer. Gupta, A., Taly, A.B., Srivastava, A., Kumar, S. & Thyloth, M., 2009, “Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: A randomised control trial”, Neuro India, Vol. 57, No. 5, pp: 622-26 Polit, D. et al (2010) Essentials of Nursing Research, Methods, Appraisals and Utilization. Philadelphia, PA: JB Lippincott Co. Saleh, M, Anthony, D & Parboteeah, S. (2008) The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients, Journal of clinical nursing (soz cnt get itallics), vol. 18 pp 1923-1929. Theaker, C., Kuper, M & Soni, N. (2005) "Pressure ulcer in intensive care- a randomised control trial of two pressure-relieving devices", Anaesthesia, Vol. 60, pp. 395-399 Vanderwee, K., Grypdonck, M.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 Verbelen, J. (2007) “Use of polarised light as a method of pressure ulcer prevention in an adult intensive care unit”, Journal of Wound Care, Vol. 16, No. 4, pp. 145-150 Read More