Pressure Ulcer among Geriatrin Patients in Long Term Care - Research Proposal Example

Background: Pressure ulcers are one of the biggest issues in geriatric long term issues represented within non-skillful or skillful facilities. Over 80% of patients complain of pain; about 4/5 of which are around the wound site and can be very costly to treat. Purpose: The primary purpose of this study was to understand how to prevent or reduce pressure ulcers among geriatric long term patients with co- morbidities and that were also non-ambulatory. Pressure ulcers can be a very common and costly problem. They are also very painful and some patients can become bedridden due to deep tissue injuries. This becomes a barrier in physical and occupational strengthening therapies due to immobilization of patients. The secondary aim of the research will be instructor; thereby providing a level of education that will emphasize the need for accurate consistent assessment, description, and documentation of pressure ulcer stages, and minimizing pressure ulcer risk factors. Literature Review: According to the literature review, the journal articles reviewed related that the outcome for pressure ulcers remains a problem affecting approximately 2-3 million in the geriatric population. On the other hand, pressure ulcers are a common costly and preventable condition (Decubitus, 1998, 24-28). However, translating increased intervention conducted for PU prevention guidelines for bedside care does not always correlate. There is little evidence about these interventions and how they can be successfully implemented. Further, intervention can be successfully integrated into routine care settings through quality improvement (QI) (Harrison, 1998, 108-110). Ten literature reviews indentified, that pressure ulcer prevention best practices were contingent upon staff education, clinical monitoring and feedback, skin care and cues to action. A smaller portion of the literatures suggested that multidisciplinary intervention to prevent PU in an acute care and long-term care setting was beneficial. Outcomes reported in this literature stipulated that such programs can be successful in reducing PU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results to the government in their monthly reports (JACO, 2006). Some of the studies used a longitudinal pretest and posttest design; no randomized controlled trials were reported. An in depth review of the studies was performed, and each study was analyzed with a few elements. These elements were the settings and scope of the programs, implementation teams and preparation for prior program implementation, intervention components (Communication, 2001, 643-644). The preventive best practice, staff education, clinical mentoring and evaluation, skin care contributed to the most acute change in occurrence of ulcers. One acute care setting study measured the use of new air-mattress; as well as the implementation of repositioning schedule. The study found that there was a significant change in preventing behavior; when use of new support air-mattresses was not taken into account. The other acute care study reported minimal improvement in some of the measured care processes. One of the many studies discussed that the proportion of residents with appropriate risk assessment completed within 2 days of admission increased from 2.2% to only 15.3%; whereas the proportion of the patients with PU that received weekly skin assessment increased from 12.6% to 32.8% ( Research, 1992, 572-578). Research Question, Hypothesis and Variable with Operational Definition: There are two research questions that will need to be answered as a function of the research. These are: How can you rate the quality of care of pressure ulcer against the value of money required for treatment? Does the nurse to geriatric patient relationship, with co-morbidities, in America affect the quality of care? Hypothesis: The amount of money spent on wound care impacts upon the overall loss of productivity for individual health care facilities and families. Nursing is a critical factor in the determining the quality of care for co-morbid and without co-morbidity geriatric populations in long term care. Variables with Operational Definitions: The independent variable is pressure ulcer wound care and the dependent variables are discomfort and change in quality of life. Operational definition: The pressure ulcer wound treatment typically takes place on a scheduled date. Thus, using appropriate treatment according to the wound stage is essential. The treatment every day generally comprises a routine cleanse with normal saline; even if the wound is not infected. In the event that the wound is infected, it is generally required to cleanse it with Dakin solution and apply an anti bacterial ointment with a non adhesive dressing. If the wound is deep, then cushioning it with duoderm is generally recommended. The next level of care is to measure wound size in three dimensions; based either on a tool provided or on paper. This allows the medical professional to have an estimation of whether or not wound healing or worsening is taking place. To provide activities of daily living (ADL), such as eating, dressing bathing, brushing teeth or dentures, and grooming, an individual within geriatric care must be as pain free as possible. However, the conditions that result in the need for assistance of 1-2 persons for a Hoyer lift assistance is required for wounds in order to avoid skin friction, abrasion. To assess skin for abrasion, the medical professional should pay special attention to incontinent reddened areas to sacrum or any boney prominent areas for soreness, or any kind of skin failure. Theoretical Framework: Pender’s theory provides a model that can potentially influence the interaction between the nurse, patient, and co-workers. Pender’s model is useful to the nurses’ goal as interventions are aimed at strengthening resources, potentials, and capabilities for each patient, coworker, nursing staff; such as Certified Nurses Assistance as well as providing education to promote patients health and better quality of life (Peterson & Bredow, 2009). Nola J. Pender’s Health Promotion Model has been used, and will continue to be used, in various areas of study and health care to encourage and expand the positive outcomes of holistic health promoting activities. Pender developed the original Health Promotion Model. The model included modifying factors: behavioral factors, situational factors, interpersonal influences, biological characteristics, and demographic characteristics (Tomey & Aligood, 2002). These modifying factors lead to cognitive-perceptual factors begin with the importance of health which leads to the perceived control of health and perceived self-efficacy (Tomey & Aligood, 2002). These perception direct towards the definition of health, perceived health status, and comprehending the perceived benefits and barriers to health-promoting behaviors (Tomey & Aligood). The cognitive-perceptual factors increase the possibility of participation in health promotion behavior. Methodology Sample/Setting Nursing homes of geriatric patients have had one hurdle for a long while now. Despite the patho-physiology and the entire formation of pressure ulcers (PU) being known in science, sustaining pressure ulcer prevention has projected out as major stumbling block in the quality of life of geriatric patients. This begs the question as to why it is nearly impossible to have sustained pressure ulcer prevention in geriatric patients with co-morbidity. The bed-ridden patients and quadriplegic patients are at an even higher risk. Not all pressure ulcers are preventable and those that do develop can become chronic. The implementation of prevention and management of the debilitating condition is believed to be less costly than reducing the incidence of pressure ulcers (Prevention and management of pressure ulcer, 2006). Prevalence and incidence studies show a substantial number of PUs develop on the heels, sacrum, tochcointer, back of the shoulder, mid-back, spinal cord, and are due to cellulitis, osteomylitis, and amputated stumps. Blisters on the heel can be stage II (transparent blister) or deep tissue injury (DTI); if they present as purple blood blister. These have been observed to go harden, then are restaged as escher/unstageable wounds. The teaching and learning that was referenced earlier is the means by which current knowledge about PU can be translated into effective methods for prevention and treatment. The teaching should emphasize the need for accurate and consistent assessment, description, and documentation of pressure ulcer, stages, and means to minimize PU risk factors. Cognitive learning can be appropriate for instructional method wound measurement such as: length, width, depth, exudates’ quantity and quality. The nature of scope of PU is a much bigger problem than meets the eye. The financial cost is in the thousands for care and treatments. The cost on a personal level is a largely physical toll on the person involved. The biggest problem is the management of PU and the lack of knowledge of the staff in proper care of PU at the stage they are first encountered. In order to prevent further damage, it is necessary for knowledgeable stake holders to act quickly; especially in a situation in which a continued deepening of skin wounds can occur. PU, also known as bedsores, are painful ulcers that form when constant pressure on a part of the body shuts down the blood vessels feeding that area of skin. This results in the surface of the skin becoming red or darkly patched (Red, Wet Skin, 2006). As the pressure sore progresses, the skin can break down to form a blister; then dead skin ultimately infects underlying tissues - sometimes even bones. As little as two hours of pressure will trigger skin damage. Skin damage can also be exacerbated by friction and moisture such as urine, sweat, and feces. The area most prone to breakdown is bony prominences such as the chin, scapula, elbow, sacrum, trochanter, isocheim, and heels. Pressure ulcers are graded or staged to classify the degree of tissue damage observed. Incontinence of the bladder and bowel can cause skin excoriation related to enzymes. Stage I PUs can be defined as nonblanchable erthema of intact skin in individual with darker skin, discoloration of the skin, warmth. Additionally, edema or hardiness may also be indicators. Stage II is defined as partial thickness skin loss involving epidermis, dermis or both. In this stage, the ulcer is superficial and appears as an abrasion blister. Stage III is characterized by full skin thickness loss; involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents itself clinically as a deep crater. Stage IV PU also shows full skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structure (Beare & Myers, 2005). Eschar and slough are associated with stage IV or unstageable PUs, because one does not know how deep, and what is under the slough or eschar. Sampling Strategy Concept: 1. Pressure Ulcers Search Strategy: Pressure ulcer, decubitus, sore, bed sore 2. Risk assessment Risk assessment, risk factors, nursing assessment, and severity of illness in geriatric with or with comorbidities Research design The research design is that of a descriptive study. This is because the internal validity is at the core of inference and study and is aimed to identify the area of more research. Extraneous Variables An extraneous variable is a general term for those variables factors in the environment that may or may not affect the studys results. However, for pressure ulcer patient that have comorbities that have gotten worse or they have become infected, the risk of death to the patient from bed sores may be even more profound. An exemplary researcher identifies those variables and tries to determine if they had and influence on the participants. In this study, the researcher can control the treatment of the PU, gain experience wound care nurses for the treatment and patients daily care activities. Simultaneously, the researcher will provide best education and training as much as possible to other nursing staff for them as much as possible just in case a lack of staff is represented within a given health care entity. Instruments Nurses use PUSH tool to measure pressure ulcer as well as to observe and measure the pressure ulcers. The tool is also used with respect to categorizing the ulcer with regard to surface area, exudates, and type of wound tissue, recording sub-score for each of these ulcer characteristics. Thus, measurement is achieved by adding the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing. Red as a“1″, when the wound is closed, score as a “0″, nurses also uses Healing panel with dates and standard graphs are also integral within this process. 4 – Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3 – Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mutinous. 2 – Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance. 1 – Epithelial Tissue: for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface. 0 – Closed/Resurfaced: the wound is completely covered with epithelium (new skin) (National Pressure ulcer graph). Writer used to use this graph for PU wound assessments, do not know when it was published, but it is reliable tool for PU measurements (NPUAP, 1997). Description of the Intervention The aim was to evaluate the effect of the educative intervention on nursing staff knowledge about PU prevention in long term facilities. Firstly, data were collected from the nursing team members who were involved in patients care with PU. There were no consent forms that were signed; because it was treated as part of the staff’s in-service for education enhancement with facility protocol. There were fifteen nurses who were eager to participate and wanted to gain further knowledge concerning PU (Ribeirao, 2012).The data was collected before and after education interventions; using a knowledge test with true-false questions related to pressure ulcer prevention and description as a research instrument. The meeting was held in the conference room with enough light, comfortable chairs, and light snacks were offered ( Ribeirao, 2012). Data Collection Procedures Consent forms were distributed to be signed among those who were involved in an education and information exchange that took place during the session time. The nurses were told in detail for the purpose of education what type of program they would be participating in. Out of fifteen nurses, three were registered nurses who participated in the pre-intervention phase. Twelve were nursing assistants (NA). The registered obtained 86 correct answers, the twelve NAs obtained 74% correct answers in the pre-intervention phase. In the post- intervention phase, it was demonstrated that there was improvement in the results after the intervention for the nurses group (Nursing, 1979). Data Analysis Plans The purpose of teaching based on the evaluation report was to ensure that proper standards of practice and care were implemented for pressure ulcers. These included assessment, treatment, wound management, and prevention. The aim of teaching was to give the care giver the knowledge to identify each pressure ulcer stage, full body assessment, accurate documentation per order, treatment, management, and prevention from new PU. As such, this aim was accomplished to a 90% rate. The descriptive statistic were utilized in order to examine the distributions and mean scores of the Braden Scale and PUSH tool. The analyst did not offer a Chi –square test between patients with or without pressure ulcer and between patients at risk and not at risk for pressure ulcer development. The deviance test, or likelihood ratio test, was used to assess the significance of the fixed parameters and to test the random parameters of the models. The total number of enabling conditions presented and the percentage of patients receiving adequate prevention as the independent variables were noted. The target nurses were not performing treatment and initial assessment on the time or in the timely manner and also with facility protocol (Beare & Myers, 2005). Describe plan for data analysis of study variable Descriptive statistics of the independent and dependent variables for two groups ambulatory, and nonambulatory with co-morbidities compared with standard error for continuous data due to insufficient care and wound treatment. It was hypothesized that the PU, co-morbid group and ambulatory patient, the co-morbid patients wound was not healing properly diabetes, hypertension, lethargy, poor appetite, depression, and vascular diseases, and insufficient hemodynamic resulted. It was hypothesizes that different function correlated between these variables (Mosby, 2000). Ethical Issues Diverse ethical issues are involved in health care today. Issues may arise in any of the five areas in which the nurse us accountable. These include issues pertaining to self, profession, patients, family, employees, facility, and society. In addition, in any area or specialty of practice, a nurse will be confronted with ethical issues unique to that practice. Because of the interdependent relationships between, one nurse’s practice affecting the practice of another, the failure of a nurse to maintain ethical standards in practice can have serious negative effects on colleagues if they are unwilling to hold the nurse accountable (St Louis, 1979). Several factors add to the complexity of ethical issues between nurses. All registered nurses, CNAs hold the license; but education preparation may vary considerably. There is disagreement within the profession as to the preferred way to reach professional nursing status. Thus situation can arise in which nurses with differing educational backgrounds, experiences, and education question each other’s ability to make sound judgments. In addition, levels of experiences vary widely. A nurse who is experienced in one area of practice and who has kept informed about current developments in nursing is likely to be more clinically qualified than a recent graduate. Nurses place differing degrees of importance on theoretical models of nursing, as well as on activities involved in the nursing process. It is common to find two nurses correctly performing the same procedure in two entirely different ways (New York, 1981). Throughout one’s experiences as a nurse there will always be situations involving other nurses that raise ethical questions. A nurse cannot be ethically responsible and ignore the unethical conduct of colleagues. Careful judgment and a methodical decision making process help a nurse to make sound ethical decisions (Nursing, 1980). No two ethical dilemmas are the same. Without a systematic approach to ethical decision making, the educator nurse can continue to teach, preach, nag and nag to get to the point of learning, retaining, and practicing accurate methods of patient care (Nursing, 1980). Limitation of proposed study Following can be expected as limitations of this research study Lack of secondary data: Some secondary dates’ data are limited and insufficient. This is due to the fact that sometimes, external parties do not like to provide their real method of approach regarding a specific intervention. Draw back in primary data collection: Sometimes this process is difficult; due to the fact that all data or the information is not available, e.g. patients charts. Likewise, people can express their own opinions or develop a particular attitude concerning the way in which such a process should proceed. The next important fact is both of the primary data points have both qualitative and quantitative behaviors. Thus both of data points are dependent on people’s opinion. Time constraints: This should conduct simultaneously with other learning activities; therefore, it is necessary to handle all learning and research activities under practices of good time management. Financial constraints: Due to the costs involved, mainly in teaching materials and snacks, there was no fund available for ancillary expenses. Unable to convert human resource to the real economic growth The human resource is obviously not based upon economic growth but they are for patients’ best care and practice (JAMA, 2008). Implication for practice One of the biggest issues in geriatric long-term non-skill or skillful facility’s is pressure ulcers. Because pressure ulcer care is complex, efforts to improve pressure ulcer prevention requires a system approach that will involve organizational change. Bringing about organizational change of any type is difficult at times. It is even more difficult when it involves multiple, simultaneous modification to workflow, communication, and decision-making as are needed in a pressure ulcer prevention initiative. Failure to assess the facility’s readiness for the change at multiple levels can lead to unanticipated difficulties in implementation, or even the complete or partial failure of the effort. Each of the questions below will help the facility explore readiness and identify action steps to improve it, if necessary (Curl, 1992). Do organization members understand why changes are needed? There are many potential reasons to implement a pressure ulcer prevention program. The motivation may be helped along by external factors, such as Federal or State mandates, and the authorities does receives monthly patients reports for pressure ulcers and the updates of the PU, deaths related to PU infection or co-morbidities, these all are the part of the quality care report. Medicare or Medicaid covers the cost of PUs $9.1-$11.1 billion per year in the US. The cost of individual patient ranges from $20,900 to $151,700 per year per pressure ulcer. Medicaid has estimated the cost of pressure ulcer care will increase to$ 53,000 per year per pressure ulcer. The deaths due to pressure ulcers are expected to cost $60,000; with the lawsuits expected to be around 17,000 related to PUs (Wound Repair Regan 2009). There are great variations across the facility in levels of knowledge and motivation among nursing staff (Nursing, 1979). There is an urgency to change because the qualities of care of pressure ulcer against the value of money patients pay. The facility has wound nurse; but the nurse does not have certificate of wound care. Thus PUs are not regularly documented nor treated. By the time a report is submitted, the PU wound has already worsened. That’s why this analyst advocates for immediate changes in the PUs wound care and nurses behaviors towards wound (Nursing, 1979). The facility owner does support the urgency to change PU practice and is willing and able to provide complete and ongoing support for change for short time; or within a time period provided by the the State or Federal government. No one from the interdisciplinary team wants to take ownership; because when the staff is short with nurses, the scheduler pulls the wound nurse to serve the medication - even though the nurse is not familiar the patients’ routine medications and patients care. The facility has a fund available for the owners use only; but human resources cannot hire extra or as needed nurses for emergency needs. The human resources hire Registered Nurses (RN) with associate degree, new License Practical Nurses or sometime Medication Technicians in order to save budget. Most of the time, RN does not stay with these firms any longer than 3-6 months. The facility does not stability of staffing, no tuition reimbursement for nurses. Resources needed which it is more likely to be strong and enduring if based on a clear understanding of the concerns behind the planned changed at all levels of the organization (Curl, 1992). It was hypothesized that pressure ulcers have been identified as a major burden of hospitalization worldwide and nurse are at the forefront of prevention. It has been recommended to carry out research based on the available assessment tools so as to identify individuals prone to pressure ulcer so that prevention and management start. Ethics are generally regarded as the standards that govern the conduct of a person. As a human reflects self-consciously on their behavior as a moral being, there are definite expectations that must be fulfilled. Some definitions are dictated by law; whereas others are predicated on individual belief system, and religion – allowing individuals the freedom to choose their own destiny. The responsibility to observe and obey legal and ethical directives, or refusing the responsibility to carry out directives that are illegal and or unethical is essential in providing individuals a way out of difficult situations. . Read More