Effect of Duration of Surgery on Pressure Ulcers - Essay Example

? Research Methods: Research Proposal Table of contents Introduction………………………………………………………………………….………3 Review of the Literature…………………………………………………………………….4 Methods………………………………………………………………………..……………8 Purpose……………………………………………………………………………………..8 Design and Research Questions……………………………………………………………………………………9 Relevance of the study…….…………………………………………………………….…………………….9 Research design…………………………………………………………………………….10 Participants…….……………………………………………………………………………11 Material Used……….…………………………………………………………....................11 Procedure…………………………………………………………………….……………...11 Analysis of Data……………………………………………………………………………..12 Research Ethics to be applied………………………………………………………………..13 Evaluation of the Study…..……………………………………………………………………………………..14 Conclusion………………………………………………………..…………………………..15 References…………………………………………………………..………………………..16 INTRODUCTION EFFECT OF DURATION OF SURGERY ON PRESSURE ULCERS Throughout the nursing profession, effective patients positioning has been such the weighty issue. Treatment and reduction of pressure ulcer cases has also been a central issue as far as the medics are concerned. Pressure ulcer is defined as damaged or discoloration areas of a skin persisting after removing of pressure, which have the higher likelihood to be due to pressure effects on the tissues (Taylor, C, & Lillis, C. 2011). This implies that pressure ulcers emanate from prolonged pressure ulcers, that cause skin, muscle or tissue damages. Perioperative period is the period at which most patients are at highest risk of developing the pressure ulcers (Tubaishat, A, & Saleh, M. 2010). Surgical patients do present a challenge in the prevention of pressure ulcers since they are quite immobile and unable in perceiving the discomforts of prolonged pressure. From the existing literature, it is quite unclear about the percentage of pressure ulcers that actually begins from the operating theatre. It is indicates that pressure ulcer beginning from the operating room seems to have a higher impact than those than the result from the medical patients (Thomas, DR. 2005). The reason behind the differences lies in the changes in the circulatory and the metabolic occurring during surgery. The incidences might be ranging from 8.55 to 67%. However, a number of studies have indicated that risks of pressure ulcers are high in older patients. Study conducted showed 9.4% incidences in patients in ages between 20, and 40 years (Schoonhaven, L, & Defloor, T. 2002). Various studies have identified various risk factors other than pressure that could be having an impact on pressure ulcer development. However, duration of surgery is one risk factor that up to date has not been confirmed as a risk factor of pressure ulcer development. A huge debate about surgery duration as a risk factor has developed over decades. Schoonhaven in 2002 studied the duration of surgery and concluded that it was not an exclusive factor for pressure ulcer. In contrast to this, another study made by Steven in 2004 concluded that pressure ulcer was a risk factor. Until today, studies made on duration of surgery fail to develop a consensus concerning the duration of surgery as a risk factor. This is because all the prior studies concentrated on a number of risk factors other than concentrating in one risk factor, therefore, giving out debatable results. The lack of consensus in the prior research has left some a gap in research in this matter. The issue of duration of surgery though, still debatable is relevant in developing a preventive measure for pressure ulcer development in nursing practice. In attempts to fill this gap, this paper proposes a research study which would investigate the duration of surgery as being one of the risk factors for pressure ulcers. This study shall concentrate on the duration of surgery as the only risk factor for pressure ulcer development. LITERATURE REVIEW For ischaemia of soft tissue to come about, the pressure in the external part of the body must exceed the pressure in the capillary so as to obstruct the flow of blood. The minimum pressure for which the capillaries would close is about 32mmHg. During the process of surgery, patients are normally positioned in an anatomical position that is not natural, for example, fossa position. In this position, patients do sit at an 80 degree angle position while their shoulder and head leans against the table of operation, thus exerting pressure in areas that are not accustomed to bearing weight. Despite the fact, that high pressure interface is a factor that is pertinent; the duration of time that is spent in an operating room would also play a significant part. In most cases, duration of surgery is determined by the period of time taken during surgery. A study that was done by Bain and Ferguson-Pell in 2002 explained that high pressure for a short length of time and low pressure for a longer length of time would lead to damage of the pressure. A number of studies advanced in this field have attempted to explain whether the duration of surgery could be a possible risk factor for pressure ulcer. Some studies like those for Guy 2004, Nasolpel 2004, Schoonhaven and Defloor 2002, Lewicki 2007, Morrison 2001, Amonovitch 2006, Stevens 2004, and Schoonhaven 2002, studied the duration of surgery and concluded that it was not an exclusive factor for pressure ulcer. In 2002, Schoonhaven conducted a study which involved 200 patients from ten specialists that performed a surgery that lasted for about three excess hours. This duration of time was picked on by the author because it reflected the recommendations of the pressure ulcers prevention and prediction panel that recommended the patients repositioning after every three hours for prevention of pressure ulcer development. In this respect, the likelihood for development of pressure ulcers within the initial three hours was minimal. In another study, the average age of the participants was 61 years and range of age 15-70, and the duration of surgery was six hours. After observing the skin of the patients, about 22% (n=44) of the participants developed about 60 pressure ulcers in the period of 48 hours during surgery. In this study, the presence of the lesion was highlighted. Twenty four participants developed lesions that could not suit the pressure ulcer description. In other participants, some numbness and pain was realized. These were, however, not included in the authors’ analysis. Pressure ulcers development was seen in a number of participants. Studies made by another author also observed that the surgery duration would cause the development of pressure ulcer, but the pattern looked not to be conclusive. In this study within 6 hours of surgery, 4.8% of the patients developed lesions, within 8 hours 19 % of patients developed lesions, and within 11 hours 47.6% of the patients developed lesions. These figures do correspond to study by Amonovitch in 2006 who observed about 1,128 patients that went through a surgery which lasted for the duration of three hours in excess. In his study, the percentage of participants who developed ulceration after 3 hours was 5.8%, 5 hours were 9.9%, and above 7 hours the percentage was 13.2%. The percentage of patients who developed pressure ulcer after 6 hours surgery reduced to 7.4. This outcome was not statistical significant and would have be due to other variables in each participant. In Schoonhaven 2003 study, 76% of ulceration occurred in stage one, 16% in the second stage, and 8% was ungradable. A study made by Steven in 2004 highlighted risks of pressure ulcer in 380 patients who had gone through urology surgery in the past ten years. The mean age of the participants was 48 years and their ages ranged between (12- 74). The period of surgery was between thirty minutes to twenty one hours. The result of this study was that pressure ulcer was developed 50 participants who were 14.4% of the entire sample. 64% of pressure ulcer developed was grade one. The author, therefore, concluded that the duration of surgery was a leading risk factor in developing pressure ulcers. Another study was made by Brem in 2004 to investigate the idea of duration of surgery as a risk factor of development of pressure ulcer. In his study, he made a small project which involved five subjects who had undergone a vascular surgery. His main purpose was to take measurements of the anatomical pressure at different stages of operation. The author took measurements during the spine positioning of the subjects. These measurements were made at three stages of the patients inter operative period. These stages included during the pre-anesthesia, during the post-anesthesia, and after the surgery completion before moving out of the operation table. The author failed to identify other comorbidity despite vascular surgery. The readings for post-anesthesia were higher (by 27.7) than those for pre-anesthesia. This difference was determined by the surgery duration. Below 2.5 hours, the reading recorded a 30%, above 2.5 hours the recorded reading had a 35% increase. This showed that the surgery duration was a clear risk factor for pressure ulcer. Vanderwee and Gunningberg in 2007 involved 500 patients in a study. The study assessed variables like duration of surgery and comorbidities. This author utilized an analysis tool which identified the likelihood of various variables, which may affect the pressure ulcer development. The patients' mean age was forty seven years, with the age range of the patients being 13- 86 years. The recorded duration of surgery was lower than one hour for 228.7% of the subjects, two hours for 29.9% of the patients, four hours for 26% of the sample and 6 hours for 10% of the patients. The author performed a postoperative assessment and the other performed a preoperative assessment. Of all the cases that were assessed the only predictor of pressure ulcer was the surgery duration. The author concluded that surgery duration is closely associated with pressure ulcer development. However, other studies in this topic do not confirm the association of surgery duration and pressure ulcer. For instance a study made by Vanderwee and Gunningberg in 2007on 100 patients, where by a number of pressures ulcer risk factors were assessed. The average age of the participants was 50 years and the age range of the patients was between 30- 80. After strict assessment of the patients, the author did not discover any cases of pressure ulceration. The author, therefore, concluded that the duration of surgery is not an exclusive risk factor for pressure ulcer development. Leape in 2001 found out that reaction to hyperaemic was directly proportional to surgery duration. This study concluded that the surgery duration might have been an over-prediction. The authors concluded that the time taken during surgery could not be a risk factor as far as pressure ulcer development is concerned. A study that was made by Lewicki in 2007 involved 300 participants going through cardiac surgery. The average age of the patients was 60 years, and their age range was between 20-80 years old. Of these, 2% of the entire sample developed pressure ulcers. The rest of the patients failed to show signs of lesions. The mean surgery duration for subjects developing the ulcer was 6.01 hours. The mean surgery duration for patients who did not experience the ulcer was 6.02 hours. The author compared the two values then came to a conclusion that surgery duration was not a risk factor for pressure ulcer development. Another study advanced by Scott in 2005 involved 130 adult subjects who were going through cardiac surgery. The subjects mean age was 60 years with an age range that was unspecified. In this study, a group of 4% (n=37) developed pressure ulcer. The surgical duration for this study was between five hours to sixteen hours. The average time for those who developed ulceration was six hours. The number of lesions had no any alteration as the duration varied. The author, therefore, concluded that the surgery duration is not a risk factor on its own. According to the many research and studies that have advanced in the determination of surgery duration as a significant risk factor of pressure ulceration, there has been no consensus on this issue. This is due to the fact that various researchers used a number of study designs and majored their studies in a number of risk factors other than concentrating in one risk factor. These researchers have used varied pressure ulcer classifications and groups that are not comparable. In other studies, the methodology that was used was remarkably precise compared to others. The experience and quality of the persons making the assessment of the skin in other studies raised a number of questions towards the reliability of their recorded outcomes. This resulted in results that were inconclusive with no undisputable evidence for the association of surgery duration with pressure ulceration. The lack of consensus in the prior research has created a gap in the development of research in this matter. The gap is that studies on surgery duration association to pressure ulcer have yielded different conclusion, therefore, calling for more research to ascertain the right conclusion that needs to be adopted. In this regard, more research needs to be done in this issue to affirm the association of surgery duration with pressure ulcer. METHODS Purpose of the research. The overarching purpose for this proposed study would be establishing the association of the duration of surgery with development of pressure ulcer. The topics to be examined would be the effects of duration of surgical operations on pressure ulcers. Research questions. This research would address the following questions. 1. What is the association of the surgery duration to the pressure ulcer development? 2. Does the duration of surgery leads to pressure ulcer development? 3. Is pressure factor a significant risk factor for pressure ulceration? Relevance of the study. Laws have changed to reduce the avenues available for data collection, mainly for policies that touch on the sensitive topic of pressure ulcer. Previously, nurses have carelessly handled patients while in theater. The duration of surgery, on the other hand, has never been taken into consideration during surgery. This has made the patients to develop different types of nosocomial diseases like pressure ulcer. This has raised concerns because some of these illnesses could have been avoided. This study will identify the best approach to take in line with prevention of the occurrence of pressure ulcer. The relevance of this research will be to establish a preventive measure for the occurrence of pressure ulcers. If this research shall manage to approve the hypothesis for the study then the percentage of the occurrence of pressure ulcers shall be reduced by reducing the period that a patient stays in the surgical room, and nurses taking precautions to reduce these cases. If the hypothesis would not be approved then, further recommendations shall be adopted in this regard. DESIGN. Research design. The design for this study would be a quantitative research design. In social sciences, quantitative research is used to refer to systematic investigation of a phenomenon through a computation technique. The aim of the quantitative research is to employ and come up with mathematical theories or models that pertain to the phenomena. Measurement processes are key elements as far as quantitative research is concerned since they provide fundamental connections linking mathematical expressions and empirical observations. A quantitative research design determines the relationship between two things (dependent and independent variable). This design can either be experimental or descriptive. In experimental design measurements of the participants is made before and after the given treatment. Descriptive design, on the other hand, involves one measurement. In this study, experimental research design would be the most appropriate design to be used in the collection of data. For accuracy, the experimental research would need less than hundred participants. This is a design that utilized a number of variables within one specific study. This design is appropriate because it normally gives out unbiased outcome and has no peculiar methodology because it gives out a lot of flexibility in the research. This design is normally an aggregate of analysis of data. This design involves establishing quantifying variable relationships, and it is employed in gathering data that is empirical on social science discipline. Data collection in quantitative research design involves observing and measuring variables on the given subject like in the case of this study the subject under research is pressure ulcer. In this study, the collection of data should be done using observation. The observation should involve taking several assessment and tests to determine the outcome. The patients should be divided into five groups. Participants would be allocated into the five groups by ensuring that they are patients that would go through surgery. Next, these participants should be going for a surgery that would last in excess of four hours. The patients should be divided into five groups. These groups should be made depending on the excess duration of surgery that the patients experienced. The dependent variable for this study would be the pressure ulcer response whereas the independent variable should be the duration of surgery for different groups. The controlled variable for this study would be other risk factors for pressure ulcer development. This is because for proper outcome other risk factors that affect pressure ulcer need to be kept constant so that the duration of surgery would remain the only factor under consideration. Participants. The opportunity sample for this study should be made up of 45 patients. These patients would be obtained from a hospital that regularly performs surgery that lasted four hours in excess. These participants should be volunteers because volunteering participants would give out unbiased data. The participants would be selected by using the fact that they had to be patients who were to go though, surgery and that the specific surgery should take at least four hours in excess. Five groups consisting of nine participants should be made. The five groups should be given names according to the duration of time spent during surgery. The first group should be 1-2 hours, the second group should be 2-4 hours, the third group should be 4-6 hours the fourth group should be 6-8 hours, and the fifth group should be 8 and above hours respectively. The mean ages of each group would be determined and recorded. MATERIAL USED The apparatus that would be used for this study include: Braden scale, multi-pad-pressure evaluator, Ramstadious pressure intervention tool, Oral and written explanations about pressure ulcer and a booklet for the researcher. Procedure Data collection should be conducted to select the participants for this study. This process should be conducted immediately after the admission of the patients into the surgery room. The demographic data of the patients should be collected at the beginning of this study. After a 50-minute monitoring, a multi-pad pressure-evaluator, and a Braden scale should be used in assessment of the risk of patients to develop pressure ulcer. This procedure should be repeated for all the groups in the different duration of surgery of the patients that have been selected for this study. For the case of the Braden scale, the procedure needs to be repeated at least three times for accuracy. Using a primary researcher, the skin of the patients should be observed at each stage. If a pressure ulcer would be observed, the researcher should stop the assessment and the patient should be withdrawn from the study. The pressure in between the bed mattress and the sacrum should then be measured by use of a multi-pad-pressure evaluator. This measurement needs to be obtained at the sacrum of the patients every one hour. This procedure should be done at least once a week. The measurements obtained should be recorded in a table inside the researcher booklet for analysis. Analysis of data Using statistical methods, the probabilities of the diagnosis (specificity, positive -predictive value, sensitivity, negative-predictive value) should be used to determine the multi-pad pressure and the Braden range of scores. The likelihood ratio in this study should also be evaluated. The likelihood ratio would establish whether development of pressure ulcer would be more depended on the duration of surgery other than other risk factors. For patients who would develop pressure ulcers, Braden scale would be used to obtain scores in the final assessment before the use of skin breakdown. In this category of the participants, the multi-pad pressure would be used to record the interface pressure values. The mean score was used for patients who would not develop pressure ulcer. However, Braden scale would not be used for patients who failed to develop pressure ulcer. From the data obtained an ROC curve plot of pressure ulcer versus the duration of surgery should be plotted and analyzed for a conclusion. If a linear graph would be obtained, it would imply that the duration of surgery is proportional to development of pressure ulcer. A nonlinear graph would indicate an otherwise assumption. Research ethics to be applied. Researchers are made to go through an array of ethical requirements. There is the need to meet professional, institutional, as well as standards for conducting any research related to human participants. In helping steer clear any ethical quandaries, this research would consider a number of research ethics. First, it would frankly discuss with patient the intellectual property. More often than not, academic competitive leads to trouble depending on who should be credited for authorship. The best way the researcher would consider in order to avoiding disagreements about who to be credited, and using which order, the researcher would talk about the issues at the start of the working relationship with patients and ensure they are put in writing. This will act as a tool to help discus and evaluate the contributions during the research process. Secondly, the researchers would be conscious of multiple roles of the participants. This could be achieved by avoiding relationships that might tend to impair the researchers’ professional performances or could cause harm to others. However, they will have to take note that many multiple relationships are not ethical especially if they are not to have adverse effects. When recruiting the patients as participants in this study, the researchers would have to think carefully before joining the multiple relationships with patients. In this case, the researcher would act as lab supervisor, as well as a mentor and make sure he or she does not abuse the power to differentiate him or herself with patients. The researcher would make sure he/she outlines the nature and structure of mentoring before mentoring begins. The third code of ethics to be upheld during the study would be to make sure the informed-consent rules are strictly followed. Doing this properly, the consent process would ensure that the participants voluntarily participate in the research when fully informed of the relevant benefits and risks. Lastly, the researcher would have to consider respecting the confidentiality and privacy of the participants. Respecting individual rights to confidentiality, as well as privacy is a key tenet for every researcher. The researcher will, therefore, have to discus confidentiality limits giving participants information about how their data will be put into use and also know the law of the state, as well as taking practical security measures. EVALUATION OF THE STUDY. Evaluation is a way to determine merits of a study, significance and worth by use of set criteria. It normally helps a researcher to ascertain the number of achievements according to the purpose of the study. Its foremost purpose is to facilitate reflection, and help in the determination of a change in future. For this study summative, evaluation would be the best evaluation process for this study. This is because it summative evaluation is always conducted at the end of a study, and it is used to give out information of effectiveness and long term effect of a study. In order to have an assessment of the efficacy of the study, the researcher shall have to follow the following criteria. To start with, the researcher would determine whether the objectives of the study would have been achieved. The researcher shall develop the weaknesses and the strengths, policy, and theory of this study. The researcher should then practice the implications of the study. Next the researcher would determine whether the ethical committee was approved and whether all the ethical considerations would have been achieved. The researcher shall also establish whether the groups that were used were comparable, whether the confounding factors were well managed, and determine whether the outcomes criteria gave out the required measurements. The researcher should also determine whether the follow-up period was sufficient to make the desired effects. If all this is put under consideration, then the researcher would be able to assess the degree of which her study was a success. CONCLUSION Pressure ulcer develops under different circumstances. In many cases, this disease develops without the knowledge of the patients. The care givers always have an intuition that the patient is experiencing the side effects of a surgery, yet it could be a developed disease. This care givers view the theater environment as cold, impersonal, and high-tech and that the nurses never treat the patients as valued humans. Studies done on the effect of the duration of surgery have failed to confirm it as an exclusive factor for the development of pressure ulcer. There has been a lack of consensus in the prior studies. This study would, therefore, bring a blink of light into the issue of the duration of surgery. Confirmation of duration of surgery as a significant risk factor for the development of pressure ulcer would not only help in filling the gap in the research but also establish a method for the prevention of the development of pressure ulcer. References Amonovitch, M., 2006. Hospital acquired pressure sores in surgical patients. New York: Jack and sons. Brem, H., 2004. Protocol for the successful treatment of venous ulcers. New York: Jack and sons. Bain, D,. & Ferguson-Pell M., 2002. Remote monitoring of sitting behavior of people with spinal cord injury. Phoenix: Br Med J publishers Nasolpel, S., 2004. Wheelchair cushion effect on skin temperature, Toronto: McGraw-Hill Ryerson. Niezgoda , J., & Mendez-Eastman., 2006. The effective management of pressure ulcers. Adv Skin Wound Care Defloor, T., and Schuijmar, J., 2000. Preventing pressure ulcers: an evaluation of four operating table mattresses, Oxford: Oxford University Press. Flanagan, M., 1995. Pressure Sore Risk Assessment. Education Leaflet. Wound Care Society, Huntington: Grous publishers. Graus, N., 1997. Skin integrity in patients undergoing prolonged operations. New York: WOCN publishers Guy, H., 2004. Preventing pressure ulcers: choosing a mattress. Professional Nurse. Phoenix: Br Med J publishers. Lewicki, L., 2007. Patient risk factors for pressure ulcers during cardiac surgery. Tokyo: AORN pub Leaper, J., 2001. Effects of warming therapy on pressure ulcers: Randomised trial, Tokyo: AORN Pub. Morrison, M., 2001. The Prevention and Treatment of Pressure Ulcers, London: Mosby. Scott, E., 2005. Pressure ulcer risk in the peri-operative environment. WellingTon: Nurs Stand Publisher. 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