Evidence-Based Practice in the Prevention of Pressure Ulcers in Community Nursing - Essay Example

Evidence-Based Practice in the Prevention of Pressure Ulcers in Community Nursing Introduction No single factor makes a person vulnerable to pressure ulcer. A home care research found out a connection between greater risk of pressure ulcer and being bed-bound, overreliance, and urinary incontinent as contributing factors for stage one pressure ulcer development. For advanced levels, there were further contributing factors, such as the existence of a bone fissure and use of oxygen (Wipke-Tevis et al., 2004). Pressure ulcers are severe and stressful, and they can occur in individuals of any age. They do not simply elevate mortality, lead to longer hospitalization, and use up sizeable amount of healthcare resources, but also represent a case of avoidable harm. In the UK, the stated rates of prevalence are 22 percent in community nursing populations and roughly 32 percent in hospital population (Armstrong et al., 2008, p. 472). Hence, pressure ulcer prevention should be prioritized by the National Health Service (NHS). Stage one pressure ulcers can be cured if diagnosed quickly, and majority of advanced stage ulcers can be cured with proper care (Armstrong et al., 2008), yet everything needs an interdisciplinary and evidence-based model of pressure ulcer prevention and management. This essay discusses evidence-based practice in the prevention of pressure ulcers within the context of community nursing. Special attention is given to the areas of nutrition and hydration; skin check, and incontinence. Prevention of Pressure Ulcers in Community Nursing Pressure ulcers are a major issue in health care sectors across the globe. Pressure ulcer is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “a localized injury to the skin and/or underlying tissue usually over a bony prominent, as a result of pressure, or pressure in combination with shear and/or friction” (Sarabahi & Tiwari, 2012, p. 283). Majority of pressure ulcers are located on the sacrum and heels. For hospitalized patients, besides sacrum and heels, elbows were a usual location of ulcers; majority of ulcers took place within a two weeks of death. Pressure ulcers are related to complications such as emotional and financial costs, greater duration of stay, sepsis, osteomyelitis, and cellulitis. Pressure ulcers develop from the duration and extent of pressure and tissue tolerance (Touhy et al., 2013). Lack of mobility as observed in chair- or bed-bound patients, weakened capacity to react to one’s environment, defective cognitive capability, friable skin, and undernourishment are several of the leading known risk factors for pressure ulcers (Sarabahi & Tiwari, 2012). Hence it is vital for community nurses to be aware of evidence-based clinical guidelines for the prevention of pressure ulcers, especially in the areas of nutrition, hydration, skin check, and incontinence. Nutrition and Hydration It is broadly recognised that diminished nutrition will affect tissue risk to external forces like pressure. Undernourishment arises when the dietary intake of a person does not satisfy his/her metabolic needs. The wound healing process and infection raise the needed amount of calories. Thorough pressure care is the basis or foundation of pressure ulcer prevention and treatment in community nursing (Crowe & Brockbank, 2009). However, even though clinical nutrition treatment is identified as serving a vital supplementary function in pressure ulcer prevention, there has been an inadequacy of good evidence-based research in this domain, with present nutrition guidelines largely derived from professional insights and small-scale research. The ideal nutrient consumption to facilitate the treatment of pressure ulcers is unidentified, with present guidelines derived from insufficient findings of heterogeneous research (Dealey, 2012). Since numerous studies have associated malnutrition with pressure ulcers, proper nutritional plan is a vital portion in the prevention and management of pressure ulcer. Micronutrients—zinc, vitamins A and C—arginine, protein, and energy are necessary in the facilitation of wound healing and present guidelines are likely to concentrate on these specific nutrients. Eating correctly and keeping an appropriate weight is vital in pressure ulcer prevention. Prevention of undernourishment lessens the vulnerability of patient to greater tissue strain associated with pressure or damaged wound healing (Crowe & Brockbank, 2009). The community care pressure ulcer guidelines endorse nutrition and hydration care that is in line with the condition and demands of the patient. This involves letting the patient eat foods and drink fluids of their preference and letting the patient take part in the preparation of his/her nutritional plan. Other recommendations involve eating several small meals every day and providing dietary supplements (Levin et al., 2013). Likewise, proper hydration facilitates general health, which consequently inhibits numerous medical disorders like wounds. Water sustains the skin’s moisture hence it is much less prone to abrasions and tearing, which if severe or ignored, can turn into pressure ulcers. With regard to the treatment of pressure ulcers, hydration serves a more important function (Crowe & Brockbank, 2009): (1) facilitates new tissue development and elimination of waste from the wound; and (2) promotes cell renewal; (3) the warmth from air fluidized mattresses trigger evaporation of moisture from the skin and will usually raise the needed amount of fluid; (4) fever and/or wounds will raise the needed amount of fluid; and (5) the usual nutritional plan to enhance treatment of wounds will be greater in protein and calories, which consequently raises the needed amount of fluid. In other words, poor nutrition, as well as insufficient fluid consumption, will have outcomes that damage healing and overall health. Dehydration damages the inflammatory functioning of the body, prevents tissue renewal, distorts metabolism, and weakens immunity, which raises vulnerability to infections and wounds. Fluid requirements should be personalised, explained, and observed, and care plans regularly assessed for improvement. Skin Check Immobility decreases the volume of blood that flows to the skin. Patients who have limited mobility have higher vulnerability to skin disintegration at pressure points, which carry a large portion of the body weight. These include the head, the neck’s back, heels, ankles, hip bones, shoulder blades, and elbows. The pressure on these parts decreases circulation, reducing the level of oxygen obtained by the cells (Wipke-Tevis et al., 2004). Moisture and warmth also further damage the skin. When the skin’s surface has deteriorated, pathogens can attack and result in infection; once infection develops the process of healing becomes slower. When the skin starts to deteriorate, it turns into a red, white, or pale colour. If pressure is left untreated, the area will continue to break down thus resulting in pressure ulcer. Pressure ulcers are painful and very hard to treat. They can result in fatal infections (Sarabahi & Tiwari, 2012). Hence prevention is imperative. Below are some of the evidence-based recommendations for simple skin care that community nurses should use (Dziedzic, 2013): (1) Provide updated documentation of the condition of the patient’s skin; (2) Provide consistent skin care to maintain cleanliness and dryness. When thorough baths are not provided or performed on a daily basis, monitor the patient’s skin and administer skin care every day; (3) Change the position of the immobile patients often; (4) Administer regular and complete skin care as frequent as required for incontinent patients; (5) Prevent scratching the skin. Inform the supervisor if a patient uses footwear that causes sores or wounds; and (6) Massage the skin regularly in order to enhance circulation. Apply slight pressure on bony parts. Massage only the tissue and skin that are not affected or are healthy. Caring for and observing the patient’s skin condition is imperative for pressure ulcer prevention and timely diagnosis of stage I pressure ulcers in order to prevent the worsening of the condition. Incontinence Another widely known risk factor for pressure ulcers is incontinence. Community nurses are extensively aware of this fact. Moist skin can result in swift skin deterioration and the growth of pressure ulcer. Urinary tract infections and incontinence generally have resulted in skin breakdown or further worsened symptoms (Brooker & Waugh, 2013). Dealing with these two problems in community nursing may result in the prevention of pressure ulcers. Here are some of the evidence-based practices that community nurses should apply in managing incontinence: (1) assess for conditions that could worsen or contribute to the development of incontinence-- if there are symptoms of developing or worsening incontinence, it could be helpful to evaluate the person for circumstances that could affect incontinence, like diabetes or urinary tract infections; (2) regular toileting or bladder exercise—scheduled toileting can ‘exercise’ or ‘condition’ the bladder; (3) promote Kegel practices—numerous patients can acquire knowledge or skills from Kegel practices, which support pelvic muscles especially in women; (4) observe fluid consumption—as stated beforehand, insufficient hydration can result in concentrated urine, which may contribute to skin breakdown; also, too much hydration, particularly before going to bed, can worsen incontinence and result in skin deterioration; (5) prevent constipation because it worsens incontinence—a full colon puts too much pressure on the urethra and bladder, which could worsen incontinence; and (6) regularly check or evaluate medications; medications could worsen or result in incontinence by raising the regularity and amount of urination; medications like opioids, sedatives, and diuretics could contribute to incontinence. National Guidelines/Policies for Prevention of Pressure Ulcers in the UK The National Institute of Clinical Excellence (NICE) has currently publicised its clinical recommendations on Pressure Ulcer Risk Assessment and Prevention. These guidelines have been widely recognised in the UK as a vital instrument in the pursuit of promoting evidence-based practice in the country. Most evidence-based practices suggest that immobile or chair- or bed-bound patients must be evaluated for risk of having pressure ulcers on admittance to a care setting and periodically that is on the basis of the speed by which the condition of the patient is predicted to alter within the setting (NICE, 2014). Majority of evidence-based guiding principles specify the risk factors related to pressure ulcers. Researchers showed that as the number of risk factors rise, the prevalence of ulcers rises (Dealey, 2012). Hence, as stated in NICE guidelines, in order to employ an index of risk factors to inform evaluations, a register of risk factors must be created and healthcare professionals must specify the existence of nonexistence of the risk factor, in addition to clinical perception as to the extent at which risk is existent and should be remedied. The index of risk factors does not provide information on the certain cut-off stage for risk or on particular medications or treatments that must be administered, and although preferred by some of the guiding principles over formal risk evaluation, such process has never been examined for clinical use, validity, or reliability (Kallman, 2009). Risk assessment instruments derived from theoretical risk factors that intersect numerous diagnoses, physiological conditions, patient attributes and other risk factors are simpler to employ with stability or coherence. The National Institute for Health and Care Excellence (NICE) recommendations are derived from methodical evaluations of the finest existing evidence and open assessment of cost effectiveness. In case negligible evidence is found, recommendations are derived from the experience and ideas of the Guideline Development Group (Brooker & Waugh, 2013). The complete guidance comprises five exhaustive procedures on diagnosing those at risk; preventing pressure ulcers; preventing pressure ulcers in young individuals, children, and new-borns; and managing of pressure ulcers. Numerous currently available papers on quality improvement suggest that unit-based quality assurance programmes that detect efficiency of preventive interventions and frequency of pressure ulcers are especially useful in inhibiting pressure ulcers (Curley et al., 2003). Unit-based performance programmes involve training healthcare providers on how to recognize risk factors and how to rank or identify stages of pressure ulcers, yet the main attribute of the quality programmes seems to be in conveying the usefulness of the treatment in terms of the number of days with no development of pressure ulcer (Bader et al., 2005). . The Institute for Clinical Systems Improvement recommends that on admittance a skin evaluation and risk assessment be carried out, current lesions be recorded, and treatment objectives be developed (Sinclair et al., 2004). If a patient is likely to develop pressure ulcers or has already a pressure ulcer, needed appointments to wound care physicians and nutritionists must be performed. Community procedures for preventing the development of pressure ulcer, which must involve nutrition assistance, moisture treatment, and pressure relief, must be administered. An evidence-based practice and research cooperation creates access to needed support services and various resources (Xakellis et al., 1995). The pursuit of effective measures for the prevention of pressure ulcers does not have to depend on a single organisation, but can be tackled more thoroughly within a bigger setting. Barriers to Implementing Evidence Based Practice In spite of the significant developments and successes that have been achieved recently, wound treatment and prevention of pressure ulcer is still a problem for numerous clinicians. Even though the creation of clinical guidelines such as NICE and the European Pressure Ulcer Advisory Panel (EPUAP) contributed to the raising of awareness about pressure ulcers, they are still not that competent enough because numerous members of the multidisciplinary group are not informed of their presence (Wounds UK, 2014). NICE was formed to assess evidence by means of a methodical, systematic model and has been useful in numerous domains of clinical care yet has been unable to generate any applied clinical guidelines for the management of pressure ulcers (Wounds UK, 2014). The tempo of change and restructuring of programmes needed to cope with emerging developments in pressure ulcer prevention create a barrier to the implementation of evidence-based practice. Knowledge or specialisation in the field of wound management is scarce and cannot be depended upon (Armstrong et al., 2008). Developing tools or instruments like clinical practice recommendations and diagnostic frameworks are a useful way of supporting and assisting less knowledgeable or skilled providers. Even though a great deal of clinical specialisation and current evidence-based practice is concentrated on the prevention, treatment, and management pressure ulcers, plan of care is not generally committed to the best standard. It is expected that such evidence-based guidelines will help reduce pressure ulcers in the UK and the enhance plan of care when pressure ulcers do develop (Clarke et al., 2005). The guiding principle is divided into two—prevention and management of pressure ulcers. Recommendations are categorised into several groups—for young people, children, new-borns, and adults (Harrison et al., 1998). According to Gordon and colleagues (2004), domains of management involved dressings, antimicrobials, debridement, adjunctive treatments, nutrition, pressure redistributing equipment, and pressure ulcer assessment. The evidence-based practice framework derived from all health care providers being capable of finding, evaluating and using evidence-based practice is unusable. A more practical practice or technique would be to have most of the health care providers deriving wound management from patient-centred and professional guidelines, while having an understanding of the processes applied in their development. In addition, teams of interdisciplinary researchers representing involved stakeholders must be trained as clinical frontrunners in the area of wound management. Conclusions Evidence-based practice presents recommendation for preventing pressure ulcers in community nursing that involve appropriate equipment, evidence-based therapy procedures, quality enhancement programmes, outcome assessment, documentation registers, enforcement of procedures and use of toolkits, techniques in building communication, training for healthcare providers, and patient awareness. It is vital to keep in mind that not all pressure ulcers could be prevented. Patients with severe illness experiencing immobility, weakened tissue performance, and multiple organ deterioration are highly vulnerable to pressure ulcers. Thus, community nurses have to make all the necessary efforts to implement evidence-based guidelines, especially those that were the product of research collaboration. Community nurses have the distinctive task of finding the proper interventions for the prevention of pressure ulcer and making sure that they are well-informed about the recommendations of the manufacturer for equipment used in patient care References Armstrong, D et al (2008) “New Opportunities to Improve Pressure Ulcer Prevention and Treatment,” Advances in Skin & Wound Care, 21(10), 469-478. Bader, D et al (2005) Pressure Ulcer Research: Current and Future Perspectives. New York: Springer Publishing Company. Baranoski, S & Ayello, E (2008) Wound Care Essentials: Practice Principles. Ambler, PA: Lippincott Williams & Wilkins. 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