How Effective Repositioning is in the Prevention and Treatment of Pressure Sores in ITU - Essay Example

How Effective Repositioning is in the Prevention and Treatment of Pressure Sores in ITU Pressure Sores or ‘decubitus’ has been defined as, “Skin discolouration or damage which persists after the removal of pressure and which is likely due to the effects of pressure on areas.” (http://www.publications.doh.gov.uk/cno/cnobulletintissueviability.pdf). It is an area of major concern in health and is a painful experience for the patients. “Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule)” is the final stage or Stage-IV of pressure sores “and the undermining and sinus tracts also may be associated with Stage-IV pressure ulcers.” (http://www.npuap.org/positn6.html). Though there are a vast number of literature available on the topic of pressure sores, it is considered that a more specific research on the effectiveness of ‘repositioning’ in the prevention and treatment of pressure sores in ITU, will provide more precise information. The study, therefore, is mainly focused on ascertaining the curative possibilities of repositioning in ITU cases. Hence it is organised in such a way that all the advantages and the drawbacks are monitored and assessed based on the available study in this area. Further more, the study also dwells on the point whether repositioning alone can be treated as enough to comfort patients from the pressure ulcers. The study is highly relevant in the context of the volume of patients across all age groups. Even the young and the healthy with no apparent possibilities for pressure sore, can develop pressure sores during the post surgical tenure on bony prominent areas. Treatment of pressure sores consumes huge time and money of patients as well as medical care system besides patients having to go through a lot of physical pain and mental stress. In most cases, though the patients have relief from disease for which they have sought medical treatment, pressure sores prevail for a long while. . The occurrence of pressure sore is so common place in aged and debilitated patients whose immobility, combined with other diseases may contribute much to the physical discomfort and thus impairs easy recovery. This study is meant to throw light on the effectiveness of repositioning as a premier curative component in the case of pressure sores. It will help widening the existing knowledge in this area to a new qualitative dimension. Repositioning has been considered as one among the components which is manual, while the other methods are either technical or equipment based. Focusing on repositioning, given its easy availability and less complication in practice, the study will supplement the existing knowledge in this area. In the clinical context, it gives rise to a question whether repositioning can be reckoned only as a component in the treatment of pressure sore or is it an alternative choice based on the patients’ conditions. This enquiry will definitely help furthering the boundary of knowledge in pressure sores treatment. Subsequently, whatever emerges from the study needs to be monitored closely to know its implications in practice. The study becomes all the more relevant with context of monetary implications involved in the treatment of pressure sores. It is apparent from the huge financial burden incurred in the treatment of patients: “Hibbs (1988) calculated the cost of hospital care for one patient with a pressure sore to be £ 25,905. The nursing practice unit (1992) studied one district general hospital to determine the annual cost of management and prevention of pressure sores. They suggested the total cost was £ 408,311.05 out of which 83,355.78 was incurred by two orthopaedic wards.” (http://www.crestni.org.uk/publications/pressure_sores.pdf) Apart from the huge medical expenses, the treatment of pressure sores treatment usually entails several medico-legal issues. Subsequently, patients who have hospital based pressure sores approach court for claims. Hospitals may be exposed to litigation if poor standards of care are shown to be responsible for the development of pressure sores. Damages of £100,000 have been awarded to a successful claimant in England. (Effective Healthcare, the prevention and treatment of pressure sore page2, October1995. http:www.crestni.org.uk/publication/pressure_sore.pdf.) Another important aspect that makes the study significant is the huge incidence of pressure sore occurrences 4% to 10& patients. Further more, the volume of pressure incidents are of an appalling proportion that prevails in England it is most apparent when one takes the available data into account, “it is estimated that as many as one in five patients in UK hospitals suffer from pressure sore, but it is not just hospital patients who are at risk. Anybody who sits or lies down for a prolonged period of time is increasing their risk of developing pressure sores” (www.your_turn.org.uk) There are going to be several implications for practice. These implications should consider the typical issues connected with the preventive and curative aspects of pressure ulcer management. While the main focus remains on the optimum utilization of medical acumen and modern technology, in order to forecast the possibility of its occurrences, through risk analysis, skin examination, and propensity of patients to develop the disease due to pathological reasons. It should also concern itself with offering best medical attention towards its cure and alleviation. Manual repositioning is achieved by changing the position of the patient from side to side. It needs to be carried out every two hours or as medically prescribed. However, there are certain implications that would suggest that it is a viable option only when sufficient staff is available for repositioning. Nurses are always preoccupied; hence the strict adherence to repositioning schedule may not always be feasible in all cases. Moreover, the question of inducting additional staff for repositioning is not economically viable for hospitals. Existing nurses would have to take up this task along with their existing work schedule. This may adversely affect the quality of care administered to the patients in ITU since nearly 40% of the time of nurses is devoted to this task. Similarly, it is important to ask the following questions while choosing a tool: 1. Does the tool take into consideration the specific needs of the patients? 2. Which clinical setting the tool originally designed for? 3. Is it easy to use and understands. Pressure is generally caused by two discrete factors: A) Extrinsic factors B) Intrinsic factors Extrinsic Factors: The following Intrinsic factors may be the primary cause of pressure sore development in patients. Pressure: The underlining cause of pressure sore may be due to pressure particularly over a bony structure, since external pressure over the tissues causes occlusion of blood vessels and damage to the skin tissue. If the capillary closing pressure is less then the pressure applied due to extrinsic factors. The blood vessels may be damaged resulting to pressure sores. Remedy: Immediate use of pressure relieving or reducing equipment has to be mobilized to relieve the pressure on the particular spot of the body. A repositioning schedule considering the needs of the patient, his medical history, his comfort level and the overall plan of care and support surface has to be mobilised. Shearing: Shearing occurs due to sliding of the patient down the bed or chair, then the shear forces cause tiny blood vessels to be stretched or torn, leading to disruption of local blood supply and subsequent ischemia. If this condition is not rectified, endothelial damage and cell thrombosis may take place. Remedy: The level of patient’s head has to be maintained at the lowest degree of elevation i.e.30º angle. Friction: It may be caused due to the movement of two surfaces across one another. This may cause surface damage to the skin. Poor lifting and moving techniques can remove the top layers of skin. (http://www.nice.org.uk/pdf) Remedy: Correct lifting and handling of the patient may reduce the friction and that can be implemented by trained carers and nurses. Intrinsic Factors: The major intrinsic factors that may lead to the development of pressure sores and the conditions, vulnerable targets etc are tabulated below. PROBLEM EXAMPLE RATIONALE Acute Illness Acute Infection Trauma Associated Dehydration and Circulatory Fractures Age > 70 YEARS 70% Of pressure sores occur in this age groups due a combination of age related skin changes and increased co-morbidity factors Incontinence Bladder or Bowel Damp skin increases friction and skin maceration Poor nutritional status Emaciated patients High association with acute And chronic illness Vascular disease Peripheral vascular insufficiency Decreased blood flow and micro vascular reflexes Neurological disease Multiple sclerosis Stroke Reduction in sensory perception and mobility Immobility Parkinson’s disease Reduced ability to relief pressure Loss of sensation Diabetes Reduced awareness of pressure Drug therapy Sedatives Reduced Mobility Reduced awareness of pressure and pain Debilitating disease Rheumatoid disease Terminal illness Multiple associated factors (http:www.crestni.org.uk/publications/pressure_sores.pdf) The Braden Scale, appended as Annexure-I, gives an exhaustive overview of the Risk Factors, Score, description etc and suggests some useful measures that can minimize the occurrence of pressure sores. Critical Review of Literature: The effectiveness of Manual Repositioning and what would constitute optimum repositioning regime is not adequately supported by statistical evidence. Little is known about the degree to which manual repositioning of patients or the deployment of pressure relieving devices adds to benefits. Etiology of pressure sores is imperfectly understood since the cause of pressure sores are multi-factorial and cannot be pinned down on one particular reason alone. A lot of factors contribute to the occurrence of pressure sores and degeneration from one stage to another. However, the review of relevant literature shows that in the present scenario, the following measures may be considered feasible for a possible reduction in the incidence of pressure sores: 1) Nurses are required to dress the wound and arrange for prompt reposition of the patients. Compliance to this should be actively monitored and the risk assessment correctly defined and implemented. 2) The prevention strategies involve identifying those at risk through grading system and providing adequate pressure relief support depending upon the severity of the case and risk involved: High risk individuals should be repositioned frequently, depending upon the results of daily skin inspection and individual needs, and should not be a mere mechanical exercise. Repositioning should take into consideration other relevant factors including the patient’s medical condition, their comfort, the overall plan of care and the support surface. Individuals who are considered to be actually at risk of developing pressure ulcers should restrict chair sitting to less than two hours, until their condition improves. All the literature that have been reviewed conclude that the repositioning of patients should ensure that prolonged pressure on bone prominence is minimised, that bone prominence are kept from direct contact and pressure, friction and shear damage is minimised. They also insist that repositioning schedule agreed with the individual should be recorded and established for each patient at risk. Willing individuals/carers should be taught how to conduct redistribution of patients though repositioning. However, most of the literature doesn’t suggest any definitive system for evaluation of practices or to assess whether the repositioning schedules etc are strictly being followed by the concerned. In conclusion, it may be said that repositioning is effective in a limited sense because it relieves the pressure in certain areas of the patient’s body. Repositioning often depends up on how regularly the patient needs to be moved if a patient is at high risk of pressure ulcer, and using a particular pressure-relieving device of any sort. It is important that she or he is regularly repositioned in order to avoid the occurrence of pressure sores. However, patients in respect of who have already developed sores, the basis of repositioning would depend upon the particular areas of the sores. Taking into account the severity of the condition and the vulnerability of the patient to develop further ulcer, if the nurses or doctors believe that a marginal relief can be provided to the patient through repositioning, then it is advised that it could be done, considering the totality of the condition available. Aims of the Study: The primary aim of this research proposal is to evaluate various methods of preventing and treating pressure sore, and to determine how effective the method of repositioning is in the prevention and treatment of pressure sores in Intensive Therapy Units. It will also attempt to compare the effectiveness of repositioning with other methods which are used for treating pressure sores. While making the comparison it will also address the practical difficulties in implementing each of the methods, with reference to both the advantages and disadvantages of each method. Thus the effectiveness of repositioning will be evaluated by weighing the pros and cons including financial implications, of all the existing practices, and then determining whether this particular method enjoys an edge over the others. On analysing the present situation and reviewing the literature it comes to fore that incidence of pressure sore is a major challenge for health care providers, especially in the geriatric care area. It has also emerged that a move focussed study will supplement the existing knowledge and enhances the quality of care to the patients. Prevention and treatment of pressure sore in ITU could be made move effective by: 1) Avoiding pressure shear and friction at site of the pressure sore. The patients may be repositioned every two hours or so in order to avoid pressure on affected parts. 2) Some conditions (e.g. diabetes) and treatment (epidural pain relief) may reduce sensitivity to pain or discomfort. In such instances the repositioning schedule has to consider the present state of health of the patient. 3) Good blood circulation is mandatory for early recovery from pressure sores. Patient suffering from poor circulation may require specialised treatment for PU. 4) The affected skin needs to be kept clean and dry so that the process of healing takes place faster. Moist skin or skin susceptible to wetness, sweat etc may take longer time. 5) Special care needs to be taken so that pressure sores do not degenerate .It has been found that if left unattended, pressure sore may become fatal leading to blood poisoning and sepsis leading to ultimate death. Hypothesis: Repositioning may be considered as one of the best methods of treating pressure sores and it is a widely accepted one. The fact that repositioning is a manual process renders it more cost effective than other methods since the investment outlays or financial burdens are almost non-existent. In some peculiar cases the patients may prefer other procedures but this is due to the special circumstances and not due to the limitations of repositioning process. As such, it may be considered to be one of the best methods and it is being widely practised. On the other hand, other pressure relieving devices entail additional investment for the hospitals which in turn will affect the cost of treatment of the patients. Therefore, manual repositioning, in addition other advantages, also enjoys the benefit of lesser financial implication, and thus becomes the best suited method for prevention and treatment of pressure sores. Concepts and Terminology: Bottoming out : Expression used to describe inadequate support from mattress or Overlay or seat cushion as determined by a hand check if, when a fist is pressed into surface of mattress or seat and the supporting base can be felt, the item has” bottomed out”, and is no longer able to provide pressure relief. Debridement: Removal of devitalised tissue and foreign matter from a wound by various means i.e., chemical, surgical or autolytic debridement. Erythema : Redness of skin. Blanchable erythema: Reddened area that temporarily turns white or pale when pressure is applied with a fingertip. Blanchable erythema over a pressure site is usually due to normal reactive hyperaemia response. Non-blanchable erythema : Reddened area that remains red when pressure is applied Eschar: Thick, leathery, necrotic, devitalised tissue Exudat: Any fluid that has been leaked from a tissue or capillaries, more specifically because of injury or inflammation. Fascia: A sheet or band of fibrous tissue that lies deep below the skin that encloses muscles and various organs of the body. Friction: Mechanical force exerted when skin is dragged across a coarse surface such as bed linens. Pressure reduction: Reduction of interface pressure, not necessarily below the level to close capillaries. Pressure relief: Reduction of interface pressure below capillary closing pressure. Support surfaces Air fluidised bed: Bed which uses a high rate of air flow to fluidise fine particulate material (such as sand) to produce support surface that has characteristic similar to liquid. Alternating Mattresses: Mattress or overlay with interconnecting air cells that cyclically inflate and deflate to produce alternating high and low pressure intervals. Rubber ring device: A rigid, ring shaped device created to relieve pressure on the sitting surface Dynamic Mattress: Pressure reducing device designed to change its support characteristics in a cyclical fashion. Overlay: General term used to describe support surfaces placed on top of a standard hospital mattress. Static Mattress: Pressure reducing device designed to provide support characteristic that remain constant. (http://www.crestni.org.uk/publications/pressure_sores.pdf) The main participants in repositioning of inert patients are the attending nurses who are responsible for care of the patients, according to the repositioning schedule chalked out for each patient .But, it may be said, that a strict adherence to the Repositioning Schedule may not always be possible in each and every situation, due to shortage of qualified nurses, paucity of time and hectic schedule of the duty nurses. The health care providers, therefore, have to ensure that those concerned do strictly follow the repositioning schedules in letter and spirit and that policies being framed are implemented for the best advantage of the patients. Research Design: Elderly individuals or residents of long term care facilities will form the core target group for this study as they are most vulnerable to development of pressure sores. Data for the proposed study will be collected through several methods and will consider both the qualitative as well as quantitative aspects. First of all, the data bases of the hospitals will be used for acquiring personal, medical history and all other relevant materials of all patients suffering from pressure sores. Contemporary Literature available on the subject including books, newspapers, periodicals, Medical journal and Bulletins, Newsletters etc will be studied. Interviews with doctors, nurses, and carers will be highly beneficial, as they possess experience pf a long period of time in evaluation and treating pressure sores of the target group and also they directly interact with the patients. Apart from this, some patients suffering from pressure sores will also be interviewed. This will help in obtaining first hand information from the target group as to which particular method they are most comfortable with. In the last stage, comparison of repositioning with other methods, such as Static Mattresses, Alternating Air Pressure Systems, Constant Low Air Pressure and Air Fluidised Systems, Seating etc. will be made. The proposed study has concerned 10 hospitals situated in the locality. Six of these Hospitals are following repositioning as the primary preventive method for pressure sores, three hospitals are following fluid beds for treating pressure sore. One Hospital is using Electronic sensor mattresses. None of the hospitals are following a single exclusive method; instead all are using a combination of different methods, depending upon the physical condition of patients and availability of resources in terms of pressure reducing devices. The Hospital which is following the Electronic Sensor method caters to an elite clientele while the other hospitals offer medical services to middle class or lower income groups. Thus a fact emerges that while high profile hospitals are able to install costly devices, the implication of which ultimately goes back to the patients, ordinary hospitals generally prefer repositioning to other methods if prevention and treatment. In the second phase of the research, the data would be collected from the data base of the designated hospitals, doctors, nurses, and also from patients, wherever possible, and analysed from all aspects. The analysis of data would help in arriving at a conclusion as to which is the most suitable method in the prevention and treatment of pressure sores. Advantages: The most important advantage of the study will be its high reliability, because the data is collected directly from patients (Primary Data Collection) who are the real beneficiaries of the proposed study; and Medical professionals who are the care givers, and who over a long period of time, have been practicing in this area. Therefore they have vast practical experience and a very realistic understanding as to the effectiveness of each method on different types of patients. They have a clear idea about which method suits which patients, which is the ideal method for a larger segment of the population. Moreover, they have dealt with numerous cases and through practices over a long period of time, they have gained sufficient insight into the effectiveness of each method and also which method suits which individual. Another advantage is that, the hospitals one located in the local area and therefore data collection will be easier, and can be done within a limited period of time and resources. Disadvantages: As far as health care professionals are concerned, time constraint due to hectic schedule may be a constraint sparing enough time for the researcher. Another disadvantage is the attitude and lack of readiness to part with information or giving incorrect information due to insufficient understanding as the target group mainly consist of elderly persons. Pilot Study: As the study is confined to a small cross section of the health care industry within a small geographical area, a pilot study doesn’t seem warranted in this case. Emergency Situations: Though all visits will be pre-scheduled by taking prior appointments from the concerned health care professionals and others, unforeseen emergencies, within in the hospitals, may break the rhythm of the research activity. Patients may also develop some unexpected complications that may disrupt the schedule. To ensure that one interruption does not break the cycle of meetings, one day break in the middle will be given in a five day week cycle while arranging the schedule of the meetings. In case, the meeting followed as per schedule, this break will be used for other research activities like review of literature, compilation of information etc. Questionnaire 1. Name of the patient 2. Age 3. Gender 4. Name of the hospital 5. Primary method of treatment for pressure sore 6. What, in your opinion, is the most effective method? 7. What are the most visible advantages of this method as compared to the other method? 8. Do you have any suggestions that would help make this method more effective? Data analysis Information collected from hospital databases and through the above questionnaire, will be analysed using Pie Chart. With the help of this method it becomes to present the effectiveness of different methods used in the treatment of pressure sores. The chart would depict the most widely used method by showing the widest area in a different colour so that any person who is using it would get a first glance impression of which method is most widely accepted. In some cases bar graphs also can be used to comprehensively represent the data available. The most widely used method (repositioning in this case) will be represented through the tallest bar. Ethical issues: In this research proposal, the ethical issues are concerned with confidentiality and consent. The question is whether the researcher will be able to protect the identity of those who are participating in it since many participants may not prefer their identity to be revealed. Moreover, it needs to be determined whether the direct written consents of participants are necessary and if so they have agreed to an acceptable process for it. Confidentiality is a concern for every data collected for the research purpose. It aims to protect the identity of the participants, and all measures will be taken to prevent leakage of information or access to information by unauthorised individuals. Timetable: The proposed study would take about 120 days. During this period the research would cover 10 hospitals in a local setting. The time allocated for each hospital is a 5 day week with 1 day break in the middle (Wednesday). Collection of data will be primarily through personal interviews with doctors, nurses, carers, etc. Information will also be taken from hospital database and the whole process would take an average of 50 days. Suggested timeframe for collection of data from patient sources would be around 15 days. Collection of data from libraries, archives would take around 20 days. The balance 35 days would be utilized for analyzing the data, compilation, preliminary editing, proof–reading, final editing and submission. Resources: The books and other literature to be referred would be available from the Local libraries. In addition, hospital resources can also be utilised. Photocopying of documents wherever required would be done by utilising the photocopying facilities available within the Library premises itself. Since the collection of Data is through personal visits, the incidence of postage is quite negligible. The Travelling includes visits to all relevant places such as hospitals, libraries and authorities through own vehicle. Printing and other miscellaneous work would be done locally using own resources. Works Cited DOH 1994: Nurse Executive Directors Meeting. Available from: http://www.publications.doh.gov.uk/cno/cnobulletintissueviability.pdf [Accessed on 1st December, 2006]. Home Page: National Pressure Ulcer Advisory Panel: Available from: http://www.npuap.org/positn6.html [Accessed on 1st December, 2006] Effective Healthcare: The Prevention and Treatment of Pressure Sore October 1995 (Page2). http://www.york.ac.uk/inst/crd/ehc21.pdf [Accessed on 1st December, 2006]. Home Page, NICE: National Pressure Ulcer Risk Assessment and Prevention: Available from: http://www.nice.org.uk/pdf [Accessed on 1st December, 2006]. Guidelines for Prevention and Management of Pressure Sore: Recommendation for Practice – 1998. Available from: http://www.crestni.org.uk/publications/pressure_sores.pdf [Accessed on 1st December, 2006]. Your Turn: Campaigning to Prevent Pressure Sores. Available from: http://www.your-turn.org.uk/images/Your_Turn_P_flyer.pdf [Accessed on 1st December, 2006]. Crest Guideline for the Prevention and Management of Pressure Sore, Recommendations for Practice October1998. Available from: http://www.crestni.org.uk/publications/pressure_sores.pdf [Accessed on 1st December, 2006] National Institute of Clinical Excellence, Pressure Ulcer Risk Assessment and Prevention April 2001. Available from: http://www.nice.org.uk/pdf/clinicalguidelinepressuresoreguidancenice.pdf [Accessed on 1st December, 2006] CREST Guidelines for the Prevention and Management of Pressure Sores. Recommendations for Practice October1998. Available from: http://www.crestni.org.uk/publications/pressure_sores.pdf [Accessed on 1st December, 2006] Journal of Clinical Nursing volume 13, issue8, November 2004 (authors: Zena Moore and Patricia Price) Available from: http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2702.2004.00972.x/abs/ [Accessed on 1st December, 2006] Bennett, G (2004): Cost of Pressure Ulcers in UK Annexure-I: Braden scale – For Preventing Pressure Risk: Guidelines for the Prevention and Management of Pressure Sores (Page 21): Recommendation for Practice: October 1998. Available from: http://www.crestni.org.uk/publications/pressure_sores.pdf [Accessed on 1st December, 2006] Annexure-I Read More