Evidence-Based Pressure Ulcer Prevention

Pressure Ulcer is commonly experienced by hospitalized adults. This skin condition is otherwise known as bed sores to which the patient’s skin as well as its underlying tissue breaks down due to pressure caused by prolonged non-movement of the affected skin areas. It provides discomfort to the patient especially to those who have medical conditions, which disable them from changing position. Pressure Ulcer can develop rapidly. However, there are several things that can help in prevention and help the patient in the healing process. The purpose of this paper is to develop a plan as to how the Pressure Ulcer can be prevented based on the evidence presented in the articles including the identified solution to the problem. The change plan will help the development of nursing practice when it comes to Pressure Ulcer and suggests that repositioning and turning the patient constantly will help in preventing the occurrence of this skin condition.

Change Plan Using John Hopkins EBP Model

Overview

The John Hopkins Nursing EBP model or JHNEBP is a framework that is used to guide the translation of gathered evidence into practice (Buchko, 2012). It has encompasses three nursing foundations such as education, practice, and research. Nurses should use this model to as a guide to facilitate change because it includes both non-research and research evidence as they create basis for nurses’ decision making. Thus, this model also proves that both external and internal factors should be put in consideration before existing nursing practice may be changed.

Practice Question

Step 1 – Recruiting inter-professional team will be composed of nurses, attending physician, and nursing aid.

Step 2 – The Evidence-Based Practice (EBP) question is “Do frequent turning of patients lead to reduction of occurrence of pressure ulcers in hospitalized adults?” For PICO elements, it is identified that (P) is the hospitalized adults that suffer from Pressure Ulcer; (I) would be the intervention approach of the problem, which is the frequent turning of the patient to prevent or recover from Pressure Ulcer symptoms; (C) is the considered alternative in treating the Pressure Ulcer such as using special cushions and mattresses, which can help in relieving the pressure in affected skin areas; and (O) pertains to the gradual healing of skin tissues that suffered from Pressure Ulcer.

Step 3 – Pressure Ulcer prevents the patient from a complete recovery as it provides addition pain due to damaged skin tissues. Cases of Pressure Ulcer continue to increase. In fact, Sullivan (2013) says that it increased by 80% between 1995 and 2008. Not only in the hospital, but residents of nursing homes also suffer from Pressure Ulcer and was reported that there was an approximate of 11% case increase in 2004 (Sullivan, 2013). This problem affects the healthcare on a broader scale. It provides additional healthcare facility costs, which may not be covered as it is a hospital-acquired health condition. Thus, the overall nursing practice will be more challenging due to the occurrence of Pressure Ulcer among adult patients.

Steps 4 and 5 – The team, which is composed of nurses, attending physician, and nursing aid will have their vital roles in achieving the targeted design for change. They are important as they hold different responsibilities. The nurses are responsible for ensuring that existing Pressure Ulcer will not become worse by constant checking the affected skin. The attending physician is responsible for knowing if there would be any other medical implication due to Pressure Ulcer occurrence. He is also responsible for providing additional medication, if needed, besides the existing medical condition. The nursing aid is responsible for providing assistance when it comes ensuring that the patient’s affected skin areas are well-ventilated through constant repositioning of the patient’s body. In combining their essential roles and responsibilities, prevention and treatment of Pressure Ulcer will be easier to achieve.

Evidence

Steps 6 and 7 – The change plan is supported by evidence to which the guidelines of handling patients with Pressure Ulcer are presented. Whitney et al. (2006) say that Pressure Ulcer is one of the challenges of health care providers. The change plan plans to prevent the increasing occurrence of such skin condition to which the articles stated that there were almost 3 million patients affected in the United States alone (Whitney et al., 2006).

The research encompasses insights from clinical experts as well as their opinion about the problem. Scientific evidence were also presented in the research such as proper patient positioning, nutrition, support surfaces, preparation of wound bed and dressing, and the underlying principles that were developed per category. The research’s quality improvement data was presented in a form of various guidelines and nursing principles. One of the strength of this research is its ability to provide detailed guidelines as to how the Pressure Ulcer can be handled accordingly without providing additional sufferings to the patient. It also highlights the principle behind every guideline in order to explain why such guideline must be followed during the treatment process.

Steps 8 and 9 – The evidence shows that frequent turning of patients will help in the reduction of the occurrence of Pressure Ulcer. There are various articles that presented the similar views and presumptions pertaining to the proper treatment of Pressure Ulcer. Kaitani, Tokunaga and Sanada (2010) suggest that there are risk factors that are related to the occurrence of Pressure Ulcer especially in critical care setting. One of the risk factors may start during the admission stage of the patient. The critical care setting involves medical conditions that will decrease the patient’s ability to move and change position from time to time. Therefore, it is important to know that at the beginning of admission stage, health care providers must be aware that the occurrence of Pressure Ulcer is high. In fact, almost 40 percent of the patients who suffer from Pressure Ulcer are the ones who are in the critical care setting or intensive care unit (Kaitani, Tokunaga & Sanada, 2010).

The authors concluded that that there is no connection between the occurrence of Pressure Ulcers among patients and the involve medication. Therefore, the frequency of positioning and turning the patient especially in the ICU is a prognostic indicator as to whether Pressure Ulcer will occur. This is also to reduce the probability of extended admission of the patient in the hospital.

The redistribution of the pressure is the main goal of repositioning the patient in order to prevent the occurrence of Pressure Ulcer. Sprigle and Sonenblum (2011) assert that such skin condition occurs when there is a constant pressure on the affected skin area. That is why; it is essential to conduct a pressure magnitude management through postural supports and support surfaces as well as proper body posture.

This approach can be done through weight shifting and turning frequency including the use of dynamic surfaces (Kaitani, Tokunaga & Sanada, 2010). Besides frequent turning, positioning device can also help in distributing the weight of the patient and improving the blood flow on skin surface. Therefore periodic repositioning of the patient combined with the positioning device are two important preventive methods against Pressure Ulcer and ideal supporting treatment procedure for existing Pressure Ulcer.

Generally, the standard turning by nurses in intensive care unit or ICU does not consistently unload all the areas of skin-bed interface pressures (Peterson et al., 2010). The standard of handling patients with Pressure Ulcer is to prevent most of the skin areas to be under pressure to avoid tissue damage. However, evidence shows that even with the presence of frequent turning and repositioning is not a guarantee that Pressure Ulcer will not occur as there are still skin areas that are at risk of tissue breakdown (Peterson et al., 2010).

Conversely, using the support materials is also not an assurance to prevent the occurrence of this skin condition. Such materials for maintaining the patient’s turned position may also influence the tissue unloading, which may jeopardized the affected areas. Therefore, it is presumable that there is still a gap between the theory and practice when it comes to Pressure Ulcer management.

Moore (2010) says that besides the increased length of stay in the hospital, Pressure Ulcer may also increase the health service costs. However, such condition is preventable through proper management in order to provide strategically-planned health service. One of the strategies that can be used is the 30 degrees tilting of the patient’s body to avoid too much pressure on the skin (Moore, 2010). Based on the evidence presented, repositioning the patient who is at risk of Pressure Ulcer every three hours using this tilt technique will reduce the possibility of Pressure Ulcer occurrence.

Step 10 – Based on the gathered evidence, the recommendation to prevent potential Pressure Ulcer is to conduct a constant turning of patient every 3 to 4 hours depending on the patient’s body weight. The heavier the patient is the shorter the time interval must be applied in repositioning the patient’s body. Thus, it is also recommended that patients, especially adults in ICU department must use positioning materials if possible. In this case, the body’s weight will be distributed evenly along with the frequent turning technique. It is also recommended to apply the 30 degrees tilt on the patient so that the weight will not produce too much pressure on the skin’s interface. Thus, the gravity pull will not be focused on the pressured area.

Steps 11, 12, 13, and 14 – The plan for implementing the change will be based on the steps that need to be followed. Important procedures must emphasize on the implementation stage. This will be followed by the importance of conducting such procedures based on the evidence, which will also be presented. There will be a specified timeline to ensure the smooth transition for old to standard practice to developed change plan. For the first quarter of the year, an initial outcome will be evaluated using statistical reports of occurrence of Pressure Ulcer. A ratio between the number of patients and Pressure Ulcer occurrence will be the basis of quarterly reports, which are targeted to decrease after the fourth quarter. The reports will include the total number of patients within the first three months, patients at risk of the skin condition, and the number of repositioning done in every patient.

Steps 15 and 16 – The desired outcome of the proposed change is to reduce the occurrence of Pressure Ulcer among adult patients especially in the critical care setting or ICU. It also aims to increase the awareness of techniques on how to apply the recommended strategies of the health care workers. The outcome will be measured based on the reports filed by the nursing staff, which is done separately from the existing medical condition of the patient. The results will be reported to the stakeholders in a quarterly basis, emphasizing how the strategies were conducted and what the specific results were.

Step 17 – The plan will be implemented on a larger scale to which other units will be included. The plan will primarily start on the intensive care unit for the first quarter and will also be implemented to regular hospital ward after the first three months. To ensure that the plan will be implemented permanently, it will be raised to the office of the director to be one of the standard procedures of the hospital. Therefore, whether or not the patient is in ICU, constant monitoring of potential Pressure Ulcer will be part of the nursing round.

Step 18 – Findings will be disseminated internally through monthly meetings to provide developments after the implementation. On the other hand, it will be externally disseminated by providing its advantages to other hospitals and healthcare setting. If possible and available, strategies, techniques and findings will be published on the hospital’s website to spread awareness throughout the concerned public.

Conclusion

Pressure Ulcer is an important problem that every health care provider must be aware of. The evidence presented is clear representation that such condition is preventable. Thus, should not be the reason for patients to extend their hospital confinement. The change model will ensure that every involved healthcare professional will be responsible in ensuring that the Pressure Ulcer will be prevented and treated accordingly to those who are already suffering from it. The three levels of change based on John Hopkins EBP process are essential aspects for the implementation of the change plan. Understanding the practice question would be the foundation of the process to which PICO elements will be analyzed for the success of change plan. On the other hand, the evidence will be the basis of the change plan as to how the and why the change plan is needed for the improvement of health service. Thus, the translation is the period to which the implementation will take place. It is essential to have these three levels of change so as to develop a strategic plan of the proposed change. In this case, once the plan has been implemented and permanently practiced, the occurrence of Pressure Ulcer will significantly decrease, which will help in the patient in the treatment process.

References

Buchko,B.L., & Robinson,L.E. (2012). An Evidence-based Approach to Decrease Early Post-operative Urinary Retention Following Urogynecologic Surgery. Society of Urologic Nurses and Associates, 32(5), 260-264.

Kaitani,T., Tokunaga,K., Matsui,N., & Sanada,H. (2009). Risk factors related to the development of pressure ulcers in the critical care setting. Journal of Clinical Nursing, 19, 414-421.

Moore,Z. (2010). Bridging the theory-practice gap in pressure ulcer prevention. British Journal of Nursing, 19(5), s15-8.

Peterson,M.J., Schwab,W., Van Oostrom,J.H., Gravenstein,N., & Caruso,L.J. (2010). Effects of turning on skin-bed interface pressures in healthy adults. Journal of Advanced Nursing, 66(7), 1556-1564.

Sprigle,S., & Sonenblum,S. (2011). Assessing evidence supporting redistribution of pressure for pressure ulcer prevention: A review. Journal of Rehabilitation Research & Development, 48, 203-214.

Sullivan,N. (2013). Preventing In-Facility Pressure Ulcers. In Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville City, MD: Agency for Healthcare Research and Quality.

Whitney,J., Philipps,L., Aslam,R., Barbul,A., Gittrup,F., Gloud,L., . . . Robson,M.C. (2006). Guidelines for the treatment of pressure Ulcers. Wound Healing Society, 14, 663-679.