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Pressure Ulcer Examination

Although modern medicine has reached a lot in preventing severe illnesses, some of them are still difficult to cure. An example is pressure ulcer, a damage which appears as a result of a prolonged pressure on tissues. Every patient is exposed to the injury, as the ulcers emerge in case of individuals’ inability to move. The project proposes modern proactive measures to be implemented during the patients’ hospital stay to prevent appearance of the pressure ulcers.

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The Spirit of Inquiry Ignited

Pressure ulcer is a treatable medical illness. Being an underestimated disease, PU can emerge spontaneously and cause considerable troubles for a recipient. The vulnerable to the disease individuals are those who have specific medical conditions that limit their mobility and ability to switch positions. Those individuals who spend most of the time in bed are also exposed. The PU can develop quickly and unexpectedly, and, while some injuries can heal over time, some traumas do not heal over time at all. Thus, the importance of appropriate care to prevent the disease is undeniable.

The PICOT Question Formulated

The PICOT question is the following: among the patients identified as those with high risk for pressure ulcer progression (P), does the implementation of a pressure ulcer protocol initiated in the emergency department (I) compared to usual treatment of patients with predisposition for pressure ulcer (C), reduce the incidence of acquired during a hospitalization pressure ulcers (O) within a 3-day period of hospital admission (T)?

Search Strategy Conducted

CINAHL, PubMed, Cochrane Database of Systematic Reviews, the National Guideline Clearinghouse, and TRIP Database were used to search the scholarly articles related to the issue of pressure ulcers. The utilized keywords were the following: Pressure ulcer, pressure ulcer protocol, hospital-acquired pressure ulcer, emergency department. The discovered studies examined the emergence of pressure ulcers and the effective measures for the prevention of the disease. The search process allowed discovering several level I evidence studies.

Critical Appraisal of the Evidence Performed

The project evaluates several researches on the matter of emergence of pressure ulcers during a hospital admission. A study conducted by Behrendt, Ghaznavi, Mahan, Craft, & Siddiqui estimated the 422 patients’ skin and overall condition (2014). The research allows comparing the continuous bedside pressure mapping (CBPM) implementation with the ordinary pressure ulcer protocols. The level I evidence of the study showed that nurses can use CBPM devices to enhance the effectiveness of patient repositioning interventions.

A pragmatic randomized controlled trial by Gunningberg, Sedin, Andersson, & Pingel, observed and controlled 190 patients’ condition in a Swedish hospital (2017). The stress of the ulcer prevention exploration was on the patients’ continuous observance by the nurses. The eligible patients of over 50 years old were observed using the digital pressure mapping system. This level I evidence failed to demonstrate drastic positive change in pressure ulcer prevention, but the authors assure the material contains useful information, can be used as a manual by nurses, and should be further investigated.

Another study, “Early detection of pressure ulcer development following traumatic spinal cord injury using inflammatory mediators”, involved 67 patients divided into several groups (Krishnan et al., 2016). Those individuals with pressure ulcers and plasma samples, with pressure ulcers and urine samples, were matched accordingly with the patients suffering from spinal cord injury but with no pressure ulcers. The study explored hospitalization-related causes of the disease using secondary analysis of the data. Being a level I study, this research proposes that the altering levels of inflammatory mediators can precede the pressure ulcers of the SCI patients.

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The other research by Shi, Dumville, & Cullum included 42 studies of patients with high risk of pressure ulcer (2018). The focus of the level I evidence study is on skin examination of the patients. The outcomes imply that the connection between erythema condition and appearance of pressure ulcers lacks evidence.

The last study included in the project examined condition of patients aged 50 or older (Swafford, Culpepper, & Dunn, 2016). The level I evidence included sufficient design, methodology, and support during the research. A result of the study is a strong evidence of combined interventions significantly reducing the incidence of pressure ulcers in patients.

Evidence Integrated with Clinical Expertise and Patient Preferences to Implement the Best Practice

Evaluation Plan

The purpose of this project based on the evidence is to decrease percentage of pressure ulcer emergence among the patients that are at a high-risk group. In order to achieve the goal, hospital staff should implement several changes in the patient care. The clinical question proposed according to the plan is the following: are precise observation, CBPM usage, and regular repositioning can decrease risk of pressure ulcer emergence compared to standard protocols? Estimated time for the intervention to act is 3 days, as evidence shows that pressure ulcers during short-term treatments typically develop within the three-day period of hospitalization. The stakeholders involved in the program implementation are the patients at risk and the nurses, but the hospitals might also need aid from the investors for CBPM devices.

Methods

The theoretical framework of the project includes complex system theory which aims to decrease the risk of PU from various approaches. The design of the project should be experiment-based, as the theory implies the results can be received solely after proper examination of the patients. The main independent variables that should be included are age, gender, length of stay, pressure on ulcer-susceptible points, nurse workload, and nursing skills to examine the emergence of PU. The data received from patients will be strictly ciphered according to a hospital confidentiality policy.

The selected 100 patients will include individuals from 18 to 65 years who are at risk of PU. The hospital capabilities and nurse staff will aid in the procedure. After admission, the patients will be observed and given proper care with CBPM devices, skin observations and other intensive protocols. The data will be measured at the end of the 3 days trial to define positive changes in the patients’ condition and the risk of PU. The used instruments for the assessment will be the nurses’ detailed reports.

Outcome of Practice Change Evaluated

The main evaluated data of the project will be incidence of pressure ulcers among the patients involved in the trial. The results will be formed according to the nurses’ reports and observations. The major aspects of the project will be compared to the initial data. The planned result will be achieved when the percentage of patients diagnosed with PU after the 3-day hospital stay remain 0% with a minimum deviation.

Project Dissemination

The results of the evidence-based project will be disseminated to the hospital nurses and staff. Senior nurses along with those who were direct participants during the experiment will receive reports and discuss the results during several meetings. Each conference will cover different method of alternative PU protocol so that the participants can decide on the most appropriate measures. The results of the study will be publicly available to promote the findings of PU elimination.

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Conclusion

In conclusion, the project aims to eliminate the risk of pressure ulcer emergence among the hospital patients. The research revealed several studies which encourage using proactive alternative methods of preventing PU. The complex systems theory and the experiment-based design were formed to create the study framework. The expectation of the experiment is elimination of PU risk and prevention of emergence of the disease after 3 days of hospital stay.

References

Behrendt, R, Ghaznavi, A. M., Mahan, M., Craft, S., & Siddiqui, A. (2014). Continuous bedside pressure mapping and rates of hospital- associated pressure ulcers in a medical intensive care unit. American Journal of Critical Care, 23(2), 127-133.

Gunningberg, L., Sedin, I. M., Andersson, S., & Pingel, R. (2017). Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial. International Journal of Nursing Studies, 72, 53-59.

Krishnan, S., Karg, P.E., Boninger, M.L., Vodovotz, Y., Constantine, G., Sowa, G.A., & Brienza, D.M. (2016). Early detection of pressure ulcer development following traumatic spinal cord injury using inflammatory mediators. Archives of Physical Medicine and Rehabilitation, 97(10), 1656-1662.

Shi, C., Dumville, J. C., & Cullum, N. (2018). Skin status for predicting pressure ulcer development: A systematic review and meta-analyses. International Journal of Nursing Studies, 87, 14-25.

Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155.

Appendix

  • Exploring the Literature
Research Tool Search Tips Search Terms & Limits Findings Features
CINAHL
CINAHL is an SSU subscription-onlyresource that offers full text access to; 336 scholarly journals and indexes over 3,000 journals from the fields of nursing and allied health.
  • Look at the Major Subject Heading in the Full Record
  • Use the Limits Feature:
    • Example: Publication Type=Systematic Review
  • Try the CINAHL Heading search:
Keyword search: Pressure ulcer, pressure ulcer protocol, hospital-acquired pressure ulcer, emergency department.
Limits:
Article is required to be in free access, full text must be available, date of publication has to be within the last 5 years. Target population: Adult.
CINAHL Heading search:
D003668, D004636
Limits:
All terms.
132 Has an elaborate search engine, which allows input of all necessary information in order to narrow down the research, and find accurate results pertaining the subject. The greatest flaw of CINAHL is that it requires a paid subscription in order to be useful.
PubMed
PubMed is a free health science citation & abstracts index from the National Center for Biotechnology Information at the U.S. National Library of Medicine.
  • Look at MeSH Terms in Full Record
  • Use the Limits Feature:
    • Examples: Article Type=Meta-Analysis; Age=All Adult
  • Look for the open access Free articles!
Keyword search: Pressure ulcer, pressure ulcer protocol, hospital-acquired pressure ulcer, emergency department.
Limits:
Article is required to be in free access, full text must be available, date of publication has to be within the last 5 years. Target population: Adult.
MESH search:
D003668, D004636
Limits:
All terms.
102 The search engine is intuitive and easy to use. Implementation of keywords allows for quick and relatively accurate search. However, I found the MeSH system to be counterintuitive and not very useful for researches that do not require in-depth research.
Cochrane Library
Cochrane Library provides access to the Cochrane Library of Systematic Reviews.Full text of reviews are subscription only.Index/summaries are a public resource.
  • Use the Simple Search and the Advance Search Features
  • Allows you to search with MeSH Terms
  • Check out the New Reviews

Browse reviews by topic

Keyword search: Pressure ulcer, pressure ulcer protocol, hospital-acquired pressure ulcer, emergency department.
Limits:
Article is required to be in free access, full text must be available, date of publication has to be within the last 5 years. Target population: Adult.
MESH search:
D003668, D004636
Limits:
All terms.
35 The advanced and simple search functions are very rudimentary and counter-intuitive. There was no box to flag the “free full text” articles, which made the research a lot harder. MeSH search had limited use due to a developed tagging system of the library.
National Guidelines
Clearinghouse
The National Guideline Clearinghouse™ (NGC) is a public resource for evidence- based clinical practice guidelines.
  • Detailed search provides limits and advance search features
  • Browse by Disease/Condition or Treatment/Intervention
  • Add guidelines to “My Collection” and select Compare Guidelines to view side-by-side comparisons of principle data
Keyword search:
Pressure ulcer, pressure ulcer protocol, hospital-acquired pressure ulcer, emergency department.
Also browse by:
Disease/condition, treatment/intervention.
40 An excellent public source with an intuitive and easy-to-use search engine as well as a very useful tool of data comparison between different articles and guidelines.
TRIP Database
TRIP is a clinical search engine to locate publicly available clinical evidence.
  • Limit to:
  • Systematic Reviews
  • Guidelines-US
Keyword search:
Pressure ulcer, pressure ulcer protocol, hospital-acquired pressure ulcer, emergency department.
Limits:
Article is required to be in free access, full text must be available, date, of publication has to be within the last 5 years. Target population: Adult. Limited to US guidelines.
20 Potentially, a very useful database, as it contains detailed information by year, by country, by year, by type, etc. However, restrictions upon the advanced search function of the site severely hamper the usability of the search engine.
Other Databases: N/A N/A N/A N/A
  • Evidence Synthesis
Database: PubMed Study #1 Study #2 Study #3 Study #4 Study #5 Synthesis
(p) Population Critically ill patients aged between 18 and 65 years, placed in ICU. Patients aged 50 or above, placed in a geriatric ward for 3 days or longer. Individuals diagnosed with ulcers Hospitalized adults in long-term care and patients already having pressure ulcers. Patients aged 50 or older admitted to the IC unit. Populations susceptible to pressure ulcers are typically 50 years or older.
(i) Intervention Mapping pressure ulcers using continuous bedside pressure mapping (CBPM), turning patients every 2 hours. Repositioning of patients based on continuous bedside pressure mapping data. Retrospective study, no intervention. None, systematic review. Risk categories based on age, nutrition, physical state, and prevalence. Revised skin care protocol. Fluidized repositioners. Silicone adhesive dressings. Popular interventions involve pressure scanning, repositioning, and using silicone bandages.
(c) Comparison Standard ulcer-prevention protocols. Standard ulcer-prevention care. Individuals with SCI and no pressure ulcers. Individuals with no skin damage associated with pressure ulcers. Standard ulcer-prevention protocols. All comparison groups were using standard ulcer-prevention protocols.
(o) Outcome Reduction of ulcer development outcomes from 4.8% to 0.9% in comparison to the control group. No significant reduction of ulcer development in the test group. Results comparable to the control group. Concentration of chemokine in plasma and interferon-alpha in urine was observed before the appearance of first ulcers. Small amounts of evidence of relation of non-blanchable erythema being linked to faster development of pressure ulcers. 69% HAPU incidence reduction in the ICU. Nearly all presented studies showed a decrease in pressure ulcer prevalence.
(t) time Two months. 14 days of observation per group, 9 months in total. One week. Studies included in the systematic review were published between 1937 and 2017. 12 months, 14-day periods. Times for study performance varied. 7-14 day intervention periods.
  • Evaluation Table
Citation Design Sample size: Adequate? Major Variables:

Independent Dependent

Study findings: Strengths and weaknesses Level of evidence Evidence Synthesis
Behrendt, R, Ghaznavi, A. M., Mahan, M., Craft, S., & Siddiqui, A. (2014). Continuous
bedside pressure mapping and rates of hospital- associated pressure ulcers in a medical intensive care unit. American Journal of Critical Care, 23(2), 127-133.
Quantitative. Randomized controlled trial. Yes. Independent: Age, sex, length of stay, ventilator time, mean arterial pressure, Braden score, pressure on ulcer-susceptible points.
Dependent: Incidence of pressure ulcers in patients.
CBPM in combination with frequent patient turning (once every 2 hours) resulted in significant reduction of ulcer incidence (Behrendt, Ghaznavi, Mahan, Craft, & Siddiqui, 2014). Strengths: Study design.
Weaknesses: Sample size, restrictive definition of HAPU.
Level 1 evidence. CBPM can be used to enhance the effectiveness of patient repositioning interventions.
Gunningberg, L., Sedin, I. M., Andersson, S., & Pingel, R. (2017). Pressure mapping to
prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial. International Journal of Nursing Studies, 72, 53-59.
Quantitative. Randomized controlled trial. Yes. Independent: Age, sex, length of stay, pressure on ulcer-susceptible points, nurse workload, leadership skills, nursing skills.
Dependent: Incidence of pressure ulcers in patients.
The study found no significant correlation between the use of CBPM and ulcer rate improvement (Gunningberg, Sedin, Andersson, & Pingel, 2017).
Strengths: Study design, number of participants.
Weaknesses: The intervention was not double-blinded.
Level 1 evidence. Evidence from this source contradicts with findings of the one presented above, indicating that there might be other factors determining CBPM effectiveness.
Krishnan, S., Karg, P., Boninger, M., Vodovotz, Y., Constantine, G., Sowa, G., & Brienza, D.
(2016). Early detection of pressure ulcer development following traumatic spinal cord injury using inflammatory mediators. Archives of Physical Medicine and Rehabilitation, 97(10), 1656-1662.
Quantitative. Retrospective analysis. Yes. Independent variables: Chemical analysis of plasma and urine.
Dependent variables: First pressure ulcer incidents.
The appearance of pressure ulcers is associated with increased concentrations of chemokine and cytokine interferon in plasma and urine (Krishnan et al., 2016).
Strengths: Study design.
Weaknesses: Secondary analysis.
Level 1 evidence. Frequent blood and urine analyses of bedridden patients could be used to determine risks of developing pressure ulcers.
Shi, C., Dumville, J. C., & Cullum, N. (2018). Skin status for predicting pressure ulcer
development: A systematic review and meta-analyses. International Journal of Nursing Studies, 87, 14-25.
Quantitative, systematic review of evidence. Yes. Independent variables: 15 skin descriptors.
Dependent variables: Incidence of pressure ulcers.
Weak evidence of non-blanchable erythema being associated with the development of pressure ulcers (Shi, Dumville, & Cullum, 2018).
Strengths: Study design, large sample.
Weaknesses: Inconclusive results, methodological and consistency limitations.
Level 1 evidence. Additional studies may be required in order to determine whether non-blanchable erythema is connected to pressure ulcers.
Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce
the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155.
Quantitative. Randomized controlled trial. Yes. Independent variables: application of CBPM, silicon-based dressings, overall reduction of continuous pressure.
Dependent variables: Incidence of pressure ulcers.
Strong evidence of combined interventions significantly reducing the incidence of pressure ulcers in patients (Swafford, Culpepper, & Dunn, 2016). Strengths: Study design, methodology, evidence-based support.
Weaknesses: Increased numbers of nursing staff.
Level 1 evidence. The utilization of CBPM, patient repositioning, and adhesive silicon-based dressings can significantly reduce HAPU.

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