Hospitalized adults ages 65 years and older are at the highest risk for developing decubitus ulcers. Their decreased muscle strength and endurance leading to limited physical mobility causes them to develop pressure ulcers (Smeltzer, Bare, Hinkle, & Cheever, 2008). Without the ability to ambulate and move about on their own, they are less likely to engage in physical activities and are more prone to staying in bed most of the time. The experienced pain when moving about and the reluctance to care for themselves decrease their likelihood of engaging in physical mobility.
These factors worsen their condition and predispose them to the development of pressure ulcers. As nurses who care for elderly patients in the hospital, there is a need to identify the best method to prevent the formation of pressure ulcers among elderly hospitalized patients. The traditional method of preventing pressure ulcers among hospitalized patients is frequent repositioning of patients in bed every two hours. However, there are growing evidences that pressure-relieving mattresses also prevent the formation of pressure ulcers in hospitalized elderly patients who are immobile (Kozier, Erb, Berman, & Snyder, 2004).
Given these two known effective methods in providing health care to the target patients, a clinical inquiry or question regarding the best method that will address the problem is identified (WCSU Libraries, n. d. ). PICOT Question Based on the stated conditions in the previous paragraph, the nurse poses the research question that will guide the nurse in seeking evidences to support the answer on which method should be used to prevent the pressure-ulcer problem among elderly hospitalized patients.
The nurse uses an organized format for developing the clinical research question, which is the PICOT format. Each letter in the term PICOT corresponds to each step that the nurse identifes in developing the clinical research question. P stands for “patient population”; I stands for “intervention or issue of interest”; C stands for “comparison intervention or comparison group”; O stands for “outcome”; and T stands for “time” (Arizona State University [ASU], n. d. ).
In this case, the formulated clinical question is: In elderly hospitalized patients 65 years and older, who are immobile and are at risk for pressure ulcer as per the Braden scale, does rotating position every two hours on a traditional hospital bed in an acute setting more effective in decreasing the incidence of pressure ulcers when compared with pressure-relieving mattresses? The formulated key words are: elderly hospitalized patients 65 years and older (P), use of rotating position every two hours on a traditional hospital bed (I), use of pressure-relieving mattresses (C), and decreased incidence of pressure ulcers (O).
It is not applicable to use a time frame (T) for this question. Search Strategies and Critique of Studies The researcher used the CINAHL Plus and PubMed search engine databases to find research articles and journals that will provide evidences in answering the PICOT question. Using the keywords generated, different valid studies that are related to the topic were reviewed by the researcher. Studies were included in the appraisal if they tackle the topic on pressure ulcers and comparative analysis of different preventive methods were used.
In addition to this, only new studies since 2007 were included and critically appraised. The researcher found five relevant research studies in answering the clinical question posed. The following paragraphs will provide a thorough article critique of the five research studies found. The first study, entitled ‘Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions,’ is a randomized control study conducted among patients in an elderly institution.
This study compares the significant difference of reduction in incidence of pressure ulcers among the patients between the use of repositioning the clients in pressure-reducing mattresses at two-hour and at four-hour intervals (Vanderwee, Grydonck, De Bacquer, & Defloor, 2007). The use of subjects from a geriatric home care unit makes this study very relevant in terms of population group given that the target population whom the researcher is determining the best method of care is the elderly group ages 65 years and older.
The authors of this research article are credible professionals who are expert in their field. Thus, it can be inferred that the direction that the research took is a highly systematic and empirical manner carried out by health professionals. This study is significant because a review of current literature shows that there is little research done to provide empirical evidence on the correct frequency of turning that will result in a significant decrease in the incidence of pressure ulcers. This prompted the direction of the research, to determine the ideal time interval or frequency of turning.
However, it should be noted that the the study was not able to look into foundational literature regarding recommended hours of turning. Also, there is not enough basis for comparing the two-hour and four-hour intervals. Thus, the question for using these specific time intervals can be posed. Moreover, there is not enough discussed rationale to inform readers of the study’s choice to compare the specific time intervals used in the research. On this note, the results of the study show that there is no significant difference between the control and treatment groups in terms of decreased incidence of pressure ulcers (Vanderwee et al.
, 2007). Going back, it is plausible that the lack of a significantly rational supporting basis for using the time-intervals can be reflected in the lack of significant statistical results in the study. However, the authors’ work are commendable for their use of a true experimental design. The control of variables helped minimize unnecessary outside factors or variables from affecting the research. The authors’ logical approach in concluding that the comparative preventive methods are just similar and that neither of the two is a more effective method also relates to the presented PICOT question.
This shows that the combination of turning and use of pressure-reducing mattresses do not result in a larger decrease in the incidence of pressure ulcers. From here, it can be suggested that the two interventions should be compared separately to see if there is a significant difference between them. The second study, ‘The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis,’ provides a highly empirical approach in providing a valid literature work on the prevention of pressure ulcers.
This study used researches from different electronic databases such as CINAHL, PubMed, MEDLINE, and Cochrane databases to gather and collate studies that compare the use of pressure-relieving mattresses and traditional hospital beds in decreasing the incidence of pressure ulcers on the heels of patients (Nicosia, Gliatta, Woodbury, & Houghton, 2007). This research study used strong theoretical evidences in providing support to the major arguments discussed in the research study.
The study’s use of meta-analysis addressed the hypothesis that pressure-relieving mattresses reduce incidence of heel ulcers. Among 1,457 subjects included from the 14 studies in the research, it was found that the use of pressure-relieving mattresses significantly reduce the incidence of the said problem (Nicosia et al. , 2007). The use of meta-analysis suggest the strong evidence support of statistical data to the conclusion of the study. This also implies that there is a significantly high number of researches available that compares the two methods of prevention of pressure ulcers.
In terms of methodology, the study also ensured similarity of population groups, in this case the studies included in the research are all clinically controlled designs. This increases the internal validity of the study. However, it has to be noted that the inclusion or exclusion of the studies to be included in the research were based on two persons only who independently reviewed the full articles searched from the databases. There is lack of supportive discussion regarding the credibility of the independent reviewers who selected the research studies for review and meta-analysis in this research.
Hence, the idea of a possible selection bias may have occurred. The third study, ‘The effect of various combinations of turning and pressure-reducing devices on the incidence of pressure ulcers,’ is a randomized control study that compares the two methods of preventing pressure ulcers: frequent turning on a traditional hospital bed and less frequent turning on a pressure-relieving mattress. The time interval for repositioning on a hospital bed is every two and three hours, while repositioning on a viscoelastic foam is done every four and six hours (Deflooe et al. , 2005).
Even though this study was conducted in 2005, the relevance of the study’s research topic and methodology makes it a good evidence or supporting literature for the PICOT question. Thus, the researcher included this in the critical appraisal. The study’s strong point is its use of equivalent population groups in terms of the number of samples per treatment and control group. The authors divided the groups into 65 participants each. However, it should be noted that the characteristics of the population are coming from a wide range of age group and medical characteristics.
This factor was not controlled in the research study. In addition, it should be noted that the differing time intervals for different treatment groups were used. There was no specific explanation discussed by the authors regarding this difference. However, this difference in time interval has a crucial implication. It is possible that the authors suggest the less frequent need to turn the patient to bring about a significant decrease in occurrence of pressure ulcers when using viscoelastic foam, a pressure-relieving mattress.
The researcher’s prior knowledge before reviewing this article is that no significant difference exists between the frequency of turning in relation to the rate of pressure ulcer incidence. However, this study showed that the frequency of turning in combination with the type of hospital mattress results in a significantly different rate of pressure ulcer incidence. The fourth study, ‘Does regular repositioning prevent pressure ulcers? ‘ is a systematic review of research studies that have experimented on the effectivity of frequent turning in comparison to other techniques used to prevent pressure ulcers.
This systematic review is limited to studies conducted since 1960 up to the time the research is being conducted (Krapfl & Gray, 2008). Systematic review showed that there is little evidence to say that the frequency and type of bed or mattress used bring about a decreased incidence of pressure ulcers. This study’s level of evidence is high because systematic reviews are considered the topmost or strongest evidence bases. Systematic reviews give readers information on the best evidences or researches conducted regarding a research topic (Cook, Mulrow, & Haynes, 2004).
In this case, the authors reviewed randomized clinical trials and quasi-experimental designs that have been previously conducted to provide information on what preventive method brings about the best results in preventing pressure ulcers. Due to the strength of this research study’s reference to outside research as well as the validity and reliability of the researches included in the systematic reviews, the results and conclusions from this study can be considered as reliable. However, it has to be noted that the systematic review did not employ any statistical method to determine and analyze the findings from this research.
In a sense, if there are no statistical data such as meta-analysis being performed on the study, there is a room for doubting the arguments of the discussion of the research. The authors also failed to provide adequate quantifiable discussion for concluding that there is little evidence to support the comparative analysis of frequency of turning and type of mattress used for patients who are at high-risk for developing pressure ulcers. The fifth study, ‘Preventing pressure ulcers: a systematic review,’ is similar to the fourth study discussed in this paper.
Through empirical review, this research found that the effective preventive methods include positioning, use of surface areas that redistribute pressure, ambulation, and adequate nutrition (Reddy, Gill, & Rochon, 2006). This study did not use studies that employed comparative analysis of effective methods that will decrease pressure ulcers by a higher degree. Instead, this systematic review used a wide-scope of studies using random control designs on the effectivity of a number of preventive methods.
Similarly, this study has a strong evidence-base supported by the number of best researches included in the study that utilized random control designs. Moreover, the study’s logical argumentation of the weaknesses and limitations of the study included in the study give readers an open mind regarding the implications of this study. This suggests that even though there are existing researches with strong evidence bases regarding this topic, there is still a lot of opportunities to explore the topic and improve the methodologies for future studies. Summary
The researches that turn up during the search performed to support the PICOT question provide the researcher a beginning knowledge on the current literature present regarding the topic. Based on the related articles that were critiqued, it can be inferred that researches show little evidence that is not enough to claim that either one of frequent repositioning or use of pressure-relieving mattresses is a better method to reduce the incidence of pressure ulcer. Also, this search helped the researcher in exploring the level of evidences present in providing the answers to the clinical question posed.
Furthermore, methodological limitations, such as small sample sizes to increase generalizability, were also identified as present in the current literature. References Arizona State University (n. d. ) PICO(T) form. Retrieved May 12, 2010, from http://nursingandhealth. asu. edu/evidence-based-practice/pico. htm Cook, D. J. , Mulrow, C. D. , Haynes, R. B. (2004). ‘Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions. ‘ Retrieved July 15, 2010, from http://www. annals. org/content/126/5/376. full Defloor, T. , De Bacquer, D. , & Grypdonck, M. H. (2005).
‘The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. ‘ International Journal of Nursing Studies, 42(1), 37-46. Retrieved July 13, 2010, from http://www. ncbi. nlm. nih. gov/pubmed/15582638 Kozier, B. , Erb, G. , Berman, A. , & Snyder, S. (2004). Fundamentals of Nursing (7th ed. ). New Jersey: Prentice Hall Krapfl, L. A. & Gray, M. (2008). ‘Does regular repositioning prevent pressure ulcers? ‘ Journal of Wound Ostomy and Continence Nursing, 35(6), 571-577. Retrieved July 13, 2010, from http://www. ncbi. nlm. nih. gov/pubmed/19018196 Nicosia, G. , Gliatta, A.
E. , Woodbury, M. G. , & Houghton P. E. (2007). ‘The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. ‘ International Wound Journal, 4(3), 197-207. Retrieved July 13, 2010, from http://www. ncbi. nlm. nih. gov/pubmed/17924876 Reddy, M. , Gill, S. S. , & Rochon, P. A. (2006). ‘Preventing pressure ulcers: a systematic review. ‘ Journal of the American Medical Association, 296(8), 974-984. Retrieved July 13, 2010, from http://www. ncbi. nlm. nih. gov/pubmed/16926357 Smeltzer, S. C. , Bare, B. G. , Hinkle, J. L. , & Cheever, K. H. (2008). Brunner & Suddarth’s
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