Prevention and care of pressure ulcers

PREVENTION AND CARE OF PRESSURE ULCERS

Pressure ulcers are a commonly seen problem among elderly hospitalized patients. Despite new findings about the causes and approaches to treatment, the incidence of these wounds is still increasing. Scott, Gibran, Engrav, Mack and Rivara (2006) revealed that during the thirteen years of their study, the incidence of pressure ulcer development has more than doubled. As our elderly population becomes greater in number, and older in age, this problem is expected to escalate. It is of great importance for the patients as well as for the institutions to find the best practice guidelines to control the occurrence of preventable wounds.

Many hospitals incorporate strict prevention measures with good effects, and others are more concentrated on treating the problem after it occurs, without paying much attention to prevention. In XY hospital, patients at risk do not receive the necessary preventive care, and many patients' existing wounds often become infected, and instead of healing, they deteriorate. This paper will review the research regarding the best prevention methods, as well as the best evidence based treatment of pressure ulcers, followed by suggestions how to implement those findings in XY hospital.

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PICO QUESTION

In elderly and immobile patients, what are the most effective prevention and treatment methods to reduce the occurrence and complications of pressure ulcers, compared to no prevention and standard wet-to-dry dressings?

SUMMARY AND APPLICATION OF RESEARCH ARTICLES

Effective management of pressure ulcers begins with a comprehensive assessment of the patient, with careful consideration of the risk factors.

Hess (2004) reported that the Braden Scale is the most commonly used risk assessment tool. Also, it is important to regularly inspect the skin of the patients found to be at risk. Such inspection should focus particularly on the areas around bony prominences. Bethell (2005) argues that once stage one pressure ulcer develops, the irreversible damage to the tissue forms, and this will progress to open, deeper wound if pressure is not relieved. Stage one is defined as a change of intact skin in one or more of the following: skin temperature, color, tissue consistency and/or sensation (Hess).

Unfortunately, the staff at XY hospital is only concerned with skin breakdown, when assessing for pressure ulcers. No prevention strategies are implemented for patients at risk until they develop stage two ulcers, when skin breakdown is visible. One article notes that educational in-service for the staff is effective, and results in the professionals' better understanding and ability of staging pressure ulcers (Thompson, Langemo, Anderson, Hanson and Hunter, 2005). It is necessary that prevention techniques are implemented for all patients at risk from the moment that risk is identified, whether there is an existing tissue injury or not.

Another study indicates that the body can endure great amount of pressure for short time periods, but low pressure for a long amount of time causes significant tissue damage (Maklebust, 2005). Repositioning of patients should be performed at least every two hours or more often if necessary. The author suggests that when repositioning the patient onto the side, he or she should be supported in a 30-degree lateral position rather than at a 90-degree angle. Such position avoids the pressure of the bony prominences on the softer tissues. Also, the head of the bed should be maintained at less than 30 degrees to avoid the shearing forces caused by patient's sliding in bed (Maklebust).

Moreover, studies advise that appropriate lifting devices should be used to prevent friction during transfer and repositioning (Grey, Harding and Enoch, 2006). Also, patients' heels are often subjected to pressure and friction. The staff at XY hospital occasionally elevates patients' heels by placing them on folded blankets. Literature suggests that the heels should be suspended, with a pillow or a blanket placed under the lower legs (Maklebust). Additionally, the use of pressure relieving mattress is encouraged, but it does not eliminate the need for frequent position changes (Hess, 2004).

Furthermore, another factor creating a risk for pressure ulcer development is malnutrition. Wysocki (2002) observed that 10 to 50% of hospitalized patients are malnourished. Nurses should be alert to inadequate nutrition and its effects. Also, Cobb and Warner (2004) noted that when thirty percent of weight is lost, spontaneous pressure ulcers begin to develop, and prevention strategies might not work. In addition, urinary and fecal incontinence are also significant risk factors. Incontinence results in excess moisture, and irritation of the skin. The nurses and assistive personnel in XY hospital often do not assist their incontinent patients for long periods of time, and they do not utilize the available skin protectants.

Studies confirmed the effectiveness of no-rinse cleansers and moisture barrier creams, and found that they were less likely to harm skin integrity than soap and water (Thompson, et al., 2005). The findings also advise that checking the patients for soiling every two hours adds to the effectiveness. Although not all pressure ulcers are preventable and curable, the literature provides supportive evidence that appropriate prevention protocols decrease the incidence of stage one and two pressure ulcers, and in turn decrease the number of pressure ulcers that could progress to stage three and four (Thompson, et al.).

Moreover, an important part of existing wound management is wound bed preparation, and use of appropriate dressings. Cobb and Warner (2004) suggest that applying dressings without debriding will not heal the wound, and constitutes wasted time and effort. The authors also point out that: "debridement must be thought of as an ongoing process. Initial debridement should be followed by maintenance debridement"(Cobb & Warner). Necrotic tissue and excess slough encourage bacterial proliferation, therefore the debris has to be removed in order to promote healing. Three types of debridement, as described by McGuckin, Goldman, Bolton and Salcido (2003), can be performed or applied by a registered nurse. Mechanical debridement, which is performed with wet-to-dry dressings, although effective, can be painful when dry gauze is pulled off, and can also remove healthy tissues. Enzymatic debridement is the application of enzymatic ointments that digest the dead tissue, but can also digest the viable tissue.

The last, autolytic debridement, involves the action of natural enzymes under hydrocolloid or film dressings. One of such dressings, Polymem, is available in XY hospital. The product contains a wound cleanser, a bacteriostatic, a moisturizer, and an absorbing agent which absorbs ten times its own weight in exudate. Polymem also promotes formulation of granulation tissue (McGuckin, et al.). Another useful dressing available in XY hospital is Aquacel Ag, an absorbent dressing composed of hydrofiber impregnated with ionic silver. Research findings recommend it for autolytic debridement, as well as for the prevention and treatment of infection (Dowsett, 2004). In the presence of moisture in the wound, silver ions are released and bind to cells including bacteria. It is recognized as an effective broad-spectrum antimicrobial dressing (Dowsett).

In addition, Ovington (2001) pointed out the distinction between the standard wet-to-dry and wet-to-moist dressings, which are often erroneously considered as one. Wet-to-dry is intended for debridement, and the gauze should be allowed to dry before it is removed. Wet-to-moist is intended to remain moist until removal, but it often becomes wet-to-dry in practice. However, the author indicates that the standard wet gauze dressing is not an optimal wound care, but despite hundreds of new more beneficial products, gauze is still widely used. In vitro studies have shown that bacteria were capable of penetrating up to 64 layers of dry gauze, and moist gauze presents even less barrier to bacteria. It has been also shown that infection rates in wounds with moist gauze dressings are higher than in wounds with film or hydrocolloid dressings (Ovington). New dressings become widely available, and ongoing research is needed to provide the evidence for the most effective options.

IMPLEMENTATION

Successful leaders thrive on continuous change. Implementation of a change is never a single action but involves a well designed, comprehensive plan, and a step-by-step process. The first step of implementing change is to identify the problem. The staff in XY hospital has to be aware of the need to change their practice related to pressure ulcers. According to Lewin (Marquis & Huston, 2006, p. 173) this is called unfreezing. Presenting statistical data of pressure ulcer occurrence on the unit, and comparing it to other units or hospitals, and to state or national goals reveal the existing problem. The staff has to recognize and understand the issue, and be motivated to do something about it. Educating the staff on the subject through verbal and written communication will facilitate sending the message.

The second phase is movement (Marquis & Huston, 2006, p. 173). This next step starts with creating an imbalance by increasing the driving forces, which lead people toward the change, or reducing restraining forces, which repel change. It requires developing an action plan, defining objectives, and establishing goals. The appropriate strategies have to be planned and implemented gradually. A careless approach to resolving the matter can cause frustration. Educational in-service for the staff informing about preventive guidelines described in research, commonly seen problems, and most effective evidence based strategies will initiate the exchange of ideas.

The leader has to acknowledge that people might respond to change in various ways. Some will feel motivated and energized, while others will feel threatened and dissatisfied. Marquis and Huston (2006, p. 180) inform that it is most effective when all those affected by a change are involved in planning that change. Collaboration and dialogue with staff are needed to gain an understanding of what they value and hold as important. Gearing the communication toward a common desire will lead to establishing an effective and achievable plan. As was previously done on the unit in XY hospital, a notice could be posted in the staff break room encouraging all to write ideas and suggestions on how to implement the needed changes. Then, action steps using those ideas should be structured cooperatively.

With the plan in hand, the leader should initiate the change process. Marquis and Huston (2006, p. 181) state that leaders must be engaged in change by role modeling and assisting staff to encourage them. The nurses and the assistive personnel should be reminded and encouraged to check incontinent patients more frequently to ensure that they are not wet and soiled for prolonged periods of time, but the leader should initiate these actions him/herself. Asking staff to help distribute the skin protection supplies to each incontinent patient's room will ease the transition. It is necessary to show commitment and consistency in implementing the change to avoid discouragement. Moreover, the innovations which will result in easier and less work can be expected to be adopted almost immediately.

For example, applying Polymem and Aquacel Ag is much easier and faster than time consuming wet gauze dressings. It can also be expected that the most difficult part of the plan would be implementing prevention strategies for patients at risk, but without pressure ulcers. Repositioning patients, lifting them appropriately, checking for wetness, and appropriate feeding are time consuming and labor intensive. The leader has to be able to energize others, and be consistently interested and committed to the plan, until completed. Each of the strategies has to be introduced one at a time, to allow slow adjustment. Marquis and Huston (p. 173) advise that to be accepted, change needs at least three to six months.

The last phase of the change theory is refreezing. The change has to be stabilized and integrated into the status quo (Marquis & Huston, 2006, p. 173). Recognizing and acknowledging the hard work of the staff should never be forgotten. Thanking for the commitment improves work performance and satisfaction. Also, reevaluation is necessary to modify and improve the change as needed. Prevention strategies to reduce the incidence of pressure ulcers need to be a team effort in order to be effective.

CONCLUSION

Pressure ulcers remain a serious type of wound seen among many hospital patients. Despite the newly developed strategies to prevent and manage those wounds, their incidence is still growing. Evaluating risk factors and identifying optimal prevention techniques are the first line of defense. Regular relief from pressure, use of lift sheets, use of incontinence skin barriers, and maintenance of adequate nutrition are the main preventive interventions. Nevertheless, some patients may develop skin breakdown despite high quality care. Optimal wound care requires an ongoing debridement of devitalized tissue, and appropriate dressings which promote healing.

Healthcare professionals have a wide variety of new treatment options from which to choose from, and should be moving away from using the ineffective and labor intensive gauze dressings. Implementing appropriate methods to better control pressure ulcers based on up-to-date evidence requires good leadership skills. The key aspects of accomplishing the goal are: developing a good plan, gaining interest of the staff, and being committed to the end. To implement any change successfully, leaders have to approach it with dedication and enthusiasm. After all, the end goals of our ongoing clinical challenges always are to promote the patient's healing, to reduce needless suffering, and to improve the quality of life.

REFERENCES

Bethell, E. (2005). Wound care for patients with darkly pigmented skin. _Nursing Standard, 20_ (4), 41-49. Retrieved April 14, 2006, from OVID MEDLINE database.

Cobb, D.K., Warner, D. (2004). Avoiding malpractice: the role of proper nutrition and wound management. _Journal of the American Medical Directors Association, 5_ (4 Suppl), H11-6. Retrieved April 14, 2006, from OVID MEDLINE database.

Dowsett, C. (2004). The use of silver-based dressings in wound care. _Nursing Standard, 19_ (7), 55-58. Retrieved April 14, 2006, from OVID MEDLINE database.

Grey, J.E., Harding, K.G., Enoch, S. (2006). Pressure ulcers. _BMJ, 332_ (7539), 472-5. Retrieved April 14, 2006, from OVID MEDLINE database.

Hess, C.T. (2004). Care tips for chronic wounds: pressure ulcers. _Advances in Skin and Wound Care, 17_ (9), 477-9. Retrieved April 14, 2006, from OVID MEDLINE database.

Maklebust, J. (2005). Choosing the right support surface. _Advances in Skin and Wound Care, 18_ (3), 158-61. Retrieved April 14, 2006, from OVID MEDLINE database.

Marquis, B.L., Huston, C.J. (2006). _Leadership roles and management functions in nursing._ Philadelphia, PA: Lippincott Williams and Wilkins.

McGuckin, M., Goldman, R., Bolton, L., Salcido, R. (2003). The clinical relevance of microbiology in acute and chronic wounds. _Advances in Skin and Wound Care, 16_ (1), 12-23. Retrieved April 14, 2006, from OVID MEDLINE database.

Ovington, L.G. (2001). Hanging wet-to-dry dressings out to dry. _Home Healthcare Nurse, 19_ (8), 477-83. Retrieved April 14, 2006, from OVID MEDLINE database.

Scott, J.R., Gibran, N.S., Engrav, L.H., Mack, C.D., Rivara, F.P. (2006). Incidence and characteristics of hospitalized patients with pressure ulcers: state of Washington, 1987 to 2000. _Plastic and Reconstructive Surgery, 117_ (2), 630-34. Retrieved April 14, 2006, from OVID MEDLINE database.

Thompson, P., Langemo, D., Anderson, J., Hanson, D., Hunter, S. (2005). Skin care protocols for pressure ulcers and incontinence in long-term care: a quasi-experimental study. _Advances in Skin and Wound Care, 18_ (8), 422-9. Retrieved April 14, 2006, from OVID MEDLINE database.

Wysocki, A.B. (2002). Evaluating and managing open skin wounds: colonization versus infection. _AACN Clinical Issues, 13_ (3), 382-97. Retrieved April 14, 2006, from OVID MEDLINE database.