Evidence-Based Practice and Applied Nursing Research

A1. Hospital-acquired pressure ulcers are a very common healthcare issue worldwide. The rise of this problem within hospitals is due to policies and protocols not followed, leading to adverse health conditions that require extended hospitalization stay for patients and high costs on hospitals. The prevention of pressure ulcers within the healthcare system has been a major nursing concern throughout the years.

A2. Hospital-acquired pressure ulcers have been a major health issue and are noted to be very problematic within the healthcare system. The occurrence of pressure ulcers on already critically-ill patients can lead to very detrimental health problems ranging from infections, loss of extremities and possibly death. The patients who develop pressure ulcers experience poor quality of life while in the hospital, and the treatment of these ulcers can be costly for the healthcare system (Sving et al., 2014).

A3. The current standard of practice in hospitals includes the use of the Braden Scale to evaluate the risk level for the prevalence of pressure ulcers, skin assessments, skin care, turning/repositioning every two to four hours and the use of pressure-reducing devices. The blame for hospital-acquired pressure ulcers is frequently put on the nursing staff. Due to the notably high nursing shortage, the increase in critically-ill and geriatric population hospitals have been facing a rise in the incidence of hospital-acquired pressure ulcers. It is believed by many clinicians that the occurrence of hospital-acquired pressure ulcers is not just the fault of nursing staff but of the whole system; therefore, a collaborative effort of all members within the healthcare team is needed (therapist, physicians, dieticians, nurses and nurses aids).

A4. Hospitals should implement changes in the already established protocols to specifically emphasize frequent patient skin assessments and care, turning and repositioning every two to four hours and pressure reducing devices due to the high rate in hospital-acquired pressure ulcers. Though it has not been determined by researchers which are more effective toward the prevention of hospital-acquired pressure ulcers, based upon data collected from research studies, it is recommended by researchers to implement these strategies together to achieve better results (Gould et al., 2015). In addition to these strategies, if hospitals could ensure adequate staffing needs are met on units with critically ill patients, the probability of the occurrence of hospital-acquired pressure ulcers will reduce drastically (JiSun & Staggs, 2014).

B.

P (patient/problem)

Hospital acquired pressure ulcers

I (intervention/indicator)

Frequent turning and repositioning every two to four hours.

C (comparison)

Pressure reducing mattress/devices

O (outcome)

Prevention of hospital acquired pressure ulcers

B1. Does frequent turning and repositioning every two to four hours versus the use of pressure reducing devices on hospitalized intensive care unit patients reduce/prevent the prevalence of hospital-acquired pressure ulcers?

C1. Keywords included in search: Repositioning and turning to prevent pressure ulcer, Hospital-acquired pressure ulcers, Prevention of pressure ulcers, turning and repositioning, alternative pressure reduction devices

C2. The initial search yielded 4815 articles; I selected and reviewed 15 based on the title and abstract. Of the 15 I looked at, 3 were qualitative (level III), 6 were quantitative (level I), 3 were quantitative (level II) and 3 were level IV & V non-research clinical practice guidelines and literature review papers.

C2a. In my first research evidence article, Sving, Idwall, Gunningberg and Hogberg conducted a cross-sectional study of the prevention of pressure ulcers while exploring evidence-based practices. This study analyzes possible variables and the relationship between patients (patient skin assessment within 24 hours of admission, risk assessment, repositioning every two hours and using pressure reduction mattresses). During the course of the study, participants were recruited from one general hospital and one university hospital; a total of 825 participants from medical, geriatric and surgical units were received. The greater the risk for the development of pressure ulcers, the greater the chances for the need to document skin assessments, the need to reposition every two hours and implement the use of pressure reducing mattresses. Adequate nursing staff definitely played a part in implementing strategies for the prevention of pressure ulcers, because with an understaffed nursing unit, participants were less likely to be repositioned in a timely manner. The study revealed that between units, the required implementations differed somehow. The use of the Braden scale was implemented to assess participants’ risk level regarding the occurrence of pressure ulcers. Participants who received a score of 17 or lower on the Braden Scale within a 24-hour period were most likely to receive a second skin assessment, repositioning every two hours and the implementation of a pressure reduction mattress. Although geriatric, surgical and medical units were used for the study, the inclusion of an intensive care unit would have been beneficial, since patients on these units were more prone to the development of pressure ulcers. Unfortunately, the study was self-limited and its ability to favor the intensive care unit was very minimal (Sving et al., 2013).

In my second research evidence article, Manzano et al. completed a study to evaluate the effectiveness of repositioning frequency, comparing two-hour and four-hour intervals. The study was conducted as a single-site, open-label, parallel-group randomized controlled trial in the two mixed ICUs of a university hospital in southern Spain. This was a voluntary participation study, with all participants receiving informed consent. The outcome measured during the trial was the incidence of pressure ulcers in the patients that were at least stage two. The experimental group had 165 randomly assigned participants, and the control group had 164. To be eligible for the study, the patients selected were critically ill and receiving invasive mechanical ventilation. The patients in the parallel groups were repositioned by nurses following the pre-assigned frequency. During this study, 17 participants from the experimental group developed pressure ulcers, as did 22 participants from the control group. The difference between both groups was minimal, and the researchers concluded that a higher frequency of repositioning did not significantly reduce the incidence of pressure ulcers, but did show a positive response to device-related adverse events with a higher incidence of adverse events in the group that was repositioned at a higher frequency. The researchers also concluded that the repositioning implementation rate could have influenced the results and that if considered independently of group, there was a lower incidence of pressure ulcers (<5%) when the patients were repositioned 60% or more of their scheduled times, compared to >20% when the patients received less than 33% of their scheduled repositioning (Manzano et al., 2014).

My first non-research evidence article was a literature review on the use of prophylactic dressings in the prevention of pressure ulcers. Lynn Cornish reviewed six articles describing studies that were conducted in the research area. One of the studies was in vitro and focused on assessing the shear resistance of the dressings when exposed to rough surfaces; the remaining five studies involved patients in care settings with varied study designs. The review identified some shortcomings with the study designs, as well as sample sizes in some of the trials, which called into question the validity of the conclusions made in those papers. The different trials reviewed had divergent conclusions regarding the use of prophylactic dressings. However, the author suggests that, for critically ill patients, prophylactic pressure ulcer dressings such as soft silicone foam dressings should be used in conjunction with other PU prevention techniques. The author recommended additional studies with better designs be completed in order to fully assess the validity of using prophylactic shear-resistant dressings for the prevention of pressure ulcers (Cornish, 2015).

My second non-research evidence article was on the wound healing society’s guidelines for treating pressure ulcers; these guidelines were intended to help provide guidance on the approach clinicians used in patient care and were not intended to serve as a standard of care for pressure ulcers. The members of the committee provided updated guidelines backed by recently published research on pressure ulcers since 2006 when the initial guidance was published. Guidelines on positioning and support surfaces, patient nutrition, wound infection control, wound bed preparation, surgery, dressings, and adjuvant therapies are presented in the paper. Some of the guidance in the paper includes:

· Have a repositioning schedule and avoid having the patients positioned on existing pressure ulcers and bony structures.

· All patients should be assessed for their risk of developing pressure ulcers and provide appropriate surfaces in line with the risk assessment.

· Bone biopsies are recommended in cases where osteomyelitis is suspected to be associated with the ulcer.

The evidence level of each guideline is listed based on the level of the research that was used to establish them. Additionally, the rationale for the guidance is clearly written along with each of the recommendations with references of the studies provided (Gould et al., 2015).

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