Importance and Implementation of Pressure Ulcer Prevention in Nursing

Introduction

Pressure Ulcers which are also known as bedsores which are the localised injury to the underlying tissues or skin usually due to long-term pressure or shear friction occurring over the bony prominence (Edsberg et al. 2016). The prevention of pressure ulcer is required for the improved well-being of the patients and the nurses pay an effective in its prevention. Thus, in this assignment, the application of the importance of preventing pressure ulcer in adults within nursing is to be discussed. Moreover, the guidelines and additional evidence available for prevention of pressure ulcers in adults are to be explored. The barriers in implementing the evidence collected and the way to resolve them are also to be discussed.

Research Strategy

The systematic review is used as the research strategy for the assignment. The systematic review is the strategy used for gathering as well as summarising the evidence that fit in a proper way with the required criteria raised in the study (Moher et al. 2015). The advantage of implementing systematic review is that it leads the research to determine and search articles and journals which are specific and appropriate to the mentioned topic. The search strategy also lower chances of biasness resulting to develop accurate conclusions for the study. The electronic database is used for collecting evidence regarding the study where keywords such as "Prevention strategies" "pressure ulcer" "bedsores" and others are used to generate require article information needed for the study.

Application of the topic to Nursing

The prevention of pressure ulcers in adults is applicable to nursing because effective nursing care is required to ensure its prevention among individuals to protect the patients from physical harm and reduce the overall care cost for them (Lannering et al. 2016). Thus, nurses need to be alert regarding the prevention strategies and guidelines so that the prevalence of pressure ulcer is reduced among adults. As mentioned by Hartmann et al. (2016), pressure ulcers lead patients to feel discomfort leading them to experience hindrance in executing everyday activities, in turn, developing dependence on nurses for care. This makes the topic of prevention of pressure ulcer among adults applicable to nursing because the strategies and guidelines to prevent the pressure ulcers would lead nurses to arrange better care for service users. It would make nurses help patients to move easily and without discomfort as well as avoid the patients being dependent on them for everyday activities thus providing them relief to some extent from care burden. As argued by Wen and Bell (2015), adults with untreated pressure ulcers often become immobile which leads them to develop depression and isolation. The adults out of depression and anxiety often show avoidance in accepting care and respond to support from the nurses. This is because they feel they cannot be cured and would die eventually (Seyhan, 2018). Thus, the topic of preventing pressure ulcer among adults is applicable to nursing as it would lead nurses to develop knowledge regarding the way they can provide care to the patients so that the emotional health of the individual is improved as well as they are provided satisfactory care to ensure their well-being.

The pressure ulcer leads the patients to experience delayed wound healing (Khalil et al. 2015). Thus, its prevention strategies are important in nursing so that the nurses are able to understand the way they are to care for the patients and treat their wounds so that pressure ulcers can be avoided. According to the NMC Code of Practice, the nurses require to provide care in such a way so that the patients are benefited and helped to lead a normal life (NMC, 2015). This makes prevention of pressure ulcer applicable in nursing as the ulcers deteriorate the health condition of the patients and the nurses not attending to care for them would lead to violation of the code. The NICE mentions that new cases of pressure ulcers occur among 4-10% of the patients who are admitted to the hospital in the UK as per precise data being collected. Moreover, it is informed that pressure ulcer presence among the adults causes 2-4 fold increase in the risk of death among adults admitted in the intensive care units (NICE, 2018). Thus, discussion regarding the prevention of pressure ulcers is required in nursing field so that care strategies are known to avoid its prevalence so that unnecessary deaths of the patients can be avoided. It is mentioned that until 2012, nearly 13,000 new cases of patients suffering from pressure ulcer is being reported. The treatment of pressure ulcers is resulting NHS to spend £1.4 million for patients on each day (NHS, 2019). Thus, the prevention guidelines regarding pressure ulcer are applicable in nursing so that the nurses can understand the way they are to develop preventive to reduce and save the huge finances being spent by the NHS in its treatment. This is because the saving could be used by NHS against other more intense disease prevention to ensure better well-being of the patients.

NICE Guidelines for Pressure Ulcer Prevention in adults

The national guidelines present for pressure ulcer prevention among adults is mentioned by the National Institute for Clinical Excellence (NICE, 2019). The NICE guidelines mention that proper skin assessment is to be made for adults who are at risk of developing pressure ulcers (NICE, 2019; Schallom et al. 2015). This is because the nurses by looking at the skin in pressure points would be able to understand if any sores are present or going to grow in turn helping them to take prior care for the patients to prevent pressure ulcer. The nurses are asked to determine the skin integrity of the patients in areas of pressure (NICE, 2019; LeBlanc et al. 2016). This means the nurses are asked to examine the health of the skin in areas where the most pressure is experienced by the patients (Yafi et al. 2017).

The guidelines in regard to skin assessment mention that discolouration or colour change in skin is to be understood (NICE, 2019; LeBlanc et al. 2016). This means that health professional needs to be aware of any presence of non-blanchable erythema mainly in patients with darker skin tones to identify discolouration or skin changes that occur in early stages of pressure ulcer (Beeckman et al. 2018). The NICE guidelines also mention that variation of firmness, moisture and heat on the skin are also to be evaluated. The nurses are guided to use diascopy or finger palpitation for identifying skin integrity (NICE, 2019). The NICE guidelines also mention using the SEM Scanner to prevent pressure ulcer among adults (NICE, 2019; Doenges et al. 2019). The SEM Scanner is a scanning device used for detecting any changes within the sub-epidermal moisture that show tissue damage induced by pressure (Moore et al. 2017). Thus, the use of SEM Scanner would lead nurses in early identification of pressure ulcer formation in patients helping them to take preventive measures to avoid its formation and negative impact on the health of the patients.

The NICE guidelines mention that nurses are to use barrier creams for patients who are found to be at risk of developing pressure ulcer after skin assessment to prevent skin damage which would have eventually lead to ulcer formation (NICE, 2019; Truong et al. 2016). This is effective as the barrier creams would reduce friction on the pressure points of the patients where ulcer formation is assumed to be developed in turn protecting the patients from bedsores. The NICE guidelines mention nurses to consider using high-specific foam mattress or mattress which distributes pressure evenly on the surface while lying or sitting for adults to prevent pressure ulcers (NICE, 2019; Soppi et al. 2015). This is because the pressure at a single point of the body results individuals to pressure sores as a result of damaged skin tissue. According to NICE guidelines, the nurses are to use Sacrum dressings and Mepilex Border Heel dressing for preventing pressure ulcers among adult patients (NICE, 2019; Marshall et al. 2019). This is because this nature of dressing avoids creating pressure on the wounds or skin tissues on heel and sacrum, in turn, helping the nurses to prevent the development of pressure ulcers among patients.

The NICE guidelines, in addition, mentions the nurses to encourage patients who are identified to be at risk of developing pressure ulcer change their position often and at least within every 6 hours. The patients in the case are unable to make movement on their own are to be offered equipment and assistance to change position frequently (NICE, 2019; Bly et al. 2016). The frequent change in position is required as it helps to avoid concentration of pressure development at a single point on the skin thus avoiding damage or injury which results in preventing pressure sores. The NICE guidelines mention that no skin massage is to be offered or skin rubbing is to be made for patients to avoid them from developing pressure ulcers (NICE, 2015).

Risk Assessment for Pressure Ulcers

The risk assessment tools such as Barden Scale and Waterlow scale can be used by health practitioners and nurses to determine which patient is at risk of developing pressure ulcers. The Barden scale is includes six assessment criteria which are sensory perception, mobility, activity, nutrition, moisture and friction. The score less or equal to 9 indicates very high risk, 10-12 score is high risk, 13-14 is moderate risk, 15-18 is mild risk and 19-23 is no risk of developing pressure ulcer (Watkins et al. 2019). The Waterlow scale uses criteria that are sex and age, skin type, weight, mobility, malnutrition, continence, neurological deficit and tissues examination for determining risk among adults to develop pressure ulcers. The score ≥10 indicates mild risk, ≥15 high risk and score ≥20 and above indicates very high risk of developing pressure ulcer. However, the criticism regarding use of this risk assessment scale is that may reduce reliability of risk examination due to its large number of scored items (NICE, 2015).

Additional evidence for Pressure Ulcer Prevention in adults

The study by Beeckman et al. (2019) informs that use of foam mattress is effective way to prevent pressure ulcer among adults. This is evident as when compared with foam hospital mattress with the low-tech CLP it was found that the foam mattress were more effective to lower pressure on the skin, in turn, reducing as well as preventing pressure ulcers. The fact is also supported by the study of Park and Park (2017) where it is mentioned that patients in the acute environment who are provided viscoelastic foam mattress in comparison to standard hospital mattress showed less pressure injury. This is evident as the incidence of pressure injury on the experimental group was 3.6% compared to 27.3% for the control group who were provided normal mattress. Thus, the studies ensure that the use of foam mattress is the best support to be used as per NICE guidelines for preventing pressure ulcers among adults.

The study by Mazlinda et al. (2018) informs that the use of barrier creams has been effective in reducing pressure ulcers among adults. This is evident as the durable barrier cream (cavillion cream) used on patients with pressure ulcers shows that the size of the ulcer was reduced on day three of the application of the cream compared to first-day application (z value was -5.028, p<0.005). Thus, the evidence supports that the use of barrier cream as guided by NICE is one of the best practice in reducing and preventing pressure ulcer formation among adult patients. In the study by Cubit et al. (2013), it is informed that the use of sacral dressing was effective in preventing development of pressure ulcers. This is evident out of the 51 patients who are recruited for the study and were provided sacral dressing, it was found that only 1 of them developed pressure ulcer. Moreover, it was found that patients who did not use sacral dressing were 5.4% more likely to develop pressure ulcer compared to those who have used it. Thus, it supports the fact by NICE that sacral dressing is effective to prevent the development of pressure ulcer among adults.

Conflicting evidence

The study by Low et al. (2017) informs that latex mattress is more effective compared to foam mattress for reducing pressure on the body or skin during lying down or sitting. This is evident as the peak pressures perceived at the back buttocks and back torso with the use of latex mattress was found to lower by 28.4% and 26.1% compared to foam mattress. In relation to side posture, the contact pressure on the side buttocks and side torso were seen to reduce by 28.2% and 35.1% for latex mattress compared to foam mattress. The latex mattress shows a drop by 30.9% contact pressure with the body compared to foam mattress in the front torso region. Thus, it contradicts that foam mattress is only to be used for preventing pressure ulcers among adults patients as the study mentioned that latex mattress is more better than the foam mattress. The study by Hawaibam et al. (2016) informs that olive oil massage was effective in reducing pressure ulcers. This is evident from the findings where it is mentioned that the mean score of the pretest was 1 which was reduced to 0.6 among patients provided with olive oil massage. The mean pretest score increased from 0.6 to 2 among the control group who were provided regular care for pressure ulcer prevention. The lower score indicates that ulcer development was significantly among patients provided with olive oil massage and vice-versa. Thus, it contradicts with NICE guidelines where any form of massage was avoided to be given for pressure ulcer prevention as the study mentions that massage therapy is effective in the prevention of ulcers.

Barriers to the implementation of the mentioned guidelines

The uncooperative patients would create barrier to implement the skin assessment and position changing guideline to prevent pressure ulcers among adults. This is because without cooperation from the patients the nurses cannot examine the pressure points on the skin as it would lead to violate their rights and privacy. Moreover, the patients who avoid changing their position mentioned the nurses in frequent manner would experience continuous pressure building on a certain point of the skin making them prone to experience pressure ulcer (Al-Ghamdi, 2017). The study by Etafa et al. (2018) mentions that lack of adequate number of nurses to implement prevention strategies along with workload, shortage of required resources and improper training and education of the nurses are key barriers to implement various prevention strategies and best practices for avoiding pressure ulcers. The shortage of staff creates barrier to prevent pressure ulcer because all the patients who are risk of developing pressure ulcer cannot be identified as well as be provided care in time. The improper resources make the nurses unable to execute the skin assessment and other prevention strategies for pressure ulcer within time as well as for all patients resulting in failure to prevent the development of bedsores.

Solution for overcoming barriers

In order to make a patient comply for skin assessment, the nurse requires to at first describe the way the entire process is going to take place as well as the reason behind such assessment. The patient is to be made comfortable through communication and the assessment is to be executed in private space so that the privacy of the patient is maintained. Moreover, the hands are to be sanitized properly before checking the skin of the patients to ensure the person that no infection would be transferred during the skin assessment (AHRQ, 2019). In order to resolve resource shortage, the nurses require examining before commencing skin assessment and applying other preventive measures of pressure ulcers whether or not the resources required for the process are present in adequate number. In case the resources are not available arrangements are to be made by informing the management, as well as alternative measures, are to be identified. A compulsory nursing training and education regarding pressure ulcer is to be arranged in each hospital where patients with risk of pressure ulcers are present or frequently admitted. This is because it would ensure all the nurses have proper knowledge and training regarding the way pressure ulcers is to be prevented. Moreover, an informative list which includes process to be followed in preventing pressure ulcer is to be installed in around intensive care wards and wards for older patients to provide direct information to the nurses about the measures they take to care for the patients to ensure the individual does not develop pressure ulcers.

Conclusion

The above discussion informs that prevention of pressure ulcer is applicable in nursing as information regarding it is required for nurses to provide satisfactory care to patients where the individual have better health condition, as well as experiences, reduce the cost of healthcare. The NICE guidelines mention that skin assessment, barrier creams, foam mattress, sacral dressing and education to the nurses regarding pressure ulcer prevention strategies are to be mentioned to avoid development of pressure ulcer among adults. The two contradictions experienced for NICE guidelines is that latex mattress is reported to be more effective than foam mattress along with oil massage is found to be effective in preventing pressure ulcer among adults. The barriers experienced are workload, shortage of required resources and improper training and education of the nurses and others. The installation of pressure ulcer prevention instruction, permanent nurse training and others are effective in resolving the barriers to prevent pressure ulcers.

Reflection

The topic “Prevention of Pressure Ulcers among Adults” in the assignment leads me to identify that it one of the essential topic to be applicable in nursing because it leads patients to suffer increased pain as well as require to invest extra money for its prevent which raises their healthcare cost. Moreover, it led me to identify that pressure ulcer is required to be prevented because it not only affects patients physically but also negatively affects their mental health as patients are said to develop depression and anxiety. The assignment further informed that it is one of the essential topics to be applicable in nursing because due to irresponsibility of care from the nurses the prevalence of the disease is increasing which is also impacting the NHS to spend extra funds which they could have been able to use for managing more intricate illness or diseases.

The assignment led me to understand that skin assessment is the initial step towards preventing pressure ulcer. This is because without assessing the skin of the patients I could never understand which patient is showing risk of developing ulcer. The assignment also educated me as a nurse about the signs and symptoms to be regarded which would indicate the patient is at risk of developing pressure ulcer. I am informed about the technological equipment which I can use for effective skin assessment of the patients. The assignment informs me about the type of mattress to be provided to patients who shows risk of pressure ulcer and importance of frequent movement for the patients. The assignment led me to understand the nature of dressings to be used for patients to prevent them from pressure ulcers. I am also informed through the assignment that the best practices for pressure ulcer prevention are using foam mattress, sacral dressing and barrier cream. However, I also came to know that latex mattress is far better than foam mattress to prevent pressure ulcer. I have developed confusion regarding whether or not to use massage therapy as a strategy to prevent pressure ulcer as one of the study though have mentioned it to be effective but the NICE guidelines strictly mention it not to be implemented.

The assignment led me to understand that workload and non-cooperation from patients are to be faced as major barriers in implementing the prevention strategies. Thus, in future, for providing care to patients to prevent them from pressure ulcer I am at first going to execute skin assessment of each patient by providing them detailed information about the way and reason of executing the assessment. I would try to ensure latex mattresses are installed for patients who are risk of developing pressure ulcer to prevent them from actually experiencing bedsores. Moreover, I would ask them to change their position and if they avoid I would make them aware of the need for the action through empathetic and detailed communication to make them comply. I would also ensure that the resources I need for assessing and providing care to the patient for pressure ulcer prevention are always available as well as I have proper training regarding the way the prevention strategies for pressure ulcer suggested by NICE guidelines are to be implemented.

References

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