Pressure Sore free essay sample

The purpose of this evidence-based research project was to determine if the use of a sacral mepilex, or like dressing, helps to prevent pressure ulcers in the intensive care unit (ICU) population. A pressure ulcer in the ICU can be life threatening. The PICO(T) question for this evidence-based research project was, â€Å" In adult intensive care unit patients, does the application of sacral mepilex, or like dressing, to the lower back/ coccyx/sacral area, lead to a decreased incident of pressure ulcer formation in the coccyx/sacral area throughout the patient’s intensive care unit stay? A literature search using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, Google Scholar, and Journal of Critical Care Nurse was performed. The search was performed using key terms identified in the PICO(T). Results yielded five articles that were found to be applicable for this project and were then reviewed. Evidence from these five articles supports the issue of pressure ulcers in high risk patients. The prevention of pressure ulcers using different quality improvement projects while utilizing a multidisciplinary team approach and appropriate measuring tools was identified. Once a patient has been identified at risk for pressure ulcers, prevention methods should be put into place. While the use of repositioning, reducing friction and shear, pressure relieving mattresses, and appropriate skin care measure can reduce the risk of pressure ulcers, pressure ulcers may still develop (McCance Huether, 2010). Because of this, additional measures should be considered. In effort to reduce the incidence of pressure ulcers, select intensive care units in Midwest have recently begun placing sacral mepilex upon the lower back region of patients on admittance. This dressing provides a moisture proof barrier to the skin that does not allow bacteria or viruses to penetrate (Molnlycke Health Care, 2011), reducing the moisture component that promotes pressure ulcer formation. The purpose of this evidence-based project is to determine if Mepilex sacral border dressings successfully reduce the risk of pressure ulcers in the intensive care unit. Background description of topic Pressure ulcers remain â€Å"one of the five most common causes of harm to patients† (Elliott, McKinley, Fox, 2008, p. 29), and can lead to significant morbidity and mortality for patients. Furthermore, it is estimated that 5% of the total ICU budget is spent on the prevention and treatment of pressure ulcers, and that the nursing workload increases by around 50% once the ulcer develops (Compton et al. , 2008 p. 417). Pressure ulcers are staged depending on the levels of tissue involved. These levels include â€Å"‘Stage I: Non-blanchable erythema’, â €˜Stage II: Partial thickness’, ‘Stage III: Full thickness skin loss’, ‘Stage IV: Full thickness tissue loss’, ‘Unstageable/Unclassified: Full thickness skin or tissue oss-depth unknown’, and ‘Suspected deep tissue injury-depth unknown (National Pressure Ulcer Advisory Panel, 2009, p. 8-9). Because of the varying levels of tissue damage that can occur, prevention methods are essential. These methods may include turning the patient at least every four hours, floating heels with pillows under legs, using specialty sacrum padding (Mepilex) and utilizing a specialty mattress, which can prevent pressure ulcer formation. Furthermore the methods of prevention are largely the responsibility of nursing. Theory/model description and connection to PICO (T) Many models have been identified in order to assist with maintaining or improving a patient’s holistic care. For instance, Myra Levine’s Conservation Model can be used as a theoretical framework for wound management. A case study involving Levine’s model talks of personal integrity, which involves the patients worth, self-esteem and physical body being maintained (Alligood Tomey, 2010). When someone enters the healthcare system, they have come to terms that they are in need of help with a health disparity. Also, with this decision to receive assistance, some personal independence must be set aside as a patient. A collaborative approach between the patient and nursing will improve outcomes, while using Levines model to help understand the importance of interventions intended to promote adaptation and maintain wholeness. The primary focus of conservation is keeping together the wholeness of the individual (Alligood Tomey, 2010, p. 229). The nurse is challenged in providing the individual with appropriate care without losing sight of the individual’s integrity while respecting the trust that the patient has placed in the nurse’s hands. Levine’s conservational model contains four conservation principles; conservation of energy, conservation of structural integrity, conservation of personal integrity, and conservation of social integrity (Alligood Tomey, 2010, p229). Conservation of structural integrity relates to this evidence based research as according to the model a patient must heal. Healing is a process of restoring structural and functional integrity through conservation in defense of wholeness (Alligood Tomey, 2010, p. 229). Nursing role is to aintain or re-establish strong skin integrity to ICU patients by preventing physical breakdown to the body, in this case, the sacral area and help promote healing. Nursing can help to limit the amount of tissue damaged through detailed assessment and being alert to risk factors on admission (Alligood Tomey 2010). Evaluation tools, such as the Braden Scale, have been and are currently utilized in practice to determine a patient’s risk for impaired skin i ntegrity and developing a pressure ulcer (Braden Maklebust, 2005). The Braden Scale allows for identification of the patient’s risk level for pressure ulcer development based upon five subsets of the scale; â€Å"sensory perception, mobility, activity, moisture and nutrition† (Braden Makelbust, 2005, p. 70). The categories of the Braden Scale are scored based upon patient findings and allow clinicians to identify the amount of attention that should be focused upon preventative skin care measures for a patient (Braden Makelbust, 2005). Using the results of this scale, patients that may benefit from the application of sacral mepilex on admission to the hospital setting can be identified. Significance of the topic/Overall importance The prevention of pressure ulcers is essential in the hospital setting. Looking from a patient standpoint, pressure ulcers â€Å"increase a patient’s length of stay, morbidity, and cost,† as well as decrease a patient’s overall â€Å"quality of life† (Campbell, Woodbury, Houghton, 2010, p. 28). In October of 2008, the Centers for Medicare and Medicaid Services (CMS) no longer provided financial reimbursement to hospitals for any pressure ulcers that were not present upon admission (United States Department of Health and Human Services, 2011, Para 1). Nursing staff must document an existing pressure ulcer within 48 hours of the patient arriving to the facility or the cost for treating this wound will not be repaid to the facility (Meehan, 2009). Most pressure ulcers can be prevented when appropriate risk factors are recognized and actions are taken (Lavrencic, 2011, p. 6). Typical pressure ulcer prevention methods include adequate positioning, nutritional status, and repositioning. In addition, new techniques such as additional skin barriers are being examined for effectiveness. PICOT In an attempt to further reduce the incidence of pressure ulcers in Intensive Care Unit Patients, the following PICOT will be addressed. (P) In Adult Intensive Care Unit patients, (I) does the application of Sacral Mepilex (or like dressing) to lower back/coccyx/sacral area, (C) when compared to no use of Sacral Mepilex on the lower back/coccyx/sacral area, (O) lead to a decreased incident of pressure ulcer formation in the coccyx/sacral area (T) throughout the patient’s ICU stay. Setting(s) Discussion Patients in the intensive care unit are at greater risk for pressure ulcers than the general population (American Journal of Critical Care, 2008). This is due to the fact that many patients are weaker than the general population. These patients are not always immobilized, however they are sedated, lack proper nutrition, typically are of an advanced age, and lack appropriate sensation (American Journal of Critical Care, 2008). All of these risk factors can lead to an increased prevalence of pressure ulcers. Because of the increased risk of pressure ulcers in the Intensive Care Unit, the use of sacral mepilex will be examined as a method to prevent pressure ulcers. Stakeholders Discussion Numerous stakeholders can be identified for this question. The National Pressure Ulcer Advisory Panel (1992) states â€Å"Responsibility for pressure ulcer prevention is shared by health care professionals, bedside caregivers, patients, and families (Para 7). † Patients are of primary concern and their skin should be protected with any method possible in order to prevent skin breakdown. Patients do not want to have an increased length of stay, increased medical cost, or the pain associated with the pressure ulcer. Nursing staff would also be prime stakeholders. Lovins and Boliek (2008) state â€Å"Never in the history of the profession have the basics of nursing care been more relevant to positive patient outcomes than now (Para 1)†. Nursing is responsible for assuring their patients are cared for appropriately. Additionally nursing has the opportunity to control numerous aspects of patients skin care. Physicians would additionally be major stakeholders. As patients develop pressure ulcers, the length of stay increases. With this the patient becomes more complicated, has an increased risk for infection and requires more personnel to attempt to heal the sore. Hospitals in general would be major stakeholders due to the funding aspect. Insurance companies that pay for pressure ulcer care could also be stakeholders, as they would prefer to not pay to treat the pressure ulcer but rather prevent it. Potential/Actual cost benefits/effectiveness The cost of treating a patient with a hospital acquired pressure ulcer is estimated to range from â€Å"$2,000 to $70,000 per wound† (Courtney, Ruppman, Cooper, 2006, p. 1). These numbers pale in comparison to the estimated national costs of, â€Å"$1. and $3. 5 billion annually† for treatment (Courtney, Ruppman, Cooper, 2006, p. 1). Since a pressure ulcer can range from an area of reddened skin that can be healed with a minimal intervention, to an ulcer that develops and causes septicemia and death, the price for treatments vary significantly. With effective interventions, such as the sacral mepilex costing only 22 dollars online, one can assume the benefit of seeking prevention far outw eighs the risk of pressure ulcer treatment (Metro Medical Online, 2011). Desired outcomes for specific (your) setting The desired outcome for this evidence-based project is to analyze the literature and determine if the mepilex can prevent pressure ulcers in the intensive care unit patient. Search Plan Method Search Methods Evidence based research and nursing practice relies heavily on the most accurate, current information available. Library databases, which provide current information and up-to-date research results, can be extremely helpful in finding appropriate research (Melnyk Fineout-Overholt, 2011). Textbooks can also be utilized to provide basic information; however the information may not be as current as journals nor are these a source for research. To supplement for this shortcoming, current journal articles should also be considered (Melnyk Fineout-Oveholt, 2011). Because numerous databases and sources can provide a diversity of information, various methods of obtaining evidence were utilized for the PICOT. The PICOT search was completed using a library computer search, a web-based search and a hand search of current nursing literature. The initial computer search was completed using of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus with Full Text database. As Melnyk Fineout-Overholt (2011) discuss databases such as CINAHL â€Å"contain the largest number and widest variation of articles describing clinical research† (p. 45). Once again to assure current information was obtained, a Google Scholar Internet search was also completed. This search was then complemented with a hand search of the 2011 journal Critical Care Nurse. This journal was identified because of the link to the population in this evidence-based research. These three methods were utilized to obtain the most comprehensive and current search on literature surrounding the PICOT. Database Search Terms and Strategy The search terms utilized in the CINHAL Plus with Full Text included: (P) Adult, intensive care unit, hospitalized patient, patient, inpatient, (I) mepilex, sacral dressing, coccyx dressing, pressure dressing, foam dressing, back dressing, (O) pressure ulcer and pressure sore (see Table 1). Table 1. PICOT Search Terms P |I |C |O | |Adult* |Mepilex* |(none entered) |Pressure Ulcer* | |OR |OR | |OR | |Intensive Care Unit* (and ICU) |Sacral N4 Dressing* | |Pressure Sore* | |OR |OR | | | |Hospitalized Patient Coccyx N4 Dressing* | | | |OR |OR | | | |Patient or Inpatient |Pressure N4 Dressing* | | | | |OR | | | | |Foam N4 Dressing* | | | | |OR | | | | |Back N4 Dressing* | | | * Truncation The search terms for the Population were first e ntered into the CINAHL Plus with Full Text database. The key words of â€Å"Adult,† â€Å"Inpatients,† and â€Å"Intensive Care Unit† were entered. The method of truncation was also used for each of the terms to include various endings for the search term. For example Adult* was expected to yield results of Adult or Adults. Next, a Boolean search was completed utilizing the word â€Å"or† to identify the possible population results. This Boolean search yielded 514448 results. The intervention was the next topic that was entered into the CINAHL database. The key terms of â€Å"Mepilex,† â€Å"Sacral Dressing,† â€Å"Coccyx Dressing,† â€Å"Pressure Dressing,† â€Å"Foam Dressing,† and â€Å"Back Dressing† were entered into the database. A proximity search was completed for the key words coccyx dressing, pressure dressing, foam dressing, and back dressing. The term N4 was entered between the two key words in each search. The results that were expected included any article in which the two words of the search were anywhere within four words of one another in an article. After these individual results were obtained, a Boolean search was completed using the operator â€Å"or† and yielded a total of 2279 results. The comparison group was not entered due to the nature of this PICOT. The outcome search was then completed. The key term â€Å"Pressure Ulcer† was searched as a main heading. Additionally the search term â€Å"Pressure Sore† was entered. A Boolean search was again completed using the Boolean operator â€Å"or. † This produced a total of 14952 results. A Boolean search was then completed to combine all of the search terms. The results from the Population, Intervention and Outcome search were combined utilizing the Boolean operator â€Å"and† to assure articles would be relevant to the PICOT. This allowed for 205 results. Limiters were then placed on the search. These limiters included articles published between 2000 and 2011, the articles must be peer reviewed, a research article, and in English. With the limiters set, 67 articles were identified that met criteria, while 138 articles were excluded due to being older than 2000, not peer reviewed, not a research article or in a language other than English. Appendix A provides a graphic of the results of this search. These results were further evaluated and excluded based upon irrelevance to the PICOT. Inclusion/Exclusion Criteria Inclusion criteria included articles for the CINAHL database search were those that were peer reviewed, research article, and English Language. Additionally, articles were examined from 2000 to present. Exclusion criteria included articles that were not peer reviewed those that were not research articles, and those in a language other than English. Articles older than 2000 were excluded from the search. Articles were further searched based upon relevance to the PICOT. Those articles that pertained to the PICOT were included while those that were irrelevant were excluded. Inclusion criteria for the Google Scholar search included articles from 2000 to present. Analyzing the Literature .Critical Appraisals Critical appraisals were completed on five articles that met the search criteria for the PICOT question. The level of evidence table established by Polit and Beck (2008) was used to analyze and rank each article depending on the strength of evidence. Critical appraisals were completed on these articles to identify the validity, reliability, adaptability and trustworthiness of the articles as well as the significance the studies may have to the PICOT. Each article has noted areas of strength and weakness. The articles appraised look at various factors related to pressure ulcer development. Critical Appraisals of Individual Studies Study One: Incidence, prevention and treatment of pressure ulcers in intensive care patients: A longitudinal study. Shahin, Dassen, and Halfens (2009) completed a level VI quantitative longitudinal study identifying the prevalence of pressure ulcers, the risk factors for pressure ulcer development, and the evolution of pressure ulcers in the intensive care unit (ICU). The study followed 121 adults admitted to two different intensive care units. Participants were assessed for pressure ulcers upon admission to the ICU and again upon discharge, death or two weeks as a patient in the intensive care unit. Tools used to collect data included an author-developed questionnaire, the European Pressure Ulcer Advisory Panel grading system, the Braden Scale, and the APACHE II scale. The findings identified an overall pressure ulcer incidence of 3. % in the ICU population with the most common site for pressure ulcer development on the â€Å"sacrum, heel, ischium† (p. 416). Patients with Braden skin assessment scores between 14-18 were identified as higher risk of pressure ulcer development. Nursing care practices of skin inspection, repositioning the patient and massage were identified as methods to reduce the risk of pressure ulcers as well as facilitate healing of pressure ulcers in this particular setting. Study Two: Outliers to the Braden Scale: Identifying high-risk ICU patients and the results of prophylactic dressing use. Brindle (2010) conducted a Level VII, performance improvement to test the effectiveness of a prophylactic sacral dressing in preventing pressure