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Effectiveness of prevention and management of pressure ulcers, as" a patient safety issues" among bed ridden Patients at University Hospital in Jeddah, Saudi Arabia

Authors:

Abstract

Background: Despite implementation of evidence-based pressure ulcer (PU) prevention protocols, patients continue to suffer from these injuries (1).So prevention of the pressure ulcer has been a nursing concern for many years. Although the prevention of pressure ulcers is a multidisciplinary responsibility, nurses play a major role in preventing it. Most pressure sores are preventable and are caused by faulty care (2). King Abdul-Aziz University Hospital (KAUH) is one of the larger sized governmental hospitals in Jeddah, Saudi Arabia with a total bed capacity of 878. It underwent accreditation process administered by Accreditation Canada from 2007 to 2008. Aim of the study is to evaluate the effectiveness of prevention and management of pressure ulcers, as" a patient safety issues" among bed ridden Patients at King Abdul Aziz University Hospital in Jeddah, Saudi Arabia. Setting : Observational cohort study of pressure ulcer was used which calculated 40 newly admitted patients and 40 nurses who cared for the same patients and carried out in King Abdul-Aziz University Hospitals in Jeddah in Kingdom of Saudi Arabian. Methods : three modified tools for data collection were used. First one namely; Braden risk assessment scale. Second one namely: risk assessment tool ,divided into 2 main parts related to Socio-demographic characteristics, Knowledge towards age, sex, level of conscious, length of staying in hospital, date of admission, level of activity, department-etc. second part is a process of care. Third one namely: observational checklist used to investigate the nurses' role. Results: present study finding revealed that no one of studied nurses done a comprehensive skin assessment is which should be performed within 24 hours of admission as providing care for high risk patients; while 80.8% high risk patient given the same care but after patients have bed sore and there is significant differences was noticed. Conclusion: The prevalence of pressure ulcer are developing at factors such as immobility, comatose status and long of stay among bed ridden patients as well as majority of participating nurses were providing care to use blue sheet pad & foam matters(used specially for bed ucer) and most of nurses were not applicable to give the patient and family health education about preventive measures of pressure ulcer, and assess with family member who is caring for patients, understanding and ability to perform skin care. Recommendations: The present study emphasized on empowering staff nurses to provide preventive pressure ulcer care by identifying risk assessment, planning staff development programs based on staff, organization, and patient needs and monitoring the process to conduct assessment of all new admissions to determine who is susceptible to develop of pressure sores. [Dr.Hasnah Ben Erfan Banjar ;Dr. Sabah M. Ahmed Mahran and Dr. Gihan Mohamed M. Ali: Effectiveness of prevention and management of pressure ulcers, as" a patient safety issues" among bed ridden Patients at King Abdul Aziz University Hospital in Jeddah, Saudi Arabia ] Journal of American Science 2012; 8(6): 100-109].(ISSN: 1545-1003). http://www.americanscience.org.12
Journal of American Science, 2012;8(6) http://www.americanscience.org
http://www.americanscience.org 100 editor@americanscience.org
Effectiveness of prevention and management of pressure ulcers, as" a patient safety issues" among bed ridden
Patients at University Hospital in Jeddah, Saudi Arabia
Dr. Hasnah Ben Erfan Banjar, PhD1 ; Dr. Sabah M. Ahmed Mahran, PhD 2 and Dr. Gihan Mohamed M. Ali,PhD 1
1Nursing Department -College of Applied Medical Science, King Abdul Aziz University, in Jeddah, Saudi Arabia
2Nursing Administration Department, Faculty of Nursing, Port-Said University, Egypt
sabahmahran@yahoo.com
Abstract: Background: Despite implementation of evidence-based pressure ulcer (PU) prevention protocols, patients
continue to suffer from these injuries (1).So prevention of the pressure ulcer has been a nursing concern for many years.
Although the prevention of pressure ulcers is a multidisciplinary responsibility, nurses play a major role in preventing
it. Most pressure sores are preventable and are caused by faulty care (2). King Abdul-Aziz University Hospital (KAUH)
is one of the larger sized governmental hospitals in Jeddah, Saudi Arabia with a total bed capacity of 878. It underwent
accreditation process administered by Accreditation Canada from 2007 to 2008. Aim of the study is to evaluate the
effectiveness of prevention and management of pressure ulcers, as" a patient safety issues" among bed ridden Patients
at King Abdul Aziz University Hospital in Jeddah, Saudi Arabia. Setting : Observational cohort study of pressure ulcer
was used which calculated 40 newly admitted patients and 40 nurses who cared for the same patients and carried out in
King Abdul-Aziz University Hospitals in Jeddah in Kingdom of Saudi Arabian . Methods : three modified tools for data
collection were used. First one namely; Braden risk assessment scale. Second one namely: risk assessment tool ,divided
into 2 main parts related to Socio-demographic characteristics, Knowledge towards age, sex, level of conscious, length of
staying in hospital, date of admission, level of activity, department------etc. second part is a process of care. Third one
namely: observational checklist used to investigate the nurses' role. Results: present study finding revealed that no one
of studied nurses done a comprehensive skin assessment is which should be performed within 24 hours of admission
as providing care for high risk patients; while 80.8% high risk patient given the same care but after patients have bed
sore and there is significant differences was noticed. Conclusion: The prevalence of pressure ulcer are developing at
factors such as immobility, comatose status and long of stay among bed ridden patients as well as majority of
participating nurses were providing care to use blue sheet pad & foam matters( used specially for bed ucer) and most
of nurses were not applicable to give the patient and family health education about preventive measures of pressure
ulcer, and assess with family member who is caring for patients, understanding and ability to perform skin care.
Recommendations: The present study emphasized on empowering staff nurses to provide preventive pressure ulcer
care by identifying risk assessment, planning staff development programs based on staff, organization, and patient
needs and monitoring the process to conduct assessment of all new admissions to determine who is susceptible to
develop of pressure sores.
[Dr.Hasnah Ben Erfan Banjar ;Dr. Sabah M. Ahmed Mahran and Dr. Gihan Mohamed M. Ali: Effectiveness of
prevention and management of pressure ulcers, as" a patient safety issues" among bed ridden Patients at King
Abdul Aziz University Hospital in Jeddah, Saudi Arabia ] Journal of American Science 2012; 8(6): 100-109].(ISSN:
1545-1003). http://www.americanscience.org.12
Key words : pressure ulcer , bed ridden patient, care of skin , comatose patient, preventive measures, bed sore
1. Introduction
Despite implementation of evidence-based
pressure ulcer (PU) prevention protocols, patients
continue to suffer from these injuries. The total number
of hospitalizations with a secondary diagnosis of PU in
the United States increased by 80% between 1993 and
2006,and in 2009, the incidence of facility acquired
PUs was determined to be 5% on the basis of
assessments of more than 92,000 patients.2
International surveys conducted during the 2001–2008
period indicated an average prevalence of 7.05%
(median, 6.8%) (1) . So prevention of the pressure ulcer
has been a nursing concern for many years. Although
the prevention of pressure ulcers is a multidisciplinary
responsibility, nurses play a major role in preventing it.
Most pressure ulcer are preventable and are caused by
faulty care. Pressure ulcers remain a major health
problem affecting approximately 3 million adults, the
prevalence of pressure ulcer among high risk
hospitalized patient has been noted high 38% among
patient age 55years patient (2) . Majority of the pressure
ulcer began soon after admission, particularly on
patients’ operation days. 34 percent developed ulcers
within the first week, and 24 percent developed ulcers
within the second week. 95 percent of pressure ulcers
occur in the lower part of the body. Incidence of
pressure ulcers is actually higher in acute care hospitals
than in nursing homes (3) . King Abdul-Aziz University
Hospital (KAUH) is one of the larger sized
governmental hospitals in Jeddah, Saudi Arabia with a
total bed capacity of 878. It underwent accreditation
process administered by Accreditation Canada from
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2007 to 2008. These are the rate of pressure ulcers
developed per 1000 admissions (p<0.020), which
decreased, and the total number of the occurrence
variance reports (p<0.002) (4) . Therefore the aim of the
study is evaluate the effectiveness of prevention and
management of pressure ulcers, as" a patient safety
issues" among bed ridden Patients at King Abdul Aziz
University Hospital in Jeddah, Saudi Arabia.
(5) define the pressure ulcer as an area of soft
tissue damage that usually developed in areas where
are compressed between bony prominence and external
surfaces. (6) added that it is result of skin breaks down
when constant pressure, or pressure combination with
shear or friction, is placed against skin. Fitzgerald(7)
Illustrated the most common bed sore location were
the sacrum (a triangular bone at the base of the spine),
heels ; buttocks; Ears; Scapula; Spinous Process
Shoulder; Elbow; Iliac Crest; Sacrum/Coccyx; Ischial
Tuberosity; Trochanter; Knee; Malleolus; Heel; and
Toes (8). Pressure ulcers were graded from I to IV:
grade I, non-blanchable erythema with intact skin
surface; grade II, epithelial damage, abrasion or blister;
grade III, damage to the full thickness of the skin
without a deep cavity and grade IV, damage to the full
thickness of the skin with a deep cavity. While ((9)
mentioned that there are many factors affecting on
developing pressure ulcers such as intrinsic risk factors
as reduced mobility; sensory impairment; acute illness;
level of consciousness; extremes of age; vascular
disease; sever chronic or terminal illness; previous
history pressure damage; malnutrition and dehydration.
(10), developed comprehensive guidelines for the
prediction and prevention of pressure ulcers. This
guidelines as risk assessment, skin care, identifying
individuals 'at risk', seating, positioning, mechanical
loading, patient and staff education by (11). He stated
that daily assessment of the skin; objective
measurement of every wound; immediate initiation of a
treatment protocol; mechanical debridement of all
nonviable tissue; establishment of a moist wound-
healing environment; nutritional supplementation for
malnourished patients; pressure relief for the wound;
elimination of drainage and cellulitus; biological
therapy for patients whose wounds fail to respond to
more traditional therapies; physical therapy; and
palliative care. Availability of the described treatment
modalities, in combination with early recognition and
regular monitoring, ensures rapid healing and
minimizes morbidity, mortality, and costs. wherever
nurses according to patient safety and quality
indicators have great role to protect patients and
accomplish their goals of patient safety management.
(1), added that pressure ulcer protocols include
admission and ongoing skin assessment plus
identification of patients at risk for pressure ulcers
using of the validated tools and patient centered written
care plans. Also ongoing skin assessment and risk
factors trigger adjustments in the patients by
prevention plans is needed. Interventions include
ensuring patient repositioning within at least every two
hours; managing moisture; providing adequate
nutrition and hydration; and minimizing friction and
shear. Pressure redistribution surfaces and special heel
protection devices may also be provided. An avoidable
pressure ulcer can develop when the provider did not
do one or more of the following: evaluate the
individual’s clinical condition and pressure ulcer risk
factors; define and implement interventions consistent
with individual needs, individual goals, and recognized
standards of practice; monitor and evaluate the impact
of the interventions; or revise the interventions as
appropriate. An unavoidable pressure ulcer can
develop even though the provider evaluated the
individual’s clinical condition and pressure ulcer risk
factors; defined and implemented interventions
consistent with individual needs, goals, and recognized
standards of practice; monitored and evaluated the
impact of the interventions; and revised the approaches
as appropriate(12).
Aim Of Study
Preventing and management of pressure ulcer
among bedridden patients (health care providers) as a
safety issues at King Abdul Aziz University Hospital in
Jeddah through;
1-Identify patient who at risk needing prevention.
2-Recognize factors affecting them .
3-Investigate the nurses' role in preventing the pressure
sore
2. Subjects and Methods
Research design
Observational cohort study of pressure ulcer was
used at King Abdul-Aziz University Hospital. To
evaluate the effectiveness of prevention and
management of pressure ulcers, as" a patient safety
issues" among bed ridden Patients at King Abdul Aziz
University Hospital in Jeddah, Saudi Arabia. Patients
who undergoing medical and surgical treatment. These
findings are reported here, and assess the relationship
between the score of risk assessment scale at admission
and the score after developing pressure sore after one
week or more.
Setting
The study was conducted at King Abdul-Aziz
University Hospital, from medical and surgical wards.
The hospital is located at the Jeddah Governorate in
Saudi Arabia.
Subjects
The subjects of this study consisted of a selected
number of admitted patients who met the following
criteria: both gender; bedridden and stayed more than
one week at hospital. Examined for pressure ulcer
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within 2 days. Determination of sample size (40 ) who
were chosen from inpatient departments such as female
medical unit, male medical unit and surgical unit .
Group of nurses: the study was included staff nurses
(40). They were working in the above mentioned
setting at king Abdul-Aziz University Hospital. The
sample size was estimated as convenience sample.
Ethical Consideration
The study was approved by the appropriate
ethics committee. Patients were informed orally and in
writing about the study by a member of the scientific
team and gave written consent.
Tools Of Data Collection
Three modified tools for data collection were used.
First one namely; Braden risk assessment scales (13)
The aim of this tool is identifying the high risk patients .
Second one namely: risk assessment tool. The main
purpose of this tool is to assess newly admitted high
risk patient for pressure ulcers on all patients. This tool
divided into 2 main parts related to Socio-demographic
data such as age, sex, level of conscious, length of
staying in hospital, date of admission, level of activity,
department------etc. Second part is a process of care
which provided to patient during hospitalization . The
researcher recorded this process of care through
medical record, patient's file, or any tool used by
hospital. Third one namely: observational checklist
used to investigate the nurses' role in preventing and
management pressure ulcer.
Methods
1-A pilot study conducted on 10 of patients and 10
nurses to identify obstacles applicability and test
it. It has also served in estimating the time needed
for filling the forms. The purpose of pilot study
was:
1- To test the applicability of the study tools.
2- To estimate any need for addition in the tool.
Otherwise, the ten patients and 10 nurses
were then excluded from the sample of research
work to assure the stability of answers.
2Performance measure
Performance measures were done by the researcher and
used three tools two for patients another one for nurses
.these tools selected on the review of the literature and
pressure ulcer prevention guidelines. Data sources
from the hospital; medical records from physicians or
nurses or checklist developed by hospital. The
researcher assess the following:1- identification of high
risk patient ( documentation as medical diagnosis);2-
Braden risk assessment scale (13); 3- skin assessment in
high risk patient. Use of a pressure-reducing device in
bed (documentation that pressure-reducing mattress
was placed under patient by nursing staff) 4-
Repositioning the patient every two hours
(documentation on each shift by nursing staff that
repositioning occurred) 5-Nutritional consults in
malnourished patients (documentation that nutritional
consult was ordered by physician) 6. Number of
hospital-acquired Stage I pressure ulcers
(documentation by physician or nursing staff). Last one
observational checklist for nurses were observed by
researcher during assessment and prevention which
done for bedridden patients.
3 Statistical Design:
Collected data was arranged, tabulated and
analyzed according to the type of each data.
Scoring system:
Scoring system was ranged from 1 to 3scores 1=
for yes, 2= NO and 3 for not applicable.
Statistical analysis:
Data analysis:
Data was collected and entered into a database
file. Statistical analysis was performed by using the
SPSS 16 computer software statistical package. Data
was described by summary tables. For comparing the
(pre admission and after admission) with socio-
demographic data, Chi-2 or Fisher Exact test was used.
Statistical significance was considered at P-value
<0.05 and highly significance at P-value <0.00.
Descriptive statistics:
Numbers and percentages: Used for describing and
summarizing qualitative data.
The following statistical measures were used:
Chi square(X2):
Used to test the association between two
qualitative variables or compared between two or
more proportion.2.Fisher exact test probability
(FETp):
They are used when X2 is not valid (>20%of the
expected cell have count less than 5).
3. Results
The high risk patients included in this study were
40 patients from medical and surgical units at King
Abdul Aziz University Hospital. The age of the
patients ranged from 14 to 90 years, (55.0%) are male;
most of them (57.5%) admitted to medical unit,
whereas (2.5%) admitted from assisting living; about
(87.5 %) from emergency. Their period of time for
developing bed sore were (62.5%) at range 5 to 10).
A majority (60.0%) of the patients were complete
dependent care, whereas 47.5 % were comatose
patients, while (100%) was reported by researcher from
the documentation in relation to item risk assessment
tool includes a Braden Scale or modified Braden Scale
score. Half (50%) of studied sample were not identified
on admission as being at risk for pressure ulcer
development, most (67.5%) of patients have developed
bed sore after admission. Slightly above third of them
(32.5%, 32.5%) respectively have first and second
stages bed ulcer and only one case (2.5%) has
developed third stages bed ulcer. All of the studied
sample of nurses (67.5 %) were women, were single ,
their mean of age was 26.5 years Min ¼ 20 Max ¼
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32, SD ¼ 2.9)above half of them (52.5%) have
experience year ranged from (1-3) years and had
about all of them (100 %) nurses had a baccalaureate
degree in nursing, who are providing care to patients.
Descriptive statistics for process of care for at-
risk patients on admission and after one week or more
as documented are shown in Table (2). All of the
patients (100%) haven't any consulted to wound team
on admission while four only of them (10.0%) have
consulted to wound team after developed bed ulcer,
whereas 7.5% of bed ridden patients have skin
inspected daily. Only five (12.5%) patients had
massage for pressure areas. With regard to Patient
repositioned every 2 hours, two third studied samples
received change position, whereas only five bed ridden
patient haven't got the same care. Majority of patients
(65%) on admission they haven't pressure
redistributing device in place within 24 hours of risk
identification. 100% of the patients haven't any
assessed for nutrition within 24 hours of risk
identification by nurse on admission, whereas 10% of
them nutrition were assessed after ulcer developed.
Further, results showed that only two patients
documented barrier cream applied if moisture issues
identified as preventive measures on admission,
whereas 57.5% of patients have barrier cream applied
after developing bed ulcer. Regarding to the last point
in the process of care, 100 % of patients were not
notified of skin problem.
Table (3) presents relation between socio
demographic data of patients and developing bed ulcer.
Findings revealed that there is significant deference
between period of time for developing bed ulcer and
patient having bed sore at mean= 7.76 and p= 0.021
whereas there are highly significant differences in
relation to Pt.'s Level of activity; Pt.'s level of
consciousness; age and sex at p= 0.000, While there
isn't significant differences between period of time for
developing bed ulcer and degree of stages at p= 0.064.
Table (4) compare between process of care for
high risk patients which recorded before developing
bed ulcer and after developing ulcer , compares
between the " Yes %" before and after for cases which
having bed sore. Findings revealed that no one high
risk patient has Consult to wound team as intervention
measures before developed bed ulcer, while only four
patients were received this intervention after
developing bed ulcer. Most of them 69.2% recorded
inspect skin daily after develop developing bed ulcer
and there is highly significant differences was showed
at p= 0.000. Twelve high risk patients repositioned
every 2 hours and Pressure redistributing device in
place within 24 hours of risk identification before
developing bed ulcer while 80.8% high risk patient
given the same care but after patients have bed sore
and there is significant differences was noticed at p=
0.000. Reported 88.5% high risk patients have Barrier
cream applied after patient 'condition become worse
there is highly significant differences at p= 0.000.
Table (5) show observational checklist for the
role of nurses in process of care for high risk patients.
finding revealed that no one of studied nurses 100%
done of those items during providing care for high risk
patients as comprehensive skin assessment is
performed within 24 hours of admission; keep the
patient's skin dry; use mild clean agent to minimize
dryness and irritation if used what it is; use absorbent
under pad and topical agent which act as moisture
barriers; don't elevate the high risk patient above 20
degree; turn and proper position to the patient at least
every 2 hours; Nurse assess nutrition within 24 hours
of risk identification; and Assess nutrition includes
dietary consult. Furthermore The majority of all
participating nurses rated 95 % nurses done in relation
to Use blue sheet pad & foam matters( used specially
for bed sores). While forty two percent nurses rated
done for " Provide orders for special diet within 24
hours after risk identification." As well as two third
nurses were not applicable in relation to Give the
patient and family health education about preventive
measures of bed ulcer, and Assess with family
member who is caring for pt. the understanding and
ability to perform skin care
4. Discussion
Prevention of pressure ulcer development risk
assessment is recommended as the first step in the
prevention of pressure on admission & must be re-
assessed whenever there is a significant change in the
patients' condition as mentioned by Lindgren et al.,
Agency for Health Care Policy and Research &
European Pressure Ulcer Advisory Panel ( EPUAP)
(8, 10,14).This is approved with the present study as risk
assessment help to identify patients who developed
pressure ulcers & it is coincide with Agency for
Health Care Policy and Research (15). In addition,
Rosenfeld (3)explained that a majority of pressure
ulcers began soon after admission particularly on
patients days which also support the study finding.
Also, findings of the Agency for Health care research
& quality (AHRQ) revealed that number of
hospitalized patients who developed pressure ulcers
hasincreasedbymorethan80%from1993to2006.
In respect to age, gender, risk factors and location
and number of ulcers found. Our study have reported
statistically significant differences between age as a
risk factor & development of pressure ulcer as coincide
with (8), recorded that the patients who developed
pressure ulcers were significantly older than non-
pressure ulcer patients.
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Table (1): Descriptive statistics of Patients information
Variable No %
Diagnosis
Brain stroke
Cancer
liver disease
C. O.P.D
Others
Total
5
13
5
4
13
40
12.5
32.5
12.5
10.0
32.5
100.0
Age ( Intervals)
(14-39)
( 40-59)
(60-90 )
Total
No
6
10
24
40
%
15.0
25.0
60.0
100.0
Age (values)
Mean = 57.2
S.D. = 19.2
Minimum = 14
Maxima = 90
Sex
Male
Female
Total
No
22
18
40
%
55.0
45.0
100.0
Admitted to
Medical
Surgical
Total
No
23
17
40
%
57.5
42.5
100.0
Admitted from
Emergency
Home
assisted living
Total
No
35
4
1
40
%
87.5
10.0
2.5
100.0
Period of time
5 to 10)
<10-15)
(> 15 ) Total
No
25
6
9
40
%
62.5
15.0
22.5
100.0
Pt.'s Level of activity
Mobile
Complete dependent
Assistant
Total
No
0
24
16
40
%
0
60.0
40.0
100.0
Pt.'s level of consciousness
Consciousness
Comatose
Confused
Total
No
10
19
11
40
%
25.0
47.5
27.5
100.0
Does the risk assessment tool includes a Braden Scale or
modified Braden Scale score.
No.
yes % No.
No % Total
40 100.0 0 00.0 40
patient identified on admission as being at risk for pressure
ulcer development.
No.
yes % No.
No % Total
20 50.0 20 50.0 40
Patients have bed sore. 27 67.5 13 32.5 40
Degree of stages
Free
1st stage
2nd stages
3rd stages
4th stages
Total
No
13
13
13
1
0
40
%
32.5
32.5
32.5
2.5
0.00
100.0
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Table (2) Describe statistics for process of care for at-risk patients on admission and after one week or more after
admission as recorded in patient's records. (.N= 40)
No Items
For at-risk patients :
on admission
After one week or more after admission
Yes No Yes No Cases not
developed
bed sore
No % No % No % No % No %
1 Consult to wound team. 0 0 40 100 4 10.0 22 55.0 14 35.0
2 Skin inspected daily. 3 7.5 37 92.5 18 45.0 8 20.0 14 35.0
3 Massage for pressure areas. 5 12.5 35 87.5 8 20.0 18 45.0 14 35.0
4 Patient repositioned every 2 hours or
"up ad lib". 17 42.5 23 57.5 21 52.5 5 12.5 14 35.0
5 Pressure redistributing device in
place within 24 hours of risk
identification. 14 35.0 26 65.0 21 52.5 5 12.5 14 35.0
6 Nurse assess nutrition within 24
hours of risk identification.(type of
food). 0 0 40 100 4 10.0 22 55.0 14 35.0
7 Nurse Provided orders special diet
within 24 hours of risk identification. 0 0 40 100 4 10.0 22 55.0 14 35.0
8 Barrier cream applied if moisture
issues identified. 2 5.0 38 95.0 23 57.5 3 7.5 14 35.0
9 Patient and family notified of skin
problem. 0 0 40 100 0 0 26 65.0 14 35.0
No Items Yes No
No % No %
G Nurse assessed nutrition includes dietary consult. 0 0 40 100
H Nurse recorded in assessment sheet admit and weekly weight. 0 0 40 100
Wound care
No Items Yes No Cases not
developed
bed sore
No % No % No %
A Provider order for wound care on the chart within 24 hours of notification. 20 50.0 6 15.0 14 35.0
B Wound care implemented as ordered. 22 55.0 4 10.0 14 35.0
C Pressure ulcer assessed for healing,/ worsening as ordered. 22 55.0 4 10.0 14 35.0
III- Third Part:
After one week or more after admission:
No Items Yes No Not having
bed ulcer
No % No % No %
1 Consult to wound team. 4 10.0 22 55.0 14 35.0
2 Skin inspected daily. 18 45.0 8 20.0 14 35.0
3 Massage for pressure areas. 8 20.0 18 45.0 14 35.0
4 Patient repositioned every 2 hours or "up ad lib". 21 52.5 5 12.5 14 35.0
5 Pressure redistributing device in place within 24 hours of risk
identification. 21 52.5 5 12.5 14 35.0
6 Nurse assess nutrition within 24 hours of risk identification.(type of
food). 4 10.0 22 55.0 14 35.0
7 Nurse Provided orders special diet within 24 hours of risk
identification. 4 10.0 22 55.0 14 35.0
8 Barrier cream applied if moisture issues identified. 23 57.5 3 7.5 14 35.0
9 Patient and family notified of skin problem.
0 0 26 65.0 14 35.0
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Wound care
No Items Yes No Missing
No. % No. % No. %
A Provider order for wound care on the chart within 24 hours of notification. 20 50.0 6 15.0 14 35.0
B Wound care implemented as ordered. 22 55.0 4 10.0 14 35.0
C Pressure ulcer assessed for healing,/ worsening as ordered. 22 55.0 4 10.0 14 35.0
Table 3 presents relation between socio demographic data of patients and developing bed ulcer
Relation between 2
χ
d.f (p-value) Contingency
coefficient (p-value)
Period of time.
and
Patient having bed sore.
7.76 2 0.021 0.403 0.021
Period of time.
and
Degree of stages.
11.93 6 0.064 0.479 0.064
Pt.'s Level of activity.
and
Patient having bed sore.
24.69 2 0.000 0.618 ***
0.000
Pt.'s Level of activity
and
Degree of stages.
26.46 6 0.000 0.631 ***
0.000
Pt.'s level of consciousness.
and
Patient having bed sore. 21.50 2 0.000 0.591 ***
0.000
Pt.'s level of consciousness.
and
Degree of stages. 22.86 6 0.001 0.603 ***
0.000
Age (interval )
and
Patient having bed sore. 11.62 2 0.003 0.475 **
0.003
Age (interval )
and
Degree of stages. 12.51 6 0.050 0.488 0.050
If the p-value is more than 0.05 this means that there is no significant relation, but if the p-value 0.05 or less this means that there
is a significant relation.
Table (4) compare between process of care for high risk patients which recorded before developing bed ulcer and after developing
ulcer , compares between the " Yes %" before and after for cases which having bed sore.
No Items Yes z (p-value) before after
No % No %
1 Consult to wound team. 0 0.0 4 15.4 * *
2 Skin inspected daily. 3 11.5 18 69.2 4.24 ***
0.000
3 Massage for pressure areas. 3 11.5 8 30.8 1.68 *
0.047
4 Patient repositioned every 2 hours or "up ad lib". 12 46.2 21 80.8 2.58 *
0.005
5 Pressure redistributing device in place within 24
hours of risk identification. 11 42.3 21 80.8 2.85 ***
0.002
6 Nurse assess nutrition within 24 hours of risk
identification.(type of food). 0 0.0 4 15.4 * *
7 Nurse Provided orders special diet within 24 hours
of risk identification. 0 0.0 4 15.4 * *
8 Barrier cream applied if moisture issues identified. 2 7.7 23 88.5 5.81 ***
0.000
9 Patient and family notified of skin problem. 0 0.0 0 0.0 * *
p-value is less than 0.05 which means that is significant difference.
Journal of American Science, 2012;8(6) http://www.americanscience.org
http://www.americanscience.org 107 editor@americanscience.org
Nurse's Observational checklist Tool
Table
Variable Results Variable Results
Unit
No. %
FS = 8 20.0
MS = 8 20.0
FM = 18 45.0
MM = 6 15.0
Marital status
No. %
Single 27 67.5
Married 13 32.5
Age (values)
Years
Mean = 26.5
S.d. = 2.9
Minimum = 20
Maxima = 32
Age ( Intervals)
Years n %
(20-24) 11 27.5
( 25-28) 18 45.0
(29-32 ) 11 27.5
Experience (values)
Years
Mean = 3.7
S.d. = 2.2
Minimum = 1
Maxima = 10
Experience( Intervals)
Years n %
(1-3) 21 52.5
(4-6) 15 37.5
(7-10) 4 10.0
Table (5) show observational checklist for the role of nurses in process of care for high risk patients
No Items Don Not done Not
applicable
No. % No. % No. %
1 Comprehensive skin assessment is performed within 24 hours of admission.
Degree of bed sores (1st,or 2nd or 3rd). 0 0 40 100 0 0
2 Keep the patient's skin dry. 0 0 40 100 0 0
3 Use mild clean agent to minimize dryness and irritation if used what it is. 0 0 40 100 0 0
4 Use absorbent under pad and topical agent which act as moisture barriers. 0 0 40 100 0 0
5 Apply appropriate dressing using clean technique. 3 7.5 37 92.5 0 0
6 Use blue sheet pad & foam matters( used specially for bed sores). 38 95.0 2 5.0 0 0
7 Clean the patient who incontinent (urine & feces) frequently. 9 22.5 31 77.5 0 0
8 Massaging bony prominences areas 5 12.5 35 87.5 0 0
9 Don't elevate the high risk patient above 20 degree. 0 0 40 100 0 0
10 Keep the linen dry and wrinkled free. 5 12.5 35 87.5 0 0
11 Turn and proper position to the patient at least every 2 hours 0 0 40 100 0 0
12 Nurse assess nutrition within 24 hours of risk identification 0 0 40 100 0 0
13 Assess nutrition includes dietary consult 0 0 40 100 0 0
14 Provide orders for special diet within 24 hours after risk identification. 17 42.5 23 57.5 0 0
15 Record in assessment sheet and weekly weight. 1 2.5 39 97.5 0 0
16 Give the patient and family health education about preventive measures of
bed ulcer 0 0 10 25.0 30 75.0
17 Assess with family member who is caring for pt. the understanding and
ability to perform skin care 0 0 10 25.0 30 75.0
On the other hand, (3) reported that pressure ulcer
may impact patients in homes, hospitals, assisted living
facilities or even people with limited mobility who are
living at home. Also, he added that pressure ulcer
remain such a common problem impacting patients in
all demographics that is supporting finding of present
study regards percentage distribution of number of pts
developed pressure ulcers at medical & surgical wards
at king Abdul- Aziz university hospital.
Whereas there are highly significant differences in
relation to Pt.'s Level of activity; Pt.'s level of
consciousness; age and sex. While there isn't
significant differences between period of time for
developing bed ulcer and degree of pressure ulcers .It
is important to realize the relation between
development of pressure ulcers and the previous
mentioned factors of :( Pt.'s Level of activity; Pt.'s level
of consciousness; age ). This coincide with (8) who
reported that more patient . More patients who had
epidural/spinal analgesia developed pressure ulcers
than those who had general anesthesia. This may be
explained by their greater age and the fact that they
were suffering from diseases affecting their mobility
greater than patients having general anaesthesia,
leading to prolonged periods of immobilization. In
Journal of American Science, 2012;8(6) http://www.americanscience.org
http://www.americanscience.org 108 editor@americanscience.org
order to provide care for patients who developed
pressure ulcers, (16) emphasized the beneficial of
performingregularinspectionoftheskinespecially
overbonyprominences.Alsoobserveforsignsof
pressure(changesinskincolor[i.e.,reddish,or
purplishhue],or change in skin temperature [either
warmer or cooler] compared to surrounding skin, or
change in skin texture such as bogginess or in duration
continue to monitor until skin change resolves or notify
a health care professional if it does not resolve.
However, in the present study all of the patients
haven't any consulted to wound team on admission
while four only of them have consulted to wound team
after developed bed ulcer. It is found significance
difference nursing care provided by nurses and patients
' that developed on admission & after 10 days. This
finding supported with Rosenfeld (2008) Bed sores
can be prevented by conducting daily skin inspections
(especially for at risk patients), using pressure reducing
mattresses, pressure-release wheelchairs, frequent
position changes, minimizing friction, and healthy diet.
Although, the importance of instruction provided by
(8,14,17) regard nutrition to offer individuals with
nutritional and pressure ulcer risks a minimum of 30-
35 kcal per kg body weight per day with 1.25-1.5
g/kg/day protein and 1 ml of fluid intake per kcal per
day. Also, consult a dietician and correct nutritional
deficiencies .Increase protein and calorie intake and A,
C, or E vitamin supplements as needed(18) .The present
study had no any assessment through documentation
on admission or consultation to dietary team.
Regarding to grad of pressure ulcer the finding
revealed that most of patients have developed bedsore
afteradmission,onethirdofthemhavefirstand
second stages pressure ulcer and only one case has
third stages pressure ulcer. This findings agreed with (8)
Eight ulcers (14.5%) progressed during the observation
period. These included seven grade I ulcers: five to
grade II, one to a grade III, and one to grade IV; one
pressure ulcer grade III progressed to grade IV. Thirty
ulcers healed during the observation period, and one
patient with a grade II ulcer died
Regards, skin daily after developing bed ulcer and
there is highly significant differences was showed;
repositioned every 2 hours ; Pressure redistributing
device in place within 24 hours of risk identification
before developing bed ulcer and Barrier cream applied
after patient 'condition become worse there was highly
significant while the same care was given but after
patients have bed ulcer significant differences was
noticed, differences. This results similar with by (3),
who found that prevention is key because decubitus
ulcers are easier to prevent than to treat, and it avoid
putting the patient in unnecessary pain and discomfort
in addition to being put at risk for serious health
complications such as sepsis and even death.
As regards nurses who provide care,. Finding
revealed that no one of studied nurses providing care
for high risk patients as comprehensive skin
assessment is performed within 24 hours of admission;
keep the patient's skin dry; use mild clean agent to
minimize dryness and irritation if used what it is; use
absorbent under pad and topical agent which act as
moisture barriers; don't elevate the high risk patient
above 20 degree; turn and proper position to the patient
at least every 2 hours; Nurse assess nutrition within 24
hours of risk identification; and Assess nutrition
includes dietary consult. This finding congruent with
(12) , who stated that most pressure (12 ) most Pressure
Ulcers are avoidable; not all Pressure Ulcers are
avoidable; there are situations that render Pressure
Ulcers development unavoidable, including
hemodynamic instability that is worsened with physical
movement and inability to maintain nutrition and
hydration status and the presence of an advanced
directive prohibiting artificial nutrition/hydration;
pressure identify the limits of prevention.
Furthermore the majority of all participating nurses
were providing care to use blue sheet pad & foam
matters( used specially for bed sores). While minimum
percent nurses rated for " Provide orders for special
diet within 24 hours after risk identification." As well
as most of nurses were not applicable in about Given
the patient and family health education about
preventive measures of bed ulcer, and Assess with
family member who is caring for pt. the understanding
and ability to perform skin care. This findings are
coincides with (19) It is commonly accepted that the
majority of pressure caused by unrelieved external
pressure are preventable. In spite of this knowledge,
the prevalence of pressure ulcers worldwide remains
unacceptably high. Lack of nursing care, in particular,
is still seen as one of the primary causes for their
development. Pressure ulcers are increasingly used as
an indicator of the quality of care.
Conclusions and Recommendations
The study concluded that prevalence of pressure
sores are developing at factors such as immobility,
over weight and mental status among bed ridden
patients as well as majority of participating nurses were
providing care to use blue sheet pad & foam matters(
used specially for bed sores). While minimum percent
Journal of American Science, 2012;8(6) http://www.americanscience.org
http://www.americanscience.org 109 editor@americanscience.org
nurses rated for " provide orders for special diet within
24 hours after risk identification." As well as most of
nurses were not applicable in about given the patient
and family health education about preventive
measures of bed ulcer, and assess with family member
who is caring for patients, understanding and ability to
perform skin care. The educational program for
prevention of pressure ulcers should be implemented
through evaluating nurses' effectiveness in preventing
pressure ulcers as quality assurance standards. In the
light of the study findings, the authors recommend the
following:
1. Empowering staff nurses to provide preventive
pressure ulcer care by identifying risk
assessment.
2. Planning staff development programs based on
staff, organization, and patient needs.
3. 3- Monitoring the process to conduct assessment
of all new admissions to determine who is
susceptible to develop of pressure sores.
4. Health care providers should be functioning as a
team, the incidence rates of pressure ulcers can
decrease. Thus, pressure ulcers and their
prevention implementation considered as
important goal to provided as safety measures in
patient care.
Corresponding author
Dr. Sabah M Ahmed Mahran. PhD.
Nursing Administration Department, Faculty of
Nursing, Port Said University-Egypt
Email: Sabahmahran@yahoo.com
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4/29/2012
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... As regards nurses who provide care; our study finding revealed that the above two third of the sample providing care for high risk patients as comprehensive skin assessment within 24 hours of admission, turn and proper position to the patient at least every 2 hour. Other results in the same line for Black et al 2011 who mentioned that most PUs are avoidable, while our finding congruent with Banjar 2012 who stated that no one of the nurses provided care for high risk patients in 24 hours of admission [3,16]. ...
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The purpose of the study was to assess the level of knowledge regarding management of bed sore among staff nurses findings of the study can help the health care professional to plan and implement awareness program for nurses to manage the patient with bed sore. The objectives of the study were to assess the level of knowledge regarding management of bed sore among staff nurses and to find the association between level of knowledge regarding management of bed sore and selected demographic variables. A survey research approach was used and the research design adopted for the present study was descriptive. The target population for the study was staff nurses in selected hospitals of Moradabad. Sample size was 157 data analysis was done by the basis of objective and hypothesis of study. The obtained data was analyzed based on objective and hypothesis by using descriptive and inferential statistics and hypothesis were tested at 0.05 level of significance. The results of the study says that level of knowledge regarding management of bed sore among 157 staff nurses that 51 (32.5%) had good knowledge, 103 (65.6%) had a average knowledge and 3 (1.9%) had a poor knowledge. There was no significant association between knowledge and demographic variable such as staff nurse age (p=0.42), education (p=0.79), gender (p=0.67), religion (p=0.37), experience (p=0.60), working place (p=0.77) www.ijcrt.org © 2021 IJCRT | Volume 9, Issue 1 January 2021 | ISSN: 2320-2882 IJCRT2101051 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org 372 and source of information (p=0.69). This study concluded that majority of the nurses have average knowledge that others regarding management of bed sore. The findings highlight that the health care providers can play a significant role to educate the nurses regarding importance of early detection, management and prevention of bed sore.
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The causes of pressure ulcer development have been the subject of investigation for centuries. It is commonly accepted that the majority of pressure related tissue injuries (pressure ulcers) which are caused by unrelieved external pressure are preventable. In spite of this knowledge, the prevalence of pressure ulcers worldwide remains unacceptably high. Lack of nursing care, in particular, is still seen as one of the primary causes for their development. Pressure ulcers are increasingly used as an indicator of the quality of care. Whilst pressure ulcer research in Australia is in its infancy, accumulated data indicate that pressure ulcers and their sequelae are a significant problem, the extent of which is not fully appreciated by government, institutions or clinicians. This failure to acknowledge the problem may be because pressure ulcers are not viewed in the same context as other acute or chronic diseases such as heart disease. Despite this, clinical practice guidelines for pressure ulcers are gaining prominence in Australia in an endeavour to reduce pressure ulcer prevalence, morbidity, cost and litigation. Institutional risk management strategies for pressure ulcers are believed to contribute to improved patient outcomes. Both of these measures need to be evaluated to ensure that they do meet the needs of the consumer. This paper briefly highlights the history of pressure ulcers, the extent of the problem in Australia and the need for improvement through education, risk management strategies and adoption of Australian clinical practice guidelines for their prevention.
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We sought to determine if a silicone border foam dressing could decrease the incidence of sacral pressure ulcers in an intensive care unit. The study setting was an intensive care unit located in a 303-bed hospital with a designation of level 2 trauma. The unit specializes in the care of critically ill medical and postoperative adults. Two hundred seventy-three patients participated in the study; their mean age was 65 years (range, 18-105 years). Baseline sacral hospital-acquired pressure ulcer (HAPU) incidence was determined during a period of 35 months; skin care representatives examined all patients in our critical care unit for HAPUs on a monthly basis. Based on this baseline incidence, we studied the effect of application of a silicone-bordered foam dressing applied to the sacrum. The observation period for our study intervention was 6 months; the sacral area was examined twice daily during this period. The average baseline sacral HAPU prevalence during the 35-month observation was 13.6% as compared to an incidence of 1.8% during a 6-month prospective study. Three of the 5 patients developed suspected deep tissue injuries and subsequently expired. The remaining 2 subjects developed stage 2 pressure ulcers, one of whom also expired. Following application of a silicone-bordered foam dressing, we were able to achieve a HAPU of 1.8%.
Background: Patients continue to suffer from pressure ulcers (PUs), despite implementation of evidence-based pressure ulcer (PU) prevention protocols. In 2009, Joint Commission Resources (JCR) and Hill-Rom created the Nurse Safety Scholar-in-Residence (nurse scholar) program to foster the professional development of expert nurse clinicians to become translators of evidence into practice. The first nurse scholar activity has focused on PU prevention. Four hospitals with established PU programs participated in the PU prevention implementation project. Pu prevention implementation project: Each hospital's team completed an inventory of PU prevention program components and provided copies of accompanying documentation, along with prevalence and incidence data. Site visits to the four participating hospitals were arranged to provide opportunities for more in-depth analysis and support. Following the initial site visit, the project team at each hospital developed action plans for the top three barriers to PU program implementation. A series of conference calls was held between the site visits. Year 1 project results: Pressure Ulcer Program Gaps and Recommendations. The four hospitals shared common gaps in terms of limitations in staff education and training; lack of physician involvement; limited involvement of unlicensed nursing staff; lack of plan for communicating at-risk status; and limited quality improvement evaluations of bedside practices. Detailed recommendations were identified for addressing each of these gaps. these Conclusions: Recommendations for eliminating gaps have been implemented by the participating teams to drive improvement and to reduce hospital-acquired PU rates. The nurse scholars will continue to study implementation of best practices for PU prevention.
Article
There have been no studies that have tested the Braden Scale for predictive validity and established cutoff points for assessing risk specific to different settings. To evaluate the predictive validity of the Braden Scale in a variety of settings (tertiary care hospitals, Veterans Administration Medical Centers [VAMCs], and skilled nursing facilities [SNFs]). To determine the critical cutoff point for classifying risk in these settings and whether this cutoff point differs between settings. To determine the optimal timing for assessing risk across settings. Randomly selected subjects (N= 843) older than 19 years of age from a variety of care settings who did not have pressure ulcers on admission were included. Subjects were 63% men, 79% Caucasian, and had a mean age of 63 (+/-16) years. Subjects were assessed for pressure ulcers using the Braden Scale every 48 to 72 hours for 1 to 4 weeks. The Braden Scale score and skin assessment were independently rated, and the data collectors were blind to the findings of the other measures. One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care hospitals, VAMCs, and SNFs, respectively. Subjects who developed pressure ulcers were older and more likely to be female than those who did not develop ulcers. Braden Scale scores were significantly (p = .0001) lower in those who developed ulcers than in those who did not develop ulcers. Overall, the critical cutoff score for predicting risk was 18. Risk assessment on admission is highly predictive of pressure ulcer development in all settings but not as predictive as the assessment completed 48 to 72 hours after admission. Risk assessment on admission is important for timely planning of preventive strategies. Ongoing assessment in SNFs and VAMCs improves prediction and permits fine-tuning of the risk-based prevention protocols. In tertiary care the most accurate prediction occurs at 48 to 72 hours after admission and at this time the care plan can be refined.
Article
Seventeen hospitals and the Peer Review Organization of Connecticut (Qualidigm) attempted to increase early identification of high-risk patients and utilization of pressure ulcer preventive measures. A multihospital retrospective cohort study with medical record abstraction was used to obtain a total of 1,955 (baseline) and 891 (follow-up) patients aged 65 years and older discharged after treatment for pneumonia, cerebrovascular disease, or congestive heart failure with a length of stay > or = five days. During a nine-month period, the hospitals conducted four plan-do-study-act improvement cycles and shared their results in conference calls and group meetings. Statistically significant increases were noted from baseline (1/1/96-12/31/96) to follow-up (10/1/97-3/31/98) in identification of high-risk patients, repositioning of bed-bound or chair-bound patients, nutritional consults in malnourished patients, and staging of acquired Stage II pressure ulcers. Daily skin assessments occurred at a high rate in both periods. There were no statistically significant changes in other processes of care, pressure ulcer incidence, or mortality. Performance of four pressure ulcer prevention processes of care increased concurrently with a multifaceted improvement intervention.
Article
Bed-bound patients with pressure ulcers are almost twice as likely to die as are those without pressure ulcers. If pressure ulcers are treated with a comprehensive regimen upon early recognition, nearly all stage IV ulcers can be avoided. Furthermore, such a regimen can significantly reduce the comorbidities, mortalities, and costs of treatments resulting from stage IV ulcers. The costs of treatments for comorbidities after the ulcer progresses to stage IV far outweigh the costs for early treatment of the ulcer before it progresses beyond the early stages. We describe herein the 4 stages of pressure ulcers, as well as the pathogeneses, costs, and complications associated with these wounds. A comprehensive 12-step detailed protocol for treatment of pressure ulcers is described; this includes recognizing that every patient with limited mobility is at risk for developing a sacral, ischial, trochanteric, or heel ulcer; daily assessment of the skin; objective measurement of every wound; immediate initiation of a treatment protocol; mechanical debridement of all nonviable tissue; establishment of a moist wound-healing environment; nutritional supplementation for malnourished patients; pressure relief for the wound; elimination of drainage and cellulitus; biological therapy for patients whose wounds fail to respond to more traditional therapies; physical therapy; and palliative care. Availability of the described treatment modalities, in combination with early recognition and regular monitoring, ensures rapid healing and minimizes morbidity, mortality, and costs.
Preventing Pressure Ulcers in Connecticut Hospitals by Using the Plan-Do-Study-Act Model of Quality Improvement Pressure sore developed in a nursing home, long-term care facility or hospital. Nursing Homes Abuse Blog www.nursinghomesabuseblog.com/bedso
  • H C Lyder
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