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Pressure Ulcer in Hospitalized Patients

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Pressure Ulcer in Hospitalized Patients

Literature Review

Various authors have indicated that there are three actions related to the prevention of pressure ulcers, including risk assessment, preventive actions, and ongoing reevaluations. Coleman et al. (2016) defines the pressure ulcer risk assessment as the identification of the factors that independently relate to the possibility of one acquiring a pressure ulcer in patient populations. Risk assessment refers to the measures taken to recognize the patients who are at risk as early as during admission for preventive care to be implemented. However, the authors suggest that risk assessment is not limited to the preventive efforts of this health problem, it is utilized for various other aspects of care. Risk assessment helps health care providers to concentrate on the factors with the probability for causing greater harm to the patient. Therefore, it is important to identify the needs and take steps to lower the possibility of harm to the patients.

Coleman et al. (2016) establishes that use of various risk assessment tools has culminated in the identification of various risk factors. The tools normally produce a numeric result relative to the risk level; with some tools, a high score indicates a higher risk. Various risk factors are linked to the development of pressure ulcer, but individuals without any destruction to feeling and mobility are less likely to acquire a pressure ulcer. Nevertheless, the findings could be oversimplifying the risk because of suggesting that lower mobility and loss of feeling are the sole risk factors, which might not be the case. The statement also suggests the importance of considering each risk factor. For example, a patient who has dementia might have an undamaged sensory pathway and yet have the capacity for mobility. The person might only have a limitation in cognitive capacity to recognize the signal of pain associated with the onset of the pressure problem (Coleman, et al., 2016). The situation would usually trigger movement, at times unconsciously.

Research has been done to establish the risk factors for developing pressure ulcers. Some of the identified factors are decreased mobility or immobility, skin marking, lack of sensation, compromised vascular supply, nutritional status, and surface (Cooper, 2013, Karayurt et al., 2016). In fact, considering the reduced mobility or immobility, there is a consensus that if pressure is put for long on a bony prominence, the level of the pressure is extremely high. The result is extended period of occluded or reduced flow of blood to tissues, which in turn causes the tissue hypoxia and ultimately death of the tissue. If the pain prevents ease of movement, then this should be reported.

It is worth noting that the lack of sensation occurs when there are no pain signals due to a lack of sensation (Cooper, 2013). In this case, patients are not aware of the damage, which is taking place, increasing the risk of pressure ulcer in individuals with, for instance, spinal cord injury, cerebrovascular accident, and neuropathy, as well as multiple sclerosis.

In skin marking, the change of skin color related to pressure damage is a risk factor to consider. A noticeable circular pink/red blanching mark, in pale skin, referred to as blanching erythema, on a bony prominence is a signal. Therefore, if the mark is not identified and the pressure continues, the discoloration darkens becoming purple/black (Karayurt et al., 2016). However, this is hard to identify in patients with dark skin color and those with conditions that damage skin color, including necrotizing infections of the skin, bruising, cellulitis, incontinence-associated dermatitis, and dermatological disorders.

Regarding nutritional status, the idea is that undernourished individuals have a greater risk of pressure ulcer. While there is not much research evidence behind this argument, some signs of malnutrition such as serum albumin are important factors to watch out for. Compromised vascular supply is seriously hampered by pressure, resulting in speedy skin deterioration. In addition, the peripheral arterial disease might be a major risk factor for heel damage. Patient’s heels are the most affected by acquired grade 4 ulcers (about 88 percent of the cases) (Tashman, 2016). Patients experiencing events like hypovolemic shock or cardiac arrest might be at a higher risk of skin damage due to the fact that sudden drop in blood pressure causes a decrease in blood supply to the skin.

The surface that the patient sits, lies, or inclines can influence the risk of developing pressure ulcers. Resting against hard surfaces using bony prominences can cause increased pressures on the bone/tissue interface, and this can fasten occurrence of pressure damage (Karayurt et al., 2016). In essence, considering the impact of the surface, it is important to avoid the risk of developing pressure damage.

Chou et al. (2013) have discussed evidence-based interventions effective in preventing pressure ulcers. In fact, deterrence is possible where risk factors are identified, and corrective strategies applied when one has already developed pressure ulcers. The strategies used are dependent on the identified risk factor. For example, for mobility, change of position can be important in preventing pressure ulcer. In fact, various preventive strategies are identified in research to be effective. For instance, the use of pressure-redistributing devices is one of these approaches (Tashman, 2016). Therefore, a decision should be made regarding which device to use depending on the results of the assessment.

There should be continuity of preventive care (Chou et al., 2013). Thus, the research recommends the adoption of post-operative management of individuals who are at-risk. Repositioning is another important preventive strategy, which should be used alongside pressure redistributing devices. Indeed, at-risk patients should be repositioned based on the results of skin assessment of the individual patient needs instead of following a ritualistic schedule. Factors like medical condition, comfort, overall plan of care, and support surface should be considered. In fact, a seating assessment for aids and equipment is critical as well as carefully considered and the assessment of the nutritional requirements of at-risk patient. Nutritional support is necessary for patients that their risk factor is related to malnutrition. Continued evaluation of effectiveness of the plan is necessary in implementing the strategies.



The study will assume a quasi-experimental design, which means that the data will be collected before implementation of a program and after some time following the implementation of the program to offer a comparison. A training program will be implemented where the nurses will be educated on the various strategies identified in literature as being effective in preventing pressure ulcers. The one-month training program will be implemented, with the involved nurses required to take part in the training program. Implementation of the program, with the strategies, is anticipated to achieve a reduction in the rate of pressure ulcer in the hospital, hence, find out the potential of the results being replicated in other hospital settings. The requirement will be for the implementers to ensure availability of resources for use in the program.

Population and Sampling    

The research will be done in a general hospital setting where the nurses will provide care to patients within the intensive care unit (ICU). All the nurses providing care to the patient in the unit will be involved in the training program; hence, sampling will be unnecessary. The nurses who will be involved are those available for most shifts in the course of the training. Thus, those who will be on whatever kind of leave of absence during the period of training will not be included. The reason for this is that the nurses will be expected to take part in all the training sections. As such, they will understand all the strategies involved in preventing pressure ulcers. Altogether, it is expected that 10 nurses will be available to take part in the program for the entire period of its implementation.

Data Collection and Analysis

Data will be collected and analyzed to find out the effect of evidence-based education in the prevention of pressure ulcer. Therefore, two main sources of data will be used: hospital records and interviews with the nurses involved in the program. From the records, data on the current rate of pressure ulcer within the unit before the implementation of the program will be taken. After one month of implementation of the program, the data will be collected to establish whether there will be any significant change. Data will also be collected from the nurses who will provide more detailed insights into the working of the program and their self-report on its effectiveness or lack thereof. Both datasets will be analyzed qualitatively and quantitatively to establish the findings of the study.










Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A. J., Reitel, K., & Buckley, D. I. (2013). Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Annals of Internal Medicine, 159(1), 28-38.

Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit. Critical Care Nurse, 33(6), 57-67.

Coleman, S., Nixon, J., Keen, J., Muir, D., Wilson, L., McGinnis, E., & … Nelson, E. A. (2016). Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument. BMC Medical Research Methodology, 161-13. doi:10.1186/s12874-016-0257-5

Karayurt, Ö., Akyol, Ö., Kiliçaslan, N., Akgün, N., Sargin, Ü., Kondakçi, M., & … Sari, N. (2016). The incidence of pressure ulcer in patients on mechanical ventilation and effects of selected risk factors on pressure ulcer development. Turkish Journal Of Medical Sciences, 46(5), 1314-1322

Tashman, N. (2016). Improving hospital-acquired pressure ulcer prevention on an orthopedic unit. MEDSURG Nursing, 4-7.

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