Turning and Reposition Patients to Prevent Pressure Ulcers

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Turning and Reposition Patients to Prevent Pressure Ulcers

 

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Turning and Reposition Patients to Prevent Pressure Ulcers

Abstract

A patient who spends most of the time in bed and is in a situation of immobility because of an illness, trauma or a condition of high dependency is exposed to a wide variety of complications that can affect different parts of the body, especially the skin. The study’s objective comes because of the increased cases of skin breakdown in the inpatient population despite interventions and measures in place. The study’s primary purpose is to benefit both the patient and the institutions to archive better patient outcomes and reduce the patient organization’s expenses. Therefore, research of the literature was conducted to find out how in immobilized patients, turning and repositioning them every two hours compared with not turning them affects skin integrity. The literature review favors the actual standard protocols and maintains that a postural change must be made to all immobilized patients every 2-3 hours to prevent skin breakdown. It is also necessary to reposition the body to keep it aligned, carrying out correct weight distribution.

 

 

 

 

 

 

 

 

 

 

Background

People who cannot move for long periods of time are at higher risk of developing pressure ulcers because oxygen and other nutrients cannot reach their cells easily. In addition, a person who is immobilized, whose skin is fragile due to age or illness, is at an even higher risk of developing ulcers. According to Cortés et al. (2021), these types of wounds are caused by “prolonged contact or friction in certain points where increased mechanical pressure is applied by the patients’ weight, especially under skeletal prominence areas such as the sacrum, trochanters, scapulae, or shoulder blades, heels, and elbows.” ( p. 2). Additionally, it is widely accepted that pressure ulcers constitute a health problem with significant repercussions on patients’ state of health and quality of life. Unfortunately, pressure ulcers have a remarkable economic impact on both the health system and the patients. Moreover, “In 2008, the Centers for Medicare and Medicaid Services (CMS) announced it will not pay for additional costs incurred for hospital-acquired pressure ulcers”. (The Joint Commission, 2016 para. 4) As a result, it is the great importance to verify with scientific evidence if the protocol of turning and repositioning patients who are not able to move could maintain skin integrity.

Methodology

This study is a systematic review of the literature that used electronic databases engineer Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar. The study used these keywords: skin integrity, pressure ulcers, immobilization, turning, and repositioning. In addition, eight comparative and quantitative cross-sectional studies were selected from the search results, and most of them used random control trials.

 

 

Review of the Literature

One of the main problems that nurses must confront every day during their shift, which is a significant intervention, is the prevention of pressure ulcers. The problems raised since these injuries are easy to appear in immobilized patients despite hospital protocols and measures. The first study analyzed in this review was completed by Bergstrom et al. This was a multi-clinical trial conducted to identify the efficacy of three repositioning schedules 2-, 3-, and 4-hours schedule during three weeks from April 2008 to June 2011. Data were collected in nursing homes located in different regions in Canada and United States. Participants were aged 65 and older, primarily female who were free of pressure ulcers, were at moderate (13–14) or high (10–12) risk of developing pressure ulcers according to the Braden Scale (Bergstrom et al., 2013, p. 1706). The study participants were long and short-term residents with impaired mobility due to physiological or cognitive changes. The exclusion criteria were based on time of stay, being less than 65 years old, and having a Braden Scale of 4, which indicates independent mobility. A Braden Scale too high (6-9) indicates poor mobility or no risk for developing pressure ulcers. The patients with poor mobility could not participate because they had to use a specialized mattress that would alter the result of the study. The research includes a protocol that includes informed consent and repositioning required one time turning, around 30 minutes while a patient is in bed. The protocols also include documented turning interventions and reporting skin changes, position in bed hourly. The records used during the study assessed the completeness of the forms in data collection and transmission to the investigators. Additionally, participants keep receiving other protocols to prevent pressure ulcers during the study, such as chair cushions, protector boots, and heels elevations. The study results showed that from 945 participants, only 2% developed pressures ulcers that were stage 1 or 2 superficial. Stage 3 or 4 ulcers did not develop during the intervention. Moreover, “There were no significant differences in pressure ulcer development between the high- and moderate risk-groups or within the high- and moderate-risk groups allocated to 2, 3, or 4-hour repositioning” (Bergstrom et al., 2013, p. 1909). The study also affirmed that the incidence of new pressure ulcers was low compared to previous studies due to the combination of viscoelastic mattresses. To summarize, Bergstrom et al. research demonstrate the effectiveness of turning immobilized patients even if not done every two hours. The study has limitations, such as the accuracy of specific protocols, the accuracy of the pressure ulcer interventions, and documentation during the trials. Additionally, the specialized mattress use during the study could compromise the results.

In a quantitative study performed in the Virginia Commonwealth University Medical Center in the cardiac surgical intensive care unit, staff implemented interventions to decrease hospital-acquired pressure ulcers. The goal of this study by Cooper et al. was to obtain zero new cases of bedsores. The nurses directing the research implemented a program of aggressive education and protocols to prevent pressure ulcers, including turning and repositioning. “Parameters such as life-threatening arrhythmias, refractory hypotension, acute hemorrhage, or the inability to recover within 10 minutes of turning were used to classify patients as “too unstable to turn” (Cooper et al., 2015, p. 78). According to the study, the National Pressure Ulcer Advisory Panel who visited the facility during the research was stunned with the positive results. Even though the study included other measures to prevent pressure ulcers, the results are consistent in that turning and repositioning are effective interventions to maintain skin integrity. Additionally, the study underlines that preventing bedsores comes with a financial advantage since the treatment of pressure ulcers is a burden for hospitals. The limitation of the study is that it was done with a small sample of participants in a specialized unit at the hospital, and there are no specific criteria for how turning and repositioning were implemented during the trial.

In like manner, Vanderwee et al.’s study support that repositioning is a recognized intervention for the prevention of bedsores. The study, conducted in several nursing homes in Belgic, was an experimental quantitative study and had two arms randomized control trials. The study took place during September 2003 and May 2005. The median age of the patients was 84, and there was a median number of 32 patients in each of the 84 participant wards. Patients were included for the experiment if they did not have pressure ulcer stage 2, 3, or 4 and if they were projected to be at the nursing facility for more than three days. Additionally, patients who developed not blanch erythema were also included in the study and monitored daily. After being entered into the study, patients were randomized to either the experimental group or the control group. Patients who belong to the experimental group were repositioned with unequal time intervals like this: semi-fowlers 30 degrees, right side lateral 30 degrees, semi-fowlers 30 degrees, left lateral 30 degrees. Patients lay for four hours in semi-fowler and two hours in lateral position. The sacrum area was checked to keep it pressure-free. In the control group, patients were repositioned using the same positions as the experiment group, but the duration of each interval was a total of four hours. The result of the study showed that “In the experimental group, 20 patients (16·4%) developed a pressure ulcer as compared with 24 (21·2%) in the control group” (Vanderwee et al., 2007, p. 63). So, the analysis of the data revealed no significant difference between the two groups. In other words, turning patient every two hours does not make a difference if it is done every four. However, the study highlights that this result is only applicable if the patient is in a pressure reducer mattress. If the patient is in a non-pressure reducer mattress, it is imperative to reposition the patient every two hours. Furthermore, the study is clear to recommend turning and repositioning patients early alone with the pressure-reducing mattress to further decrease the incidence of pressure ulcers. One of the study’s limitations is that it was impossible to blind the nursing personnel to perform the two turning protocols, which could have created some bias. Additionally, despite the large number of people who participated in the study, it was still not enough to make it powerful.

On the other hand, it was essential to review an experiment that evaluates lateral turning on skin-bed interface pressures in the sacral, trochanteric, and buttock areas. The study presented by Peterson et al. aims to establish if standard reposition practices in patients affect the skin interface pressure since decreasing the skin interface pressure is one of the primary interventions to prevent pressure ulcers. Additionally, the researchers of this descriptive and observational study wanted to know why pressure ulcer occurrence remains high despite applying standard preventive measures. The participant of the study were hospital workers, a total of 14 men and one woman. Participants were between the ages of 23 to 54. “Participants dressed in standard operating room attire were positioned supine, with their sacrum centered on the pressure-sensing pad on the bed. A calibrated interface pressure profile was acquired for each participant in the supine position (0° HOB).” (Peterson et al., 2010, p. 1558). An experienced ICU nurse oversaw turning each participant into right lateral or left lateral positions using wedges or pillows. The result of the study reveals that standard turning does not relieve areas of high pressure on the skin. As a result, these areas remain at increased risk for skin breakdown. Also, the pressure on the skin interface area is greater when the head of the bed is elevated even at 30 degrees. The study also illustrates some triple jeopardy areas where the skin pressure was never released, even when the patient was turned to both sides. One limitation of the study is that it was done in healthy adults who typically have better muscle tone, which could elevate the sacrum above the support surface, relieving the pressure. In addition, tissue interface pressure does not evaluate internal tissue pressures and capillary refills. Finally, this study leaves the door open to organized additional research to determine the best practices for turning and repositioning patients.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., Barrett, R., & Watkiss, M. (2013). Turning for ulcer reduction: A multisite randomized clinical trial in nursing homes. Journal of the American Geriatrics Society61(10), 1705-1713. https://doi.org/10.1111/jgs.12440

Cooper, D. N., Jones, S. L., & Currie, L. A. (2015). Against all odds: Preventing pressure ulcers in high-risk cardiac surgery patients. Critical Care Nurse35(5), 76-82. https://doi.org/10.4037/ccn2015434

Cortés, O. L., Herrera-Galindo, M., Villar, J. C., Rojas, Y. A., Del Pilar Paipa, M., & Salazar, L. (2021). Frequency of repositioning for preventing pressure ulcers in patients hospitalized in ICU: Protocol of a cluster randomized controlled trial. BMC Nursing20(1). https://doi.org/10.1186/s12912-021-00616-0

The Joint Commission. (2016, July). Quick safety issue 25. Leading the Way to Zero | The Joint Commission. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/

Peterson, M. J., Schwab, W., Van Oostrom, J. H., Gravenstein, N., & Caruso, L. J. (2010). Effects of turning on skin-bed interface pressures in healthy adults. Journal of Advanced Nursing66(7), 1556-1564. https://doi.org/10.1111/j.1365-2648.2010.05292.x

Vanderwee, K., Grypdonck, M. H., De Bacquer, D., & Defloor, T. (2007). Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. Journal of Advanced Nursing57(1), 59-68. https://doi.org/10.1111/j.1365-2648.2006.04060.x

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