Problem Statement for Geriatric Population
With the improvement in care and lifestyle modifications, the US and other nations globally continue to report an unprecedented increase in the number of elderly people aged 65 and above. For instance, the data from 2019 showed that the US alone had 54.1 million adults, with the numbers anticipated to increase to 80.8 million in 2040 and over 94 million in 2080; this will represent 25% of the US population compared to the recent 16% (Moore et al., 2019). Despite increasing life expectancy becoming celebratory, the health risks associated with old age are immense.
The risk of chronic diseases such as dementia, type 2 diabetes, hypertension, cancer, fractures, and arthritis increases with age. Consequently, most of these conditions impair both the mental and physical ability of the elderly patient. Immobility predisposes to various skin conditions, including pressure ulcers. Preventing pressure ulcers requires implementing a nurse-led intervention to reduce the burden it causes.
This paper purposes to discuss the impact of pressure ulcers on the geriatric population, intervention, and literature review of the problem. The following PICOT question will guide the discussion of the paper and the evidenced-based practice proposal.
PICOT: Among immobilized elderly individuals (P), does turning patients (I), compared to the use of pressure mattresses (C), reduce the risk of pressure ulcers (O) over 3 months? (T)
Pressure ulcers (PU), otherwise referred to as bedsores, are localized skin and tissue damages, commonly over body prominences, caused by constant pressure and shear pressure. Prolonged pressure between the skin and a hard surface causes interruption in blood supply resulting in ischemia and hypoxia, resulting in tissue injury (Gibelli et al., 2022). The knees, shoulders, buttocks, back, and face are potential areas for ulcer formation (Galivanche et al., 2020).
The severity of skin damage continues with increased exposure to pressure and is graded differently. In stage 1, the skin forms nonbankable erythema that disappears within 30 minutes, while in stage 2, the skin is partially involved with exposed dermis. In the third stage, all the layers of the skin are lost with exposure of the fatty tissue, which is worsened in stage 4 with the exposure, and loss of muscles, tendons, cartilage, and bone may be involved in severe cases with deep tissue injuries incurring.
Due to old age, most people are faced with chronic conditions such as spinal injuries, fractures, diabetes, arthritis, and hypertension that render them immobile. Immobility, together with other risk factors such as malnutrition, skin humidity, and incontinence, contribute to the development of PU. Notably, the prevalence of individuals is increasing, with an estimation of 12.3% in the US (Moore et al., 2019).
Of the total cases, up to 18% develop in the intensive care unit, 2.3 to 28% in the long-term care unit, while home care units contribute up to 295 of the cases. Consequently, pressure ulcers negatively impact patient outcomes. They cause pain, limit patient mobility, worsen the quality of life, prolong recovery time, increase the cost of care, and death from complications such as sepsis and infections.
In terms of cost, management of PU cases costs the government an excess of $11 billion in total, with each case costing between $500 to 70,000 (Galivanche et al., 2020). Due to increased hospital stay, an additional amount of $43000 is spent on each extra day spent in the hospital. While some patients recover, about 60,000 individuals die every year due to pressure ulcers.
In addition, the health sector is also affected negatively by pressure ulcers (Galivanche et al., 2020). For instance, any ulcer developing within the hospital sector is considered an art of carelessness, making some insurance companies not cover medical expenses. Such expenses are covered by the health facility which had the case. In worst cases, a lawsuit is filed against the facility for negligence.
Huge amounts of money are used in courts while the hospitals are fined in case they lose the case. Regrettably, healthcare providers risk losing their licenses due to negligence. Therefore, to reduce the negative consequences, there is a need to employ preventive issues to prevent bedsores since they are expensive to manage.
Prevention of bedsores requires the implementation of a nurse-led initiative. Among the various initiatives, the turning of the patient is an evidence-based practice that caregivers have employed to reduce the risk of bedsores (Galivanche et al., 2020). Hourly turning is a simple yet effective method applicable to immobilized individuals who cannot move for several reasons.
Those in wheelchairs require shifting of position every quarter-hourly. Frequent change of position helps in distributing pressure while maintaining tissue vitality. Compared to turning, other centers employ the use of pressure mattresses which are specially designed to relieve pressure and distribute the pressure around the body. Either overlays or full replacements are used in preventing or treating pressure ulcers. They use air to relieve the pressure, which helps in reducing pain and allows the sore to heal while the body recovers (Woodhouse et al., 2019).
However, it is inconclusive which of the two methods is effective in preventing bedsores and improving patient outcomes. Implementing either method and assessing outcomes after three months would help guide the appropriate method. Therefore, a literature search on the subject is paramount to filling the gaps in knowledge.
Finding evidence regarding an EBP intervention is an extensive task that requires mastery of skills to find the relevant resources. Various sources that provide reliable knowledge, including ProQuest, Medline, google scholar, and CINAHL, among others, are applicable during data search. The search strategy for this paper focused on finding various studies that addressed either turning of patients, the use of pressure mattresses, or both in the prevention of PU.
To start with, the issue of an increasing number of aging individuals who are at increased risk of comorbidities, care dependency, and decreased physical performance has led to the recent increase in the case of PU. The expected increase in the number of elderly individuals in the coming years further strains the health sector and social care system. Compared to a survey carried out between 2001 and 2012 that reported a prevalence of PU between 4.1 and 32.2%, with incidences of 59%, the survey from the previous ten years reports a further increase in incidences and prevalence (Beeckman et al., 2019).
Because nursing home care is associated with caring for elderly patients with comorbidities, impaired mobility, incontinence, and alterations of skin structure, patients in these settings are at increased risk of PU compared to hospital and ICU settings. The increasing incidences of PU affect not only the quality of life but also the hospital stay, the cost of care, the risk of death from complications, and the incidences of lawsuits (Gibelli et al., 2022).
The government penalties and litigation affect the performance metric of hospitals. Further cases of PU may increase, prompting more financial requirements of caring despite prevention being cheaper.
The clinical guidelines for prevention provide key strategies required to prevent PU, including patient repositioning, risk assessment, skin care, nutritional care, and use of support surfaces (Beeckman et al., 2019). While patient repositioning relieves or redistributes pressure to enhance comfort, the frequency should be adjusted depending on the patient’s condition and the availability of the support surface.
On the other hand, despite support surfaces being recommended for the prevention of PU, the arguments concerning the appropriate surface among the several commercially available option still exist. However, several considerations should be observed before choosing the support surfaces, including individual characteristics, availability of materials, general health, training, patient comfort, and the outcomes of the risk assessment.
Nonetheless, the static air mattress is cost-effective and associated with lower incidences of PU than alternating air pressure mattresses (Stone, 2020). Furthermore, the time required to develop PU is longer in static mattresses than in the latter.
Among the issues that were inconclusively regarded was the frequency of repositioning to achieve ulcer control. Two hourly turnings have been practiced in various settings; however, other economists argue that it is labor intensive and non-cost effective.
A proposal to try either three hourly or four hourly turning is in the cards (Woodhouse et al., 2019). The need to understand the effectiveness of frequency of repositioning prompted the assembling of various studies. To begin with, Avsar et al. (2020) performed a systemic review of 16 records. In ICU, patients who had repositioning every 2-3 hours had a PU incidence of 8% compared to 13% in the patients who had repositioning every 4 to 6 hours. The same findings were supported by a randomized control trial by Cortés et al. (2021), which encouraged an increase in the frequency of turning, preferably 2-hourly, to reduce the risk of PU.
Arguably, the higher the frequency of turning, the more pressure is relieved by reducing contacts between the surfaces and the body. Besides, while comparing the effectiveness of using a turning team verse the usual care, low PU incidences were reported in patients who received care from the turning team compared to the usual care. This assertion supports the need to train nurses on basic principles of turning to prevent PU by frequent repositioning. Therefore, repositioning requires understanding the patient characteristics and expertise of caregivers.
While determining the time required for the development of PU and the effectiveness of repositioning to reduce the risk of PU, a cross-sectional survey by Sharp et al. (2019) provided insights. Approximately 4 to 6 hours of constant pressure are enough to initiate skin damage to cause PU. The process accelerates in the presence of other risk factors such as incontinence, malnutrition, and wet beddings to less than 4 hours.
Understanding such a concept is essential in understanding the different rates of PU formation in different groups. Besides, despite the implementation of two hourly turnings, some patients still developed PU. A case of neglect or abuse could easily be imposed on healthcare providers, however, providing a pressure mattress in addition to turning is essential to reduce the risk of PU. The same authors argued that two hourly turns, especially at night, could lead to chronic sleep deprivation, potentially resulting in physical and cognitive impairment due to sleep disturbances.
Pain from chronic conditions or PU may further be aggravated by turning, leading to behaviors of concern such as refusing care, yelling, screaming, or wincing during repositioning (Moore et al., 2020). Therefore, using a pressure mattress would reduce the frequency of turning, especially at night, and improve the sleep pattern. Furthermore, all healthcare providers should adopt the use of screening tools to identify the population at risk and allow for the provision of early intervention.
Pressure ulcers remain a global health problem with the increasing number of aging individuals. PU impact patients negatively in terms of cost, increased risk of mortality and morbidity, poor patient recovery, and increased risk of complications that further complicate patient outcomes. Therefore, devising preventive measures such as hourly turning of the patients is paramount to reducing the risk of PU as well as reducing the health burden caused by pressure ulcers.
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