Evidence-Based RUA: Decubitus Ulcer Prevention

Though they could be prevented or cured in most cases, decubitus ulcers continue to pose a challenge to society. Over the last two decades, attention to pressure sores has increased, as the prevalence of the burden remains unchanged. The high prevalence of decubitus ulcers is a matter of concern due to the associated mortality rates and healthcare costs. Being aware of the populations within increased risk and implementing effective preventive interventions is critical to managing the health problem. Besides being cognizant of the early changes that patients face, nurses should be able to appropriately identify and stage decubitus ulcers to ensure proper care is not delayed. This paper aims to discuss the importance of resolving pressure ulcers, patient population, proposed solution, goals, barriers, benefits, and appropriate participants, and interdisciplinary approach. The health promotion and maintenance aspect of the nursing practice shows that a nurse should direct and provide the patient’s nursing care that incorporates information on early detection, prevention, and strategies to foster optimal health for the people (National Council of State Boards of Nursing, 2019). While decubitus ulcers are preventable and curable, it remains a major health challenge in contemporary society. 

Importance 

Effective prevention and therapeutic care for the decubitus ulcers is imperative. Browning notes that “decubitus ulcers should never be allowed to develop” (as cited in Levin, 2018, p.140). This note underscores the importance of preventive care in managing pressure sores. Nurses should attentively care for their patients to prevent the onset of the decubitus ulcers. Development of decubitus ulcers interferes with the patient’s functional recovery, could lead to more infection and pain, and further leads to prolonged hospital stays (Arose, Hiner, & Rajbhandari, 2016). Notably, the development of the pressure ulcers could culminate in premature mortality, particularly for patients requiring long-term hospitalization. In light of these views, prevention of the decubitus ulcers is necessary to prevent further infection and pain on patients, reduce the likelihood of prolonged hospital stays, and minimize the premature death of patients requiring acute, institutionalized hospital care. About 40 percent of patients noted to be at risk of developing decubitus ulcers receive best-practice care, and less than 10 percent of them access proper prevention interventions (Stadnyk, Mordoch, & Martin, 2018). 

Lack of early detection and proper management of the pressure sores is a major contributor to the rising mortality rate among at-risk patients. According to Atkinson and Cullum (2018), an estimated 8 percent of the deaths registered among spinal cord injury patients are caused by the poor management of the pressure sores. The resulting deaths among the bed-ridden patients with poorly managed decubitus ulcers culminate from intestinal fluid pressure. Incidentally, the external solid tissue pressure on the patients’ body creates increased intestinal fluid pressure, which upon exceeding a certain level to the venomous limb (12 mm Hg) it leads to higher total tissue pressure causing autolysis, edema, increased pressure on the capillary arteriolar, and filtration of capillary fluid (Alimansur & Santoso, 2019). 

Another negative effect of delayed detection and management of the decubitus ulcers is the blocking of the lymphatic vessels. Alimansur and Santoso (2019) postulate that, the lack of mobility among the wheelchair or bed-bound patients causes increased mechanical load on the body, thus affecting the active contractility of the patients’ lymphatics. As the scholar further elucidates, the reduced lymphatics’ active contractility coupled with changes imminent to the blood microvascular system causes a high level of aerobic metabolic wastes, with increased accumulation culminating into tissue necrosis. The basal layer cells die, become detached, and therefore the tissue necrosis progresses into the deeper layers beyond the basal membrane. In this case, it is highly likely that the patient may develop stage 3 and, ultimately, acute stage 4 decubitus ulcers resulting in the systemic infection of the patient. 

Late detection and poor management of the decubitus ulcers have a huge impact on the cost of healthcare. Statistics indicate that despite being preventable and manageable, pressure sores increase the medical cost of treatment among acutely hospitalized patients by around $8000 (Dibirov, 2016). Illustratively, while the decubitus ulcers could have affected the patients individually, including causing permanent tissue damage or death, they further affect the patients’ family, the community, or the society financially. 

Patient Population 

The pressure-induced soft tissue or skin ulcers are among the commonly encountered healthcare challenges among patients placed on long-term residential care or acutely hospitalized clients. However, as Stadnyk et al. (2018) claim, the incidence varies extensively depending on the clinical setting. Atkinson and Cullum (2018) posit that about 2.5 million patients are treated for pressure ulcers annually in the various acute care hospitals in the United States alone. 

Despite the current developments in clinical therapy, at-risk patients remain largely affected by the decubitus ulcers. According to Crespo, Stevens, Chiu, Pham, & Leucht (2020), contracting pressure ulcers mostly depends on the level of risk exposure. Immobility is a major contributing factor since it implies bed-ridden patients lie on one side for a prolonged period (Crespo et al., 2020). Statistics of the affected patients are increasingly alarming in the face of advanced medical care in the modern world of medicine. Past research studies indicate that between 25 percent and 85 percent of patients suffering from spinal cord injuries develop decubitus ulcers (Atkinson & Cullum, 2018). Immobility among these patients is a concern because it reduces their ability to reduce pressure on their bodies. Patients placed on acute hospitalization face increased pressure, friction, moisture, and shearing forces, all of which act on a unit area, thus causing decubitus ulcers on the patients (Stadnyk et al., 2018). Therefore, with the utter reduction of their mobility, patients in acute hospitalization are at increased risk of developing pressure sores. 

Besides the acute care facilities, decubitus ulcers are high in general hospitals. Stadnyk et al. (2018) submit that between 3% and 4.5% of the patients’ population in general hospitals develop decubitus ulcers during their hospitalization. Similarly, Crespo et al. (2020) argue that patients who are at risk of developing pressure sores have some common characteristics. They are mostly elderly, unable to ambulate in the absence of assistance, having altered mental status, uniformly wheelchair or bed-bound, or often incontinent. 

Poor management of the decubitus ulcers due to cultural issues is suspected to be a key contributor to the high number of grade 3 and 4 pressure sores among the elderly. The rising number of poorly managed pressure sores, 3 to 4 percent of the elderly population on institutionalized care, has grade 3 or 4 decubitus ulcers (Stadnyk et al., 2018). However, cultural issues are partly to blame for the rising population. Dibirov (2016) says that elderly people believe that physicians and nurses know the best and, thus, they avoid taking an active role in defining the effective care they need. The author explains that the elderly are cautious and hesitant about what to say lest they offend the nurses. Notably, nurses are responsible for the skin integrity of their patients. Lack of ethical concern is a delimiting factor to the establishment and implementation of effective evidence-based wound care for patients with decubitus ulcers (Dibirov, 2016). Patient care should be guided by the ethical code governing nursing practice. The nurses should ensure patient engagement and privacy are maintained (Stadnyk et al., 2018). 

Proposed Solution 

Nurses should take the earliest opportunity to prevent the development of decubitus ulcers among their patients. However, Levin (2018) presents that decubitus ulcers could inevitable among patients under acute hospitalization or with prolonged institutionalized hospital care. Based on this view, it is imperative to explore appropriate and effective prevention interventions to minimize the impact of pressure sores among patients. One of the most appropriate prevention solutions is skincare for wheelchair and bed-bound patients. The development of stage I and II decubitus ulcers could be managed by using skin protection and body wash products combined with continuous nursing education on skincare (Mervis & Phillips, 2019). Intuitively, it is a common understanding among nurses that maintaining a clean and dry skin prevents excessive moisture and irritants that could cause frictional forces and tear of the skin. 

Nurses should develop a detailed skincare schedule for decubitus ulcers patients. Mervis and Phillips (2019) recommend the need to create an individualized skincare schedule. According to the author, nurses should focus on using non-drying products while implementing the bathing schedules. On a similar note, the authors submit that nurses would be able to assess and identify any signs of skin breakdown during the individualized bathing plans. The nurses should monitor the patient’s skin turgor, temperature, moisture status, color, and integrity. This aspect would ensure early treatment interventions are developed to prevent the escalation of the pressure ulcers. 

Recommendations associated with the skincare prevention approach include diverse approaches. First, avoid hot water during the patient’s skin bathing procedure. Second, use mild cleansing agents. Third, minimize the dryness and irritation of the patient’s skin by avoiding low humidity (Mervis & Phillips, 2019). As the author emphasizes, nurses should not massage vigorously on reddened, bony surfaces on the patient’s skin to avoid causing deep trauma to the skin tissue. The scholar notes that nurses should minimize exposure of the client’s skin to moisture while mitigating skin breakdown resulting from friction with lubricants, protective dressings, protective padding, and protective films. 

Goals 

The skincare prevention measure’s short-term goal is to ensure the integrity of the patient’s skin is maintained to prevent stage I and II decubitus ulcers that could lead to stage 3 or 4 if left unattended. Skincare intervention is designed, specifically to ensure the prevention of pressure ulcers through an individualized schedule. Key indicators of quality skincare include moisture status that can be tested through bioelectric impedance analysis, whereby 0-40 indicates dry skin, 41-70-normal, and 71-99 implies excessive moisture (Mervis & Phillips, 2019). Skin color is also crucial with reddish pigmentation, implying the likelihood of pressure ulcers. Skin turgor in which the skin’s elasticity could be monitored is also paramount to maintaining skin integrity. The patient’s skin should be able to change shape when altered and return to its normal when released. 

The long-term goal of skincare prevention is to reduce the number of pressure ulcer patients among elderly people committed to institutionalized hospital care. Over 60% of decubitus patients are elderly people (Dibirov, 2016). Monitoring the number of patients placed in acute hospitalization care would identify those affected by the health problem for immediate and effective treatment intervention. 

Barriers 

The skincare approach is a simple intervention in the prevention of decubitus ulcers. However, various barriers could interfere with the effectiveness of the prevention approach. According to Atkinson and Cullum (2018), lack of continuous education among nurses could negatively affect the skincare prevention approach. Changes in technology and the rise of new and substitute products in the market poses a challenge to the nursing community, but continuous education allows the nurses to be informed of the emerging trends and new treatment ways. Thus, nurses should strive to upgrade their education continuously. Lack of proper hospital programs to facilitate the nursing training could derail the learning process among the nurses (Atkinson & Cullum, 2018) 

Another major barrier that could prevent the skincare measure’s effectiveness is cultural issues among elderly patients, who are the most affected population. Notably, the elderly rarely participate in their care decision-making because they believe the medical staff knows everything about treatment (Dibirov, 2016). Lack of participation could conceal historical issues such as side effects of certain care agents, treatment preferences, and challenges. Hence, cultural beliefs among at-risk patients could affect the formulation and implementation of an individualized skincare program to prevent the development of decubitus ulcers. 

Benefits 

The skincare prevention approach is beneficial to both the patient and the nursing community. Skincare prevents the development of stage I and II decubitus ulcers that could culminate to stage III and IV if not properly addressed (Atkinson & Cullum, 2018). In light of this perspective, the skincare approach prevents pain and further infection that could cause prolonged hospital stay among patients suffering from pressure ulcers. Additionally, it allows the development of individualized patient-care that takes into account the patient’s views. On the other hand, the Skincare approach enhances the nursing community’s reputation besides promoting knowledge acquisition among the nurses. Skincare intervention presents nurses with an opportunity to learn emerging products and skincare ways. 

Participants and Interdisciplinary Approach 

Significant work is involved in the prevention and treatment of decubitus ulcers. According to Levine (2018), prevention and treatment of the pressure sores are labor-intensive, especially in acute care facilities that offer prolonged care for clients with debility and chronic illness. Collaboration among the medical staff is imperative in managing pressure ulcers. Dibirov (2016) argues that collaboration is critical, especially in interventions that require repositioning of the patients using pressure-reducing devices. 

On a different note, education is key to the improvement of patient care. Mervis and Phillips (2019) present that quality enhancement is crucial in managing decubitus ulcers, and these nurses need continuous education to be able to develop evidence-based wound care. The author attributes the need for continuous education to the cultural diversity of patients and changing technology in medicine and nursing practice. Dibirov (2016) explores the necessity of risk assessment of patients upon admission. The scholar states that risk assessment skills are essential in detecting the possibility of developing pressure sores and, thus, earlier planning and the development of prevention measures. 

Conclusion 

Prevention of decubitus ulcers among institutionalized patients implies effective, quality nursing care. Thus, nursing care is a critical factor in the development and prevention of pressure ulcers. While prevention is still a challenge, particularly among the elderly due to cultural issues and patients requiring acute hospitalization, vigilant care should be provided to mitigate the most consistent risk factors that foster the development of decubitus ulcers. Leaving the health problem unattended is detrimental to the patient, the nursing community, and society. Besides further infection and pain to the patient, it could lead to mortality. It could affect the reputation of nursing as it is a mark of the quality of nursing care. It adds to the healthcare costs associated with caring for long-term hospital stays. Appropriate skin care could be used to prevent the development of decubitus ulcers. Although some factors, such as lack of continuing nursing education, cultural issues among the elderly patients, and inadequate nursing staff, proper patient engagement is recommended. Nurses should engage the patient while developing an individualized skincare schedule. Nursing facilities should develop continuous training programs for nurses to remain informed of the emerging trends and disease management ways in the market. 

References

Alimansur, M., & Santoso, P. (2019). The main prevention of pressure sores in stroke patients. In  Proceeding Surabaya International Health Conference 2019  (Vol. 1, No. 1, pp. 169-175).

Arosi, I., Hiner, G., & Rajbhandari, S. (2016). Pathogenesis and treatment of callus in the diabetic foot.  Current Diabetes Reviews ,  12 (3), 179-183.

Atkinson, R. A., & Cullum, N. A. (2018). Interventions for pressure ulcers: a summary of evidence for prevention and treatment.  Spinal Cord ,  56 (3), 186-198.

Crespo, A., Stevens, N. M., Chiu, E., Pham, V., & Leucht, P. (2020). Incidence of osteomyelitis in sacral decubitus ulcers and recommendations for management.  JBJS Reviews ,  8 (6), e0187.

Dibirov, M. D. (2016). Decubitus: prevention and treatment.  Hospital-Replacing Technologies: Ambulatory Surgery , (1-2), 55-63.

Levine, J. M. (2018). 100 years of bedsores: How much have we learned?  Advances in skin & wound care ,  31 (3), 139-141.

Mervis, J. S., & Phillips, T. J. (2019). Pressure ulcers: Prevention and management.  Journal of the American Academy of Dermatology ,  81 (4), 893-902.

National Council of State Boards of Nursing (2019). NCLEX-RN Examination . Retrieved from https://www.ncsbn.org/2019_RN_TestPlan-English.pdf

Stadnyk, B., Mordoch, E., & Martin, D. (2018). Factors in facilitating an organizational culture to prevent pressure ulcers among older adults in health-care facilities.  Journal of Wound Care ,  27 (Sup7), S4-S10.