The goal of this PICOT paper is to eliminate any flawed practices related to pressure ulcer prevention in favor of those practice showing evidence that is would yield a better outcome. In conclusion, the outcome of this research must be communicated within the nursing profession for practical use. This paper sought to answer the clinical question raised on the effectiveness of nutrition support in preventing pressure ulcer in hospitals over a three-week period.
Clinical Question
When clinical quandaries arise, the acronym P.I.C.O.T. is a commonly used formula to format the question. P stands for patient/population, I represents the intervention or treatment that is introduced in the study, C stands for comparison which refers to the reference group that will be used to compare with the intervention being proposed, O represents the outcome or what would be measured to examine the effectiveness of the intervention, and finally, T stands for the time or the duration for the data collection (Riva, Busse, Endicott, Malik & Burnie, 2012).
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Clinical Question: What is the effectiveness of nutrition support in preventing pressure ulcer among bedridden patients in the hospitals over a three-week period.
Levels of Evidence
Level 1- Systematic review and meta-analysis of randomized controlled trials
Level 2- One or more randomized controlled trials
Level 3- Controlled trial (no randomization)
Level 4- Case-control or cohort study
Level 5- Systematic review of descriptive and qualitative studies
Level 6- Single descriptive or qualitative study
Level 7- Expert opinion
(Melnyk & Fineout-Overholt, 2011)
Three databases appropriate to the healthcare practice were utilized for this study. These databases included the MedLine, CINAHL, and Pub-Med. In each database, the use of the advance search button was utilized whenever necessary. Key words like nutrition support, and pressure ulcer prevention provided more selections. Analyzing the abstracts of several relevant articles provided helpful information which assisted in the inclusion and exclusion process of articles. Articles published within the last fifteen years were included in the review of literature. Each of the articles included in the review was assigned a level of evidence using the level of evidence chart specified below—level one being the highest level, and seven being the lowest level.
Discussion of Literature
Article One
The first article was “Cost Effectiveness of Nutrition Support in the Prevention of Pressure Ulcer in Hospitals” by Banks, Graves, Bauer, and Ash (2013). This article is a level one of evidence because the authors adapted a systematic review and meta-analysis of randomized controlled trials, for which the economic estimates on the effect estimates was derived from the meta-analysis of five studies (Banks, Graves, Bauer & Ash, 2013, p.45). The articles that were examined by the authors were published from 2004-2005. The articles discussed person-centered care implemented in Queensland public hospitals from 2002-2003.
The study revealed that pressure ulcer was avoided using the nutrition support intervention compared with the standard of care as manifested in the mean 2896 (SD 632). The study concluded that nutrition intervention is both cost-effective and treatment reliable as far as prevention of pressure among at-risk patients are concerned (Banks, Graves, Bauer & Ash, 2013, p.46).
Article Two
The second article is “Supporting Evidence-Based Practice in Nutrition and Hydration” by Carter and Lecko (2018). This article is a level six of evidence because the experts who worked on the study employed a rigorous process of gathering evidences, assessing, screening, synthesizing, and publication of findings to address the clinical issue. A total of 172 trust were submitted to meet the aim of building the original Stop the Pressure Campaign which was previously spearheaded by the Midlands and East regions. The collaboration was set to end in four months. Among the guidelines that were included in the systematic review were the NPUAP, EPUAP, PPPIA, and NICE 2014 (Carter & Lecko, 2018, p.19).
The efforts exerted by the team on working on this paper resulted to the publication of the NHS Improvement Nutrition and Pressure Ulcers resources that enumerate the role of nutrition and hydration in efforts on pressure ulcer prevention and the application of nutritional care into the clinical practice.
Article Three
The third article is “Nutrition Strategies for Wound Healing” by Posthauer (2013). This article is a level seven of evidence because the author Mary Ellen Posthauer, RD, LD, CD is an expert in the field of nutrition. She is a registered dietician, a licensed dietician and certified dietician. She spent years of studies specializing her field. The author combined numerous insights she acquired over her years of experience. While it was not necessarily from her actual clinical practice, it was generated from numerous evidence-based practice that she has studied and observed during her professional career.
The author summarized the article with a statement that stresses the role of nutrition being a key player in wound treatment for individuals with PrU’s or chronic wounds (Posthauer, 2013, p.21). Furthermore, the author emphasized the importance of early detection of undernutrition and rectification of nutritional deficits to help promote healing and improvement of quality of life. Finally, the author said that the amount and type of nutritional support must always be complimentary with the medical goals and the patient’s needs and desires (Posthauer, 2012, p.21).
Article Four
The fourth article is “Effectiveness of Enteral Nutritional Therapy in the Healing Process of Pressure Ulcers: A Systematic Review” by (Blanc et al., 2015). This article is a level five of evidence as explained in the article because it included a systematic review of articles published in English from databases that included PubMed, the Cochrane Library, TRIP, Clinical Evidence, National Electronic Library for Health guidelines finder and National Service Framework. Furthermore, the study also included 432 studies of person-centered care in the meta-analyses. The authors used the Cochrane Collaboration tool for assessing the risk of bias in randomized clinical trials to measure the benefits of enteral nutritional support in preventing and treating pressure ulcers among the selected population.
The author concluded that “enteral nutritional support can diminish the progression of pressure ulcers in high-risk patients” (Blanc et al., 2015, p.160).
Article Five
The fifth article is “A Nutritional Formula Enriched with Arginine, Zinc, and Antioxidants for the Healing of Pressure Ulcers” by Cereda, Klersy, Serioli, Crespi and D'Andrea (2015). This article is a level two of evidence because it involved a randomized, controlled trial. The study involved adult malnourished patients with stage II, III, and IV pressure ulcer (n= 200). The participants were given 400ml daily of a supplement enriched with arginine, zinc, and antioxidants (n=101) or an equal volume of an isocaloric, isonitrogenous formula (n=99) for 8 weeks. The study revealed that while nutritional supplementation with arginine, zinc, and antioxidants manifested improved pressure ulcer healing.
Significance to Nursing
According to the current research, nutritional support in the prevention of pressure ulcer is effective. However, this investigation also revealed that while the development of pressure ulcer may not be completely prevented, the onset and progression may be delayed or reduced if nutritional support is initiated early. Thus, early detection and management of pressure ulcer especially among high-risk patients is very critical.
|
Citation |
Type of StudyDesign Type Framework/Theory |
Setting |
Key Concepts |
Findings |
Hierarchy of Evidence Level |
| Banks, M., Graves, N., Bauer, J., & Ash, S. (2013). Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals. European Journal of Clinical Nutrition, 67(1), 42-46. DOI: 10.1038/ejcn.2012.140 | Qualitative Study – A systematic review of descriptive and qualitative studies | Queensland public hospitals |
Concepts: Nutrition support is cost-effective in preventing pressure ulcer. IV: Introduction of nutrition support among patients with pressure ulcer. DP: Cost spent on treatment of pressure ulcer CV: Cost of bed day in Queensland public hospitals |
The study revealed that pressure ulcer was avoided using the nutrition support intervention compared with the standard of care as manifested in the mean 2896 (SD 632). The study concluded that nutrition intervention is both cost-effective and treatment reliable as far as prevention of pressure among at-risk patients are concerned (Banks, Graves, Bauer & Ash, 2013, p.46). |
5 |
| Carter, R., & Lecko, C. (2018). Supporting Evidence-Based Practice in Nutrition and Hydration. Wounds UK, 14(3), 18-21. | Qualitative Study | All care setting |
Concepts: Importance of nutrition and hydration helps support the healing of pressure ulcer. IV: DP: CV: |
The efforts exerted by the team on working on this paper resulted to the publication of the NHS Improvement Nutrition and Pressure Ulcers resources that enumerate the role of nutrition and hydration in efforts on pressure ulcer prevention and the application of nutritional care into the clinical practice |
6 |
| Posthauer, M. (2013). Nutrition Strategies for Wound Healing. Journal of Legal Nurse Counselling, 23(1), 15-21. | Recommendation was provided based on the author’s expertise and clinical experience | Palliative and hospice care setting | Concepts: Nutritional support improves the quality of life and promote healing of pressure ulcer. | The early detection of undernutrition and rectification of nutritional deficits to help promote healing and improvement of quality of life is very important. The author also said that the amount and type of nutritional support must always be complimentary with the medical goals and the patient’s needs and desires (Posthauer, 2012, p.21). |
7 |
| Blanc, G., Meier, M., Stocco, J., Roehrs, H., Crozeta, K., & Barbosa, D. (2015). Effectiveness of Enteral Nutritional Therapy in the Healing Process of Pressure Ulcers: A Systematic Review. Revista Da Escola De Enfermagem Da USP, 49(1), 152-161. DOI: 10.1590/s0080-623420150000100020 | Systematic review and meta-analysis of randomized controlled trial | Post-surgery hospitals in Brazil |
Concepts: The role of enteral nutritional support can diminish the progression of pressure ulcers. IV: Mixed nutritional supplement DP: Depth and area of lesion development and progression. CV: Setting, dosage, composition of nutritional supplement |
The author concluded that “enteral nutritional support can diminish the progression of pressure ulcers in high-risk patients” (Blanc et al., 2015, p.160). |
1 |
| Cereda, E., Klersy, C., Serioli, M., Crespi, A., & D'Andrea, F. (2015). A Nutritional Formula Enriched with Arginine, Zinc, and Antioxidants for the Healing of Pressure Ulcers. Annals of Internal Medicine, 162(3), 167-174. DOI: 10.7326/m14-0696 | Experimental design involving a controlled trial | Long-term care residents or patients receiving home care services |
Concepts: Nutritional supplementation with arginine, zinc, and antioxidants can help improve the healing process in pressure ulcer. IV: 400ml daily of a supplement enriched with arginine, zinc, and antioxidants; and 400 ml of an isocaloric, isonitrogenous formula DP: Pressure ulcer progression CV: Age, sex, setting of care, main diagnosis and presence of diabetes |
The study revealed that while nutritional supplementation with arginine, zinc, and antioxidants manifested improved pressure ulcer healing |
2 |
References
Banks, M., Graves, N., Bauer, J., & Ash, S. (2013). Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals. European Journal of Clinical Nutrition , 67 (1), 42-46. DOI: 10.1038/ejcn.2012.140
Blanc, G., Meier, M., Stocco, J., Roehrs, H., Crozeta, K., & Barbosa, D. (2015). Effectiveness of Enteral Nutritional Therapy in the Healing Process of Pressure Ulcers: A Systematic Review. Revista Da Escola De Enfermagem Da USP , 49(1), 152-161. doi: 10.1590/s0080-623420150000100020
Carter, R., & Lecko, C. (2018). Supporting evidence-based practice in nutrition and hydration. Wounds UK , 14 (3), 18-21.
Cereda, E., Klersy, C., Serioli, M., Crespi, A., & D'Andrea, F. (2015). A Nutritional Formula Enriched with Arginine, Zinc, and Antioxidants for the Healing of Pressure Ulcers. Annals of Internal Medicine, 162(3), 167-174. DOI: 10.7326/m14-0696
Melnyk, B., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare . Philadelphia, Pa. etc.: Wolters Kluwer.
Posthauer, M. (2013). Nutrition Strategies for Wound Healing. Journal of Legal Nurse Counselling , 23 (1), 15-21.
Riva, J., Busse, J., Endicott, A., Malik, K., & Burnie, S. (2012). What is your research question? An introduction to the PICOT format for clinicians. Journal of the Canadian Chiropractic Association , 56 (3), 167–171.
