Pressure ulcers in the skin

2 Evidence based nursing Outline of Clinical Issue Brief description Pressure injuries occur due to a breach in the skin as a result of unrelieved pressure on tissues that have been pressed between an external hard surface and a bone. The predominance of skin breakdown and pressure injuries (PI's) has turned into a standard by which emergency clinics are assessed and surveyed, with the advancement of PI's perceived as a patient wellbeing issue as they can expand bleakness and mortality. Prevalence and incidence rate

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Evidence based nursing
Outline of Clinical Issue
Brief description
Pressure injuries occur due to a breach in the skin as a result of unrelieved pressure on tissues that have been pressed between an
external hard surface and a bone. Along with these, other contributing factors include friction, poor blood flow and tissue ischaemia.
The time period for which the skin is exposed is also of the essence for the intensity of breach of the skin. Pressure ulcers are
described by a harm to the skin and fundamental tissues brought about by the pressure (Elsabrout et al. 2018). The hazard factors
for this complexity incorporate idleness, high skin temperature, dampness, and the nearness of frictional and shear powers (Science
Direct, 2016). In this manner, the danger of pressure ulcers would increment in instances of obviousness, loss of motion, and
neurological infections or patients admitted to Intensive care units (ICUs).
Significance of the issue
Healthy skin is a property of value nursing care. The predominance of skin breakdown and pressure injuries (PI's) has turned into a
standard by which emergency clinics are assessed and surveyed, with the advancement of PI's perceived as a patient wellbeing
issue as they can expand bleakness and mortality. Most PI's are preventable if suitable measures are executed (Ncbi , 2019).
Background information
The tissue’s capacity to endure the weight including the force and span are elements influencing PI advancement. Restricted
territories of tissues that have drawn out weight cause the impediment of the bloodstream, anticipating the stockpile of supplements
and oxygen to the tissue, bringing about ischaemia and damage, prompting cell pulverization and in the long run tissue death (Al-
Otaibi et al. 2019.
Prevalence and incidence rate of the problem
The assessed pressure damage commonness in Australian hospitals ranges from 9.5% to 17.6%, and in a nursing home and long
term care settings are evaluated to be around 8.9%. the joined outcomes announced 1,195 individuals or one out of ten (10%
pervasiveness rate) were found to have at least 1 pressure injuries on skin examination. 669 or six out of ten of these injuries being
an emergency clinic or wellbeing administration gained (Richard-Denis et al. 2017).
Risks involved
Risks factors include lack of mobility, sensation in the affected areas and the blood flow in the area can also be affected. Severe
complications include bone and joint infection that occurs from a pressure ulcer that has burrowed to the joints or to the bones. Such
an infection can harm the joint cartilage and the bone which can cause more serious and permanent immobility (Science Direct ,
2019).
Need for using an evidence-based approach
Evidence-based practice approach differs structure the much well known conventional type of practice where work frameworks keep
on resembling, they have been with no real changes. While, in evidence-based practice, a clinical issue is tackled through research
and evidence. This is substantially more logical and consistent instead of putting together practice choices with respect to

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Evidence based nursing
convention, instincts or individual inclinations (Forni et al. 2018). It additionally guarantees that the practice examples are uniform as
they are based on logical evidence.
Clinical Question
Identify your clinical question, using the PICO format
Population How are the patients who are bedridden
affected by pressure injuries or ulcers?
Intervention How does the use of air mattresses or liquid
mattresses impact on the recovery or
prevalence of pressure injuries?
Comparison Why are air mattresses or liquid mattresses
preferred than standard hospital mattresses?
Outcome What is the impact air mattresses or liquid
mattresses on the prevalence of pressure
injuries?
Identify the domain
The domain is of harm to patients while being in long term care.
Evidence Search

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Evidence based nursing
Description of the evidence-based search strategy
The basic topic was that of pressure injuries that were seen in patients that have been bedridden in hospitals or in long term care.
This narrowed down the domain and purpose of the search articles. The search strategy began with keywords and narrowing down
on a single intervention for pressure injuries. This was seen to be the use of air or liquid mattresses and hence was used to narrow
the search through the use of proper operators (Pernik et al. 2016). The evidence was also narrowed on the basis of the medical
database as it ensures that the information is reliable and valid. Then the search was even constricted based on the year of
publication.
Recency of information
The recency of the information is essential so as to ensure that the information is relevant and still applicable to the present context.
Four of the five articles are fairly recent and have been published after 2015 whereas one dates back to 2009. This article was
chosen irrespective of the date because the information was found to be relevant and impactful.
How you narrowed your search to find relevant information
The topic chosen was that of pressure wounds as it is a common nursing issue in hospitals and an evidence-based intervention is
required. The search was limited by adding a specific group of people who have suffered from this issue. The research articles only
deal with pressure injuries of patients who have been in long term care in hospitals. The next concept used to narrow down the
search was the chosen intervention for the problem that was air or liquid mattresses.
Hierarchy of evidence

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Evidence based nursing
Types of studies that you considered appropriate to include
The survey, systematic review, 2 randomized clinical trial and a meta-analysis were included due to their high rank in the hierarchy of
evidence and the strength of the data which objective and free from any bias.
Key search terms
Pressure injuries, pressure injuries from hospital beds, pressure injury intervention, air or liquid mattresses for pressure injuries,
preventing pressure injuries.
Key search strategies
Boolean operators were used and citations from the chosen article were used to find similar ones.
Inclusion or exclusion criteria that you applied and why
Sys
tem
atic
revi
ewRandomised
controlled trials
Meta analysis
Survey

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Evidence based nursing
The inclusion criteria were that the article focused on hospital patients who suffered from pressure injuries and the chosen
intervention was air or liquid mattress. Articles before 2013 were ignored because of the relevance and currency of information.
Publication types
Journal articles from the medical database like PubMed, Science Direct and Cochrane.
The rationale for selecting the five sources
The articles chosen are from respectable medical databases that provide access to current informative research. The article shows
no form of bias, subjectivity or difference in views. Also, the articles provide valuable information about the topic.
Literature Synthesis of Best Evidence
Synthesize information
Pressure injuries to the skin and the underlying tissue are common when there is an extended period of pressure and ischemia which
may lead to blood vessel damage and tissue necrosis giving rise to a pressure injury. This is common among patients who have
undergone complicated surgeries and cannot be repositioned to relieve the pressure (VanWyhe & Willer, 2018). The sacral bone was
found to be the most common area of injury and the blood flow in the area was indirectly proportional to the body mass index. Lower
body mass index was found to be more effective in relieving or altering the pressure on the area.
Alternating pressure (AP) is an element of a help surface that gives pressure redistribution by means of cyclic changes in stacking
and emptying. The intermittent pressure alleviation given by AP surfaces have been accounted for to help keep up tissue feasibility
as estimated by gas strain recuperation and tissue perfusion, along these lines lessening the hazard for ischemia instigated tissue
injury. Making small changes at various positions rather than only on the affected region if more affective in relieving pressure than a
major change at the affected area (Meaume & Marty, 2018). A towel can be placed directly below the body to minimise the effect of
movement or position change on the pressure injury as well as the operated area. Most effective position of the towel was under the
femoral or thoracic region which dissipated the pressure from the sacral region by 4mm/Hg
The use of tragacanth gel mattresses rather than traditional mattresses in the ICU have been found to be able to prevent the
chances of developing a pressure ulcer. Also, these mattresses were able to delay the onset of erythema.this intervention was
favoured the most as it was cost-effective and the gel was naturally available requiring no need for further synthesis (Cochrane
Library, 2018).

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Evidence based nursing
However, it is difficult to discern which support surface, for instance, mattresses, cushion or towels are more effective than the other.
The relative impact of these supporting devices is unclear, but it is known that all these devices are able to relieve the pressure from
the sacral region up to some extent.
The hospitals and other care organisations need to be therefore more alert about the prevalence of pressure injuries among the
intensive care unit patients who are rendered immobile because of postoperative pain and wear. As a result, precautions need to be
taken beforehand rather than searching for the cure later. An alternative to the normal mattress is the foam mattress that reduced the
incidence rate of pressure ulcers. Pressure-relieving overlays used on the operating table are also effective in reducing the cause of
pressure injuries however, they have other detrimental effects on the exposed skin (Cochrane Library, 2015).
Identify, justify and support highest evidence
The highest evidence was provided by the article “Effectiveness of Tragacanth Gel Cushions in Prevention of Pressure Ulcer in
Traumatic Patients: a Randomized Controlled Trial”. According to the hierarchy of evidence, a randomised, randomised control trial is
the best kind of evidence as the chances of bias is lowest in it. The participants were chosen randomly without allowing the bias or
preference of the researcher to keep in. Moreover, the evidence provided by this article is also impactful and essential for evidence-
based practice. The conclusion drawn from the said study proved that gel mattresses in the ICU were successful in lowering the
prevalence of pressure wounds among patients (Richard‐Denis et al. 2017). Also, it is superior to many other forms of mattresses
like the foam geel mattresses which caused redness or itchiness of the skin surface. The tragacanth gel has been associated with
the lowest forms of complications or side effects and is a naturally occurring substance that can be easily procured.
This evidence-based article also satisfied all the PICO questions. The population focus of the article where patients from the
intensive care unit who have undergone complex surgery and will be bedridden for postoperative care. The chosen intervention was
that of air or liquid mattresses and the article ensured that liquid or gel-based mattresses especially tragacanth gel mattresses are
most effective compared to the standard mattresses in preventing pressure injuries in ICU ( Gefen & Santamaria, 2017). the outcome
of the randomised control trial showcased that among 100 patients who participated in the research 14 patients did not show any
impact of pressure and also no redness on the exposed skin area.
Recommendations for practice and research
From the evidence, it was clear that tragacanth gel mattresses were effective in preventing the prevalence of pressure injuries.
However, more research and information is required to understand which support devices are better and relatively more effective in
treating pressure injuries. The use of gel-based mattresses needs to be promoted rather than foam mattresses as they are
economically viable, naturally available in nature and do not have to be artificially synthesised like foam or other substances (Meah et
al. 2019). Moreover, they are associated with the least number of complications such as redness or swelling in the affected skin.
Future investigations are required to imitate this examination with a bigger example size and thought of the impacts of meddling
variables, for example, hereditary qualities as it was not inside the extent of this examination. In addition, it is proposed that the

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impact of tragacanth gel pads. Current rules for the anticipation of careful pressure wounds show the adequacy of pressure injury
counteractive action utilizing pressure redistributing surfaces, for example, exchanging pressure on the working room table during a
medical procedure, and prescribe their utilization over standard surgery surfaces for people in danger (Gunningberg et al. 2018). The
rules show the requirement for more research on the adequacy of pressure redistributing surfaces for various body types.
References
Al-Otaibi, Y. K., Al-Nowaiser, N., & Rahman, A. (2019). Reducing hospital-acquired pressure injuries. BMJ Open Qual, 8(1),
e000464. Retrieved from https://bmjopenquality.bmj.com/content/bmjqir/8/1/e000464.full.pdf
Cochrane Library, (2015), Support surfaces for pressure ulcer prevention, Retrieved from
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001735.pub5/full
Cochrane Library, (2018), Support surfaces for treating pressure ulcer, Retrieved from
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009490.pub2/full
Elsabrout, K., Orbacz, E., McMahon, L. A., & Apold, S. (2018). Large‐Scale Hospital Mattress Switch‐Out Leads to Reduction
Hospital‐Acquired Pressure Ulcers: Operationalization of a Multidisciplinary Task Force. Worldviews on Evidence
‐Based
Nursing, 15(3), 161-169. Retrieved from https://sigmapubs.onlinelibrary.wiley.com/doi/abs/10.1111/wvn.12280
Forni, C., D’Alessandro, F., Genco, R., Mini, S., Notarnicola, T., Vitulli, A., ... & Morri, M. (2018). Prospective Prognostic Cohort Study
of Pressure Injuries in Older Adult Patients with Hip Fractures. Advances in skin & wound care, 31(5), 218-224. Retrieved
from https://journals.lww.com/aswcjournal/Fulltext/2018/05000/Prospective_Prognostic_Cohort_Study_of_Pressure.6.aspx
Gefen, A., & Santamaria, N. (2017). Comment on'Effectiveness of a multi-layer foam dressing in preventing sacral pressure ulcers for
the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel mattress'. International
wound journal, 14(5), 882. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/iwj.12710
Gunningberg, L., Bååth, C., & Sving, E. (2018). Staff's perceptions of a pressure mapping system to prevent pressure injuries in a
hospital ward: A qualitative study. Journal of nursing management, 26(2), 140-147. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/jonm.12526
Meah, Y. S., Ko, F. C., & Arrabito, E. (2020). Pressure Injuries. In Home-Based Medical Care for Older Adults (pp. 71-77). Springer,
Cham. Retrieved from https://link.springer.com/chapter/10.1007/978-3-030-23483-6_11
Meaume, S., & Marty, M. (2018). Pressure ulcer prevention using an alternating-pressure mattress overlay: the MATCARP
project. Journal of wound care, 27(8), 488-494. Retrieved from https://www.theotshow.com/__media/libraries/exhibitor-press-
releases/1111A9D7-5056-B759-2A1105C14422D938-image.pdf

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Ncbi , (2019), Effectiveness of Tragacanth Gel Cushions in Prevention of Pressure Ulcer in Traumatic Patients: a Randomized
Controlled Trial, Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428161/
Pernik, M. N., Seidel, H. H., Blalock, R. E., Burgess, A. R., Horodyski, M., Rechtine, G. R., & Prasarn, M. L. (2016). Comparison of
tissue-interface pressure in healthy subjects lying on two trauma splinting devices: The vacuum mattress splint and long spine
board. Injury, 47(8), 1801-1805. Retrieved from https://www.sciencedirect.com/science/article/pii/S0020138316301905
Richard‐Denis, A., Thompson, C., & Mac‐Thiong, J. M. (2017). Effectiveness of a multi‐layer foam dressing in preventing sacral
pressure ulcers for the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel
mattress. International wound journal, 14(5), 874-881. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/iwj.12710
Richard-Denis, A., Thompson, C., & Mac-Thiong, J. M. (2017). Reply to: Effectiveness of a multi-layer foam dressing in preventing
sacral pressure ulcers in the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel
mattress by Gefen and Santamaria. International wound journal, 14(5), 885. Retrieved from
https://onlinelibrary.wiley.com/doi/abs/10.1111/iwj.12710
Science Direct , (2019), Sacral skin blood flow response to alternating pressure operating room overlay, Retrieved from
https://www.sciencedirect.com/science/article/pii/S0965206X15000960
Science Direct, (2016), The effectiveness of small changes for pressure redistribution; using the air mattress for small changes,
Retrieved from https://www.sciencedirect.com/science/article/pii/S0965206X18301244?via%3Dihub
VanWyhe, J., & Willer, S. (2018). The Use of Immersion Therapy Mattress With Low Air Loss in Patients With Myocutaneous
Flaps. Journal of Wound Ostomy & Continence Nursing, 45(3), 270-273. Retrieved from
https://www.sizewise.com/Sizewise/files/fc/fcfb75ea-9b90-4754-939a-3a9145a69567.pdf

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Appendix 1

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SEARCH QUESTION/TOPIC:
Author (s)
(date)
Study
Design
Question
Domain
Key
informatio
n
Validity
Check
(eg bias)
Author’s
Results/
Findings
Author’s
Conclusio
ns
Reviewer
Commen
ts
(Your
appraisal
)

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Evidence based nursing
Evidence Source
No. ___
Sacral skin blood flow response to alternating pressure operating room overlay Patricia
Karg, Vinoth
K.
Ranganatha
m, Michael
Churilla and
David
Brienza
Purpose:
to quantify
the impact
of
alternating
pressures
and small
changes
on
pressure
injuries
Design:
surey
Level:
Domain:
pressure
injuries
developed
in patients
recovering
from long
surgeries
P: patients
recovering
from long
surgeries
I: air or
liquid
mattresses
and
support
devices
C:
standard
mattresses
O:
alternating
pressure
can reduce
ischemia
Conflict of
interest
was noted
in the
article.
Alternating
pressure or
small changes
in the posture
can relieve
pressure and
chances of
ischemia
The impact
of
alternating
pressure
might be
dependent
on the
body mass
index of
the patient.
Further
need for
research
and
evidence
is
required
to ensure
the effect
of BMI on
alternatin
g
pressure.

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Evidence based nursing
Evidence Source
No. ___
Effectiveness of Tragacanth Gel Cushions in Prevention of Pressure Ulcer in
Traumatic Patients: a Randomized Controlled Trial
Javad
Sjakibamehr
, Mojtaba
Ras, Rahim
Akrami ad
Mostafa
Rad
Purpose:
comapre
the effect
of
tragacanth
gel
mattresses
and foam
mattresses
Design:
Randomis
ed control
trial
Level:
Domain:
patients
admitted to
intensive
care unit
P:
patients
admitted to
intensive
care unit
I: air or
liquid
mattresses
and
support
devices
C:
standard
mattresses
O:
tragacanth
gel
cushions
reduce the
prevalence
of
pressure
injuries
No bias
noted.
Tragacanth gel
cushions
reduces the
chances of
skin irritation
and redness as
well as the
pressure
injuries
Cost
effective
and
naturalnes
s can be
considered
when
opting for
pressure
supporting
devices.
future
research
is
required
to
consider
the effect
of other
interferin
g factors

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Evidence based nursing
Evidence Source
No. ___
The effectiveness of small changes for pressure redistribution; using
the air mattress for small changes
Sayumi
Tsuchiya,
Aya Sato,
Eri Azuma,
Hiroko
Urushidani,
Masako
Osawa,
Kanaho
Yokono and
Junko
Sugama
Purpose:
quantify
the
effectivene
ss on
small
changes
for
relieving
pressure
Design:
survey
Level:
Domain:
healthy
adult
females
P: healthy
adult
females
I: air or
liquid
mattresses
and
support
devices
C:
standard
mattresses
O: small
changes
are more
effective
than a
major
movement
The study
used
health
adult
females
who
naturally
had less
chances
of
developin
g pressure
ulcers.
Small changes
at the sacral
region can
improve blood
flow
Physical
sensation
and hence
the feeling
of pressure
may
change
with
maintaining
a position
of a long
period.
More
opportuni
ty for
research
is there
as the
participan
ts were
chosen
randomly.

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Evidence based nursing
Evidence Source
No. ___
Support surfaces for treating pressure ulcers
Elizabeth
McInnes,
Asmara
Jammali
Blasi, Sally
EM Bell
Syer and
Vannessa
Leung
Purpose:
assess the
impact of
pressure
relieving
support
devices,
Design:
meta
analysis
LOE:
Domain:
use of
support
devices
P: patients
with
pressure
ulcers in
long term
patients
I: air or
liquid
mattresses
and
support
devices
C:
standard
mattresses
O: no clear
difference
in the use
of water or
foam filled
mattresses
on the
healing of
pressure
injuries.
Unpublish
ed articles
were used
whose
genuity
cannot be
guarantee
d.
Not ready to
make firm
determinations
about the
impacts of
various help
surfaces for
treating weight
ulcers in light
of the fact that
the general
nature of the
proof is low to
exceptionally
low.
Difficult to
ascertain
which
support
surfaces
has the
best
results.
More
research
and study
is
required.

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Evidence based nursing
Evidence Source
No. ___
Support surfaces for pressure ulcer prevention
Elizabeth
McInnes,
Asmara
Jammali
Blasi, Sally
EM Bell
Syer, Jo C
Dumville,
Victoria
Middleton
and Nicky
Cullum
Purpose:
pressure
relieving
devices
can
prevent
pressure
injuries
Design:
sytematic
review
Level:
Domain:
pressure
P:
pressure
ulcers
among
long term
patients
I: air or
liquid
mattresses
and
support
devices
C:
standard
mattresses
:
O: relative
impact of
effectivene
ss to
prevent
pressure
ulcers
No bias or
subjectivin
g noted
Alternating
pressures
devices such
as air or liquid
filled
People
who are
more
susceptible
to pressure
injuries
need to be
provided
with
support
mattresses
.
more
research
is
required
for
detecting
the skin
damage
at an
early
stage.

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Evidence based nursing
Appendix 3
1. https://www.sciencedirect.com/science/article/pii/S0965206X18301244?via%3Dihub
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428161/
3. https://www.sciencedirect.com/science/article/pii/S0965206X15000960
4. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009490.pub2/full
5. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001735.pub5/full

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Evidence based nursing
Appendix 4
Highest clinical evidence appraisal through the CASP tool
Question Yes No Can’t tell Comments
Did the study
address a
clearly focused
issue?
✓
Was the
assignment of
patients to
treatments
randomised?
✓
Were all of the
patients who
entered the trial
properly
accounted for at
its conclusion?
✓
Were patients,
health workers
and study
personnel
‘blind’ to
treatment?
✓
Were the
groups similar
at the start of
the trial?
✓
Aside from the
experimental
intervention,
were the groups
✓

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Evidence based nursing
treated equally?
How large was
the treatment
effect?
14 out of 100
patients
showed positive
impact from the
intervention.
How precise
was the
estimate of the
treatment
effect?
Can the results
be applied to
the local
population, or in
your context?
✓
Can the results
be applied to
the local
population?
✓
Were all
clinically
important
outcomes
considered?
✓ The clinical
outcome of
body mass
index of the
patients was
not considered.
Are the benefits
worth the harms
and costs?
✓