Evidence-Based Practice for Repositioning in Pressure Ulcer Prevention

This paper explores the evidence-based practice of repositioning in pressure ulcer prevention. It discusses the effectiveness of different repositioning measures and their impact on reducing pressure ulcer frequency. The study also highlights the gaps in standardized patient repositioning and provides recommendations for further research.

Part – A
Introduction
The pressure ulcer management across the health care settings proves highly
problematic for professional nurses, particularly during the post-operative phase across the
surgical ward. The assessment by (Wong, Amin, & Dumville, 2016) considers repositioning
as a recommended pressure-relieving measure that substantially reduces the risk of the
patient’s pressure ulcer in the inpatient and surgical wards. Contrarily, the study by prioritizes
air mattress over two-hourly repositioning measure in the context of reducing the risk of
pressure ulcers for the admitted patients (Sharp, Schulz Moore, & McLaws, 2019). The
systematic analysis by Gillespie, et al. (2014) reveals the patient repositioning measures at
90º and 30º tilts as the standard conventions warranted to minimize the frequency of pressure
ulcers in bed-confined patients. Repositioning measures are widely utilized in clinical
practice; however, the repositioning frequency remains debatable unsubstantiated in the
context of evidence-based clinical literature. Physical inactivity and immobility are the
precursors of patients’ pressure ulcers in hospital settings (Bhattacharya & Mishra, 2015).
The pressure sores include non-blanching erythematous patches and blisters or decubitus
ulcers that develop under the impact of sustained pressure over the skin and resultant
reduction in tissue oxygen tension. These outcomes necessitate the patients’ repositioning
with the core objective of minimizing oxygen tension across the immobile skin locations.
Furthermore, patients’ age, physical activity level, gender, bed-confinement/immobility level,
and disease type determine their repositioning frequency in the hospital setting (Latimer,
Chaboyer, & Gillespie, 2015). These outcomes reveal substantial evidence-based gaps related
to the standardized patient repositioning and eventual pressure ulcer reduction in the patients
of various age groups and disease conditions. Accordingly, the presented paper thoroughly
explores EVB (evidence-based practice) process in the context of determining the true
essence of the patients’ repositioning for their pressure ulcer reduction in the hospital setting.
The critical appraisal of the selected evidence-based articles is based on evaluating pressure
injury development causes in patients affected with spinal cord injury and the impact of
hydrocolloid dressings utilization for pressure ulcer frequency reduction in the health care
settings.
Clinical Issue

The most critical issue in the presented case study is based on the pressure ulcer
prevention through 2-hourly patient repositioning measure in the surgical ward or another
inpatient unit. The following PICO question effectively addresses the pressure ulcer
prevention concern for the admitted patients.
P: Surgically intervened/bed-confined/immobile/physically less active/inactive/admitted
patients across surgical wards or inpatient settings
I: 2-hourly repositioning
C: Absence of repositioning
O: Pressure ulcer prevention
PICO Question: Does 2-hourly repositioning of surgically
intervened/bed-confined/immobile/physically less active/inactive hospitalized patients reduce
their frequency of decubitus/pressure ulcers to a greater extent than the pressure ulcer
frequency of the patients who do not receive repositioning support from professional nurses?
Databases Utilized During Search Strategy
The search approach effectively utilized three databases including CINAHL
(EBSCO_Health, 2019), Cochrane database of systematic reviews (Cochrane_Library, 2019),
and PubMed/Medline (PubMed.Gov, 2019), in the context of exploring relevant articles
related to the relevance of 2-hourly repositioning in pressure ulcer reduction.
Search Limits
The search limits were based on the articles’ publication dates between 01-Jan-2007
to 31-Dec-2014. The content type included systematic reviews and randomized controlled
trials.
Search Terms
The following search terms were categorically utilized in accordance with the selected
PICO question.
1. Repositioning
2. Pressure ulcers
3. Decubitus ulcers
4. Pressure ulcer prevention

5. Regular turning
6. 2-hourly repositioning
7. 3-hourly repositioning
8. 4-hourly repositioning
9. Pressure ulcer lesions
The evidence-based search strategies in the presented context retrieved the following
three articles related to patients’ repositioning and a corresponding reduction in pressure ulcer
frequency.
Reddy, M. (2011). Pressure ulcers. BMJ Clin Evid, 1-43. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217823/
Article Relevance
The systematic review by (Reddy, 2011) is substantially relevant to the answerable
question since its systematic review provides the safety and effectiveness of regular
turning/repositioning intervention in the context of minimizing the frequency of pressure
ulcers in hospital patients affected with a poor skin condition and reduced immobility.
Practice Recommendations
The systematic review by (Reddy, 2011) does not recommend any standard
repositioning regimen in the context of preventing decubitus ulcer progression in hospitalized
patients. The study outcomes provide weak evidence in relation to the pressure ulcer
prevention capacity of 90degree supine/lateral and 30degree tilt repositioning approaches for
elderly patients in the hospital setting. The findings of the systematic review do not provide
substantial evidence related to the effectiveness of the patient repositioning interventions as
compared to the standard ulcer prevention strategies across the clinical practice environment.
However, the study outcomes substantiate the need for further investigation in the context of
evaluating the effectiveness of the patient repositioning with other standard approaches
(including surgery, low-pressure supports, topical medication, pressure relieving surfaces,
and foam mattresses) for pressure ulcer prevention. The study outcomes do not
fundamentally support the sole administration of 2-hourly patient repositioning interventions
for pressure ulcer prevention inside the hospital setting.
Bergstrorm, N., Horn, S. D., Rapp, M., Stern, A., Barrett, R., Watkiss, M., & Krahn, M. (2014).
Preventing Pressure Ulcers: A Multisite Randomized Controlled Trial in Nursing Homes.

Ont Health Technol Assess Ser., 14(11), 1-32. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552218/
Article Relevance
The article by (Bergstrorm et al., 2014) is highly relevant to the answerable question
since it categorically evaluates the repositioning optimization frequency over high-density
foam mattresses in the context of minimizing the prevalence of pressure ulcers among the
residents of selected long-term care settings.
Practice Recommendations
The RCT findings advocate 2-3-4 hourly repositioning of high-risk residents on
elevated density foam replacement mattresses in the context of minimizing their risk of
decubitus ulcer and related clinical complications. The study findings support the
configuration of repositioning frequency in accordance with the risk factors and skin changes
of the concerned recipients. The study outcomes emphasize the need for less frequent
repositioning in the context of enhancing the health-related quality of life, activities of daily
living, and sleep pattern of the resident population.
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. J Adv Nurs., 57(1),
59-68. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/17184374
Article Relevance
The two-arm RCT by (Vanderwee, Grypdonck, De-Bacquer, & Defloor, 2007) is
highly relevant to the answerable question since it attempts to comparatively analyze the
effects of 2-hourly and 4-hourly repositioning measures in the context of reducing the
frequency of pressure ulcer lesions in the selected medical facility.
Practice Recommendations
The RCT findings do not recommend 2-hourly repositioning measures over 4-hourly
repositioning interventions in the context of minimizing the percentage of decubitus ulcer
among the selected subjects. In summary, the study outcomes advocate the need for adopting
less frequent repositioning of the hospital patients over pressure controlling mattresses for
proactively controlling the prevalence of decubitus ulcers among the admitted patients.

Part – B (Critical Appraisal of the Selected Articles)
Article – 1
The retrospective cohort study by Cortés et al. (2018) evaluated the following
question.
PICO Assessment
Population: Subjects (above 18 years of age) with an elevated predisposition to pressure
ulcers in accordance with the Braden scale.
Intervention/Exposure: Conventional pressure ulcer care supported by hydrocolloid dressing.
Comparison: Conventional care for preventing pressure ulcer.
Outcome: Reduction in pressure ulcer frequency
Literature Review
The literature review by Cortés et al. (2018) describes pressure ulcers and their
reported frequencies in the clinical settings across the globe. The literature review also
describes pressure ulcer-related morbidities and their causative factors. The literature review
reveals limited evidence and knowledge gaps in relation to the use of hydrocolloid dressings
with conventional ulcer prevention care modalities for minimizing the risk of pressure ulcers
and related complications. The uncertainty regarding pressure ulcer prevention capacity of
hydrocolloid dressings against conventional care necessitated the organization of
retrospective intervention in the presented context. However, the authors could have used a
more systematic framework to determine the research gaps in relation to the subject of
interest.
Methods
Cortés et al. (2018) retrospectively evaluated 1461 medical records of 170 adult
patients (registered with pressure ulcer prevention program) for a tenure of 7 months (i.e.
June-2014 to Dec-2014). The comparative testing of both interventions was undertaken
through Cox proportional risk model, bivariate analysis, multivariate analysis (i.e. p-value
assessment), and hazard ratio. A retrospective study in the presented context is the best

approach to evaluate the patients’ exposure to the hydrocolloid dressing (LaMorte, 2017).
The p-value of greater than 0.05 in the presented context is indicative of the statistically
insignificant relationship between the selected ulcer prevention modalities (Nahm, 2017).
Findings
The study outcomes did not reveal the statistical significance of hydrocolloid
dressing/conventional care application over conventional care intervention. These outcomes
indicate that hydrocolloid dressing use with conventional care does not produce better ulcer
prevention outcomes as compared to the sole conventional care intervention for the selected
patients. The findings of the presented study effectively concord with the evidence-based
outcomes that do not testify greater effectiveness of hydrocolloid dressings in terms of
pressure ulcer prevention as compared to other similar modalities (Pott, Meier, Stocco,
Crozeta, & Ribas, 2014). These outcomes substantiate the need for conducting prospective
research to evaluate the true potential of hydrocolloid dressings in combination with routine
ulcer prevention interventions.
Article – 2
Floríndez et al. (2019) evaluated the following question.
PICO Assessment
Population: Medically underserved patients affected by SCI (spinal cord injury).
Intervention/Exposure: Assessment of factors related to pressure ulcer development in SCI
patients.
Comparison: SCI Patients who do not develop pressure ulcers.
Outcome: Exploration of pressure ulcer prevention themes
Literature Review
The literature review emphasized limited evidence regarding lifestyle and educational
strategies warranted to minimize the occurrence of pressure ulcer complications in SCI
patients. However, the literature review did not evaluate the evidence-based circumstances
responsible for the development of pressure ulcers in SCI patients. The literature review also
did not discuss any evidence-based finding that could have emphasized the need for
conducting the presented secondary assessment. The absence of knowledge gaps and the

inappropriate justification of the need for conducting the present study substantially
weakened the credibility of the recommended research approach. However, the literature
review advocated the requirement of evaluating prospective rehabilitation for SCI patients in
the context of reducing their pressure ulcer frequency.
Methods
Floríndez et al. (2019) utilized QSA (qualitative secondary case assessment) in the
context of understanding the outcomes of a randomized controlled trial that attempted to
evaluate cost-effectiveness and ulcer reducing the potential of lifestyle approaches for a
specific subset of SCI patients. QSA undoubtedly proves to be the best to contextualize and
explicitly evaluate the outcomes of a credible study while reducing the methodological rigor
(Tate & Happ, 2018). The absence of statistical interventions in the presented analysis
substantially reduced the strength of the selected study.
Findings
The findings of the study highlighted various themes/patterns responsible for the
increased occurrence of pressure ulcers in SCI patients. However, the assessment did not
categorically describe the mechanisms that the reported pattern/themes deployed for elevating
the pressure ulcer frequency in SCI patients. However, the findings effectively concord with
evidence-based outcomes that advocate the need for evaluating SCI patients’ psycho-socio-
somatic outcomes, personalized demands, and health literacy level to rehabilitate them for
pressure ulcer prevention in the clinical settings.
Articles’ Summary & Relevance to Clinical Practice
The retrospective cohort assessment by (Cortés et al., 2018) evaluated the
effectiveness of hydrocolloid dressing in the context of minimizing the risk of pressure ulcers
in the patients undergoing hospital treatment. The authors presented a dynamic rationale for
initiating the research intervention in the context of the limited research evidence regarding
the use of hydrocolloid dressing for pressure ulcer reduction. The authors, however, utilized a
limited sample size that proved to be insufficient in studying the pressure ulcer potential of
hydrocolloid dressings on a wider scale. The utilization of statistical tools in the presented
study improved the credibility of findings to a considerable extent. The study findings were
prone to errors since the authors did not use any intervention to evaluate the credibility of

pressure ulcer information in the patients’ medical record. The authors did not approach
qualified PPCP (Prevention of Pressure Ulcers and Skin Care) program nurses in the context
of directly obtaining pressure ulcer-related information. However, the study outcomes
substantially emphasized the need for conducting prospective studies in the context of
evaluating the effectiveness of hydrocolloid dressing in minimizing the frequency of pressure
ulcers. The article by (Cortés et al., 2018) has high relevance in the clinical practice since it
provides credible evidence of future ulcer prevention studies. The article findings also
motivate nurses and other health care professionals in the context of testing the efficacy of
hydrocolloid-based ulcer prevention interventions in the clinical setting.
The article by (Floríndez et al., 2019) utilized qualitative secondary case assessment
in the context of evaluating significant factors responsible for the pressure ulcer development
in clinical underserved SCI patients. The article emphasized the need for improving the
pressure ulcer prevention knowledge and lifestyle of the SCI patients in the context of
minimizing the occurrence of their pressure ulcers. The thematic assessment through a
secondary case analysis of an already conducted randomized controlled study proved to be
the greatest strength of the presented article. The findings systematically revealed various
health care aspects requiring clinicians’ attention in the context of improving the health-
related quality of life of SCI patients. These aspects include unreachable circumstances,
patient inactivity, absence of bed rest, comorbidities, supply/equipment problems, and limited
wound care knowledge. The emphasis on these aspects by the concerned authors proved to be
an evidence-based rationale for their further testing through quantitive studies. However,
limited sample size and narrow criteria for sample selection barricaded the generalizability of
the study findings across the clinical practice environment. Furthermore, the subjective
interpretation of qualitative data elevated the risk of errors in study findings. The
rehabilitation implications emphasized by the authors prove to be the significant
guidelines/recommendations for professional nurses in the context of minimizing the
prevalence of pressure ulcers in SCI patients.
Conclusion
The presented paper critically analyses various aspects of pressure ulcer preventions in health
care settings. The analysis of various case studies, evidence-based articles and practice
recommendations regarding pressure ulcer prevention and management substantially elevate
the critical thinking skills and practice expertise of the professional nurses. The entire

assessment, however, advocates the use of repositioning measure, lifestyle management,
conventional management, and educational enhancement of the patients to challenge the
occurrence of pressure ulcers in various surgical or hospital settings.
References
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(2014). Preventing Pressure Ulcers: A Multisite Randomized Controlled Trial in
Nursing Homes. Ont Health Technol Assess Ser., 14(11), 1-32. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552218/
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