Prevalence and Management of Pressure Ulcers in Acute Care Wards: A Systematic Review

Running head: MSC NURSING
Dissertation
Name of the Student
Name of the University
Author Note

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Abstract
Background- Pressure ulcers occur when a strong pressure is applied over the soft tissues
that underlie the skin, thus resulting in complete or partial obstruction of blood flow to the
regions of soft tissue. Also referred to as bed sores, the condition usually occurs over a region
of bony prominence and is found widely prevalent, on a global scale.
Methodology- The research philosophy of interpretivism was adopted to conduct an
extensive systematic review of English scholarly articles that were published from 2008 to
2018, followed by organisation of the data findings on the basis of themes or data patterns.
Results- 12 articles provided an exhaustive detail on the prevalence of pressure ulcer among
most patients admitted to the acute wards across hospitals and nursing homes in different
countries. Most of the studies graded PU into 4 different categories, based on the NPUAP and
EPUAP classification guidelines. PUs were found to affect most people in the sacral region,
heels and the hips, and is more found among older adults, females, people who are under
affected with malnutrition and diabetics. Most common impacts of PU were identified as a
restriction in mobility of the patients, lack of participation in activities of daily living,
increased stay at hospitals, and economic burden on the patient and family members. Poor
knowledge among nursing assistants, inadequate staff, lack of time, and huge workload were
recognised as the major barriers that prevented the proper implementation of prevention
strategies.
Conclusion- Efforts must be taken by nursing staff to explain the management process to all
patients. Provisions for nursing education and training are imperative for increasing their
clinical knowledge and attitude towards PU prevention. Skin grafting surgery can prove
effective in management of the condition.
Keywords: pressure, ulcer, prevalence, acute, management, nursing

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Table of Contents
Chapter 1:...................................................................................................................................4
Introduction............................................................................................................................4
Problem statement..................................................................................................................6
Rationale................................................................................................................................9
Research question.................................................................................................................12
Research aim........................................................................................................................12
Research objective...............................................................................................................12
Chapter 2:.................................................................................................................................13
Introduction..........................................................................................................................13
Qualitative research..............................................................................................................13
Research philosophy............................................................................................................14
Research approach...............................................................................................................14
Research design....................................................................................................................14
Literature search...................................................................................................................14
Keywords.............................................................................................................................15
Bibliographic Aids...............................................................................................................16
Inclusion and Exclusion Criteria..........................................................................................17
Justification between inclusion and exclusion criteria.........................................................18
Revised inclusion and inclusion criteria..............................................................................18
Search Strategy.....................................................................................................................19
Search Outcomes..................................................................................................................19

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Snowball Technique.............................................................................................................21
Quality Assessment..............................................................................................................23
Conclusion............................................................................................................................24
Chapter 3:.................................................................................................................................25
Chapter 4:.................................................................................................................................39
Results..................................................................................................................................39
Theme 1: Following NPUAP and EPUAP classification pattern....................................39
Theme 2: Methodological quality of the studies..............................................................41
Theme 3: Location of the PU...........................................................................................44
Discussion............................................................................................................................45
Impacts of pressure ulcer.................................................................................................45
Nursing knowledge and attitude on pressure ulcer..........................................................48
Nursing implications and preventive strategies in pressure ulcer....................................50
Limitations...........................................................................................................................53
Chapter 5:.................................................................................................................................54
Conclusion............................................................................................................................54
Recommendation..................................................................................................................56
References................................................................................................................................59
Appendix..................................................................................................................................70

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Chapter 1:
Introduction
Pressure ulcers (PU) are most commonly defined as localized injuries to the skin
and/or tissues that underlie the skin, usually present over a bony prominence. The ulcer most
commonly occurs due to pressure, often in combination with friction and/or shear. Some of
the most common sites that get affected due to pressure ulcer are the skin regions that overlie
the coccyx, sacrum, hips and the heels (McGinnis et al. 2014). However, some other sites that
might also be affected include the elbows, ankles, knees, and the back of shoulder.Pressure
ulcers usually occur due to burden that is applied to the different soft tissues of the body,
thereby causing completeand/or partial obstruction to the blood flow in soft tissues. Shear is
considered as a major cause for the physiological condition owing to the fact that shear forces
pull on different blood vessels that are responsible for feeding the skin. Pressure ulcers have
been found to most commonly develop in persons who follow a sedentary lifestyle and
generally do not move about much, such as patients or disabled individuals who are confined
to wheelchairs or are bedridden. Researchers and healthcare professionals hold the strong
belief that a plethora of other factors are also responsible for influencing theforbearance of
the skin for shear and pressure, thusgrowing the risks of development of pressure ulcer
(Edwards et al. 2014).
Some of these factors are associated with microclimate(wetness of the skin that is
caused due to incontinence or sweating), protein-calorie malnutrition, diseases that play a role
in reducing the flow of blood to the skin, such as, arteriosclerosis, and other illnessesthat
directly lower the perceptionpower in the skin, such as, neuropathy or paralysis. The time that
is taken by an affected individual for the healing of PUoften gets slowed down with an
increase in age of the patients, in addition to a range of concomitant factors such as, diabetes,

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smoking, infection, and/or medications namely, anti-inflammatory drugs. PU has been
identified as a grave safety matter in healthcare systems in recent years (Kasuya, Sakabe and
Tokura 2014). This can be attributed to the fact that the condition has been found to create an
adverse impact on all patients, owing to the pain that it results in, and the time that is required
for healing of the injury or wound. These ulcers are also responsible for greatly increasing the
workload of healthcare professionals, due to which the costs of healthcare
servicesincreaseradically. These ulcers have also been found responsible for death, under
extreme situations (Fu Shaw et al. 2014). The period of compression that is tolerated by the
skin, until there occurs a breakdown differs from one person to another, and tissue damage as
a result of pressure ulcer are most commonly found to occur within less than two hours
among patients who are incapable. Pressure ulcers are primarily caused due to inadequate
supply of blood that leads to a reperfusion injury, upon re-entry of the blood into the tissues
(Manorama et al. 2013).
One common example of mild pressure related soresare often experienced by healthy
persons while they sit in same position for long periods of time. They report experiences of a
dull ache that is generally indicative of an obstructing in the blood flow to the regions that are
mostly affected. Within few hours of this condition, blood supply shortage, referred to as
ischemia, leads to damage of tissues and/or cell death. The sores usually beginin the form of a
red and painful sensation. Other events that have been found responsible for pressure ulcer
development are instances when pressure is large enough to result in damage of the cell
membrane of the muscle cells. This leads to subsequent death of the muscle cells, in addition
to death of the skin that is fed through blood vessels that originate from the muscles
(Coleman et al. 2014). This is usually categorised as a deep tissue injury type of pressure
ulcer and appears in the form of a purple intact skin.According to data estimates provided by
the NHS Safety Thermometer, 25,000 new patients had been identified to develop symptoms

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of pressure ulcer from April 2014 to March 2015. On average, an estimated 2,000 newly
acquired instances of pressure ulcers are encountered every month withinNHS, in England.
Aged population is more likely to suffer from pressure ulcer, especially people aged more
than 70 years, and those who have been operated for a hip fracture. People having spinal cord
injuries are another major group where the prevalence of PU is as high as 20-30%, following
one or five years after the injury has occurred (GOV.UK 2018). Hence, healthcare
professionals should have an understanding of the needs and demands of the community,
individual, and population, in addition to thinking about the resources that are easily available
in the healthcare facility. Obtaining relevant data regarding the prevalence of pressure ulcer
in acute wards will help in identifying the specific quality standards that need to be
implemented and coordinated across the acute care units, in order to encompass the complete
pressure ulcer pathway. This research will further facilitate identifying the ways by which an
appropriate system-based method can be utilised, with the aim of conducting investigation on
the prevention measures and interventions, to reduce the prevalence.
Problem statement
The National Pressure Ulcer Advisory Panel (NPUAP) has divided pressure ulcer into
four stages, depending on the severity of the condition. While stage 1 represents a condition
where there occurs a reddened spot that is not blanched by pressuring and is often
accompanied by edema, damage of the skin surface layers occur in stage 2. The epidermis
and dermis usually get affected in the second stage (Edsberg et al. 2016). Thickness of the
skin gets lost completely in stage 3 where the damage of the subcutaneous tissue often gets
extended deep into the muscular tissues. This stage encompasses a clinical observation of the
ulcer in the form of a deep cavity that generally gets extended to the adjacent tissues and
requires a longer healing time. Complete skin loss, in addition to skin destruction and

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necrosis are the characteristic features of stage 4. This stage also comprises of secretory
sinuses (Biglari et al. 2014).
Thus, the rate of infection that are associated with pressure ulcers are of prime
concern due to the fact that staying in a fixed position for a prolonged time increases the
likelihood of the condition getting aggravated (Cooper 2013). Shearing of skin most
commonly refer to its separation from the tissues present beneath it. In instances when a
patient is found to partially sit up on the bed, the skin gets stuck to the sheet or mattress,
thereby making it susceptible to shearing forces. This generally happens when the underlying
tissues go downwards along with the entire body, towards the bed foot. Friction is also
damaging to the blood vessels that are superficial on the skin and is experienced when the
two surfaces get rubbed against each other. Friction most commonly occurs an injury to the
skin present over the elbows (Brienza et al. 2015). It also injures the back when the patients
are slid or pulled over the bed sheets, while they are transferred from the bed to stretchers or
wheelchairs. Upon exertion of pressure over a specific area of the body, primarily the bony
prominences, the blood capillaries get obstructed as a result of which the tissues are deprived
of their oxygen content and nutrients. This leads to the development of ischemia, edema,
hypoxia, or inflammation, followed by ulcer. Patients are also subjected to development of
PU due to moisture (Solovyev et al. 2013). Urine, sweat, fecal matter, and excess wound
drainage often exacerbate the damage that pressure, friction and shearing forces create on the
skin and its tissues. This directly contributes to a maceration of the skin surrounding the
affected point, thereby potentially aggravating the deleterious impacts of ulcers.
PUs have also been associated with morbidity and infection caused due to Methicillin-
resistant Staphylococcus aureus (MRSA), which in turn are directly responsiblefor increasing
the length of stay at hospitals. Research evidences have established the fact that PUs ensue in
patients, admitted across different healthcare units, which most commonly includes acute