Interventions for Pressure Ulcer Prevention

Running head: RAPID REVIEW
RAPID REVIEW: THE MOST EFFECTIVE INTERVENTIONS IN PREVENTION
FOR PRESSURE INJURIES AND BED SORES AMONG PATIENTS IN ALL
HEALTHCARE SETTINGS
Name of the Student:
Name of the University:
Author note:

1RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
Executive Summary
Background: Incorporation of preventive interventions for pressure injuries and bed sores
management across all healthcare settings, will not only ensure effective patient care and timely
prevention of symptom aggravation but will also mitigate financial losses across healthcare
organizations and ensure positive levels of patient satisfaction, feedback and perceptions related
to healthcare care. Hence, this review focusses on evaluation of the various interventions for
pressure injury and bed sore prevention.
Objective: To systematically review the most effective interventions in prevention for pressure
injuries and bed sores among patients admitted in all healthcare settings.
Inclusion Criteria: Systematic reviews, published within 2009 to 2019, evaluating preventive
measures for pressure injuries and bed sores management were included.
Types of Studies: For obtaining findings pertaining to the primary objective of the study, the
types of studies which were selected were qualitative in nature, that is, studies which involved
the usage of systematic reviews.
Types of Participants: The systematic reviews included patients admitted in all types of
healthcare settings, who are severely diseased, malnourished, bed ridden, elderly or suffering
from mobility disruptive conditions such as spinal injuries, along with being inflicted with
pressure injuries and bed sores s.
Outcomes: The primary outcome targeted by all the selected articles was the incidence and rate
of prevalence of pressure injuries and bed sores s upon administration of preventive
interventions.

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Search Strategy: The first phase of searching consisted of insertion of keywords relevant to the
research and screening the abstracts of the papers so obtained which showed considerable
similarity to the same. For improved article acquisition, the second search was conducted using
advanced search options and setting limiters in terms of English language, study subjects
selected to humans, time period ranging from 2009 to 2019, MeSH terms and Boolean operators
Methodological Quality: For the purpose of critically appraising, validating and evaluating the
articles selected for the rapid review, the critical appraisal tool of Assessment of Multiple
Systematic Reviews (AMSTAR) was used. AMSTAR is a beneficial, reliable and efficient tool
formulated for the assessment of the significance, methodological quality and relevance of
qualitative based studies such as systematic reviews, which is of relevance for this study.
Data Extraction and Synthesis: The data and findings so obtained from the systematic review
were categorized in terms of the interventions used which were found to be effective for pressure
injuries and bed sores prevention, the population so selected, methods used for study and
outcomes as per the identified aims and objectives of the review. The findings so obtained from
the systematic review were analyzed in the form of a narrative synthesis resulting in the
development of relevant themes and inclusion of tables and figures for the purpose of sufficiently
fulfilling the research objective
Result: A total of 5 studies were included for this research, of which 3 of them were obtained
from Cochrane and 2 of the studies were obtained from Medline databases. 1 study discussed on
patient repositioning, 1 study on massage therapy, 1 on topical agents and dressing, 1 on Braden
score assessment and 1 on repositioning, skin regimen, dressings, nutrition, staff education and
support surfaces. The studies scored moderate to high (5 to 8) in terms of methodological quality
as per AMSTAR scores.

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Conclusion: To conclude, it was observed that pressure ulcers result in considerably detrimental
health implications and financial costs in the patient as well as in the healthcare organization,
hence necessitating their immediate prevention. There is a need to rely on not just one, but
multiple interventions for pressure ulcer prevention, preferable in the form of a care bundle,
since no single intervention has been scientifically proven for efficacy. Considering limitations
in quality and quantity of evidence, further research on multiple interventions with credible
quality studies is required to be conducted in a wide variety of settings and populations.

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Background
Pressure injuries and bed sores s are a debilitating dermal condition, characterized by
injuries and damages to the skin and the associated dermal tissues and bony prominences
adjacent to the same. Pressure injuries and bed sores s are also known as decubiti, bed sores or
pressure injuries and undergo emergence due to prolonged application of pressures along with
the presence of additional risk factors such as friction, shearing and excessive levels of moisture
in the form of urine, sweat and feces (Moore & Cowman, 2015). Areas of the body which have
the highest risk factor for pressure injuries and bed sores occurrence, include heels, elbows,
knees, shoulders, ankles and the cranium. One of the primary causative factors for pressure
injuries and bed sores s include the prolonged administration of pressure resulting in restrictions
in the flow of circulating blood. It is worthwhile to remember that adequate blood circulation is
required for the deliverance of oxygen and essential nutrients to the surrounding cells and tissues
of the body (et al., 2015). Hence, the presence of excessive pressures results in hindrances in the
flow of blood and nutrients leading to nutrient deprivation, death of surrounding tissues and
hence the emergence of symptoms of skin damages and injuries. Additional factors which affect
the occurrence of pressure injuries and bed sores s in individuals include friction and shearing
(Norman et al., 2016).Friction is the result of the skin rubbing excessively at surfaces of bedding
and clothing further leading to increased skin fragility and susceptibility to injury. Shearing is a
resultant of the application of forces opposite to the surface of the skin. A prevalent example of
this is during situations of bed elevation which occurs as a result of the skin sliding upon the bed
surface in directions opposite to that of elevation. Such factors coupled with increased moisture

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and engagement in long hours of lying down are key determinants of pressure injuries and bed
sores occurrence (Dumville et al., 2015).
As evident from the above mentioned influencing circumstances, it be evident that
individuals who are primarily bed ridden, are malnourished, are inflicted with spinach injuries or
are suffering from detrimental chronic conditions such as cystic fibrosis, chronic obstructive
pulmonary disorders, or serious illnesses such as after surgery, cardiovascular illnesses
associated with cerebrovascular accidents, strokes and neurological or neurocognitive disorders
such as paralysis, dementia or Alzheimer’s are at increased risk of developing pressure injuries
and bed sores s. A number of health conditions and determining factors wcompel individuals to
lie down and be at rest for prolonged periods (McInnes et al., 2015). These include factors like:
immobility in the patient, limitations in terms of sensory abilities, inadequate status of hydration
and nutrition and health issues which result in restrictions in terms of the flow of blood. While
such factors and hence the resultant susceptibility of pressure injuries and bed sores s, may be
present across any diseased of affected individual who remains primarily bedridden irrespective
of age groups or genders, the population of the elderly, especially individuals aged above the age
of 65 years along with those adult patients who are suffering from serious illnesses resulting
metabolic, cardiovascular and neurological disturbances as mentioned above, pose greater
susceptibilities to the acquisition of this harmful skin condition (Qaseem et al., 2015).
Post-surgical patients, patients with serious illnesses and the elderly, as a result of being
inflicted with the physiological deficits associated with diseases, malnourishment and ageing, are
victims of increased of levels of oxidative stress, catabolism, muscle wastage, loss of muscular
fibers resulting in compromised musculoskeletal systems, deficits in bone and muscle volumes
and flexibilities, resulting in difficulties to conduct normal motor movements which compels

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them to be bed ridden with mobility issues. Additionally, as will be discussed in the succeeding
sections, pressure injuries and bed sores s are a resultant of constant lying down whose severity
can be prevented by alteration of positions (Dealey et al., 2015). Issue of immobility prevalent
among the severely diseased and malnourished patients and the elderly not only result in their
increased adherence to being bed ridden for long but also hinder their ability to switch positions
in order to reduce the pressure. Further, loss of neuronal functioning evident in neurological
conditions in adult diseased patients and age associated degradation of nerve fibers due to ageing
in the elderly results in loss of sensory perceptions within patients resulting in difficulties to
sense pain, the need to report or alter positions for the same and hence increased susceptibility to
pressure injuries and bed sores symptoms (Black et al., 2015). Further detrimental symptoms
associated with chronic disease conditions in severely ill adults patients include deficits in the
absorption of nutrients and deceased ability to ingest and swallow required food resulting in
nutritional deficiencies and poor nutritional status. Maintenance of optimum nutritional status is
required for the healing and repair of damaged tissues which is compromised in the severely ill
patients and hence contributes to their increased susceptibility of pressure injuries and bed sores
acquisition (Jaul & Calderon‐Margalit, 2015). Patients with neurological diseases are also
susceptible to reduced thirst sensation and perception, reduced thirst perceptions and hence poor
status of hydration further aggravating to symptoms of skin dryness and increased vulnerability
to forces of shearing and friction – risk factors of pressure injuries and bed sores prevalence in
the severely ill patients. Lastly, the compromised immunological and metabolic functioning
within the diseased patients as well as the elderly resulting in the increased acquisition of chronic
diseases such as diabetes and cardiovascular deficits which further lead to restrictions in blood

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flow, deprivation of essential nutrients and hence increased susceptibility of pressure injuries and
bed sores acquisition (Neloska et al., 2016).
Hence, as evident from the above, patients who are elderly, suffering from chronic or
severe disease conditions, are malnourished or inflicted with mobility issues due to neurological
or spinal injury associated conditions are at an increased risk in the acquisition of pressure
injuries and bed sores s hence necessitating immediate administration of preventive and
treatment interventions. Authors Jaul et al. (2018), reviewed the various co-morbidities
associated as risk factors for pressure injuries and bed sores acquisition in acute, community as
well as long term care facilities of healthcare organizations. Among adult patients, disease
conditions contributing as risk factors for pressure injuries and bed sores acquisition include
diabetes, cardiovascular diseases, renal diseases, chronic pulmonary diseases and
neurodegenerative disorders, along with additional complications such as malnutrition, anemia
and occurrences of infectious diseases. Additional co-morbidities which increase the prevalence
of pressure injuries and bed sores s in the elderly include frailty, disability, incontinence,
polypharmacy and increased experiences with hospitalization. Additionally, Biçer et al. (2019),
with the aid of a cross sectional study, researched that the highest incidences of pressure injuries
and bed sores s were reported across individuals with disease conditions such as cancer or with
neurodegenerative conditions such as Alzheimer’s and is hence, indicative of the widespread
prevalence of pressure injuries and bed sores s across healthcare settings. It has been estimated
that patients who are elderly and undergoing admissions for receiving orthopedic treatments
which are non-elective, comprise of almost 66% of the patients suffering from pressure injuries
and bed sores s (Kirman, 2018). Elderly patients, aged 65 years or older, have been reported to
acquire symptoms of a pressure injuries and bed sores within 32 days of being admitted to the