NU4073 Assignment: Pressure Ulcer Risk Assessment and Prevention

This report critically appraises scholarly literature on pressure ulcer prevention within the context of intensive care units (ICU). The assignment addresses the research question of whether pressure ulcer risk assessment and repositioning interventions effectively prevent pressure ulcers in critical care patients. It begins with an introduction outlining the prevalence of pressure ulcers in ICUs, their causes, and potential complications. The report details the search strategy employed, including inclusion and exclusion criteria for selecting relevant research articles from databases such as Google Scholar, PubMed, and MedLine. Key terms and Boolean operators used in the search are also specified. A total of nine articles were selected for review and appraisal, using the CASP critical appraisal tool. The discussion section summarizes the findings of several key studies, including those by Peterson et al. (2013), Moore and Cowman (2015), Chou et al. (2013), and Tayyib et al. (2015), evaluating the effectiveness of repositioning, risk assessment tools, and pressure injury prevention bundles. The report highlights the strengths and weaknesses of the reviewed studies, concluding that there is mixed evidence supporting the efficacy of repositioning strategies. The report also emphasizes the need for standardized risk assessment tools and further research to improve pressure ulcer prevention in critical care settings. This assignment is available on Desklib.

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Introduction:
Pressure ulcers also known as Pus are widely prevalent among the patients of the
intensive care unit. The problem is characterized by a localised injury over the surface of the
skin or the underlying tissues located above a bony framework which manifests itself on
account of pressure (Baath et al., 2014; Sving et al., 2014). As stated by Lala et al. (2014), it
has been reported that the incidence of pressure injuries is highest among the patients of the
Intensive care unit on account of two major reasons that include restricted mobility and
confinement to the bed. Research studies suggest that the most common sites where pressure
injuries manifests itself includes the shoulder blades, hip-region, the lower back and the
tailbone, within the skin behind the knees, heels or the ankles and back or at the sides of the
head (Meddings et al., 2013; Mallah et al., 2015). It should be noted in this context that
improper management of pressure ulcers could trigger a number of complications such as
cellulitis, squamous cell carcinoma, sepsis or bone and joint infections (Liao et al., 2013;
Cooper, 2013). This paper in particular aims to critically appraise the available scholarly
literatures in order to address the research question that whether or not a pressure ulcer risk
assessment and repositioning intervention can help in the prevention of pressure ulcers
among the patients of the critical care unit.
Search Strategy and justification:
The research question for the assessment is “Is there any evidence that conducting a
risk assessment and changing position reduces the development of pressure ulcers among
immobilized critical care patients in comparison to not changing the posture?”
In order to address the research question, an exhaustive search was conducted on three
popular electronic databases that included Google Scholar, PubMed and MedLine. In orderto
conduct the search an effective search strategy was used, which specifically used a set of

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inclusion and exclusion characteristics. Also, the search was conducted using key terms that
closely aligned to the concept of the research question.
Inclusion and Exclusion Criteria:
The exclusion and inclusion criteria that was used to conduct the search helped in
narrowing down the search so as to retrieve relevant research studies. As stated by Harriss et
al. (2017), exclusion criteria forms the set of characteristics that are used in order to exclude
research studies that do not align to the research question. The list of exclusion criteria that
was followed while conducting a search on the electronic databases comprised of four
characteristics. The first criterion comprised of papers that were published in foreign
languages. The second criterion comprised of papers that were published before 2013. The
third criterion included research papers that were not full-text accessible and the fourth
criterion included papers that were case control studies or quasi-experimental studies. On the
other hand, as stated by Walliman (2017), inclusion criteria forms the set of characteristics
that are used to include relevant scholarly journals. In this case, the inclusion criteria
comprised of characteristics that included, scholarly journals published in between 2013 to
2018, papers that were published in English language, papers that were full text accessible
and papers that followed a study design of randomised controlled trials and systematic
review. Also, the inclusion criteria comprised of a sample size that included patients admitted
within the critical care unit. The flow diagram of the search strategy that was followed to
conduct a search on the electronic database of Google scholar is shown in appendix 1. A
similar strategy was used to conduct a thorough search on the electronic database of PubMed
and MedLine.

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Key terms:
According to Faden et al. (2013), key terms can be defined as terms and short phrases
that are used while conducting a search on the popular electronic databases. It should be
noted in this context that electronic databases are unable to retrieve relevant results when
long sentences are used. In this case, the key words that were used included, pressure ulcers,
intervention, critical care patients, bed sores, risk assessment, effective intervention,
changing posture and effective clinical outcome.
Further, in order to refine the search, Boolean operators like ‘OR’ and ‘AND’ was
used. The key terms were used in combination with the Boolean operators in order to retrieve
relevant research studies, for instance, Pressure ulcers OR bedsores AND critical care
patients. The effective search with the help of the key terms helped in retrieving 50 relevant
research papers on google scholar. Additional, 23 articles were retrieved through other
electronic databases that included PubMed and MedLine. The total number of research
records after the removal of duplicates comprised of 67 research articles. All 67 research
articles were screened. A total of 27 research articles were removed as the articles were not
full-text accessible and only comprised of the abstract. 40 research articles were full-text
accessible which were thoroughly evaluated for inclusion in the review. A total of 21 articles
were excluded as the research studies did not meet the specific inclusion criteria of research
designsthat was considered for the research study. A total of 12 articles were excluded as the
research studies included the sample population that comprised of elderly patients within
Geriatric care unit. A total of 9 research papers were considered for the review and appraisal.
The search strategy was same for all databases.
The rationale for the selection of the 9 articles included their close relevance with the
research question. Also, the articles that stringently qualified the inclusion criteria were only

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included in the review. The inclusion criteria was specifically devised and considered the
appropriate sample size of patients within the critical care unit and also included the research
designs that included randomised control trials and systematic reviews.
Critical appraisal:
According to Walliman (2017), critical appraisal is broadly defined as the method of
systematic evaluation where clinical research papers are thoroughly evaluated in order to
address a specific research question. The use of a critical appraisal tool helps in appraising
the quality of a research paper in order to evaluate its strengths and weaknesses and
accordingly derive conclusions so as to understand whether or not the results can be
generalized. In this case, the CASP critical appraisal tool was used in order to critique the
research papers that were included in the review. The critical appraisal checklist for
randomized control trail and systematic review was browsed and downloaded online and was
then used to critique the research papers.
Discussion:
A research study undertaken by Peterson et al. (2013) made use of a randomized
control trail in order to evaluate that whether or not routine repositioning among high risk
patients can help in envisioning relief from high-risk peri-sacral area using the technique of
interface pressure mapping. The authors collected the research data from the tertiary care unit
and considered 23 participants in total. The sampling method that was followed included the
convenience sampling method and constituted of the patients admitted within the
intermediate and intensive care unit. The participants were recruited from the intensive and
the intermediate care unit on the basis of the inclusion criteria that comprised of the risk of
pressure injury formation based on the Braden risk score<18. The patients had their peri-
sacral skin-bed interfaces documented post 30 seconds and the patients were given a

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repositioning care every four to six hours. There was no control group. The results revealed
that the enrolled participants had characteristic skin areas (206+ /- 182 cm2) where the
pressure thresholds had exceeded more than 95% during the entire research period. An
observation was conducted on 13 participants for the specific postures that included the
supine, right turned and left turned position and the areas exceeded 95% of the pressure
threshold. Further, the risk probability did not change for high risk patients during their
complete hospital stay despite the repositioning. The findings of the research therefore
suggested that the repositioning strategies are not effective in mitigating the risks of ulcers.
Therefore, it can be mentioned that the results overall helped in evaluating that the change of
positioning intervention within the critical care unit does is not much effective in acquiring
positive outcome in terms of reducing risks of pressure ulcers among bedridden patients.
However, the sample size considered by the researchers is not significant in order to
generalize the findings of the research study.
Moore and Cowman (2015) conducted a systematic review in order to evaluate if
repositioning as an intervention could prevent pressure injuries. The researchers conducted an
exhaustive review of literatures on four electronic databases that included Cochrane Register
of Controlled Trials (CENTRAL), Ovid (MedLine), Ovid (EMBASE) and EBSCO CINAHL.
The researchers made use of RCTs (randomised controlled trials) that compared the
repositioning intervention in relation to no repositioning. In addition to this, in the absence of
randomised controlled trails, the researchers considered controlled trials, which suggested
clarity in relation to research design.The review was conducted by two authors independently
which suggests that biases in relation to research outcome or influence was avoided. The
overall conclusion suggested that despite the prevalent use of repositioning as a therapeutic
intervention to treat pressure ulcers among critical care patients, the evidence base does not
confirm that repositioning can help in achieving positive outcome. In addition to this the

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overall results of the research study suggested that there are no randomised controlled trails
that could help in effectively establishing a clinical guideline on repositioning which could
reduce the risks associated with pressure ulcer formation.
A systematic review conducted by Chou et al. (2013), evaluated that whether or not
the effective use of pressure risk assessment devices can help in the early application of
preventive interventions among high risk patients. The researcher conducted an exhaustive
search on MedlIne, CINAHL, Cochrane Library and grant databases. In addition to this,
clinical trial registries were also considered. The research studies considered in the review
was evaluated by multiple investigators which suggest research bias was overruled. The
overall findings of the scholarly literatures considered in the review suggested that there are
no clear differences between the use of formal risk assessment instruments and less
standardized assessment methods that could help in assessing the risks in association with the
formation of pressure injuries. In addition to this, the findings also suggested that the use of
advanced static support surfaces yielded better outcome when compared to the standard
mattresses for preventing pressure ulcers in patients. The overall results helped in effectively
identifying the existing gap in terms of developing appropriate risk assessment device for the
early identification of pressure ulcers among patients who were placed at a high risk.
Therefore, it can be said that through this research study, the researchers have significantly
highlighted the need to conduct research studies so as to develop standardized risk
assessment tools in order to identify risks in association with pressure ulcers in patients.
Tayyib et al. (2015) conducted a two-arm cluster randomized experimental control
trail in order to examine the strategy of pressure injury prevention in reducing the occurrence
of Pus among the patients based within the 2 intensive care units of Saudi Arabia. The
researchers considered a total of 140 participants, out of which 70 participants were
considered as control and 70 participants were a part of the intervention group. The

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researchers provided PU prevention bundle to the participants of the intervention group while
the control group was provided with conventional skin care regimen as mentioned in the local
ICU policies. The researchers made use of descriptive correlation statistics, Poisson
regression and Kaplan-Meier survival analysis in order to analyse the data. The cumulative
findings suggested that the group of participants that received the pressure injury prevention
bundle within the ICU showed positive clinical outcome in relation to incidence and severity.
Also, the Poisson regression analysis stated that the likelihood of developing a pressure injury
was 70% lower among the intervention group when compared to the control group. The
findings of the study could be considered appropriate for envisioning relief to patients placed
at the critical care unit who are at a high risk of developing pressure injuries. Therefore, the
research findings suggested an effective intervention strategy apart from repositioning which
could help in preventing the risk of pressure injuries among the patients.
McInnes et al. (2015) expanded on the findings of Tayyib et al. (2015) and
mentioned that pressure ulcers are common in patients whose movement and localisation are
restricted. The researchers conducted a systematic review in order to analyse the level to
which the support surfaces could help in reducing pressure injuries. The researchers followed
a systematic review research design and conducted an exhaustive search of the evidence base
on the electronic databases that included Cochrane library, MeLine, EMBASE, CINAHL and
Cochrane Library. A total of 59 trials were included by the researchers. The overall outcome
suggested that using foam mattresses could reduce the occurrence of pressure ulcers among
the high risk patients. Further, the researchers overall conclusion stressed upon the effective
use of high-specification foam mattresses to reduce the risks of pressure injuries among
patients. The findings of the researchers can be considered as the best evidence based strategy
for managing pressure injuries in critically ill and bed-ridden patients.

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Siddiqui et al. (2014), conducted a prospective controlled study in order to evaluate if
continuous bedside pressure mapping (CBPM) could help in preventing the risks associated
with the formation of a pressure injury formation. The researchers considered a sample size
of 422 patients who were assigned to beds that either had or did not have a continuous bed
mapping device. The patients were repositioned every 2 hours and the patients who had a
CBPM device attached were repositioned in order to offload high-pressure points during the
positioning process in accordance to a graphic display. The outcome evaluated a number of
newly formed ulcers and the ulcer formation was measured with the help of aX2 test. The
overall findings suggested that ulcers formed in 2 out of 213 patients within the CBPM group
against 10 out of the 209 patients within the control group. Overall, it can be mentioned that
real time visual feedback in the process of repositioning proved to be helpful in reducing the
risks associated with ulcer formation. The sample size considered by the researchers was
impressive which facilitates the generalization of the research. Also, the research findings
highlighted the need to incorporate pressure monitoring devices so as to improve patient
outcome in relation to pressure injuries.
Suzanne et al. (2015), conducted a systematic review in order to review the available
scholarly literatures and evaluate the effect of bed and wheelchair positioning to prevent the
formation of pressure ulcers. The sample size considered of patients who suffered from
critical spinal cord injuries. The researchers conducted a thorough search on the databases
that included PubMed, CINAHL, EMBASE and PsycINFO. A total of 2834 sample size was
considered out of which 923 patients suffered from spinal cord injury, 717 patients did not
suffer from spinal cord injury and 1194 patients were healthy control subjects. The overall
research results suggested that there is lack of evidence about optimal positioning posture for
the maintenance of appropriate skin pressure and metabolism rate. However, the overall
results suggested that avoiding the 90̊ lateral position could help in avoiding risks of

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developing pressure ulcers among the patients. In addition to this, the researchers concluded
that during sitting, the pressure is linearly redistributed from the sitting area, however, during
reclining or tilt, there is an increased risk of shear forces on the skin. Also, the findings
critically mentioned that the evidence base lacked clear guidelines in relation to positioning
or repositioning technique so as to avoid the formation of pressure ulcers. The sample size
considered by the researchers in this case can also be treated significant and the findings can
be generalized.
As per Tayyib et al. (2016), implementation of effective prevention strategies within
the clinical setting can help in the prevention of pressure ulcer formation. The researchers
conducted a systematic review in order to critically investigate the evidence base and retrieve
relevant studies that mentioned about appropriate intervention strategies that could help in
prevention of pressure ulcers among the patients. The researchers conducted an exhaustive
search on the databases that included, CINAHL, MedLine, EMBASE, SCOPUS, Mednar and
Cochrane Library. The researchers reviewed a total of 25 studies and conducted a meta-
analysis in order to validate the findings. The overall findings suggest that appropriate
positioning and repositioning strategies in combination with support surfaces, effective skin
care routine and nutrition can help in preventing risks with respect to pressure ulcers.
However, the sample size only included a total of 25 research studies and therefore the
findings cannot be generalized on an overall population.
Dorien et al. (2016) conducted a multicentre, cluster, three arm randomized controlled
trail and cost effective analysis in order evaluate the effect of repositioning on the prevention
of pressure ulcers in patients. In this research study, the researchers critically, compared the
cost effectiveness of repositioning patients and made use of an algorithm for evaluating
tailored repositioning against usual care to improve the repositioning frequency among the
research participants. The expected outcome suggests that an optimal repositioning could

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help in obtaining positive outcome, however the research is ongoing and the results have not
been published as of now. However, the research seems promising for obtaining effective
results.
Evaluation and correlation with practice guidelines:
Therefore, on the basis of the critical appraisal of the reviewed articles, it can be
mentioned that risks of developing a pressure ulcer is common in patients that are critically ill
and are bed-ridden. As per Levine et al. (2013), pressure ulcers are caused on the surface or
the underlying tissues due to the exertion of prolong pressure. As stated by Shaked and Gefen
(2013), bedsores generally develop in patients who suffer from a critical medical condition
that limits their ability to move or change their posture and spend most of their time confined
to a bed or a chair. The research study conducted by Peterson et al. (2013), suggested that the
use of routine repositioning among high-risk patients did not yield positive results in relation
to prevention of pressure ulcer formation. The findings of Peterson et al. (2013) were
supported by the findings of Moore and Cowman (2015) who conducted a systematic review
to compare the impact of repositioning on the healing process of pressure ulcers among two
groups. The first group comprised of patients who received repositioning against the second
group that did not receive repositioning as an intervention. The results did not exhibit a
significant difference in the clinical outcome which suggests that repositioning alone is not an
effective intervention for the prevention of pressure ulcers among critically ill patients. The
research findings of Chou et al. (2015) suggested that the evidence base lacks appropriate
knowledge in relation to risk assessment guidelines which could help in identifying risks and
implementing appropriate interventions. Also, the research findings suggested that the use of
static surfaces as an intervention strategy other than repositioning could also help in
achieving positive patient outcomes. The findings of this research study is supported by a
number of research studies which suggest that the application of therapeutic intervention

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strategies such as use of appropriate pressure relieving mattresses is more effective than
repositioning (Moore & Cowman, 2014; Sving et al., 2014; Manzano et al., 2014). Tayyib
etal. (2015), has also mentioned that the use of pressure ulcer prevention bundle is more
effective than using local skin care routine or using repositioning as a therapeutic intervention
to provide relief and prevent further risks. Also, the findings of McInnes et al. (2015),
elaborated on the findings of Tayyib et al. (2015) and stated that the use of appropriate
support surfaces could help in avoiding risks in relation to pressure ulcer formation among
high risk patients. The findings presented by McInnes et al. (2015) suggested that the use of
high specification foam mattresses could prevent the risk of pressure ulcer formation among
patients with critical illness. The findings were supported by a number of research studies
which mention that the use of higher specification pressure reducing foam mattress can help
in effectively reducing friction and shear and adapts appropriately according to the body
contours so as to provide relief (Kruger et al. 2013; Demarre et al., 2015; Sullivan &
Schoelles, 2013). In addition to this, another research study conducted by Igrashi et al.(2013),
suggested against the findings of Kruger et al.(2013) and mentioned that patients who are
vulnerable and are placed at a high risk of developing pressure ulcers must be recommended
non-dynamic overlays which are made of foam, fibre or are filled with foam chips or are
viscous fluid filled (Jiang et al., 2014). This type of mattress reduces shear and friction and
helps in promoting positive clinical outcome (Bhattacharya & Mishra, 2015).
Siddiqui et al. (2014) on the basis of his research findings suggested that repositioning
could turn out to be an effective intervention of the pressure applied was continuously
monitored using a bedside pressure mapping device. The researchers evaluated the
positioning procedure on the basis of a graphic display and the findings suggested positive
outcome in relation to the use of continuous bed-side pressure mapping. However, Suzanne et
al. (2015), evaluated the correct positioning technique in association with the prevention of

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pressure ulcers among the patients who had suffered a spinal injury. The research reported no
significant findings but suggested that avoiding the 90̊ lateral position could help in avoiding
risks of developing pressure ulcers. The researchers concluded that while maintaining the
sitting posture, the pressure is linearly redistributed redirecting from the sitting region
however, during reclining or tilt, there is an increased probability of the shear forces acting
on the skin. As stated by Briggs et al. (2013), elevation of bed at the head and elevation at an
angle of 30 degress could help in preventing shearing. Further, repositioning every hour can
also help in relieving pressure and at the same time prevent the risks of forming pressure
ulcers. On the contrary, Tayyib et al. (2015) mentioned that using a combination of
repositioning along with support surfaces, proper nutrition and effective skin care routine can
help in achieving positive outcome which was supported by the overall results of Gillespie et
al. (2014). The findings of Dorien et al.(2016) intends to evaluate the cost effectiveness and
clinical outcome of using repositioning as a clinical intervention to prevent the risks of
pressure ulcer formation.
Therefore, on the basis of the research papers and the evidence base, it should be
stated that repositioning alone cannot be treated as an effective intervention for the treatment
of pressure ulcers among the patients with critical illness. A number of other factors such as
the choice of appropriate support surface, nutrition regimen, skin care as well as choice of
mattress can effectively help in preventing the risk of developing pressure ulcers among the
patients (Gillespie et al., 2014; Tayyib et al., 2015). The evidence base clearly lacks
information about an appropriate clinical guideline on repositioning that help in achieving
positive positioning. Although, it can be mentioned that the evidence base suggests frequent
repositioning and close monitoring of the applied pressure due to repositioning can
effectively help in achieving positive patient outcome. It should further be mentioned that the
research papers included in the review are research papers of high quality that are relevant to

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the research topic and are published in the recent years suggesting the present development in
relation to the guidelines of curing pressure ulcers. Also, it should be mentioned that use of a
combination of intervention strategies could ensure positive patient outcome but at the same
time would require an in-depth understanding about the evidence base on the end of care
professionals and appropriate economic budget and infrastructure within the hospital for
effective implementation.

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Conclusion:
Hence, to conclude, it should be stated that critically ill patients with restricted
mobility are placed at an increased risk of being affected with pressure injuries within the
critical care unit. Risk assessment and repositioning can prevent pressure injury formation
among patients within the intensive care units. However, it is important to consider here that
the evidence base does not contain information in relation to effective repositioning
guidelines as well as risk assessment protocol which would help in preventing incidences of
pressure ulcers. However, the evidence base suggests that using pressure relieving mattresses,
support surfaces, skin care routine, proper nutrition along with repositioning can help in
achieving positive outcome. Also, it is critical to consider that the utilization of pressure
monitoring devices for the purpose of repositioning could also help in achieving positive
patient outcome. However, the research area needs future researches so as to establish a clear
clinical guideline.

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Walliman, N. (2017). Research methods: The basics. Routledge.P.90

20NURSING ASSIGNMENT
Appendix 1:
PRISMA 2009 Flow Diagram