Pressure Injuries: An Evidence-Based Approach to Nursing Practice

This report provides an evidence-based analysis of pressure injury prevention and management strategies within a nursing context. The report begins with an outline of the clinical issue, emphasizing the significance of pressure injuries, their prevalence, and associated risks. It then details the need for an evidence-based approach, framing a clinical question using the PICO format to guide the literature search. The methodology includes a description of the evidence-based search strategy, focusing on the use of air and liquid mattresses as interventions, and outlines the inclusion/exclusion criteria, search terms, and types of studies considered. The report synthesizes the best available evidence, highlighting the effectiveness of tragacanth gel mattresses in preventing pressure injuries, particularly in ICU patients. It justifies the choice of evidence based on the hierarchy of evidence and the PICO framework. The report concludes with recommendations for practice and research, advocating for the use of gel-based mattresses and suggesting future investigations to further refine pressure injury management strategies.

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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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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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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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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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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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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