MSC Nursing Dissertation: Prevalence, Management & Prevention of PUs

This MSC Nursing dissertation investigates the prevalence and management of pressure ulcers (PUs) in acute care settings. Employing an interpretivist research philosophy and a systematic review of literature from 2008-2018, the study analyzes 12 articles detailing PU prevalence, classification based on NPUAP and EPUAP guidelines, and common locations such as the sacral region, heels, and hips. The research identifies key impacts of PUs, including restricted mobility, increased hospital stays, and economic burdens, along with barriers to prevention like inadequate staffing and poor nursing knowledge. The dissertation concludes with recommendations for improved nursing education, management processes, and the potential effectiveness of skin grafting, emphasizing the need for comprehensive strategies to reduce PU prevalence and improve patient outcomes. The study highlights the importance of understanding the needs of the community and utilizing appropriate system-based methods for prevention and intervention.

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

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care wards. Acute care units generally comprise of surgical, medical, orthopedics, critical
care, and elderly care wards. Placing focus on a specific healthcare setting such as, acute care
ward, will facilitate the process of investigating the prevalence of pressure ulcer, through
epidemiology (Beeckman et al. 2014). Acute care wards refer to those settingsin healthcare
institutions where patients are provided medical care facilities, while they are recovering
from any surgery or illness. Furthermore, due to the fact that acute care wards generally
comprise of patients who are severely ill, and have restricted mobility or activity, they are
more prone to be bedridden and develop pressure ulcers. These patients also report a loss of
their sensory perception and circulatory/metabolic changes due to anesthesia and surgery.
Pressure ulcers are largely responsible for several economic challenges to the allocation of
resources in any healthcare system. The high costs of treating pressure ulcer patients every
day have been found to vary from 1.71€ to 470.5€, across different healthcare settings
(Demarré et al. 2015). Similar results have also been retrieved from the United Kingdom,
where PU treatment costs were found to range from £1,214 for stage 1 patients to £14,108 for
stage 4 patients (Dealey, Posnett and Walker 2012).
Use of biofilms are cited as one of the primary reasons that contribute to a delay in the
healing of PU. Biofilm stall the wound healing process by maintaining an inflammation at the
site of injury. Antimicrobial dressings and frequent debridement are essential for controlling
the biofilms (Seth et al. 2012). This infection creates an impairment in the process of healing
of pressure ulcers. Certain signs and symptoms that help in the detection of a pressure wound
are presence of erythema, fever, edema, drainage and odor (Delmore et al. 2015). Erythema
around a wound or injury results in the form of normal response of the body to the traumatic
injury (Chan et al. 2013). However, presence of a poorly defined of erythema indicates
infection. PU is also accompanied with systemic fever along with concomitant complaints of
malaise. This in turn indicates the presence of infection, and an increase in local temperature,

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which is a direct result of inflammation. Presence of a sweet smell from the site of the skin
that has been injured provides evidence for the presence of infection due to Pseudomonas.
Proteus infection leads to a smell of ammonia gas.
Rationale
Some of the intrinsic factors that contribute to the incidence of pressure ulcer are
illnesses that affect the mobility of a person. These mobility issues are commonly faced by
people who have suffered from a spinal cord injury that have resulted in paralysis of the
limbs Brain damage due to stroke or severe head injury or other conditions such as, multiple
sclerosis, fractured bones, or a coma state make it difficult for a person to move freely.Poor
nutrition that occurs due to dehydration and anorexia nervosa is another major contributor to
the condition (Posthauer et al. 2015). Normal blood flow to the skin and underlying tissues
are a direct manifestation of type 1 and 2 diabetes, and peripheral artery disease. The latter
condition has been found responsible for restricting blood flow due to an accumulation of
fatty substances in the major blood vessels (arteries) present in the legs. Furthermore, renal
failure also leads to loss of all or most functions of the kidney that results in an accumulation
of poison or toxin in the blood, thereby causing damage to the tissues. Some of the primary
reasons that make an aeging skin more vulnerable to development of pressure ulcer is that the
skin generally loses the property of stretching and elasticity, with an increase in age that
makes it prone to get damaged (Qaddumi and Khawaldeh 2014). Direct effects of ageing are
also associated with a reduction in blood flow and a lowering in the amount of fat that is
present under the skin.However, there are a plethora of extrinsic factors that also increase the
likelihood of a person of acquiring pressure ulcer. Pressure exerted by a hard surface such as,
a wheelchair or bed that the patient has been using for a prolonged period of time in acute
wards, is one major factor. Pressure on the skin is also exerted through several involuntary
movements like muscle spasms (Anderson et al. 2014). Thus, the time that PU takes to

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develop in patients depends on the amount of pressure that is applied, and the vulnerability of
the patient skin to the damage.
The development of PU can lead to several health complications. One of the most
serious complication is onset of sepsis. Presence of a PU is most often accompanied with
aerobic and/or anaerobic bacteremia, owing to the fact that these kinds of ulcers are one of
the most common source of the infection. Further health complications of Pus also include
cellulitis, localized infection, and osteomyelitis. Fair often, development of a non-healing
PUprovides an indication underlying osteomyelitis. Several studies have been conducted that
have successfully established a correlation between development of PU and patient mortality
in both nursing home and hospital settings (Girard et al. 2014). Furthermore, mortality rates
have been found to be as large as 60%, for the aged population, who generally develop an
ulcer within a year of discharge from a hospital. Hence, it is imperative to conduct a careful
assessment of PU among patients. Some other complications related with PU include
depression and pain, both of which have largely been connected with reduced wound healing
(McInnes et al. 2015).Long term non-healing PUs have also been found to result in the
development of squamous cell carcinoma. This calls for the need of healthcare professionals
providing care in the acute medical wards to try shifting the weight of the patients who use a
wheelchair, or are bedridden, every 15-20 minutes, and reposition them after every hour to
prevent the hard surface of the chair of bed from exerting a pressure on their skin (Gillespie
et al. 2014).
Under conditions, when the patients admitted to acute wards are found in possession
of upper body strength, they should also be provided an assistance in wheelchair push-ups.
Use of appropriate cushions and special pressure relieving mattresses that reduce pressure
and ensure well-positioning of the entire body. In addition, adjusting the bed elevation at less
than 30 degrees are another essential step that can be taken in acute wards. However, there

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exist several gaps in the theory and practice of pressure ulcer. Time and again researchers
have identified presence of an inconsistency between the guidelines of PU prevention and
management that are taught and those that are implemented by nurses, across a range of
healthcare settings (Padula et al. 2014). These gaps are directly related to the clinical
expertise and education that nurses have on prevention of PU and its elimination from acute
medical wards. The fact that nursing colleges across the globe differ in the education and
training they provide to the nursing professionals on the condition, significantly contributes
to a major difference in the ways the prevalence of PU is perceived across the different
countries. New graduate nurses often lack an empowerment and are not able to take
necessary clinical decisions such as, adding a pressure relieving surface or preventing shear
or friction forces in the affected people. Further gaps in research on pressure ulcer can be
attributed to the risk factors that make a person susceptible to the condition. In addition, the
range of risk factors such as, nutrition, moisture, shear, friction varies among people based on
their geographical location, socio-economic condition, and employment status (Cremasco et
al. 2013). People belonging to poor economic households most often resort to occupational
roles that requires them perform manual handling tasks that increases risks of shear, in
addition to inadequate nutritional intake (Bain et al. 2013). Furthermore, the risk assessment
tools that are used in acute care units of developed nations often do not encompass all aspects
that are necessary for long-term care of PU patients. Another major gap lies in the fact that
developing countries have medical departments that are devoid of such risk assessment tools,
or even if present, the nursing professionals do not have adequate knowledge on utilising
them (Chou et al. 2013). This prevents detailed analysis of the skin of the affected people.
Further gaps that established the need of conducting this research lie in the fact that there are
discrepancies in the guidelines that are most often followed by clinicians and interventions
that are supported by scientific evidences. Hence, identifying the prevalence of pressure ulcer