PIC0 for Pressure Ulcers Literature Review

Pressure ulcers are caused by factors such as unrelieved pressure and shearing forces on the surfaces of the body. The condition can be prevented and treated if it is diagnosed early enough in a patient. However, if it advances, it can be deadly. The condition poses a numerous challenge to medical practitioners in the developed world since it causes substantive iatrogenic deaths.

There are four main stages of pressure ulcer which range from stage I to stage IV. Stage I is superficial and is visually similar to a condition known as reactive hyperemia witnessed after the skin has been exposed to prolonged application of pressure. Stage II becomes evident when damage to the epidermis extends to the dermis thereby forming a blister. Stage III is extending to the subcutaneous tissue which has poor blood supply hence its inability to heal faster. Stage IV pressure ulcers can extend to the muscles and bones. It is the deepest stage of pressure ulcer. This study seeks to come up with a nursing problem (pressure ulcers), identify its possible solution and conduct a review of related literature to pressure ulcers. This will enable the researcher to come up with the possible solutions to the problem. In conducting the review, five main scholarly sources will be used. The study will then analyze and critically appraise the evidence based on the literature to support the solution to the problem.

Hew de Laat and Van Achterberg (2005, p. 466) study intended at describing the current scientific evidence surrounding diagnosis and pain treatment, the malodor of the wound and fluids that ooze from the pressure ulcers. The study similarly intended at making recommendations to be used in the nursing practice informed by the findings. The objectives and methods involved systematic search of literature to attain current knowledge in relation to pain diagnosis, wound malodor and exudates from individuals suffering from pressure ulcers and ways used to mitigate such problems. The search strategies used in searching related publications was based on key words pressure ulcers combined with pain and exudates were Medline, CINAHL, and Cochrane. Distinction was created between opinionated, contemplative or journalistic scientific publications through filtration of the publication.

Terms used in filtration included randomized controlled trial, controlled clinical trials and clinical trials among others. The review entailed issues related to pain, wound and exudates. Studies were integrated in the review only if they touched on patients with pressure ulcers. Intervention studies were only allowed on condition that they relieved pain. Publications that did not touch on patient oriented research were not used in the review as well as those dealing with patients with non-chronic wounds. The first author on basis of inclusion and exclusion criteria screened the abstracts of all the publications. In case of doubts, the whole article had to be retrieved. If there were still doubts, on the whole article, one of the authors was consulted to decide on the inclusion and exclusion criteria to be used. A total of 13 publications were selected. The publications zeroed on pressure ulcer patients. One publication could however not be found. Three pertinent guidelines were proposed as sure ways of treating pressure ulcers.

Reliable rating scales were also used to diagnose pain. This was achieved by using McGill Pain Questionnaire (MPQ), The Visual Analogue Scale (VAS) used in measuring pain intensity and the Faces Rating Scale (FRS). Interventions to reduce pain included use of benzydamine gel to wounds occasioned by pressure ulcers. Due to lack of available scales for conducting evaluation of wound malodor, patients were subjectively judged. Some other studies classified the level of malodor as strong, moderate, slight or absent. This classification has however not been put into operation. Wound malodor was treated by regular cleansing of wound using tap water or by recommendation of a regime of antibiotics. Availability or unavailability of wound exudates was determined through observation.

Pieper, Langemo and Cuddigan (2009, p. 76) posit that patients with pressure ulcers undergo excruciating pain. These scholars define pain as an unpleasant sensory and emotional experience that results from tissue damage. Pressure ulcers pain therefore have to be assessed and treated regardless of the age of the patient or their status of health due to its far reaching physical and psychosocial ramifications to the patient, their family members and nurses. This study identified 32 grants in a bid to examine pressure ulcer research funding. Aspects of assessment of pressure ulcers, its prevention and treatment, quality of care were put into perspective. Only one grant focused on pain associated with pressure ulcers. It was noted that despite the fact that pressure ulcers pain was underrepresented compared with other funded projects, clinicians and nurses are urged to assess pain and treatment of pressure ulcers basing on the research evidence.

Research findings were summarized based on tools used to assess pain, the medications given to pressure ulcer patients, the care given to the wound occasioned by the pressure ulcer and the kind of food patients with pressure ulcers take. The study inferred that pressure ulcers can be caused by tissue trauma from sustained loads, inflammation or damage to the nerve endings. The skin has a rich supply of sensory nerves than any other organ in the human body. As pressure ulcers continue damaging the skin, nociceptive nerve terminals are affected resulting into acute or chronic inflammation. The resultant effect is damage to nerve terminals. Regeneration of the peripheral nerves force nociceptive nerves to send immature sprouts of nerve tissue hypersensitive to noxious and non-noxious stimulus.

The study performed literature searches using PubMed and the Cumulative Index in Nursing and Allied Health Literature between 1992 and 2008. Phrases used in the search were pressure ulcers pain. Only English language was used. Human research was used in the study. A total of 15 papers were identified four of which captured topical medication treatment. The other eleven covered varying aspects of measuring pain. The most prominent sign of the existence and intensity of pain was the patient self-report. Pain rating scales used included the MPQ, FRS, and VAS. MPQ was basically used because of its ability to describe pain qualities. In addition, it gave a quantitative measure of pain. In addition, it was used to categorize pressure ulcer into stages from stage I to stage IV.

Catania et al (2007, p. 45) regrets that despite the technological and preventive advances, pressure ulcers incidence in acute care facilities has remained high. This called for establishment of pressure ulcer prevention protocol interventions. As a result, risks and nutritional status of the patients were assessed. Skin care, referrals and documentations of the patients were conducted. Intervention measures considered included development of PUPPI (pressure ulcers prevention protocol intervention. Evidence based guideline for pressure ulcer prevention and skin care was the benchmark used for all activities.

The World Health Organization analgesic dosing ladder has to be used to systematically manage the pain. The WHO ladder integrates many categories of systemic medication to manage pain. These include opioids, adjuvants, and NSAIDS.

Hydrocolloid dressings can be used in treatment of wounds that result from pressure ulcers. This method is much better than topical dressing since less pain is felt when dressing the wound. In addition, Hydrocolloid dressing removal during subsequent dressing does not cause much pain compared to other dressing removal methods.

Sorting out incidence and prevalence helps in determining the rate at which the condition occurs. Incidence means the number of new cases that have been identified while prevalence refers to all case both the existing and new ones.

One of the guidelines that should be considered includes developing a repositioning schedule. In addition, clinicians should ensure that patients lay in specialized beds. The patients should not lay on the side which has pressure ulcer. This helps in reducing pain associated with pressure ulcers.

Laying the patients on specialized beds other than the normal hospital beds also aids in reducing pain. However, this should depend on assessment of the physician.

Continuous patient’s assessment should be conducted to minimize risk of patient developing pressure ulcers.

Search of databases for evidence based guidelines for treatment of pressure ulcers was done between 2004 and 2006 by use of electronic and online data sources (Whitney, 2006. p.43). PubMed, EMBASE and Cochrane data base reviewed to ascertain if they had any data relating to treatment of pressure ulcers. The project intended to come up with a comprehensive evidence based guideline for treatment of pressure ulcer and show case these guidelines in a clear and simple format made to enhance health care provider’s decisions in managing pressure ulcers. This study’s published guidelines were founded on clinical human studies. In addition, well controlled animal studies with proof of principle to corroborate laboratory results by clinical series were considered.

Strength of evidence formed the basis for classifying pressure ulcers into level one, two, or three. Current evidence and expert opinion came up with guideline one which encompassed establishment of repositioning schedule to avoid positioning of patients suffering from pressure ulcer. Pressure ulcer origin was associated with soft tissue compression on bony prominence. This study associated delayed healing of pressure ulcers and therefore repositioning of patients reduces their chances of getting pressure ulcers. However, the study does not give an exact turning interval hence the need for empirical derivation of turning interval. Other intervention included having the head of the bed at low elevation. Patients with large stage 3 or 4 pressure ulcers a specialized bed is recommended especially bed with low air loss or those that have been air fluidized. These type of beds minimize the amount of pressure that is exerted on the wound even if the patient lies with the side having pressure ulcers.

Reference list

Catania, K. (2007). The Pressure Ulcer Prevention Protocol Interventions. AJN, Nursing 107(4): 44-52.

Hew de Laat, E., Reimer, W.J.S., & van Achterberg, T. (2005). Pressure ulcers: diagnostics and interventions aimed at wound-related Complaints: a review of the literature, Journal of Clinical Nursing 14: 464–472.

Pieper, B., Langemo, D., & Cuddigan, J. (2009). Pressure Ulcer Pain: A Systematic Literature Review and National Pressure Ulcer Advisory Panel White Paper. Scottsdale Wound Management Guide 55(2).

Whitney et al. (2006). Guidelines for the treatment of pressure ulcers. Wound Rep Reg 14: 663–679.

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