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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Repositioning Every Two Hours Reduces the Incidence and Severity of Pressure Ulcers

in Elderly or Immobile Patients

Samantha Pabalan Grand Canyon University

NRS 441V: Professional Capstone

Instructor: Catherine Beasley MSN, BSN, LNCC

February 21, 2016

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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Abstract

According to multiple studies, pressure ulcers are noted to be one of the top leading preventable

errors in the United States. Pressure ulcers can have medical costs that range up $70,000 per

pressure ulcer, (Moore & Geist, 2015). They are also noted to cause an increase in the rates of

hospital readmissions and increases the risks of death. Multiple studies have been done on the the

prevelance of pressure ulcers and outcomes related to frequent repositioning or turning schedules

in the elderly or less mobile patient. In this reseach a definite link has been shown to a reduction

in pressure ulcers in those patients who were turned every two hours verses 1 hour turning

schedules. In efforts to decrease the number of pressure ulcers in elderly or less mobile patients,

a set practice of preventative measures and procedures, to include patient repositioning every two

hours, should be established. The incorporation of the new pressure prevention procedures will

begin to be implemented on all units within the next three months. Without the support of key

stakeholders, implementation plans fail to receive the focus and attention needed to push new

plans forward into practice. By utilizing Florence Nightingale’s Environmental Theory, nurses

are able to assess patients on an individual basis and determine their specific repositioning needs

and tailor a plan of care accordingly, thus reducing the incidence of pressure ulcers. Before

implementing the plan, nurses, assistive personnel, and other key staff must be educated on their

new expectations. They will be required to understand the basic principles surrounding pressure

ulcer development. The methods of determining how effective the solution proposal is will be the

final comparison of pressure ulcer rates. Rates from the beginning must be compared to those at

least six months after implementation of the plan. This will produce a true assessment of

effectiveness of the proposed plan. A reduction in pressure ulcers would be a testament to an

effective plan Proper assessment of at risk patients as well as follow up care based on protocols
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

and education are essential for optimal treatment plans to be effective. By implementing new

guidelines and protocols, patients quality of life will be improved, cost of care will decrease and

pressure ulcer prevalence will dwindle.

Key words: pressure ulcer, wound prevention, repositioning, turning, bed sores.
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Problem Statement

Repositioning Every Two Hours Reduces the Incidence and Severity of Pressure Ulcers in

Elderly or Immobile Patients

In elderly or immobile patients, does repositioning every two hours reduce the incidence

and severity of pressure ulcers as compared to those repositioned every 1 hour?

Pressure ulcers are a major concern in the healthcare industry today. Although there have

been great strides made in recent years to reduce the incidence of pressure ulcers, healthcare

facilities around the world are plagued by them. They are costly and increase the length of stay

for patients. Pressure ulcers are related to a reduced quality of life for patients and high costs for

the healthcare system (Sving, Idvall, Högberg, & Gunningberg, 2014). In 2008, the Centers for

Medicare and Medicaid Services announced that they will not pay for additional costs incurred

for hospital-acquired pressure ulcers (Cooper, 2013). An increasing aged population coupled

with a nursing shortage is sure to keep the numbers of pressure ulcers on the rise.

Nurses are faced with the challenge on a daily basis of preventing pressure ulcers from

occurring, worsening, and healing existing ones. Patients with comorbidities including

immobility, nutritional deficits, diabetic imbalances, or obesity come into the hospital and are all

at risk of developing pressure ulcers. It is the nurse’s responsibility to check all areas of the

patient’s skin to ensure that any skin abnormality, including redness or breakdown, is

documented. If pressure ulcers arise, it is often seen as a result of poor nursing care. Florence

Nightingale once said, “If he has a bedsore, it’s generally not the fault of the disease, but of the

nursing” (Nightingale, n. d.).

Normal blood pressure within capillaries ranges from 16 to 33 mm Hg. External pressure

of more than 33 mm Hg occludes the blood vessel so that the underlying and surrounding tissues
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

become anoxic and if the pressure continues for a critical duration, cell death will occur,

resulting in soft tissue necrosis and eventual ulceration, (Agrawal & Chauhan, 2012). Keeping

the external pressure less than 32 mm Hg should be sufficient to prevent the development of

pressure ulcers. However, capillary blood pressure may be less than 32 mm Hg in critically ill

patients due to hemodynamic instability and comorbid conditions allowing for even lower

applied pressures to be sufficient to induce pressure ulcers in these patients. Pressure ulcers can

develop within two to six hours. The key to preventing pressure ulcers is to accurately identify

at-risk individuals quickly, so that preventive measures may be implemented before problems

arise.

Failure to complete a proper risk assessment on admission can cause both the patient and

the nurse extra time and unnecessary care in the future. With proper assessments and education,

nurses are be able to place the at risk patient in the bed with the correct mattress that will lessen

their chances of getting pressure ulcers. This assessment also allows the nurse to implement a

plan of care unique to the patient to include a precise turning or repositioning schedule. Turning

and repositioning schedules are based on best practice and include assessments from tools like

the Braden Scale that measure the risk assessment based on sensory perception, moisture,

activity, mobility, nutrition, and friction and shear.

Pressure ulcers are defined by The National Pressure Ulcer Advisory panel and The

European Pressure Ulcer Advisory Panel (NPUAP-EPUAP) as “an area of localized injury to the

skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure

in combination with shear. A number of contributing or confounding factors are also associated

with pressure ulcers; the significance of these factors is yet to be elucidated” (NPUAP, n. d.).

Elderly patients are at an increased risk of developing pressure ulcers. Nurses often see patient
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

populations that consist of elderly people with thin fragile skin. This type of skin impairment can

lead to deterioration of the skin quickly in the bedbound patient. Pressure ulcers are a problem

and can lead poor patient outcomes as well as hospital fines. Evidence based studies have shown

that “the average cost of care in an acute care hospital for a patient with a stage III or stage IV

pressure ulcer reported by the Centers for Medicare & Medicaid Services (CMS) is $43,180”

(Jackson et al., 2011). Pressure ulcers and other skin breakdowns are among the most significant

adverse events causing distress for patients and their care givers and compromising patients'

recovery from illness or injury. Prevention of these complications are daily nursing tasks.

In efforts to decrease the number of pressure ulcers in elderly or less mobile patients, a set

practice of preventative measures and procedures, to include patient repositioning every two

hours, should be established. These measures and procedures would include a two hour rounding

and repositioning checklist for each patient. Incontinence and moisture would also be checked

during this time, as it is a precursor to skin breakdown. Documentation of time and care provided

to the patient as well as the position the patient was left in would be noted. Checklists will be

posted by each patient’s door and signed off by staff upon completion. These checklists will then

go into the patients’ charts for continuity of care. Proper body mechanics and positioning will be

followed. Continued use of this practice will reduce the incidence on pressure ulcers in the

elderly or less mobile patient.

Interdisciplinary team members involved in executing the new plan will attend a meeting

before the process is to begin on the unit. During this meeting, what the proposed plan is, a

strategy of how the plan will be implemented, and why there is a change in current practice will

all be discussed. There will also be a chance for staff to ask any questions if they have any. Staff

will sign off that they have received the training and are to comply with new guidelines.
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Performance assessments along with collected data would be discussed with those involved in

the plan. This helps the staff know how and if the implementation of the change is effective or

how it is progressing. “Audit and feedback, performance gap assessment (PGA), and trying the

EBP are strategies that have been tested. PGA and audit and feedback have consistently shown a

positive effect on changing practice behavior of providers” (Titler, 2008).

In a two-arm cluster randomized control trial study conducted in Saudi Arabia, 70 control

participants and 70 intervention participants in two tertiary hospital ICUs were studied. The

intervention group participants were given PU prevention bundles, while the control group

received skin care according to ICU policy. Information obtained included demographic and

clinical differences. Every two days from admission to discharge or death, for up to twenty eight

days, patients were followed and information analyzed. The Kaplan-Meier survival analysis and

Poisson regression were both used. Results of PU incidence were lower in the intervention group

in comparison to the control group, (7.14% and 32.86% respectively). Poisson regression showed

that the likelihood of pressure ulcers in the intervention group was 70% lower. Stage I and Stage

II pressure ulcers were also less significant in the intervention group. In another study patients

were placed on a controlled turning schedule and documentation of the event as well as any other

intervention was also done at this time. Participants were new short-stay residents or long-stay

residents in the US and Canada with the bed size ranging from 151 to 350 beds. Individuals were

65 and older, no evidenced of PUs, had a risk of developing PUs, had mobility limitations and

were using high-density foam mattresses. Results from this study noted a significance difference

over a 3 week period. The incidence of PUs reflects on the consistency of the monitoring of skin

and nursing care (Barrett et al., 2013).

Implementation
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Any proposed change in a workplace can bring along its own unique set of challenges.

Several individuals must be included and informed during the proposal and implementation

process. Without the support of key stakeholders, implementation plans fail to receive the focus

and attention needed to push new plans forward into practice. It is imperative that each

individual involved know the importance of the proposed plan in order for it to be incorporated

properly and successfully. Successful implementation plans involve several steps and can take

anywhere from weeks or months to be successful. Most of this will depend on the type of change

that is being presented. Some key elements to include in implementation are increasing staff

knowledge, including audit and feedback, use of clinical reminders and practice prompts,

opinion leaders, change champions, interactive education, mass media, educational

outreach/academic detailing, and characteristics of the context of care delivery. Senior leadership

and those leading EBP improvements should be aware of change as a process and continue to

encourage and teach others about the change in practice. The new practice must be continually

reinforced and sustained or the change will be intermittent and fade soon, allowing old habits to

return (Titler, 2008). It is important before beginning any implementation plan that it is met with

support from stakeholders and that the proposed plan carries the proper approval. Any change in

a facility must be approved. This can be accomplished using an oral presentation with descriptive

handouts. Beginning at the unit level to determine how much or how far up the organization

approval needs to go is a good start. The unit manager, clinical supervisor, and director are a

good source to start with. A project's success is mitigated in large part by the amount of support it

receives. The best plan, best team, and the best vision mean nothing if there is insufficient

backing from key stakeholders. The plan may be doomed before it even gets off the ground.
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

This lack of support isn't always obvious unless you uncover your stakeholders and understand

their needs right from the start.

For this particular implementation plan approval from the ethics committee as well as the

CEO of the hospital will need to be obtained. If supported at this level, further approval from an

Institutional Review Board would be required due to the involvement of patient participants.

Informed staff and those in other leadership roles are also needed and are critical to the success

of the implementation plan. With each of these in place, a study on repositioning elderly or

immobile patients every two hours to reduce the incidence and severity of pressure ulcers can be

conducted.

Nursing staff, certified nurse’s aides, and the wound care nurse will all be included as part

of the interdisciplinary team tasked with implemented the plan. Before implantation, the staff

will be briefed on the upcoming change. A new policy document will be drafted and each

member of the staff will sign in acknowledgment of training on the procedure. Management will

be briefed and given handouts to allow any notes to be taken if needed.

The incorporation of the new pressure prevention procedures will begin to be

implemented on all units within the next three months. The first units to begin incorporating

these procedures into practice will be the ICU and stepdown units. Nurse Managers will be

responsible in ensuring that all of their staff is properly trained and aware of the new guidelines,

requirements and implantation dates. The wound care nurse along with the assessment of the

nurse will be responsible for daily skin documentation, to include the absence presence, or stage

of current pressure ulcer. Members from the process improvement board or a Nurse Educator

will educate Nurse Managers who will in turn educate their staff and will be responsible for

ensuring that compliance is being met.

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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

For educational purposes, nurses and assistive personnel will receive a questionnaire to

assess their knowledge on pressure ulcers. Scores of 8 out 10 will be considered passing. Those

possessing scores below this will receive additional education until a passing score is obtained.

Handouts will key points as well as photos of different stages of pressure ulcers will be provided.

Teaching will be provided in the unit’s breakroom. Educational materials and questionnaires will

be printed using hospital supplies and budgeted as educational costs. Direct observation of

practice will ensure that the procedures are be implemented accordingly.

Incorporated Theory

While healthcare has had many changes throughout the years, nurses have been there to

see them through. Florence Nightingale has been considered the first nursing theorist (Petiprin,

2015). Her Environmental Theory is a patient-care theory that focuses on the way the nurse takes

care of the individual needs of the patient. Environment factors affect each patient on an

individual basis and as such, nursing care must be tailored according to those factors to achieve

optimum care. There are ten major concepts in the Environmental Theory, listed below:

1. Ventilation and warming

2. Light and noise

3. Cleanliness of the area

4. Health of houses

5. Bed and bedding

6. Personal cleanliness

7. Variety

8. Offering hope and advice

9. Food
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

10. Observation

Pressure ulcer prevention includes a great deal with numbers 1, 3, 5, 6, 7, 8, 9, and 10. All of

these are nursing focused and can be directly related to prevention.

Florence Nightingale’s Environmental Theory was chosen because it speaks to nursing as

a one to one practice. The theory itself is able to distinguish the role of the nurse verses

medicinal treatment. It incorporates environmental factors that nurses are able to manipulate in

order to produce more positive outcomes. This includes simple measures like repositioning

elderly patients every two hours to prevent pressure ulcers. Hygiene, nutrition, proper bedding

and observation are all interventions that work along with repositioning that help with pressure

ulcer prevention. While human anatomy may be the same, no two people are alike and nursing

care must be tailored to each individual.

A two, three, or even four hour repositioning schedule may be adequate for some

patients, but not all. By utilizing Florence Nightingale’s Environmental Theory, nurses are able

to assess patients on an individual basis and determine their specific repositioning needs and

tailor a plan of care accordingly, thus reducing the incidence of pressure ulcers. Patients who are

elderly, less mobile, with decreased body fat will need different environmental interventions than

a young, active, average or overweight patient. Plans of care can be made from the ten concepts,

focusing on with numbers 1, 3, 5, 6, 7, 8, 9, and 10.

Evaluation

The two primary causative factors of pressure ulcers are pressure and time (Sprigle &

Sonenblum, 2011). Bates-Jensen (2012) describes clock-based and event-based repositioning as

the two acceptable strategies for patient repositioning. This paper proposes to decrease the

number of pressure ulcers in elderly or less mobile patients by setting in place a practice of
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

preventative measures and procedures, to include patient repositioning every two hours. These

measures and procedures would include a two hour rounding and repositioning checklist for each

patient. Incontinence and moisture would also be checked during this time, as it is a precursor to

skin breakdown. Documentation of time and care provided to the patient as well as the position

the patient was left in would be noted. Checklists will be posted by each patient’s door and

signed off by staff upon completion. These checklists will then go into the patients’ charts for

continuity of care. Proper body mechanics and positioning will be followed. Continued use of

this practice will reduce the incidence on pressure ulcers in the elderly or less mobile patient.

Pressure ulcer rates would be compared and evaluated according to rates documented six months

before implementation date.

The methods of determining how effective the proposed solution will be are going to

require several components. Before implementing the plan, nurses, assistive personnel, and

other key staff must be educated on their new expectations. They will be required to understand

the basic principles surrounding pressure ulcer development. A short general knowledge quiz

will be given to each staff member (see attached file). Briefings, meetings, and conferences

with informational handouts will all be held before implementation of the plan (see attached

information sheet). Periodically throughout the implementation phase, the quiz will be reassessed

in order to check for proper education on the subject.

Daily chart checks and auditing will help ensure compliance of the turning schedule and

patient checks. These checks will be completed by the oncoming nurse while doing her routine

chart checks. This will help keep everyone accountable for their own tasks.

The methods of determining how effective the solution proposal is will be the final

comparison of pressure ulcer rates. Rates from the beginning must be compared to those at least
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

six months after implementation of the plan. This will produce a true assessment of effectiveness

of the proposed plan. A reduction in pressure ulcers would be a testament to an effective plan.

Change will be introduced after staff has been provided an opportunity to offer input into the

change and after a period of staff education. Baseline HAPU rates and repositioning compliance

will be determined before any interventions are introduced.

Many plans have variables that must be accounted for when trying to implement anything

new. When trying to implement a new turning or repositioning schedule for patients, some

variables that you must account for are, patient’s nutritional status, weight, mobility level,

compliance and staff attitude. In one study, nurse attitudes were the factor most directly

associated with HAPU rate. The lowest incidence of HAPUs was found in settings where nurses

believed that nursing care could prevent HAPUs and that most HAPUs were preventable

(Beeckman et al., 2011).

Before beginning the new phase on the floor, each staff member will take a quiz (see

attached) to test their knowledge on the basics of pressure ulcers. An educational class will be

given with handouts available. The chance to ask questions will be available to anyone who has

them. After the educational class, staff will have the chance to take the quiz again until a passing

grade is received. Further review of the material and plan may be reviewed as needed.

To assess whether or not the proposed education was effective, the quiz will be collected

and placed in employee records. There will also be an opportunity for the nurses to demonstrate,

and be checked off, on competency in performing the task (see appendix B for competency

checklist). Direct observation of the implementation plan by the staff will also show an

understanding of the proposed education. Auditing charts for complete charting on repositioning

and a follow up by the wound care nurse will help track the follow-through of the teaching. The
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

wound care nurse will be following any patient with skin issues. A good follow up rate will be

those listed by the wound care nurse or a reduction listed by the wound care nurse since the

implementation of the new plan.

Dissemination

The term dissemination is used in reference to spreading the information or

knowledge gained during research. “Without dissemination, there is no knowledge building,

theory confirmation, or benefit to clients,” (Thyer, 2001). Once a study has been completed, the

results must then be disseminated to key stakeholders as well as the nursing community in order

for the health promotions to be adopted into practice. In an article on the Centers for Disease

Control and Prevention (CDC) website, it is suggested that a wider adoption of evidence-based,

health promotion practices depends on developing and testing effective dissemination

approaches, (Harris, Cheadle, Hannon, Forehand, Lichiello, Mahoney, Snyder & Yarrow, 2012).

It is important for key stakeholders to know the results of proposed studies.

Stakeholders included in this study would include the nurse manager, Chief Nursing

Officer, CEO of the hospital, nursing staff, supportive staff, Nurse Educator, Wound Care Nurse

and EBP committee. There are a few ways to reach all of these individuals. Staff meetings,

company emails, training sessions, conference days, and company bulletins will all work. Staff

meetings and conferences are ideal because they offer the chance for questions to be asked and

answered with open communication. The community may also want to know the results of the

study when they are concluded. These results can be posted on the hospital newsletter, on the

hospital information television channel, or posted on bulletin boards.

Conclusion

There has been a great deal of research done on the evidence-based practice of

repositioning patients every two hours to prevent pressure ulcers. Placing patients on turning or
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

repositioning schedules reduces the incidence of pressure ulcers. Regular repositioning prevents

pressure ulcers by reducing the duration of pressure and shearing forces. Studies have revealed

that when preventive guidelines are implemented, the prevalence of pressure ulcers decrease

(Sving, et al, 2014). Data suggest that the combination of support surface, repositioning, and

documentation were successful in preventing ulcers in the moderate- and high risk groups

(Bergstrom, Horn, Rapp, Stern, Barrett, & Watkiss, 2013). Proper assessment of at risk patients

as well as follow up care based on protocols and education are essential for optimal treatment

plans to be effective. By implementing new guidelines and protocols, patients quality of life will

be improved, cost of care will decrease and pressure ulcer prevalence will dwindle. Research has

proven its effectiveness and with support from key stakeholders, proper dissemination and

implementation of this plan could be a great asset to the patient and organization. It is essential to

the prevention of the serious complications, or even mortality, which may accompany pressure

ulcers.

.
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Review of Literature

Amr, S., Baumgarten, M., Hawkes, W. G., Margolis, D., Miller, R. R., Rich, S. E. & Shardell, M.

(2011). Frequent manual repositioning and incidence of pressure ulcers among bedbound

elderly hip fracture patients. Wound Repair and Regeneration : Official Publication of the

Wound Healing Society [and] the European Tissue Repair Society, 19(1), 10–18.

http://doi.org/10.1111/j.1524-475X.2010.00644.x

Repositioning is often used as a tool in prevention of pressure ulcers. In a study done

during 2004 and 2007, between Pennsylvania and Maryland, hip fractured patients were

studied for repositioning and the incidence of pressure ulcers. New pressure ulcers

resulted in 12% following frequent repositioning verses 10% following less frequent

repositioning. Repositioning does have an impact on the incidence of the development of

pressure ulcers. Frequent repositioning reduces the incidence.

Barrett, R., Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., & Watkiss, M. (2013). Turning for

Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. Journal of The

American Geriatrics Society, 61(10), 1705-1713 9p. doi:10.1111/jgs.12440

This article looked at the best repositioning schedule of patients in nursing homes at risk

for pressure ulcers. Documentation served as a reminder to staff to report changes thus

adding an extra safety measure. A significance difference was not noted over a 3 week

period. The incidence of PUs reflects on the consistency of the monitoring of skin and

nursing care.
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Beeckman, D., Clays, E., Schoonhoven, L., Vanderwee, K., Van Hecke, A. & Verhaeghe, S.

(2013). A multi-faceted tailored strategy to implement an electronic clinical decision

support system for pressure ulcer prevention in nursing homes: A two-armed randomized

controlled trial. International Journal of Nursing Studies, 50(4), 475-486 12p.

doi:10.1016/j.ijnurstu.2012.09.007

Failure to adhere to PU prevention policies in healthcare is a common problem. This

study looks at if support systems may change the behaviors and effectiveness of

implementation of prevention guidelines. Pressure ulcer intervention is only successful

when the attitudes and knowledge of healthcare workers improved.

Bredesen, I. M., Bjøro, K., Gunningberg, L., & Hofoss, D. (2015). The prevalence, prevention

and multilevel variance of pressure ulcers in Norwegian hospitals: A cross-sectional study.

International Journal of Nursing Studies, 52(1), 149-156 8p.

doi:10.1016/j.ijnurstu.2014.07.005

Elderly patients are at a greater risk for developing pressure ulcers. This study looks at

the difference organizational structures may have on the occurrence of these pressure PUs

in the hospital. End analysis of data showed a difference in occurrence at both the patient

and ward level, but not at the hospital level. Patient interventions are important, but

improvements at the ward and hospital level are also important since PUs were also notes

at the ward level.

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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Chaboyer, W. P., Gillespie, B. M., Kent, B., McInnes, E., Thalib, L., Whitty, J. A. (2014).

Repositioning for pressure ulcer prevention in adults. Cochrane Database of Systematic

Reviews. 4. Art. No.: CD009958. DOI: 10.1002/14651858.CD009958.pub2.

Pressure ulcers commonly occur in less mobile patients. One study looked at the effects

of repositioning patients despite their setting or PU risk category. This study was unable

to yield conclusive evidence on whether or not frequent repositioning is more effective in

reducing PUs. Pressure ulcers are a growing problem. There is a huge need for studies on

the effectiveness of turning and repositioning for PU prevention. It is essential to keep the

classification of pressure ulcers consistent regardless of how severe it may be.

Cooper, K. (2013). Evidence-Based Prevention of Pressure Ulcers in the Intensive Care. Critical

Care Nurse, 33(6), 57-67. doi: http://dx.doi.org/10.4037/ccn2013985

New rules and regulations have now made stage III and stage IV pressure ulcers never

events. This article looks at the risk factors and scales used to address pressure ulcers in

the ICU and evidence for interventions aimed at preventing pressure ulcers. Outcome of

the article was educational on the risk of pressure related devices and how to prevent

pressure ulcers related to them. In the critical care setting, nurses are faced with several

chances to create inquiries about treatment and prevention of PUs. More studies are

needed relating to device-related pressure ulcers as well as interventions used in

preventing PUs.
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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Cowman, S. & Moore, Z. (2015). Repositioning for treating pressure ulcers. Cochrane Database

of Systematic Reviews. Issue 1. Art. No.: CD006898.

DOI:10.1002/14651858.CD006898.pub4.

Pressure causes a lack of oxygen to tissues. Prolonged pressure due to immobility results

in pressure ulcers. This article discussed the effect of repositioning on prevention of

pressure ulcers. Repositioning is used as a widespread plan of care in the management of

patients with existing pressure ulcers; however there were no randomized trials meeting

criteria for this study. This subject needs further evaluation.

Coyer, F., Lewis, P. A. & Tayyib, N, (2015). A Two-Arm Cluster Randomized Control Trial to

Determine the Effectiveness of a Pressure Ulcer Prevention Bundle for Critically Ill

Patients. Journal of Nursing Scholarship, 47(3), 237-247 11p. doi:10.1111/jnu.12136

Critically ill patients are at high risk for developing pressure ulcers due to immobility.

One study looks the effect of prevention bundles in this population. Results of PU

incidence were lower in the intervention group in comparison to the control group,

(7.14% and 32.86% respectively). Poisson regression showed that the likelihood of

pressure ulcers in the intervention group was 70% lower. Stage I and Stage II pressure

ulcers were also less significant in the intervention group. Using a bundle approach and

standardized nursing care can improve care and patient outcome. The use of pressure

ulcer prevention bundles proved to have marked improvements related to reduction on

PUs in Saudi Arabia intensive care units. By implementing these bundles, the overall

amount of pressure ulcers, including severity could be reduced.

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Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Elg, M., Fossum, B., Härenstam, K. P., Sterner, E., Thor, J., & Unbeck, M. (2013). Design,

application and impact of quality improvement 'theme months' in orthopedic nursing: A

mixed method case study on pressure ulcer prevention. International Journal Of Nursing

Studies, 50(4), 527-535 9p. doi:10.1016/j.ijnurstu.2013.02.002

The study was performed to look at quality awareness and improvement in healthcare

with a focus on pressure ulcers. This approach offers a study with a long view approach to

quality improvement in orthopedic nursing, with information shown over time. Most

queries only have information summarized in one particular instance before and after

intervention, whereas this one demonstrates change over time. Improvements were found

in follow up and annual county wide measurements. The first years showed improvement

but need for reinforcement. The design application of this study showed a reduction of

PUs. For continued improvement, interventions and monitoring are needed on a regular

basis.

Faulstich, J., Johansen, E., Moore, Z., Smith, B. E., Solbakken, T. E., Strapp, H., & Van Etten,

M. (2015). Pressure ulcer prevalence and prevention practices: a cross-sectional

comparative survey in Norway and Ireland. Journal of Wound Care, 24(8), 333-339 7p.

The study was performed to look at the risk assessment method of pressure ulcer

prevalence or prevention strategies between Ireland and Norway. One was based on

formal structured risk while the other was based on clinical judgment alone. Most clinical

practices use a formal pressure ulcer risk assessment, but not all of them. The results of

this study indicate that there is a missing link between risk assessment and pressure ulcer
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prevention. Regardless of knowledge pertaining to the subject, these strategies are not

consistently applied.

Gunningberg, L., Högberg, H., Idvall, E., & Sving, E. (2014). Factors contributing to evidence-

based pressure ulcer prevention. A cross-sectional study. International Journal Of Nursing

Studies, 51(5), 717-725 9p. doi:10.1016/j.ijnurstu.2013.09.007

Pressure ulcers are associated with a reduced quality of life. This study looks at how

nursing care relates to the prevention of pressure ulcers. Those individuals with increased

rick had higher odds of receiving assessment documentation and pressure mattresses.

Patients were less likely to receive skin assessment or pressure reducing mattresses, but

more likely to have planned repositioning at the general hospital. Routines should be

established and nurses should begin to take responsibility for patient care.

Moore, A., & Geist, R. (2015). Keeping patients safe from falls and pressure ulcers. American

Nurse Today, 14-17 4p

Patient safety is a crucial aspect of nursing. At the top of patient safety is preventing

patient falls and pressure ulcers. This article presents a case study to help explain how to

prevent these. Medical costs can range up to $70,000 per PU. They are noted to be one of

the leading preventable errors in the US. PUs increase the risk of death and readmission.

Medical costs can range up to $70,000 per PU. They are noted to be one of the leading

preventable errors in the US. PUs increase the risk of death and readmission.

Preventing pressure damage when seated. (2015). Wounds UK, 11(3), 18-23 6p
 22
Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Pressure ulcers are a common problem and can be even more of a problem to those that

spend a majority of their time in a seated position. This article discusses the common

instruction and advice on PU prevention in the individual requiring prolonged seating.

Seated persons are at a severe risk of pressure ulcers. Risk assessment is the beginning to

starting prevention strategies. Any individual that spends a prolonged amount of time in

the seated position is at risk for PU development. The first step in prevention of PU

development is identification of those at risk, followed by a plan of care individualized

and suited to that patient.

Sonenblum, S. & Sprigle, S. (2011). Assessing evidence supporting redistribution of pressure for

pressure ulcer prevention: A review. Journal of Rehabilitation Research & Development,

48(3), 203-213 11p. doi:10.1682/JRRD.2010.05.0102

Pressure ulcers are complex. This article looks at common interventions used to address

the treatment and prevention of them. Data obtained in the study reinforced interventions

used for repositioning. Repositioning patients is a key preventative measure. Patients that

can independently redistribute pressure should be instructed and informed of strategies to

ensure compliance. Individuals unable to redistribute pressure themselves are forced to

rely on someone else’s repositioning schedule.

Demarré, L., Verhaeghe, S., Annemans, L., Van Hecke, A., Grypdonck, M., & Beeckman, D.

(2015). The cost of pressure ulcer prevention and treatment in hospitals and nursing homes

in Flanders: A cost-of-illness study. International Journal Of Nursing Studies.

http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005
 23
Running head: REPOSITIONING REDUCES PRESSURE ULCERS

The cost of PU treatment and prevention is costly. Current data regarding the cost of

practice of PU prevention or treatment in Flanders, Belgium, is minuscule. This study

examined the cost of PU prevention and treatment adults in hospitals and NH from the

payer perspective. Average cost of PU prevention was 7.88/ hospitalized patient a day and

2.15/NH a day. Labor cost the most at 79–85% of prevention. The cost of treatment of

pressure ulcers can be expensive. Prevention studies are needed to weight the effect of

cost to illness.

References

Agrawal, K., & Chauhan, N. (2012). Pressure ulcers: Back to the basics. Indian Journal of

Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India,

45(2), 244–254. http://doi.org/10.4103/0970-0358.101287

Amr, S., Baumgarten, M., Hawkes, W. G., Margolis, D., Miller, R. R., Rich, S. E. & Shardell, M.

(2011). Frequent manual repositioning and incidence of pressure ulcers among bedbound

elderly hip fracture patients. Wound Repair and Regeneration : Official Publication of the

Wound Healing Society [and] the European Tissue Repair Society, 19(1), 10–18.

http://doi.org/10.1111/j.1524-475X.2010.00644.x
 24
Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Barrett, R., Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., & Watkiss, M. (2013). Turning for

Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. Journal of

The American Geriatrics Society, 61(10), 1705-1713 9p. doi:10.1111/jgs.12440

Beeckman, D., Clays, E., Schoonhoven, L., Vanderwee, K., Van Hecke, A. & Verhaeghe, S.

(2013). A multi-faceted tailored strategy to implement an electronic clinical decision

support system for pressure ulcer prevention in nursing homes: A two-armed randomized

controlled trial. International Journal of Nursing Studies, 50(4), 475-486 12p.

doi:10.1016/j.ijnurstu.2012.09.007

Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., Barrett, R., & Watkiss, M. (2013). Turning for

Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. Journal of

The American Geriatrics Society, 61(10), 1705-1713 9p. doi:10.1111/jgs.12440

Bredesen, I. M., Bjøro, K., Gunningberg, L., & Hofoss, D. (2015). The prevalence, prevention

and multilevel variance of pressure ulcers in Norwegian hospitals: A cross-sectional

study. International Journal of Nursing Studies, 52(1), 149-156 8p.

doi:10.1016/j.ijnurstu.2014.07.005
Chaboyer, W. P., Gillespie, B. M., Kent, B., McInnes, E., Thalib, L., Whitty, J. A. (2014).

Repositioning for pressure ulcer prevention in adults. Cochrane Database of Systematic

Reviews. 4. Art. No.: CD009958. DOI: 10.1002/14651858.CD009958.pub2.

Cooper, K., L. (2013). Evidence-Based Prevention of Pressure Ulcers in the Intensive Care Unit.

Critical Care Nurse, 33(6), 57-67. doi: http://dx.doi.org/10.4037/ccn2013985

Cowman, S. & Moore, Z. (2015). Repositioning for treating pressure ulcers. Cochrane Database

of Systematic Reviews. Issue 1. Art. No.: CD006898.

DOI:10.1002/14651858.CD006898.pub4.
 25
Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Coyer, F., Lewis, P. A. & Tayyib, N, (2015). A Two-Arm Cluster Randomized Control Trial to

Determine the Effectiveness of a Pressure Ulcer Prevention Bundle for Critically Ill

Patients. Journal of Nursing Scholarship, 47(3), 237-247 11p. doi:10.1111/jnu.12136

Crane, P., & Selanders, L. (2012). The Voice of Florence Nightingale on Advocacy. OJIN: The

Online Journal of Issues in Nursing, 17(1), doi: 10.3912/OJIN.Vol17No01Man01

Demarré, L., Verhaeghe, S., Annemans, L., Van Hecke, A., Grypdonck, M., & Beeckman, D.

(2015). The cost of pressure ulcer prevention and treatment in hospitals and nursing

homes in Flanders: A cost-of-illness study. International Journal of Nursing Studies,

52(7), 1166-1179 14p. doi:10.1016/j.ijnurstu.2015.03.005

Elg, M., Fossum, B., Härenstam, K. P., Sterner, E., Thor, J., & Unbeck, M. (2013). Design,

application and impact of quality improvement 'theme months' in orthopedic nursing: A

mixed method case study on pressure ulcer prevention. International Journal Of Nursing

Studies, 50(4), 527-535 9p. doi:10.1016/j.ijnurstu.2013.02.002

Executive Agency for Heath and Consumers (EAHC). (n.d.). Managing Projects. Retrieved from

http://ec.europa.eu/eahc/management/Fact_sheet_2010_10.html

Faulstich, J., Johansen, E., Moore, Z., Smith, B. E., Solbakken, T. E., Strapp, H., & Van Etten,

M. (2015). Pressure ulcer prevalence and prevention practices: a cross-sectional

comparative survey in Norway and Ireland. Journal of Wound Care, 24(8), 333-339 7p.

Gunningberg, L., Högberg, H., Idvall, E., & Sving, E. (2014). Factors contributing to evidence-

based pressure ulcer prevention. A cross-sectional study. International Journal Of

Nursing Studies, 51(5), 717-725 9p. doi:10.1016/j.ijnurstu.2013.09.007

Harris, J., R, Cheadle, A, Hannon, P., A, Forehand, M., Lichiello, P., Mahoney, E., Snyder, S.,

Yarrow, J. (2012). A framework for disseminating evidence-based health promotion

practices. Preventing Chronic Disease. DOI: http://dx.doi.org/10.5888/pcd9.110081

 26
Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Jackson, M., McKenney, T., Drumm, J., Merrick, B., LeMaster, T., & VanGilder, C. (2011).

Pressure Ulcer Prevention in High-Risk Postoperative Cardiovascular Patients. Critical

Care Nurse, 31(4), 44-53. http://dx.doi.org/10.4037/ccn2011830

Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare:

A guide to best practice. 2nd ed. Philadelphia: Lippincott Williams I Wilkins

Moore, A., & Geist, R. (2015). Keeping patients safe from falls and pressure ulcers. American

Nurse Today, 14-17 4p

National Pressure Ulcer Advisory Panel (NPUAP). (n. d.). NPUAP Pressure Ulcer

Stages/Categories. International NPUAP-EPUAP Pressure Ulcer Definition. Retrieved

from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-

ulcer-stagescategories/

Nightingale, F. (n. d). Notes on nursing . Philadelphia: Lippincott; p. 1859

Nightingale, F. & Skretkowicz, V. (2010). Florence Nightingale's Notes on nursing. New York:

Springer Publishing Co.

Petiprin, A. (2015). Environmental Theory. Nursing Theory. Retrieved from http://www.nursing-

theory.org/theories-and-models/nightingale-environment-theory.php

Preventing pressure damage when seated. (2015). Wounds UK, 11(3), 18-23 6p.
Sonenblum, S. & Sprigle, S. (2011). Assessing evidence supporting redistribution of pressure for

pressure ulcer prevention: A review. Journal of Rehabilitation Research & Development,

48(3), 203-213 11p. doi:10.1682/JRRD.2010.05.0102

Sving, E., Idvall, E., Högberg, H., & Gunningberg, L. (2014). Factors contributing to evidence-

based pressure ulcer prevention. A cross-sectional study. International Journal Of

Nursing Studies, 51(5), 717-725 9p. doi:10.1016/j.ijnurstu.2013.09.007

 27
Running head: REPOSITIONING REDUCES PRESSURE ULCERS

Thyer, B. (2001). Disseminating Research Findings. The Handbook of Social Work Research

Methods. DOI: http://dx.doi.org/10.4135/9781412986182

Titler, M. G. (2008). The Evidence for Evidence-Based Practice Implementation. Patient Safety

and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for

Healthcare Research and Quality

 APPENDIX A

Provider: ___________________________ Date: __________________

Title/Position: _______________________

Pressure Ulcer Questionnaire

Circle the BEST answer:

1. Which of the following statement(s) are true concerning pressure ulcers?

a. They are localized areas of tissue damage

b. They tend to occur at bony sites

c. They are caused by prolonged pressure

d. The patient/resident’s nutrition status affects the development of a pressure ulcer

e. All of the above

2. Which sites are the most susceptible to pressure ulcer development?

a. Sacrum and heels

b. Temporal (side)area of the head

c. hands and elbows

d. Abdominal area

e. All of the above

© 2011. Grand CanyonUniversity. All Rights Reserved.

3. Which of the following patients/residents would be considered most “at risk” to develop a
pressure ulcer

a. A healthy, active 22-year-old new mother

b. A 28-year-old patient in a leg traction

c. An immobile 65-year-old patient who has had a stroke

d. A physically active 80-year-old nursing home resident

e. None of the above

4. To prevent pressure ulcers from developing, which of the following steps should NOT be taken?

a. Routinely observe high-risk bony skin areas

b. Turn patient/residents only upon their request

c. Minimize pressure

d. Keep the skin dry and clean

e. Depending on the patient/resident’s condition, encourage physical activity and a balanced diet

5. A resident/patient is at risk for pressure ulcers when they are or have:

a. Bed or chair bound (immobility)

b. Poor nutritional status

c. Moisture from urine and feces or wound drainage

d. Sensory impairment (such as stroke or dementia)

e. All of the above

6. According to best guidelines, residents and patients who are at risk of developing a pressure ulcer
should be evaluated for which of the following:

a. Minimizing pressure by repositioning every 2 hours

b. Use of pressure reduction surfaces

© 2011. Grand CanyonUniversity. All Rights Reserved.

 c. Nutritional status

d. Incontinence

e. All of the above

7. Which of the following repositioning techniques are key in preventing pressure:

a. Turning residents/patients at least every two hours while in bed

b. Repositioning residents/patients confined to a chair at least hourly

c. Floating heels

d. Padding between bony areas

e. All of the above

True or False: State whether the statement is true or false

8. A pressure ulcer can lead to death. _____

9. The entire health care team, including the nurses, dietitians,

and physicians should be concerned with pressure ulcers. _____

10. Pressure ulcers are easy to cure. _____

11. A pressure ulcer can begin to form in hours. _____

12. The nursing time per patient doubles with a pressure ulcer. _____

© 2011. Grand CanyonUniversity. All Rights Reserved.

Answers:

1. E

2. A

3. C

4. B

5. E

6. E

7. E

8. True

9. True

10. False

11. True

12. True

© 2011. Grand CanyonUniversity. All Rights Reserved.

 APPENDIX B

Teaching Module

Definition of Pressure Ulcers : State basic pathophysiology as an ischemic injury

leading to wounding :

Pressure ulcers are the result of tissue hypoxia

caused when pressure exerted on tissue impedes

blood flow and oxygenation. The tissues at highest

risk are structures in proximity to bony

prominences; consequently, the most common

sites for HAPUs are heels, sacrum, and acromion

processes (Lyder et al., 2012)

Attitude and Empathy Discuss impact of nurse attitude on success of

pressure ulcer reduction efforts:

The attitude of the nurses was the factor most

© 2011. Grand CanyonUniversity. All Rights Reserved.

 directly associated with HAPU rate. The lowest

incidence of HAPUs was found in settings where

nurses believed that nursing care could prevent

HAPUs and that most HAPUs were preventable

(Beeckman et al., 2011). This study would support

that content designed to influence nurse attitude is

an important component of HAPU prevention.

Risk Factors Name and discuss three risk factors for developing

pressure ulcers:

Stool and urinary incontinence, smoking, anemia,

not using a pressure-reducing bed surface, and

infrequent change of position in bed are

considerable risk factors for the development of

PUs. Immobilized patients should be assessed for

these risk factors, and measures should be taken to

prevent PU development, (Cakmak et al, 2009).

Protocol Review Implementation of repositioning is a critical factor

in the reduction of the risk for HAPU

development. Body alignment, joint flexion and

bed elevation at the head and knees are key

considerations. In the supine position, the body

should be in alignment with the head of the bed

© 2011. Grand CanyonUniversity. All Rights Reserved.

 elevated at thirty degrees because elevation at

angles greater than thirty degrees increases the

risk of pressure ulcer. When clinical indications

for increased elevation of the head of the bed

supersede HAPU prevention, additional skin

protection strategies may be necessary. The hips

and knees should be elevated and flexed with care

taken to off-load, “float” the heels. One side of the

pelvis should be lifted to reduce pressure on the

sacrum. The ankle should always be kept as close

to a ninety-degree angle as possible to prevent

foot drop. If special boots are used to protect the

heels and maintain alignment, these should be

properly applied and removed completely for

assessment every shift. The bed itself can be

flexed at the knees or a limb elevator used; this

reduces pressure on the hip joints (Rappl, 2012;

Johnson & Mayenburg, 2009).

The lateral positions will usually be alternated

with the supine position on a rotational basis.

Proper positioning in the lateral position is

optimally at a thirty-degree tilt maintained by a

wedge, which minimizes pressure on the acromion

© 2011. Grand CanyonUniversity. All Rights Reserved.

 processes (Harada, Shigematsu, & Hagisawa,

2002; Moore, Cowman, & Conroy, 2011; Sprigle

& Sonenblum, 2011). The uppermost arm should

be supported on a pillow at shoulder level and the

uppermost leg should be slightly flexed at the hip

and knee and supported by a pillow or wedge. The

heels need to be floated (Rappl, 2012).

© 2011. Grand CanyonUniversity. All Rights Reserved.

© 2011. Grand CanyonUniversity. All Rights Reserved.