Pressure Ulcer Prevention – Literature Review

The gap in the literature is that very little research has been conducted in this country to determine nurses knowledge in the prevention of pressure ulcers in hospitals and elderly care units in Ireland.

Chapter 2 literature review

2.0 Introduction

In this literature review we are looking at international and national studies carried out on pressure ulcers and their prevention. A pressure ulcer is also known as bed sores and decubitis ulcers can be defined as areas of localized damage to the skin and underlying tissue caused by exposure to pressure, shear or friction or a combination of these (EPUAP 2003). ADD MORE HERE

It is estimated that 1.5% of the population are affected by a wound at any one point in time. Wounds have a major personal, social, and economic impact. Wounds not only impact on the individual and their quality of life, they also have a significant impact on the health service and our society as a whole. Studies in the UK indicate that up to 4% of the total health care expenditure is spent on the provision of wound management while in Ireland it is estimated that two thirds of community nursing time is spent on the provision of wound management (HSE 2009)

The data bases used were Blackwell Synergy, Health and Wellness Resource Centre, CINAHL and Medline. Keywords used were pressure ulcers, pressure sores, prevention, nurses knowledge, risk factors and cost.

This literature review explains in-dept what a pressure is, nurses knowledge including barriers, classifications, risk factors, cost.

2.1 Definition of a pressure ulcer

The International NPUAP-EPUAP (2009) has defined a pressure ulcer as 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 factors or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. ADD MORE HERE

2.2 Classification of a pressure ulcer

Pressure ulcers are classified as stages, grades or category. The National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel (2009) have devised a common classification system that can be by the international community. EPUAP/NPUAP 20009.

Category/Stage 1: Non-blanchable erytheme

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category 1 may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

Category/Stage 2 : Partial thickness

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or brusing. This category should not be used to describe skin tears , tape burns, incontinence associated dermatitis, maceration orexcoriation. Bruising indicates deep tissue injury.

Category/Stage III:Full thickness skin loss

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. The depth of a category/stage lll pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage lll ulcer can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage lll pressure ulcers. Bone/tendon is not visible or directly palpable.

Category/Stage IV: Full thickness tissue loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunnelling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. (NPUAP/EPUAP 2009).

Beechman et al. (2007) conducted a study of the inter-observer reliability of the European Pressure Ulcer Advisory Panel pressure ulcer classification system and of the differential diagnosis between moisture lesions and pressure ulcers.

A survey was carried out between September 2005 and February 2006 with a convenience sample of 1452 nurses from five European countries, Belgium(n=666;45.9%), the Netherlands(n=411;28.3%), Portugal(n=47;3.2%), Sweden(n=107;7.4%) and the United Kingdom(UK) (n=221;15.2%). A random selection of 40 photographs, divided into two sets, both sets contained one photograph of normal skin, one of blanchable erythema, three for each pressure ulcer grade, three of moisture lesions and three of combined lesions.

The two sets of photographs were randomly presented to the participants who were asked to classify them as normal skin, blanchable erythema and non-blanchable erythema (grade 1 pressure ulcer), blister (grade2 pressure ulcer), superficial pressure ulcer (grade 3), deep pressure ulcer (grade 4), moisture lesion or combined lesion. No further information was given.

Beechman et al. (2007) concluded that inter- observer reliability for the EPUAP classification system was found to be low. European Pressure Ulcer Advisory Panel appears to be aware of the limitations in the current classification system. Efforts to clarify the differences between moisture lesions and pressure ulcers are being made. EPUAP defined wound related characteristics (cause, location, shape, depth, edges and colour) and patient- related characteristics to clarify the difference between a pressure ulcer and a moisture lesion. However much more work is needed to reduce the difficulties experienced with the present classification system.

Pancorbo-Hidalgo et al. (2007) conducted a study in three phases to determine (a) Spanish nurses’ level of knowledge of existing guidelines for pressure ulcer prevention and treatment, (b) the level of implementation of this knowledge in clinical practice and (c) the professional and educational factors that influence knowledge and practice. The study was carried out in the Andalusia region in Spain, which has a population of 7,100,000, which is 18% of the entire Spanish population. the Andalusion health care system has three levels of care (268 healthcare centres), specialized health care (33 hospitals) and social health care (103 elder care centres or nursing homes). The study consisted of registered nurses with (3 year university degree) and LPNs with (2- year diploma) all of whom were involved in direct patient care. The sample was composed of 80% RNs and 20% LPNs. Data was collected through a questionnaire which was designed on basis of pressure ulcer prevention and treatment recommendations published by the Spanish Pressure Ulcer and Chronic Wound Advisory Panel. The questionnaire was divided into three parts (1) professional data: degrees and diplomas, years of professional experience, specific education on pressure ulcer prevention and care, participation in any kind of research on pressure ulcers.(2) prevention interventions: 16 interventions which were considered effective or ineffective by the GNEAUPP guidelines were selected. (3) treatment interventions which consists of 21 interventions which were considered effective or ineffective by the GNEAUPP. For each intervention, participants were asked to indicate: (1) the degree of appropriateness of the interventions according to their knowledge (Yes/In part-Sometimes/No) and (2) how often they implemented the interventions in their clinical practice with patients who had or were at risk of PU (Always/Sometimes/Never).

(Hulsenboom et al 2007), conducted a cross sectional and comparative study among nurses employed in Dutch hospitals in 2003 to investigate nurses knowledge and differences in knowledge between nurses employed in different types of institutions. The aims of the study were to find out, (1) how much nurses know about the usefulness of 28 preventive measures considered in the most recent national pressure ulcer guidlines; (2) if the differences in knowledge exists between nurses in hospitals that audit pressure ulcers and those employed in hospitals that do not: (3) to study whether knowledge among Dutch hospital nurses regarding the usefulness of preventive measures had changed between 1991 and 2003. RESULTS were that the knowledge in the 2003 study was slightly better than in 1991, however nurses working in hospitals that monitor pressure ulcers did not display a greater knowledge than nurses employed in organisations that did not. Halfens et al. Sited in Hulsenboom 2007 showed that participation in the Annual Prevalence Survey in the Netherlands, resulted in organisations engaging in activities to improve the prevention and treatment of pressure ulcers.

2.3Prevalence Rates

Annual national prevalence surveys in the Netherlands, conducted since 1998, indicate that an average of 18.1% of the patients in hospitals suffer from pressure ulcers. Recent studies conducted in Europe, the United States, Canada and Australia have provided estimates of pressure ulcer prevalence in hospitals ranging from 8.3% to 25.1% (Hulsenboom et al 2007).

Pressure ulcer prevalence estimates for 2001 for the UK were 4.4-6.8% for community settings and 4.6-7.5% for nursing homes, for the same year, US and Canadian community prevalence estimates were reported as 19.2-29% and 15.3-20.7% for nursing homes. In a six year national pressure ulcer incidence study in the United States, it was reported that, despite current knowledge and improvements in practice, incidence rates varied little from 8% in 1999 to 7% in 2004 (McDermott-Scales et al 2009).


The cost of prevention and treatment of pressure ulcers in the Netherlands in 1998 revealed that more than 1% of the health care budget was spent on pressure ulcer care. (Hulsenboom et al 2007)

The 2003 questionnaire was sent to 1626 nurses, 976 nurses had been selected on the basis of their subscription to the Dutch professional nursing journal Verpleegkunde Nieuws and 750 nurses selected because they were employed by hospitals that participated in the 2003 Annual National prevalence Survey. In 1991 the study population consisted of 730 nurses, selected on the basis of their subscription to Verpleegkunde Nieuws and being employed by a Dutch hospital. (Hulsenboom 2007).

The 2003 study used a cross-sectional design to examine current knowledge among nurses regarding the usefulness of measures to prevent pressure ulcers. Also a comparative design was used to assess whether nurses knowledge had changed between 1991 and 2003. Secondary analyses were conducted to test whether nurses knowledge about the usefulness of preventive measures used the same classification as that used in the national guidlines. (Hulsenboom 2007).

The inclusion criteria in the 1991 and 2003 for participation were that respondents (1) had to be qualified nurses ; (2) had to be employed by a university hospital or general hospital in the Netherlands; (3) had to be directly in patient care; (4) had to have answered more than 10% of the questions regarding the preventive measures. (Hulsenboom 2007)

Their conclusion was that nurses knowledge on prevention has improved little since1991. The results of the present study show that the knowledge about the usefulness of preventative measures mentioned in the national guidelines on Pressure Ulcers is moderate, and that being employed in hospitals that monitors pressure ulcers annually does not lead to better knowledge about preventative measures. Comparing their results with the study conducted in 1991 they that despite the increased attention and new developments in the area of pressure ulcer care, knowledge about useful measures had not greatly increased. (Hulsenboom 2007).

Risk Aaaessment

Epidemiological research has increased considerably in recent years, each health care setting should have a policy in place that includes clear recommendations for: a structured approach to risk assessment relevant to the health care setting; clinical areas to be targeted; the timing of risk assessment and reassessment; documentation of risk assessment; and communication of that to the wider health care team. Quick reference guide on pressure ulcer preventation NPUAP-EPUAP 2009

European Pressure Ulcer Advisory Panel (2003), Pressure Ulcer Prevention Guidelines. Available at: http// accessed –/–/—-.

Mirjam a hulsenboom, gerri jjw bours and ruud jg halfens. Knowledge of pressure ulcer prevention: a cross-sectional and comparative study among nurses 2007 bmc nursing 2007, 6:2, doi:10.1186/1472-6955-6-2

Beeckman, D., Schoon oven, L., Fletcher, J., Furtado, K., Gunning-Berg, L., Heyman, H., Lindholm, C., Paquay, L., Verdu, J., & Defloor, T., (2007), EPUAP classification system for pressure ulcers: European reliability study. Journal of Advanced Nursing, 60(6), 682-691 doi:10.1111/j.1365-2648.2007.0447.x

National Best Practice and Evidence Based Guidelines for Wound Management October 2009

McDermott-Scales, L., Cowman, S., Gethin, G., 2009 Prevalence of Wound in a Community Care Setting in Ireland, Journal of wound care, vol 18, no 10, October 2009, p 405-417

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