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In the vast majority of cases, appropriate identification and mitigation of risk factors can prevent or minimize pressure ulcer (PU) formation. However, some PUs are unavoidable. Based on the importance of this topic and the lack of literature focused on PU unavoidability, the National Pressure Ulcer Advisory Panel hosted a multidisciplinary conference in 2014 to explore the issue of PU unavoidability within an organ system framework, which considered the complexities of nonmodifiable intrinsic and extrinsic risk factors. Prior to the conference, an extensive literature review was conducted to analyze and summarize the state of the science in the area of unavoidable PU development and items were developed. An interactive process was used to gain consensus based on these items among stakeholders of various organizations and audience members. Consensus was reached when 80% agreement was obtained. The group reached consensus that unavoidable PUs do occur. Consensus was also obtained in areas related to cardiopulmonary status, hemodynamic stability, impact of head-of-bed elevation, septic shock, body edema, burns, immobility, medical devices, spinal cord injury, terminal illness, and nutrition.

Pressure ulcers (PUs) are a very common health problem. Nurses in clinical practice collect large volumes of PU data every day, which must be recorded and used appropriately. With this in mind, this research explored how PU data is recorded and used in clinical settings. In addition, the magnitude of PU problem in Jordan was assessed. A mixed methods approach was utilised to address the research objectives. As a first stage, Tissue Viability Nurses (TVNs) in the UK from the Tissue Viability Society (TVS) and the National Health Service (NHS) were asked to complete an online questionnaire. Subsequently, a number of them (n=16) participated in semi-structured interviews in order to complement and explain the questionnaire responses. In Jordan, a cross sectional point prevalence survey employing the European Pressure Ulcer Advisory Panel (EPUAP) methodology was conducted to measure the prevalence rate of pressure ulcers. Integration between the questionnaire and interview results occurred on a number of different occasions. The questionnaire findings (n=167) showed there to be a difference in the prevalence rate between the primary and secondary settings (X2=20.59, df=3, p<0.001), with an overall mean of 7%, and a range of 0.5-25%. It was also found that the prevalence survey and clinical audits (71.8%, n=120), conducted annually (40.9%, n=67) or monthly (22.6%, n=37) by TVNs (63.6%, n=105), were the most common methods of calculating the reported prevalence rate. The field notes taken during the interviews, which were analysed thematically using the template analysis approach, highlighted that PU audits can be conducted via additional methods to those reported in the questionnaires. These include: actual audits where patients are inspected by TVNs or link nurses; relying on the nurses to complete audit forms; and, finally, reviewing the recording systems to generate reports. Moreover, the questionnaire findings showed that PU data is mainly recorded on a combination system (48.2%, n=79), or in some cases recorded on a computerised system (9.8%, n=16). The interviews again complement these findings by expanding that PU data can be recorded, reported and referred using paper, electronic or combination records. The advantages and disadvantages of each recording system were explored and defined into separate themes. Additionally, conducting a PU audit requires certain tools. It was clear from the questionnaire that the Waterlow risk assessment scale (RAS) (88.8%, n=142), and the EPUAP classification tool (83%, n=132) were the most commonly used in the UK. Regarding the uses of PU data, the interview findings showed that there are several. For example, it can be used to generate reports about PU in a given organisation, and these reports can be used to provide feedback to the nurses, TVNs, and management, and could also prompt decisions about purchasing equipment, employing nurses or offering training in areas where there are high levels of PU cases. Prevalence and incidence data, in particular, can be used to evaluate intervention, to monitor quality, to ensure best practice is provided, as educational tools for conducting audits, and for initiating safeguarding and investigating procedures. Despite all these potential uses, however, some interviewees think that some PU data, especially the prevalence data, is useless and difficult to capture, and that incidence data is more reliable and powerful. In Jordan, the researcher examined the skin of all inpatients aged eighteen or above, except patients in the emergency, day care and maternity wards, in both university and general hospitals. This yielded a sample of 302 patients. Any PU identified was graded according to the EPUAP grading scale (GS). The risk of PU development was assessed using the Braden scale. Data was also collected on preventive measures used in the clinical setting. Of the patients examined, 11.9% (n=36) had PU grade 1-4 (excluding grade 1: 6.6%, n=20). Interestingly, this PU prevalence rate is lower than that published in most studies which have employed the same methodology but it is thought that the differences in age and frailty in the Jordanian sample, compared with most others, could explain the low prevalence. The sacrum and heel were the most commonly affected sites (55.6%, n=20). Grade one was the most common grade (44.4%, n=16) and 85 (28.1%) patients were considered at risk of developing pressure damages. Despite the relatively low prevalence, very few patients at risk received adequate prevention measures (16.5%, n=14), and there is therefore a need to raise awareness of the need for PU prevention in Jordan.

FundaÃÃo Cearense de Apoio ao Desenvolvimento Cientifico e TecnolÃgico / Com o aumento da expectativa de vida populacional, tem-se a Ãlcera por pressÃo (UP) como um dos agravos com elevada incidÃncia. Assim, esforÃos para o desenvolvimento de pesquisas que resultem em contribuiÃÃes reais para a prÃtica clÃnica dos enfermeiros assistenciais sÃo necessÃrios. Por isso, optou-se em realizar esta revisÃo integrativa, um dos mÃtodos da PrÃtica Baseada em EvidÃncias que tem por objetivo incorporar as evidÃncias encontradas na literatura à prÃtica assistencial e/ou gerencial. Para isso, a presente investigaÃÃo objetivou analisar as evidÃncias disponÃveis na literatura sobre as intervenÃÃes de enfermagem aplicadas para o tratamento das UP em pacientes acamados. Para seleÃÃo dos artigos, foram utilizadas cinco bases de dados (CINAHAL, SCOPUS, COCHRANE, LILACS e PUBMED) alÃm da revista ESTIMA. A amostra dessa revisÃo foi composta por 27 artigos, referentes a intervenÃÃes, de Ãmbito geral, utilizadas para tratar UP. ApÃs anÃlise dos artigos incluÃdos, os resultados apontaram que a eletromagnÃtico-terapia possui evidÃncias do seu beneficio para cicatrizaÃÃo das UP, porÃm nÃo existem diretrizes sobre sua aplicabilidade. Isto tambÃm foi descrito para o Ultrassom terapÃutico e a V. A. C. terapia. Quanto ao processo de limpeza de ferida, foram descritas utilizaÃÃo de vÃrias substÃncias, dentre essas, nÃo foi encontrada evidÃncia de que uma se sobressaia em relaÃÃo à outra. Na questÃo alimentar, ficou evidente que os pacientes que recebem suplementaÃÃo de proteÃnas, zinco e vitamina C em suas dietas, tendem a cicatrizar a UP em um menor perÃodo. Ao abordar a etiliologia das UP, enfocou-se o reposiciosamento e as superfÃcies de suporte (SS). Ficou patente que os pacientes devem ser reposicionados a cada duas horas, quando deitados, e a cada 15 minutos, quando sentados, como forma de minimizar as forÃas de pressÃo e cisalhamento. No entanto, a evidÃncia referente a esse cuidado possui limitaÃÃes que impedem concluir quanto ao real alÃvio de pressÃo que causa. Com relaÃÃo à forma de mensurar a UP, um Ãnico estudo fez parte da amostra desta dissertaÃÃo, de modo que este apenas descreveu a aplicaÃÃo da Escala de PUSH como forma de documentar a UP. Outro ponto crucial foi a abordagem quanto ao conhecimento dos enfermeiros e as tÃcnicas de cuidados empregadas por eles ao tratar UP. Percebeu-se que prevalece a desinformaÃÃo destes em decorrÃnca do desconhecimento que inicia na graduaÃÃo. Diante desse quadro, pensa-se em como as UP estÃo sendo tratadas e para isso analisaram-se as evidÃncias empregadas diante da dor, do odor e do exsudato. Quanto à dor, ficou clara a recomendaÃÃo do gel de benzidamina e a pomada EMLA, principalmente antes da realizaÃÃo procedimentos, como desbridamento. Quanto ao odor, nÃo foram encontrados estudos que descrevessem a melhor forma de minimizÃ-lo. Para a quantidade de exsudato, este està intimamente relacionado ao perÃodo de cicatrizaÃÃo que a UP encontra-se. Em se tratando das coberturas propriamente ditas, os estudos selecionados abordaram o hidrocoloide, a aloe vera, terapia normotermica e o colÃgeno. Estas coberturas foram abordadas em UP com diferentes estÃgios de cicatrizaÃÃo e ambos os estudos apresentaram taxa de cura adequada com ao descrever o uso de cada uma delas. Entretanto, nÃo foram identificadas evidÃncias que comprovem a superioridade de uma destas terapias. Logo, reforÃa-se a necessidade da busca de conhecimento contÃnuo por parte dos enfermeiros, bem como a importÃncia da avaliaÃÃo global dos pacientes que sÃo submetidos a seus cuidados, haja vista que as contribuiÃÃes reais para prÃtica de tratamento de UP ainda sÃo limitadas. Com isso, urgem que sejam desenvolvidos ensaios clÃnicos para elucidar muitas das respostas que ainda nÃo estÃo explÃcitas. / With the increase in life expectancy, pressure ulcer (PU) has become one of the high incidence injuries. Thus, it is necessary to develop research efforts that result in actual contributions to the clinical practice of nurse assistants. So, we chose to perform this integrative review, one of the methods of Evidence-Based Practice that aims to incorporate the evidence found in the literature to assistance and/or management practice. Therefore, this research aimed to analyze the evidence available in the literature on the nursing interventions applied to the PU treatment in bedridden patients. For articles selection we used five databases (CINAHAL, Scopus, Cochrane, LILACS and PubMed) and Estima Journal. The sample of this review was composed of 27 articles related to interventions of general purpose used in PU treatment. After analyzing the articles included, the results showed that electromagnetic therapy has evidence of its benefit for healing of PU; however there are no guidelines for its applicability. This has also been described for Therapeutic ultrasound and VAC therapy. Regarding the wound cleaning process, they described the use of many substances, such as aloe vera, tap water and saline solution. They also approached the use of hydro massage. We did not find any evidence that among these substances one stood out more than others. Regarding the food issue, we verified that patients who receive supplemental protein, zinc and vitamin C in their diets tend to heal the PU in a shorter period. By dealing with the etiology of PU, we focused on repositioning and support surfaces (SS). It became evident that the patients should be repositioned every two hours when lying down and every 15 minutes when sitting, as a way of minimizing the pressure and shear forces. However, the evidence for this care has limitations that don not allow us to conclude on the real pressure relief it causes. Regarding the method of PU measurement, a single study composed the sample of this dissertation, so it only described the application of the Pressure Ulcer Scale for Healing (PUSH) as a way of documenting PU. Another crucial point was the approach to knowledge of nurses and care techniques employed by them when treating PU. We noticed the prevalence of lack of information among them that starts at graduation. Given this situation, we reflect on how PU is being treated, and thus we analyzed the evidence used against pain, odor and exudate. As for the pain, we verified the recommendation of benzydamine gel and EMLA cream, especially before performing procedures such as debridement. As for the odor, we did not find any study describing the best way to minimize it. As for the amount of exudate, it is closely related to the healing period of PU. Regarding the coverage itself, the studies selected approached the hydrocolloid, aloe vera, normothermic wound therapy and collagen. The coverage were approached in PU with different healing stages, and both studies presented appropriate cure rate when describing the use of each one of them. However, there were no evidences to prove the superiority of any of these therapies. Thus, we reinforce the need for the continuous pursuit of knowledge made by nurses, as well as the importance of the overall assessment of patients who are submitted to their care, given that the actual contributions to the PU treatment practice are still limited. Therefore, there is urgent need to develop clinical trials to elucidate many of the answers that are not yet explicit.

Chronic tissue injuries present an enormous problem to both patients and healthcare professionals, and yet little is definitively known as to the underlying pathophysiology. While there are numerous comorbidities associated with these wounds, a unifying theme has been proposed to be the repetitive incidence of ischemia reperfusion injury.A mouse model of cyclic ischemia reperfusion was employed to examine the initiation events in the pathology of chronic wounds. Mice were subjected to eight hours of magnetic skin compression via four cycles of two-hours ischemia and thirty minutes of reperfusion. The presence of neutrophil markers of oxidative stress and inflammation such as myeloperoxidase and matrix metalloproteinases were measured at time points 1, 3, & 5 days post-injury. A sharp increase in MPO and MMP-9 was witnessed throughout, with the highest concentrations found at day 1. Simultaneously, immunodetection of heme oxygenase was performed, revealing high levels of inducible HO-I throughout the time course, with no change in HO-2 expression. Tissue damage was confirmed through histological examination.

With the prolonged lifespan of the average person, the number of hospital stays have increased. Currently, pressure ulcers are one of the most severe complications associated with prolonged hospital stay. The protocol in today€™s hospital is to rotate bedridden patients once every two hours to prevent pressure ulcers. This puts a strain on attending nurses as the risk of a pressure ulcer for a patient is not universal and therefore, a universal preventative protocol is not the most effective solution. This thesis describes the circuit design and physical implementation of a device to address the issue of pressure ulcers. The device has the form factor of a patch to be placed on specific, at risk areas of the human body. The device was designed and prototyped first on a rigid structure and then on a flexible printed circuit board substrate. A calibration procedure was developed to reduce part to part variability inherent to the pressure sensor. The resistance measurement was achieved through a novel approach including the use of a timer removing the need for an analog-to-digital converter. A seven hour experiment was conducted with live, animal subjects to measure the pressure and temperature of at risk areas of the body. The results of the experiment successfully prove the fundamental approach outlined in this thesis and justify continued research and refinement into the product design.

Each year, approximately 3 million people in the United States develop a pressure ulcer. Although a preventable complication, pressure ulcers are among the top 5 adverse outcomes in the acute care setting with the prevalence as high as 42% in the intensive care unit (ICU). The purpose of this systematic review was to evaluate the inclusion of the Braden Scale as part of a multicomponent pressure ulcer intervention protocol, or care bundle, to identify geriatric patients hospitalized in the ICU who were at risk for pressure ulcers. The Cochrane protocol guided this review; findings were reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Through a structured search strategy in 6 electronic databases, 409 studies were reviewed, of which 11 studies were analyzed and the data included in a literature review matrix for synthesis. Four key findings emerged from the data analysis: effective pressure ulcer prevention programs use a risk assessment, daily reassessment of risk, daily skin inspections, moisture removal strategies, nutritional support and hydration, and offloading pressure; the Braden Scale is effective in detecting pressure ulcer risk in the ICU; an evidence-based bundle is effective in preventing pressure ulcer development; and decreased risk for pressure ulcer development increases patient safety, improves quality of care, and reduces the overall cost of care. The findings from this project can result in positive change by providing the evidence to guide improvements in pressure ulcer protocols to increase the quality of care and decrease the incidence of pressure ulcers in the ICU.

<p>Förekomst av trycksår utgör ett omfattande problem inom hälso- och sjukvården fortfarande trots</p><p>kunskap om förebyggande faktorer som presenteras i litteraturen. Detta medför att det</p><p>förebyggande omvårdnadsarbetet avseende trycksår även i fortsättning kan vara en mycket</p><p>angelägen fråga för sjuksköterskan. Syftet i föreliggande studie är därför att belysa</p><p>omvårdnadsåtgärder som kan utföras i vårdbädden för att förebygga trycksår hos äldre.</p><p>Litteraturstudie valdes som metod. Sökorden; pressure ulcer, prevention, bed and mattresses,</p><p>scoles, skin-care, decubitus ulcer, aged och nursing används. För att elektronisk söka relevanta,</p><p>vetenskapliga artiklar i databaserna CINAHL och MEDLINE. Resultatet bygger på åtta</p><p>vetenskapliga artiklar som kvalitetsgranskades. Vid dataanalysen användes en modifierad form av</p><p>komponenten nr 4 i Viginia Hendersons omvårdnadsteori som teoretisk utgångspunkt. Resultatet</p><p>redovisas utifrån två huvudrubriker med två respektive tre underrubriker. Den första</p><p>huvudrubriken är: Hur kan patienter med risk för utveckling trycksår identifieras? Med</p><p>underrubrikerna: Sjuksköterskans kunskaper och bedömningsinstrument. Resultatet visar att</p><p>sjuksköterskan utför riskbedömningar för att identifiera patienter i riskzon men att dessa inte är</p><p>tillräckligt omfattande och att visa faktorer såsom födo-och vätskeintag saknas i bedömning.</p><p>Studien visar också att det finns många olika riskbedömningsinstrument (skalor) med olika</p><p>variabler för att identifiera patienter som ligger i riskzonen för att utveckla trycksår. Den andra</p><p>huvudrubriken är: Att hjälpa patienten inta lämplig kroppsställning när han / hon ligger samt att</p><p>växla ställning, omfattar underrubrikerna: intervall, position och hjälpmedel. Resultatet visar att</p><p>vändning på en tryckreducerande madrass leder till minskning av trycksår grad II-IV. Litteraturen</p><p>visar även att patientens position i vårdbädden inte bör överstiga 30 grader av huvudändan för att</p><p>undvika för höga tryck mot korsbenet generellt ger lägre tryck på patientens hud. Hjälpmedel som</p><p>rekommenderas för tryckavlastning på häl och korsben är exempelvis gelkuddar.</p>

Förekomst av trycksår utgör ett omfattande problem inom hälso- och sjukvården fortfarande trots kunskap om förebyggande faktorer som presenteras i litteraturen. Detta medför att det förebyggande omvårdnadsarbetet avseende trycksår även i fortsättning kan vara en mycket angelägen fråga för sjuksköterskan. Syftet i föreliggande studie är därför att belysa omvårdnadsåtgärder som kan utföras i vårdbädden för att förebygga trycksår hos äldre. Litteraturstudie valdes som metod. Sökorden; pressure ulcer, prevention, bed and mattresses, scoles, skin-care, decubitus ulcer, aged och nursing används. För att elektronisk söka relevanta, vetenskapliga artiklar i databaserna CINAHL och MEDLINE. Resultatet bygger på åtta vetenskapliga artiklar som kvalitetsgranskades. Vid dataanalysen användes en modifierad form av komponenten nr 4 i Viginia Hendersons omvårdnadsteori som teoretisk utgångspunkt. Resultatet redovisas utifrån två huvudrubriker med två respektive tre underrubriker. Den första huvudrubriken är: Hur kan patienter med risk för utveckling trycksår identifieras? Med underrubrikerna: Sjuksköterskans kunskaper och bedömningsinstrument. Resultatet visar att sjuksköterskan utför riskbedömningar för att identifiera patienter i riskzon men att dessa inte är tillräckligt omfattande och att visa faktorer såsom födo-och vätskeintag saknas i bedömning. Studien visar också att det finns många olika riskbedömningsinstrument (skalor) med olika variabler för att identifiera patienter som ligger i riskzonen för att utveckla trycksår. Den andra huvudrubriken är: Att hjälpa patienten inta lämplig kroppsställning när han / hon ligger samt att växla ställning, omfattar underrubrikerna: intervall, position och hjälpmedel. Resultatet visar att vändning på en tryckreducerande madrass leder till minskning av trycksår grad II-IV. Litteraturen visar även att patientens position i vårdbädden inte bör överstiga 30 grader av huvudändan för att undvika för höga tryck mot korsbenet generellt ger lägre tryck på patientens hud. Hjälpmedel som rekommenderas för tryckavlastning på häl och korsben är exempelvis gelkuddar.

Syftet med denna litteraturstudie var att beskriva riskfaktorer som påverkade uppkomsten av trycksår samt de vanligaste förekommande preventiva åtgärderna. Vidare var syftet att beskriva sjuksköterskans roll vid förebyggandet samt behandlingen av trycksår. De vetenskapliga artiklar (n=21) som ingick i studien söktes manuellt samt datoriserat via databaserna Blackwell Synergy, CHINAL, Elin@Dalarna och Elsiever. Inklusionskriterierna var att de skulle vara vetenskapliga samt av kvalitativ och kvantitativ design. Även litteraturstudier inkluderades. Artiklarna skulle vara publicerade 1990 eller senare och vara svensk eller engelskspråkiga. Resultatet visade att patienter med lågt nutritionsstatus och låga serum albuminvärden riskerade att utveckla trycksår. En annan stor riskgrupp var patienter i peri- och postoperativa skeden där operationstiden kraftigt inverkade på uppkomsten av sår. Även anestesiformen spelade roll. Trycksåren uppkom vanligen på hälarna och korsbenet. I preventativt syfte var evidensbaserade mätskalor viktiga. Även trycksårsreducerande madrasser visade sig vara betydelsefulla. Vidare framkom att hälso- och sjukvårdspersonalen visade ett svalt intresse för trycksår och att kvalitetssäkringen var bristfällig. Sjuksköterskan hade främst en informerande roll inom trycksårspreventionen. Såren rengjordes lämpligast med fysiologisk koksaltlösning och omlades med våt omläggning. Resultatet visade även att smärtanalyser i högre grad borde involveras i trycksårsbehandlingen.