Pressure Ulcers and Their Treatment

Pressure Ulcers and Their Treatment and Effects on Quality of Life: Hospital Inpatient Perspectives

Bedsores, which are also called pressure sores or pressure ulcers, are areas of damaged skin and tissue. These develop when sustained pressure usually from a bed or wheelchair, cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue ends up dying (Bedsores (pressure sores), 2007).

It is estimated that 1.3 to 3 million patients in the United States have pressure ulcers. The incidences are higher in older patients, especially those who are hospitalized or in long-term care facilities. Aging increases a patient's risk, in part because of reduced subcutaneous fat and decreased capillary blood flow. Immobility and co-morbidities also increase risk. Patients who are cognitively weakened or immobile are at increased risk. Immobility, because of decreased spontaneous movement or inability to change position frequently because of weakness is a very important factor. "Other risk factors include urinary and fecal incontinence; poor nutritional status, including dehydration; diabetes; and cardiovascular disease" (Pressure Ulcers, 2008).

Pressure ulcers are a significant health problem on which some research has been conducted. In the paper Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives one such research study is discussed. This study was conducted in order to explore patients' perceptions and experiences of the impact of a pressure ulcer and its treatment on their health and quality of life. The purpose of conducting the research in this paper is based on the idea that there is limited research on the impact of pressure ulcers on patients' health and quality of life.

Recently quality of life issues have attracted an increasing interest from healthcare professionals and researchers. There has been however, little agreement as to what the term actually describes. The term is often used as a substitute for physical health, functional ability, psychological well-being and social relationships. Interest in determining quality of life in relation to health care has increased in recent years. The purpose is to be able to provide a more accurate assessment of an individuals' health and of the benefits and harm that may result from health care. The term quality of life sometimes misleadingly suggests an abstract and philosophical approach. But most approaches used in medical contexts do not attempt to include more general ideas such as life satisfaction or living standards and tend rather to concentrate on aspects of personal experience that might be related to health and health care (Fitzpatrick, Fletcher, Gore, Jones, Spiegelhalter, and Cox, 1992).

The study in this paper was aimed at exploring individual patients' perceptions and subjective experiences of the impact of pressure ulcers and treatment on their health and quality of life. Two important points must be looked at when researching people's understanding of quality of life. First, people an illness or chronic conditions do not always report poorer quality of life than healthy individuals, and secondly, quality of life is related to individual expectations. Thus, the impact of pressure ulcers and their treatment has to be considered within the context of existing conditions. It also needs to be separated from the perceived quality of life that is related to other conditions.

The method that was used to collect data in this study which was semi-structured interviews, was well-suited with the purpose of the research which was to find out the following three things: 1) How people with pressure ulcers rate their health and quality of life?, 2) What were the patients' experiences with developing a pressure ulcer? 3) What are patients' experiences of pressure area care and treatment? Using interviews was the best method that could have been used in order to address the idea of exploring patients' perceptions and experiences and the impact of a pressure ulcer and its treatment on their health and quality of life. Semi-structured interviews are conducted with a rather open framework which allows for focused, conversational, two-way communication. They can be used both to give and receive information (Tool 9:Semi-Structured Interviews, n.d.).

In this study there was a set of criteria that was put forth in how the study was to be completed: Participants were informed of what the study was about, what would be involved if they agreed to take part in the study and how their narratives would be used and distributed. The participants were informed that they could choose to stop the interview at any point, without giving a reason. They were also reassured that their decision to take part or not would not affect any aspect of their care. Written consent was obtained from all participants and they were guaranteed of confidentiality and anonymity. To minimise the influence of the researchers, throughout the interviews they responded to issues raised by patients by checking meaning and understanding.

A purposive sample of 23 participants (five men, 18 women: age range 33 -- 92) from medical, elderly care, orthopaedic and vascular surgery wards in four hospitals were recruited. A purposive sample is a sample of people that are selected in a deliberative and non-random fashion in order to achieve a certain goal. The purpose may be to recruit subjects who have the best knowledge and experience in an area (What is a Purposive Sample, 2005). All participants were patients with pressure ulcers. Semi-structured interviews were used to gather data on patients' general health, their pressure ulcer and the impact of the ulcer and its treatment on physical health, functional ability, psychological well-being and social relationships.

All the interviews were recorded with participants' consent, transcribed verbatim and put into a qualitative data analysis management software package. To increase the validity of the research, two researchers were used to code the data, thereby ensuring the trustworthiness of the findings. By providing a clear account of data collection and analysis, and patients' quotes to support data interpretation, the researchers have enabled readers to judge the authenticity of their conclusions. A thematic analysis was used and themes and sub-themes were developed to be used in the analysis of the data. A thematic analysis is based on the identification of themes in qualitative material, often identified by means of a coding scheme. It is a widely used approach to qualitative analysis, generally treating accounts as a resource for finding out about the reality or experiences to which they refer, this is similar to interpretive content analysis (Look Up: Qualitative Thematic Analysis, n.d.).

Findings from qualitative research cannot be generalized into a larger group. Yet, the understandings gained from these participants may have transferability to other patients and settings. The validity of the findings can be judged by the transparency of the research process. The researchers found that it was not possible to differentiate the impact of the pressure ulcer in relation to length of time participants had suffered with their chronic condition. Information on chronic conditions came from the patients because the researchers did not have ethics approval to check medical records. Therefore the data was limited because patients did not always report their co-morbidities and patients were not always able to remember how long they had been diagnosed with a certain condition. It is thought that researchers in the future may wish to consider how to improve the collection of these data in future research.

Qualitative research looks for the why and not the how in regards to its topic through the analysis of unstructured information. Instruments that might be used are things like interview transcripts and recordings, emails, notes, feedback forms, photos and videos. This type of research doesn't just rely on statistics or numbers. Qualitative research is used to expand insight into people's attitudes, behaviors, value systems, concerns, motivations, aspirations, culture or lifestyles. Focus groups, in-depth interviews, content analysis and semiotics are a few of the many formal approaches that are used, but qualitative research also involves the analysis of any unstructured material, including customer feedback forms, reports or media clips (What is Qualitative Research, 2007).

The findings of this study showed that although the age range of the sample was quite broad (33 -- 92 years), 70% (n = 16) of the patients were aged over 70 (median age: 78 years). The majority (83%, n = 19) had been admitted to hospital for reasons other than a pressure ulcer and 21 (91%) reported that they had a chronic condition. The researchers considered it important to obtain descriptions of patients' health and quality of life, which could provide insights into their condition before they developed a pressure ulcer.

This study showed the suffering that pressure ulcers cause for patients, and highlighted the important areas of practice that need to be addressed by healthcare professionals. These include the management of dressings, providing information, undertaking preventative interventions and understanding the importance of comfort and positioning for patients. In addition, it is thought that healthcare professionals need to respond to patients' criticisms of their lack of involvement, or poor standards in the treatment, management and care of pressure ulcers.

Evidence-based studies that delineate how to manage and treat pressure ulcers have determined that the most effective approaches include keeping the wound moist, appropriate repositioning, using support surfaces, and proper nutrition. Non-traditional approaches, including electrical stimulation, hyperbaric oxygen, growth factors and skin equivalents, and negative pressure wound therapy, are also showing promising results (Resources for Managing Hospital-Acquired Conditions, 2008).

Organizational level activities for dealing with hospital-acquired pressure ulcers include:

developing and adhering to a written plan and procedure for preventing and treating pressure ulcers educating and training staff in the care processes associated with skin assessment, staging of pressure ulcers, prevention strategies, and treatment modalities carefully selecting and provisioning the necessary equipment and supplies to prevent and treat pressure ulcers the measuring and monitoring of pressure ulcer rates that depend on honest, transparent reporting of all pressure ulcers (Resources for Managing Hospital-Acquired Conditions, 2008).

The significance of this study in regards to nursing is made explicit when the author states that nursing staff play a major role in the prevention, treatment, management and care of pressure ulcers. Some of the preventive steps to reduce the prevalence of pressure ulcers either by the staff or attendants of the patients included: change of side or position (95%); removal of wrinkles from the bed sheet (60%) and use of cushions or air rings (55%). More than 50% nurses reported 'care of back' as a preventive step. In addition, cleanliness (35%); and massaging (25%) also help in the prevention of pressure ulcers. Although care of pressure points is a fundamental care activity many nurses are unable to adopt preventive measures dues to lack of time and low priority given to prevention of pressure ulcers in the clinical practice. Thus there is a great need to educate not only the nurses but relatives of the patients to adopt certain preventive strategies to reduce the prevalence of pressure ulcers (Vati, Chopra, and Walia, 2004).