Pressure Ulcers Can Be Defined

Pressure ulcers can be defined as "lesions caused by unrelieved pressure, resulting in damage of underlying tissue," (Hart, Bergquist, Gajewski & Dunton, 2006, p. 257). Although pressure ulcers are preventable, they occur with a high rate of prevalence especially in elderly nursing care facilities (Wipke-Tevis, Williams, Rantz, Popejoy, Madsen, Petroski & Vogelsmeier, 2004). The Braden Scale is the most commonly-used means of determining patients who may be at risk for developing pressure ulcers, but the scale is not used enough in professional nursing settings. Likewise, interrater reliability (IRR) and rater-to-standard reliability tests both indicate that current pressure ulcer assessment methods are valid and reliable. The problem is not a dearth of research nor a lack of reliable assessment methods but a lack of nursing education and training in preventing pressure ulcers. Research-based assessment methods are inadequately employed in long-term and acute care facilities, especially those that address the needs of patients at risk for pressure ulcers such as the elderly. Intensive care, acute care, and neurological care patients are also at risk for developing pressure ulcers. Because they are relatively easy to detect and prevent, pressure ulcers are commonly used as a benchmark test to determine quality of care in geriatric and other specialized care facilities. For instance, a high rate of pressure ulcer prevalence may indicate cause for concern, drawing attention to the need for better training and education for nursing staff. Moreover, preventing and treating pressure ulcers is relatively simple and cost-effective. Simply adjusting patient bed position can be an effective means of preventing the development of a pressure ulcer. Performing regular assessments on patients can also prevent the development of pressure ulcers to minimize unnecessary discomfort, complications, and costs.

Author/Year

Vanderwee, K., Grypdonck, M.H.F., DeBacquer, D. & Defloor, T. (2006). The reliability of two observation methods of nonblanchable erythema, Grade 1 pressure ulcer. Applied Nursing Research 19: 156-162

Problem

Pressure ulcers remain a prevalent but preventable problem in nursing care facilities. Nonblanchable erythema (NBE) in Grade 1 pressure ulcers is the most severe manifestation of the condition. Risk-assessment methods are not always reliable and risk assessment does not necessarily accurately predict which patients will develop a pressure ulcer. Moreover, two different methods of observation are used to determine the presence of NBE: a finger method and the transparent disk method. Prior research has failed to determine which of these two methods is more reliable for observing NBE or how often the two methods yield similar results. Furthermore, prior research has also inadequately addressed interrater reliability (IRR) between researchers and trained nurses in observing NBE. The current research addresses weaknesses in prior research on Grade 1 pressure ulcers.

Purpose

The first aim of the current study was to "assess the IRR between the researcher and the trained nurses in observing blanchable erythema and NBE using the transparent disk method and the finger method," (p. 157). The second aim was to assess the level of agreement between the transparent disk method and the finger method," while the third aim of the current research was to "evaluate predictive validity of the two observation methods," (p. 157).

Variables

Independent Variables:

Presence of erythema at the heels, hips, or sacrum, the most commonly affected sites.

Researchers observed patients' pressure points with erythema each morning

Nurses observed patients' pressure points with erythema separately, thirty minutes after the researcher's observation

Use of both finger method and transparent disk method by both researchers and nurses

Dependent Variables:

Interrater reliability (IRR) between researchers and nurses in their observation of the erythema

Correspondence between results of observation methods: finger method vs. transparent disk method

Predictive validity of each of the two observational methods

Feasibility

Feasibility for the current study is high, based on the high rate of prevalence of pressure ulcers and NBE among patients in acute geriatric hospital wards. Moreover, nurses and researchers are both familiar with the appearance and risk factors associated with pressure ulcers.

Sample, Population, and Setting

Setting: 34-bed acute geriatric ward of a general hospital. Patients were assessed by both researchers and nurses during the morning hours.

Population: 265 patients with erythema at the heels, hips, or sacrum were eligible and participated in the study. All patients of the acute geriatric wards who met the criteria were included in the study. 57.8% of the participants were female and the median age was 88 years. None of the participants had dark skin, which might impact the reliability of the results. 87.5% of the nurses participating in the study were female.

Design/

Methods

The researchers observed patients' pressure points with erythema using both finger method and transparent disk method each morning. Thirty minutes later, nurses observed the same patients' pressure points with erythema using both finger method and transparent disk method. The researchers and nurses worked independently and the two observation methods were applied randomly, in no particular order.

The finger pressure method involves pressure on the erythema for three seconds. If the erythema blanches after the finger is removed the erythema is blanchable; if the erythema does not blanch then it is classified as an NBE. The transparent disk method is similar to the finger pressure method. However, instead of a finger, a standardized 4 x 4 cm disk is pressed on the erythema for 3 seconds. Pressure is equalized because the disk is applied evenly by holding it at the edge.

Researchers evaluated general patient data including age, gender, body mass index (BMI), and urinary continence. The Braden Scale was also used for risk assessment; the lower the Braden Scale score, the greater the patient's risk for developing a pressure ulcer.

Data

Collection

The software SPSS was used to randomize the application of the two observation methods, as well as to perform statistical analysis. Researchers and nurses catalogued their findings and the researchers used SPSS to input data and calculate results.

Data

Analysis

SPSS was used to analyze data, including the percentage of agreement between the two observation methods. "Sensitivity, specificity, PPV and NPV were also calculated as measures of validity," (p. 158).

Findings

Percentage of agreement between researchers and nurses was high, indicating high IRR. Correspondence between the results for finger method and transparent disk method was also high. When nursing educational background was controlled for, researcher found no differences in the results. Interestingly, the researchers and the nurses were more likely to disagree about male than female patients. Sensitivity was slightly higher for the transparent disk method and sensitivity was also slightly higher when observed at the heels rather than the sacrum. Specificity was almost equivalent between the two methods (95.5% for finger method and 95.6% for transparent disk method). Thus, overall agreement between the two methods was high. Results corroborate prior research and research hypotheses.

Strengths and Weaknesses

The current study did not include participants with dark skin, and NBE is more difficult to assess and observe in patients with dark skin. Therefore, future research is required to determine how the results can be generalized to a broader population. Another significant limitation of the current research is the possible influence of time in affecting the results of the observations. Researchers observed the patients a full half-hour in advance of the nurses. "Spontaneous healing" may account for some of the disagreements between researchers and nurses (p. 161). The research was also conducted on a limited population sample, in the acute care geriatric ward of a hospital. Future research should be conducted on a wider sample of patients in nursing homes and differential care facilities.

However, the current study did illustrate the high correlation between the two common types of NBE observation. Results have broad applications for nursing training programs. In particular, nurses should become more aware of the various methods used to diagnose NBE and pressure ulcers and apply those methods more readily. Training in NBE observation is relatively simple. Furthermore, prevention and treatment of pressure ulcers is also simple, suggesting that nursing staff can improve patient outcome with simple, low-tech, and inexpensive training.