Effect of comfort measures and repositioning on prevention of pressure ulcers in bedridden children

Transcription

1 Effect of comfort measures and repositioning on prevention of pressure ulcers in bedridden children Salam Jibanlata Devi, Sukhwinder Kaur, Sukhpal Kaur Abstract : Pressure ulcer is a pervasive problem among the patients who are immobile and debilitated. They cause a great deal of suffering and frustration to patients, their relatives and caregivers. They also increase the workload of the health care professionals and health care cost drastically. The development of pressure ulcers in children, however, has been less studied. The present study was conducted to assess the effectiveness of comfort measures and repositioning to prevent pressure ulcers in hospitalized bedridden children. Using purposive sampling technique, 40 bedridden children were enrolled in the study. Protocol on the use of comfort measures and repositioning technique were developed. Daily assessment sheet and repositioning schedule proformas were used to record the findings related to development of pressure ulcer. Braden scale was used to predict the risk of development of pressure ulcer. The intervention and daily assessment were continued till the patient got discharged from the hospital or for 14 consecutive days after identifying the children who are at risk of developing pressure ulcer. They were provided comfort measures and two hourly change of position. The caregivers of the identified children were trained regarding the intervention and were also provided with repositioning chart for documentation the time of positioning.more than half (55%) of the subjects were in the age groups of 1-48 months. 60% were males. About half (40%) of the subjects were suffering from neurological conditions followed by pulmonary and orthopedic problems, 10% had undergone surgery. On the day of enrollment 41.6% were on 'high risk' category and 20.9% were on 'Very high risk' category of developing pressure ulcer as per the Braden scale. On the 14th day of intervention the significant decrease was found in the number of bed ridden children falling under the 'very high risk' and 'high risk' category of developing pressure ulcer (x 2 =72.1, p<0.00).none of the child developed pressure ulcer during their hospital stay. Comfort measures and repositioning were effective in prevention of pressure ulcers in bedridden children.hence use of these measures along with regular change of position of bedridden children is recommended. Keywords Pressure ulcer, Comfort measures, Repositioning, Bedridden children. Correspondance at Ms Salam Jibanlata Devi Sister Tutor, Holy Family Hospital, Okhla Road, New Delhi-25 Introduction Prevalence rates of pressure ulcer(pu) as high as 27% have been reported among patients in Pediatric Intensive Care Unit and 20% in Neonatal Intensive Care Unit with most ulcers occurring within two days of admission 1. Among non-critical hospitalized pediatric patient prevalence rates of 0.47% - 13% and incidence rates of 0.29% - 6% have Nursing and Midwifery Research Journal, Vol-9, No.3, July

2 been cited 1-3.The pressure ulcer incidence rates have been reported as high as 20% - 43% in myelomeningocele patients 4,5.The most frequent sites of ulcer formation reported are the sacrum/coccyx, followed by heels and occiput 6. The development of pressure ulcers in children, however, has been less studied because of their presumed relative rarity as compared to adult population 7. However, a new focus in pressure ulcer research aims to determine whether pressure ulcers are, indeed, relatively uncommon in the pediatric population and takes into account the unique physiologic and psychosocial needs of children. Physiologically, fluid and electrolyte disturbances occur more frequently and develop more rapidly in infants and young children than in older children and adults. Thus they are at higher risk of dehydration,which may lead to breakdown of skin even with minimal trauma 8. Psychosocially, the very young child depends on caregivers for providing a safe physical environment that includes repositioning and turning. Children who do not have someone to turn and reposition them or children who do not have caregivers educated in the importance of repositioning are placed at a higher risk than those who have a knowledgeable caregiver. Knowledge of pediatric pressure ulcer prevalence is essential for planning a pediatric ulcer prevention and treatment program 9.The various comfort measures like pillows, cotton rings and hand rolls, play an important role in prevention of pressure ulcer by reducing the pressure from bony prominences and by redistributing the pressure to other areas of the body 10. Frequent positioning prevents the adverse effects of pressure, friction, and shear in the bedridden individuals. For most clients, maintaining current activity levels, mobility, and range of motion is sufficient to prevent pressure ulcers. For the immobilized clients turning and repositioning every two hourly helps the ischemic areas to recover thus prevent the development of pressure ulcers 10. The current study was conducted with the objective to assess the effectiveness of comfort measures and repositioning to prevent pressure ulcer in bedridden children. Material and Methods An interventional research approach was employed. Study was conducted in the medical and surgical ward (including neuro & ortho) of Advanced Pediatric Centre,PGIMER,Chandigarh. Permission was obtained from the head, Deptt.of Pediatrics, PGIMER, Chandigarh. Informed written consent was obtained from the caregivers of the admitted children.the research was approved by the Institute Ethics Committee. The tools used for data collection were survey proforma,identification and demographic data sheet, Braden Scale to assess the risk of development of pressure ulcers, daily assessment proforma to document the development of bedsore, and repositioning scheduled proforma. The total score of Braden scaleranges from Lower scores indicate a higher risk of developing pressure ulcers.the patient was considered to be at 'risk' of developing bedsore if the score was between15-18, at 'moderate risk' if the score was 13-14, at 'high risk' if the score was and at 'very high risk' if the score was 9 or Nursing and Midwifery Research Journal, Vol-9, No.3, July

3 less. Providing comfort measures (pillows, cotton rings and hand rolls) and repositioning the child every two hourly were the interventions used in this study. These were developed after consulting the relevant literature and under the guidance of experts in nursing education. The re-positioning schedule proforma was used to document the two hourly position change i.e. supine, left lateral, right lateral, semi-fowlers', prone position etc. In the absence of the researcher, the caregivers were asked to give position and document in the proforma. Initially a survey was conducted to identify the bedridden children who were at risk of developing pressure ulcer. Data was collected by interviewing the care givers and was entered in the survey proforma. Forty children were identified who were at risk of developing bedsore as per Braden Scale score. They were followed up till their discharge from the hospital or at maximum of 14 days. The interventions i.e. providing pillows, the cotton rings, and the hand rolls; and repositioning the child, were carried out for each subject by the investigator daily from 8AM- 4PM. The caregivers of the admitted children were trained regarding the use of all these comfort measures and repositioning technique, and they were asked to continue with the interventions for the rest of the day and night and to document in the repositioning schedule proforma. The researcher demonstrated and took return demonstration from the caregivers regarding the interventions during day time (8AM to 4PM). At any given time, the caregiver was either the mother or the father of the child. So, both were trained regarding the interventions and they were asked to carry on these in the absence of the researcher.the intervention and daily assessment were continued till the patient got discharged from the hospital or for 14 consecutive days. From day 6 th, the patients started getting discharge from the hospital. On day 14 th, only fifteen patients were left. All the bony prominences were assessed for the development of bedsores in the morning as well as in the evening by the investigator and the findings were recorded in the daily assessment proforma. Analysis was carried out using descriptive (mean, SD, and range) and inferential (x 2 test) statistics. Results Socio-demographic profile of the study subjects Table 1 shows the demographic data of the subjects. Age of the subjects was in the range of 1-79 monthswith mean age Table 1: Socio-demographic profile of the subject N = 40 Sample Characterstics n(%) Age(months)* <12 12 (30.0) (25.0) (20.0) > (25.0) Gender Male 24 (60.0) Female 16 (40.0) Habitat/Residence Urban 20 (50) Rural 20 (50) *Mean age (months) ±SD: ± 57.2 Range: 1-79 months Nursing and Midwifery Research Journal, Vol-9, No.3, July

4 subjects were in the age group of 1-48 months. Sixty percent were males. Half of the subjects each (50%) belonged to rural and urban areas respectively. Demographic profile of the caregiver Table 2 depicts the demographic characteristics of the caregivers. Majority (82.5%) were in the age group of years. Among the care givers 17.5% were illiterates and the rest had attained primary, middle or senior secondary schooling. Half of the subjects each (50%) belonged to rural and urban areas respectively. Fifty percent of the care givers had monthly income between Rs /- Table 2: Demographic profile of the caregivers N = 40 Sample Characterstics n(%) Risk of Pressure Ulcer (PU) as per Braden scores among the subjects Risk of development of PU as per Braden Score amongst the subjects at the time of enrollment in the study is presented in the figure 1. It depicts that 41.6% were in the 'high risk category', 20.9% in 'very high risk' group whereas 20.7% were in the 'moderate risk' of development of PU. Only 13.8% subjects were 'at risk' category at the time of enrollment in the study. Percentage(%) Age(yrs) (42.5) (40.0) >40 07 (17.5) Educational status Illiterate 07 (17.5) Residence Primary 11 (27.5) Middle 15 (37.5) Sr Sec. and above 07 (17.5) Rural 20 (50.0) Urban 20 (50.0) Family Income (Rs/month) (50.0) (25.0) >4001 Fig 1: Risk of PU as per Braden scale scores among the subjects Risk of PU as per Braden scale score and the diagnosis of the subjects A total of 435 observations were made for all the patients under study for the14 consecutive days or till the patient got discharged from the hospital. Significantly higher percent of the subjects with neurological problems (35.3%) were at 'very high risk' for the development of pressure ulcer as compared to the patients who had undergone surgery (17%),the orthopedic patients(16.2%), and the patients with pulmonary disorders (13.2%). (x 2 =72.1, p=0.01)(table-3). Nursing and Midwifery Research Journal, Vol-9, No.3, July

5 Table 3: Association of Risk of Pressure Ulcer as per Braden sale score and diagnosis of the subjects N = 435 Diagnosis At Risk Moderate High Risk Very High x 2, df, p- (n=60) Risk Risk Risk value (n=90) (n=181) (n=104) Neurological 9(4.7) 33(17.4) 81(42.6) 67(35.3) (n=190) Surgery 25(26.6) 18(19.1) 35(37.2) 16(17.0) 72.1, 9, (n=94) 0.01 Pulmonary 11(9.6) 30(26.3) 58(50.9) 15(13.2) (n=114) Orthopedic 15(40.5) 9(24.3) 7(18.9) 6(16.2) Usage of comfort measures among the subjects The subjects were provided with different comfort measures to prevent pressure ulcer irrespective of the category of the patients. Majority (97.2%)were given pillows, 83.9% cotton rings whereas only 23% were provided hand rolls. Pillow Cotton rings Hand rolls Percentage(%) Pillow Cotton rings Hand rolls Fig 2:Usage of comfort measures among the subjects Nursing and Midwifery Research Journal, Vol-9, No.3, July

6 Risk of Pressure Ulcer as per Braden scores among the subjects A total of 435 observations were made in 14 consecutive days on the subjects. As shown in table 5, from day 6 th onwards of observation, the general condition of the patients improved and children started getting discharged and were not at risk of PU as per Braden Scale. There was decrease in the no. of observations on the subject in the 'very high risk' category as the days progressed. None of the child developed pressure ulcer. Table 5: Risk of PU as per Braden scores among the subjects n=435 Braden scores Day At Risk Moderate Risk High Risk Very High Risk No. of n=60% n=90(%) n=181(%) n=104(%) Observations (1.1) 14 (7.7) 25 (24.0) (1.1) 18 (9.9) 21 (20.2) (6.6) 18 (9.9) 16 (15.4) (1.7) 8 (8.9) 20 (11.1) 11 (10.5) (6.7) 5 (5.6) 22 (12.2) 9 (8.7) (8.3) 10 (11.1) 18 (9.9) 5 (4.8) (13.3) 9 (10.0) 14 (7.7) 4 (3.8) (16.7) 7 (7.8) 12 (6.7) 5 (4.8) (18.3) 6 (6.6) 15 (8.3) 2 (1.9) (8.3) 8 (8.9) 10 (5.5) 1 (1.0) (8.3) 8 (8.9) 7 (3.9) 1 (1.0) (3.4) 9 (10.0) 6 (3.3) 1 (1.0) (6.7) 7 (7.8) 3 (1.7) 2 (1.9) (8.3) 5 (5.6) 4 (2.2) 1 (1.0) 15 Nursing and Midwifery Research Journal, Vol-9, No.3, July

7 Discussion: Pressure ulcers represent a major burden of sickness and reduced quality of life for patients and their care givers 11. Increased morbidity and mortality associated with pressure ulcer development in hospitalized patients is documented in multiple studies 12. Among long term care residents who develop pressure ulcer, mortality rates within 6 months have been reported up to 67% 13. Additionally, hospitalized patients who develop pressure ulcers are twice as likely to develop nosocomial infections and to acquire other hospital complications 14. Hospital length of stay, readmission rates and hospital charges are greater in patients who develop pressure ulcers 15. Identifying this burden of pressure ulcer among hospitalized patients,the present study was undertaken to analyze the effectiveness of comfort measures and repositioning technique to prevent pressure ulcer in bedridden children. The study was conducted in selected wards(medical & surgical)of Advanced Pediatric Centre, PGIMER, Chandigarh. Literature review revealed no standard protocol for the use of comfort measures alone,but these are used along with the positioning of the subjects. Hence, a standard protocol for every two hourly repositioning scheduled and use of comfort devices was developed and operationalized in the study. The pediatric population is at risk for skin breakdown and therefore pressure ulcer development. It is important to have an understanding of the underlying physiology of ulcer formation, the factors responsible for ulcer development, and the factors that put infants and children at risk for developing pressure ulcers. 16 The development of pressure ulcers in children has been less studied because of their presumed relative rarity as compared to adult population 7, but the literature also revealed that there are studies showing development of pressure ulcer occurring within 2 days of admission in children 1.Although there is no agreement about the size of the problem, there is evidence that critically ill children are more at risk of pressure ulcers than the general pediatric population. In addition to tissue damage associated with immobility, equipment and objects pressing or rubbing on the child's skin have also been implicated in the development of pressure ulcers. To prevent disfiguring and potentially lifethreatening pressure ulcers, it is important that risk factors are identified and minimized 17. In the current study, Braden scale was used to assess the risk of development of PU amongst the subjects. As per this scale,41.6% subjects were at 'high risk' and 20.9% were at 'very high risk 'category of development of pressure ulcer. Children suffering from neurological conditions like meningitis, encephalitis etc.were found to be at the greatest risk of developing PU. Children who suffered an attack of these infections getfully dependent on their caregivers, as their sensory perception as well as the mobility function is diminished. They are at the greater risk of developing pressure ulcers due to their prolonged confinement to the bed. This finding was supported by the study conducted by Nursing and Midwifery Research Journal, Vol-9, No.3, July

8 Iyun AO et al to assess the pattern of presentation of pressure ulcers in traumatic spinal cord injured patients in University College Hospital, Ibadan. They found that pressure ulcers were commonest in the sacral and gluteal regions and tend to occur within the first week of admission in the neurosurgical wards 18. Nursing interventions such as change in body position every 2 to 4 hours, use of blanket rolls, hand rolls, pillows, and cotton rings play an important role in the prevention of pressure ulcers. These strategies were found to be associated with less frequent development of pressure ulcers in pediatric intensive care. 19 In the present study, pillows, cotton rings and hand rolls were used as comfort measures and repositioning was done every two hourly. The caregivers were taught regarding use of these measures. There was a significant decrease in the number of bed ridden children falling under the 'very high risk' and 'high risk' category of developing pressure ulcer as per the Braden scale. None of the child developed pressure ulcer during their hospital stay. Similar findings are reported in the study by Horsley that pillow bridging i.e. supporting of bony prominences of patient above the bed surface through the use of pillows was a simple and effective method of prevention of pressure ulcer. The pillows are of low cost, acceptable and require no training and can be easily used by the caregiver 20.On similar lines Chang CH et al also conducted a program for lowering the incidence of pressure sores in neurosurgical patients. Cotton rolls were used to pad the pressure sites in this programme. It was found that the incidence of pressure sore in neurosurgical patients reduced from 9.5% to 7% 21. The findings of the current study are further supported by a study conducted by Schluer et al to describe the patients at risk as well as to identify the preventive and therapeutic interventions in a pediatric care setting. Repositioning was given as preventive action in 84% of the patients. 22 Krapfl et al also found that repositioning every 2 hours, when combined with an appropriate pressure redistribution surface was effective in the prevention of PU. 23 To conclude, it is emphasized that the use of comfort measures in the form of pillows, cotton rings, and hand rolls along with frequent repositioning of the bedridden patients is quite simple and easy to perform. These have been found to be effective in the prevention of bedsore development in the current study. These should be practiced regularly by the health care providers. Future studies may be carried out on large sample, for a longer duration and by having a control group. References 1. Curley MAQ, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients -the Braden Q scale. Nursing Research. 2003;52(1): Okamoto GA, Lamers JV, Shurtleff DB. Skin breakdown in patients with myelomeningocele. Arch Phys Med Rehabil. 1983;64: Nursing and Midwifery Research Journal, Vol-9, No.3, July

9 3. Baldwin K, Incidence and prevalence of pressure ulcers in children. Advances in Skin and Wound Care 2002;15: Schmidt JE. Skin breakdown in children with high frequency oscillatory ventilation. Archives in Physical Med & Rehab. 1998;79: Malloy MB, Perez-Woods RC, Neonatal skin care, prevention of skin breakdown. Pediatric Nursing. 1991;17(1): Pallija G, Mondozzi M, Webb AA, Skin care of pediatric patients. J of Pediatric Nursing. 1999;14 (2): Willock J, Hughes J, Tickle S, Rossiter G, Johnson C, Pye H. Pressure sores in children the acute hospital perspective. J Tissue Viability. 2000;10: Hockenberry MJ, Wilson D, Winkelstein ML, Kline NE. Wong's Nursing Care of Infants and Children, 7th ed. St. Louis: Mosby; Baumgarten M. Designing prevalence and incidence studies. Adv Wound Care.1998;8: DeLaune SC, Ladner PK. Fundamentals of Nursing, Standards and Practice. 2 nd ed. US: Delmer; Franks PJ, Winterburg H, Moffatt C. Quality of life in patients suffering from pressure ulceration: a case controlled study. Ostomy and Wound Management. 1999;45: Ducker A. Pressure ulcers: Assessment, prevention and compliance. Case Manager. 2002;13: Brown G. Long term outcomes of fullthickness pressure ulcers: healing and mortality. Ostomy and Wound Management. 2003;49(10): Allman RM, Goode PS, Burst N, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Advances in skin and wound care. 1999;12(1): Stauberg J, Kroger K, Maier I, Niebel W. Pressure ulcer in secondary care: incidence, prevalence and relevance. Advances in Skin and Wound care. 2005;18(3): Butler CT. Pediatric skin care: guidelines for assessment prevention and treatment. PediatrNurs. 2006;32(5): Willock J, Maylor M. Pressure ulcers in infants and children. Nurs Stand. 2004;18(24) Iyun AO, Malomo AO, Oluwatosin OM, Ademola SA, ShokunbiMT.Pattern of presentation of pressure ulcers in traumatic spinal cord injuredpatients in University College Hospital, Ibadan.Int Wound J. 2012;9(2) Schindler CA, Mikhaailov TA, Kuhn EM, Christopher J, Conway P, Ridling D et al. Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. Am J Crit Care. 2011;20(1): Horsley JA. Preventing decubitus ulcers: CURN Project. New York, Grune& Stratton, Chang CH, Chen HL, Chen HC. Program for lowering the incidence of pressure sores in neurosurgical patients. Hu Li ZaZhi. 2007;54(6): Schluer AB, Cignacco E, Halfens RJ. Pressure ulcer prevention therapy: results of a descriptive study. Pflege Z. 2008;61(3): Krapfl LA, Gray M. Does regular positioning prevent pressure ulcers?j Wound, Ostomy Continence Nurs 2008;35(6): Nursing and Midwifery Research Journal, Vol-9, No.3, July