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Turning and Reposition Patients to Prevent Pressure Ulcers

Abstract

A patient who spends most of the time in bed and is in a situation of immobility because of an illness, trauma or a condition of high dependency is exposed to a wide variety of complications that can affect different parts of the body, especially the skin. The study’s objective comes because of the increased cases of skin breakdown in the inpatient population despite interventions and measures in place. The study’s primary purpose is to benefit both the patient and the institutions to archive better patient outcomes and reduce the patient organization’s expenses. Therefore, research of the literature was conducted to find out how in immobilized patients, turning and repositioning them every two hours compared with not turning them affects skin integrity. The literature review favors the actual standard protocols and maintains that a postural change must be made to all immobilized patients every 2-3 hours to prevent skin breakdown. It is also necessary to reposition the body to keep it aligned, carrying out correct weight distribution.

Background

Methodology

This study is a systematic review of the literature that used electronic databases engineer Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar. The study used these keywords: skin integrity, pressure ulcers, immobilization, turning, and repositioning. In addition, eight comparative and quantitative cross-sectional studies were selected from the search results, and most of them used random control trials.

Review of the Literature

In a quantitative study performed in the Virginia Commonwealth University Medical Center in the cardiac surgical intensive care unit, staff implemented interventions to decrease hospital-acquired pressure ulcers. The goal of this study by Cooper et al. was to obtain zero new cases of bedsores. The nurses directing the research implemented a program of aggressive education and protocols to prevent pressure ulcers, including turning and repositioning. “Parameters such as life-threatening arrhythmias, refractory hypotension, acute hemorrhage, or the inability to recover within 10 minutes of turning were used to classify patients as “too unstable to turn” (Cooper et al., 2015, p. 78). According to the study, the National Pressure Ulcer Advisory Panel who visited the facility during the research was stunned with the positive results. Even though the study included other measures to prevent pressure ulcers, the results are consistent in that turning and repositioning are effective interventions to maintain skin integrity. Additionally, the study underlines that preventing bedsores comes with a financial advantage since the treatment of pressure ulcers is a burden for hospitals. The limitation of the study is that it was done with a small sample of participants in a specialized unit at the hospital, and there are no specific criteria for how turning and repositioning were implemented during the trial.

In like manner, Vanderwee et al.’s study support that repositioning is a recognized intervention for the prevention of bedsores. The study, conducted in several nursing homes in Belgic, was an experimental quantitative study and had two arms randomized control trials. The study took place during September 2003 and May 2005. The median age of the patients was 84, and there was a median number of 32 patients in each of the 84 participant wards. Patients were included for the experiment if they did not have pressure ulcer stage 2, 3, or 4 and if they were projected to be at the nursing facility for more than three days. Additionally, patients who developed not blanch erythema were also included in the study and monitored daily. After being entered into the study, patients were randomized to either the experimental group or the control group. Patients who belong to the experimental group were repositioned with unequal time intervals like this: semi-fowlers 30 degrees, right side lateral 30 degrees, semi-fowlers 30 degrees, left lateral 30 degrees. Patients lay for four hours in semi-fowler and two hours in lateral position. The sacrum area was checked to keep it pressure-free. In the control group, patients were repositioned using the same positions as the experiment group, but the duration of each interval was a total of four hours. The result of the study showed that “In the experimental group, 20 patients (16·4%) developed a pressure ulcer as compared with 24 (21·2%) in the control group” (Vanderwee et al., 2007, p. 63). So, the analysis of the data revealed no significant difference between the two groups. In other words, turning patient every two hours does not make a difference if it is done every four. However, the study highlights that this result is only applicable if the patient is in a pressure reducer mattress. If the patient is in a non-pressure reducer mattress, it is imperative to reposition the patient every two hours. Furthermore, the study is clear to recommend turning and repositioning patients early alone with the pressure-reducing mattress to further decrease the incidence of pressure ulcers. One of the study’s limitations is that it was impossible to blind the nursing personnel to perform the two turning protocols, which could have created some bias. Additionally, despite the large number of people who participated in the study, it was still not enough to make it powerful.

On the other hand, it was essential to review an experiment that evaluates lateral turning on skin-bed interface pressures in the sacral, trochanteric, and buttock areas. The study presented by Peterson et al. aims to establish if standard reposition practices in patients affect the skin interface pressure since decreasing the skin interface pressure is one of the primary interventions to prevent pressure ulcers. Additionally, the researchers of this descriptive and observational study wanted to know why pressure ulcer occurrence remains high despite applying standard preventive measures. The participant of the study were hospital workers, a total of 14 men and one woman. Participants were between the ages of 23 to 54. “Participants dressed in standard operating room attire were positioned supine, with their sacrum centered on the pressure-sensing pad on the bed. A calibrated interface pressure profile was acquired for each participant in the supine position (0° HOB).” (Peterson et al., 2010, p. 1558). An experienced ICU nurse oversaw turning each participant into right lateral or left lateral positions using wedges or pillows. The result of the study reveals that standard turning does not relieve areas of high pressure on the skin. As a result, these areas remain at increased risk for skin breakdown. Also, the pressure on the skin interface area is greater when the head of the bed is elevated even at 30 degrees. The study also illustrates some triple jeopardy areas where the skin pressure was never released, even when the patient was turned to both sides. One limitation of the study is that it was done in healthy adults who typically have better muscle tone, which could elevate the sacrum above the support surface, relieving the pressure. In addition, tissue interface pressure does not evaluate internal tissue pressures and capillary refills. Finally, this study leaves the door open to organized additional research to determine the best practices for turning and repositioning patients.

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