CID1083 MSc Nursing - Snowball Technique

Chapter 1:

Introduction

Pressure ulcers (PU) are most commonly defined as localized injuries to the skin and/or tissues that underlie the skin, usually present over a bony prominence. The ulcer most commonly occurs due to pressure, often in combination with friction and/or shear. Some of the most common sites that get affected due to pressure ulcer are the skin regions that overlie the coccyx, sacrum, hips and the heels (McGinnis et al. 2014). However, some other sites that might also be affected include the elbows, ankles, knees, and the back of shoulder.Pressure ulcers usually occur due to burden that is applied to the different soft tissues of the body, thereby causing completeand/or partial obstruction to the blood flow in soft tissues. Shear is considered as a major cause for the physiological condition owing to the fact that shear forces pull on different blood vessels that are responsible for feeding the skin. Pressure ulcers have been found to most commonly develop in persons who follow a sedentary lifestyle and generally do not move about much, such as patients or disabled individuals who are confined to wheelchairs or are bedridden. Researchers and healthcare professionals hold the strong belief that a plethora of other factors are also responsible for influencing theforbearance of the skin for shear and pressure, thusgrowing the risks of development of pressure ulcer (Edwards et al. 2014).

Some of these factors are associated with microclimate(wetness of the skin that is caused due to incontinence or sweating), protein-calorie malnutrition, diseases that play a role in reducing the flow of blood to the skin, such as, arteriosclerosis, and other illnessesthat directly lower the perceptionpower in the skin, such as, neuropathy or paralysis. The time that is taken by an affected individual for the healing of PUoften gets slowed down with an increase in age of the patients, in addition to a range of concomitant factors such as, diabetes, smoking, infection, and/or medications namely, anti-inflammatory drugs. PU has been identified as a grave safety matter in healthcare systems in recent years (Kasuya, Sakabe and Tokura 2014). This can be attributed to the fact that the condition has been found to create an adverse impact on all patients, owing to the pain that it results in, and the time that is required for healing of the injury or wound. These ulcers are also responsible for greatly increasing the workload of healthcare professionals, due to which the costs of healthcare servicesincreaseradically. These ulcers have also been found responsible for death, under extreme situations (Fu Shaw et al. 2014). The period of compression that is tolerated by the skin, until there occurs a breakdown differs from one person to another, and tissue damage as a result of pressure ulcer are most commonly found to occur within less than two hours among patients who are incapable. Pressure ulcers are primarily caused due to inadequate supply of blood that leads to a reperfusion injury, upon re-entry of the blood into the tissues (Manorama et al. 2013).

One common example of mild pressure related soresare often experienced by healthy persons while they sit in same position for long periods of time. They report experiences of a dull ache that is generally indicative of an obstructing in the blood flow to the regions that are mostly affected. Within few hours of this condition, blood supply shortage, referred to as ischemia, leads to damage of tissues and/or cell death. The sores usually beginin the form of a red and painful sensation. Other events that have been found responsible for pressure ulcer development are instances when pressure is large enough to result in damage of the cell membrane of the muscle cells. This leads to subsequent death of the muscle cells, in addition to death of the skin that is fed through blood vessels that originate from the muscles (Coleman et al. 2014). This is usually categorised as a deep tissue injury type of pressure ulcer and appears in the form of a purple intact skin.According to data estimates provided by the NHS Safety Thermometer, 25,000 new patients had been identified to develop symptoms of pressure ulcer from April 2014 to March 2015. On average, an estimated 2,000 newly acquired instances of pressure ulcers are encountered every month withinNHS, in England. Aged population is more likely to suffer from pressure ulcer, especially people aged more than 70 years, and those who have been operated for a hip fracture. People having spinal cord injuries are another major group where the prevalence of PU is as high as 20-30%, following one or five years after the injury has occurred (GOV.UK 2018). Hence, healthcare professionals should have an understanding of the needs and demands of the community, individual, and population, in addition to thinking about the resources that are easily available in the healthcare facility. Obtaining relevant data regarding the prevalence of pressure ulcer in acute wards will help in identifying the specific quality standards that need to be implemented and coordinated across the acute care units, in order to encompass the complete pressure ulcer pathway. This research will further facilitate identifying the ways by which an appropriate system-based method can be utilised, with the aim of conducting investigation on the prevention measures and interventions, to reduce the prevalence.

Problem statement

The National Pressure Ulcer Advisory Panel (NPUAP) has divided pressure ulcer into four stages, depending on the severity of the condition. While stage 1 represents a condition where there occurs a reddened spot that is not blanched by pressuring and is often accompanied by edema, damage of the skin surface layers occur in stage 2. The epidermis and dermis usually get affected in the second stage (Edsberg et al. 2016). Thickness of the skin gets lost completely in stage 3 where the damage of the subcutaneous tissue often gets extended deep into the muscular tissues. This stage encompasses a clinical observation of the ulcer in the form of a deep cavity that generally gets extended to the adjacent tissues and requires a longer healing time. Complete skin loss, in addition to skin destruction and necrosis are the characteristic features of stage 4. This stage also comprises of secretory sinuses (Biglari et al. 2014).

Thus, the rate of infection that are associated with pressure ulcers are of prime concern due to the fact that staying in a fixed position for a prolonged time increases the likelihood of the condition getting aggravated (Cooper 2013). Shearing of skin most commonly refer to its separation from the tissues present beneath it. In instances when a patient is found to partially sit up on the bed, the skin gets stuck to the sheet or mattress, thereby making it susceptible to shearing forces. This generally happens when the underlying tissues go downwards along with the entire body, towards the bed foot. Friction is also damaging to the blood vessels that are superficial on the skin and is experienced when the two surfaces get rubbed against each other. Friction most commonly occurs an injury to the skin present over the elbows (Brienza et al. 2015). It also injures the back when the patients are slid or pulled over the bed sheets, while they are transferred from the bed to stretchers or wheelchairs. Upon exertion of pressure over a specific area of the body, primarily the bony prominences, the blood capillaries get obstructed as a result of which the tissues are deprived of their oxygen content and nutrients. This leads to the development of ischemia, edema, hypoxia, or inflammation, followed by ulcer. Patients are also subjected to development of PU due to moisture (Solovyev et al. 2013). Urine, sweat, fecal matter, and excess wound drainage often exacerbate the damage that pressure, friction and shearing forces create on the skin and its tissues. This directly contributes to a maceration of the skin surrounding the affected point, thereby potentially aggravating the deleterious impacts of ulcers.

PUs have also been associated with morbidity and infection caused due to Methicillin-resistant Staphylococcus aureus (MRSA), which in turn are directly responsiblefor increasing the length of stay at hospitals. Research evidences have established the fact that PUs ensue in patients, admitted across different healthcare units, which most commonly includes acute care wards. Acute care units generally comprise of surgical, medical, orthopedics, critical care, and elderly care wards. Placing focus on a specific healthcare setting such as, acute care ward, will facilitate the process of investigating the prevalence of pressure ulcer, through epidemiology (Beeckman et al. 2014). Acute care wards refer to those settingsin healthcare institutions where patients are provided medical care facilities, while they are recovering from any surgery or illness. Furthermore, due to the fact that acute care wards generally comprise of patients who are severely ill, and have restricted mobility or activity, they are more prone to be bedridden and develop pressure ulcers. These patients also report a loss of their sensory perception and circulatory/metabolic changes due to anesthesia and surgery. Pressure ulcers are largely responsible for several economic challenges to the allocation of resources in any healthcare system. The high costs of treating pressure ulcer patients every day have been found to vary from 1.71€ to 470.5€, across different healthcare settings (Demarré et al. 2015). Similar results have also been retrieved from the United Kingdom, where PU treatment costs were found to range from £1,214 for stage 1 patients to £14,108 for stage 4 patients (Dealey, Posnett and Walker 2012).

Use of biofilms are cited as one of the primary reasons that contribute to a delay in the healing of PU. Biofilm stall the wound healing process by maintaining an inflammation at the site of injury. Antimicrobial dressings and frequent debridement are essential for controlling the biofilms (Seth et al. 2012). This infection creates an impairment in the process of healing of pressure ulcers. Certain signs and symptoms that help in the detection of a pressure wound are presence of erythema, fever, edema, drainage and odor (Delmore et al. 2015). Erythema around a wound or injury results in the form of normal response of the body to the traumatic injury (Chan et al. 2013). However, presence of a poorly defined of erythema indicates infection. PU is also accompanied with systemic fever along with concomitant complaints of malaise. This in turn indicates the presence of infection, and an increase in local temperature, which is a direct result of inflammation. Presence of a sweet smell from the site of the skin that has been injured provides evidence for the presence of infection due to Pseudomonas. Proteus infection leads to a smell of ammonia gas.

Rationale

Some of the intrinsic factors that contribute to the incidence of pressure ulcer are illnesses that affect the mobility of a person. These mobility issues are commonly faced by people who have suffered from a spinal cord injury that have resulted in paralysis of the limbs Brain damage due to stroke or severe head injury or other conditions such as, multiple sclerosis, fractured bones, or a coma state make it difficult for a person to move freely.Poor nutrition that occurs due to dehydration and anorexia nervosa is another major contributor to the condition (Posthauer et al. 2015). Normal blood flow to the skin and underlying tissues are a direct manifestation of type 1 and 2 diabetes, and peripheral artery disease. The latter condition has been found responsible for restricting blood flow due to an accumulation of fatty substances in the major blood vessels (arteries) present in the legs. Furthermore, renal failure also leads to loss of all or most functions of the kidney that results in an accumulation of poison or toxin in the blood, thereby causing damage to the tissues. Some of the primary reasons that make an aeging skin more vulnerable to development of pressure ulcer is that the skin generally loses the property of stretching and elasticity, with an increase in age that makes it prone to get damaged (Qaddumi and Khawaldeh 2014). Direct effects of ageing are also associated with a reduction in blood flow and a lowering in the amount of fat that is present under the skin.However, there are a plethora of extrinsic factors that also increase the likelihood of a person of acquiring pressure ulcer. Pressure exerted by a hard surface such as, a wheelchair or bed that the patient has been using for a prolonged period of time in acute wards, is one major factor. Pressure on the skin is also exerted through several involuntary movements like muscle spasms (Anderson et al. 2014). Thus, the time that PU takes to develop in patients depends on the amount of pressure that is applied, and the vulnerability of the patient skin to the damage.

The development of PU can lead to several health complications. One of the most serious complication is onset of sepsis. Presence of a PU is most often accompanied with aerobic and/or anaerobic bacteremia, owing to the fact that these kinds of ulcers are one of the most common source of the infection. Further health complications of Pus also include cellulitis, localized infection, and osteomyelitis. Fair often, development of a non-healing PUprovides an indication underlying osteomyelitis. Several studies have been conducted that have successfully established a correlation between development of PU and patient mortality in both nursing home and hospital settings (Girard et al. 2014). Furthermore, mortality rates have been found to be as large as 60%, for the aged population, who generally develop an ulcer within a year of discharge from a hospital. Hence, it is imperative to conduct a careful assessment of PU among patients. Some other complications related with PU include depression and pain, both of which have largely been connected with reduced wound healing (McInnes et al. 2015).Long term non-healing PUs have also been found to result in the development of squamous cell carcinoma. This calls for the need of healthcare professionals providing ca

Under conditions, when the patients admitted to acute wards are found in possession of upper body strength, they should also be provided an assistance in wheelchair push-ups. Use of appropriate cushions and special pressure relieving mattresses that reduce pressure and ensure well-positioning of the entire body. In addition, adjusting the bed elevation at less than 30 degrees are another essential step that can be taken in acute wards. However, there exist several gaps in the theory and practice of pressure ulcer. Time and again researchers have identified presence of an inconsistency between the guidelines of PU prevention and management that are taught and those that are implemented by nurses, across a range of healthcare settings (Padula et al. 2014). These gaps are directly related to the clinical expertise and education that nurses have on prevention of PU and its elimination from acute medical wards. The fact that nursing colleges across the globe differ in the education and training they provide to the nursing professionals on the condition, significantly contributes to a major difference in the ways the prevalence of PU is perceived across the different countries. New graduate nurses often lack an empowerment and are not able to take necessary clinical decisions such as, adding a pressure relieving surface or preventing shear or friction forces in the affected people. Further gaps in research on pressure ulcer can be attributed to the risk factors that make a person susceptible to the condition. In addition, the range of risk factors such as, nutrition, moisture, shear, friction varies among people based on their geographical location, socio-economic condition, and employment status (Cremasco et al. 2013). People belonging to poor economic households most often resort to occupational roles that requires them perform manual handling tasks that increases risks of shear, in addition to inadequate nutritional intake (Bain et al. 2013). Furthermore, the risk assessment tools that are used in acute care units of developed nations often do not encompass all aspects that are necessary for long-term care of PU patients. Another major gap lies in the fact that developing countries have medical departments that are devoid of such risk assessment tools, or even if present, the nursing professionals do not have adequate knowledge on utilising them (Chou et al. 2013). This prevents detailed analysis of the skin of the affected people. Further gaps that established the need of conducting this research lie in the fact that there are discrepancies in the guidelines that are most often followed by clinicians and interventions that are supported by scientific evidences. Hence, identifying the prevalence of pressure ulcer across acute wards in different countries, followed by dissemination of the findings would help healthcare professionals to effectively manage the condition.

Research question

A research question is most commonly formulated in the form of an answerable inquiry of a specific issue or concern that acts as the preliminary step for a research project. The research question formulated for this systematic review is as follows:

What is the prevalence of pressure ulcer among patients admitted to the acute ward?

Research aim

The main aim of the research is to determine the rates of prevalence of PU in acute care units, by conducting a thorough and exhaustive search of available literature that are relevant to the research question. This would help to explore the size of the health problem in acute wards in hospitals and nursing homes, while taking into consideration the major contributing factors of its development, specifically in the target population.

Research objective

• Determine the prevalence of pressure ulcer in acute ward patients
• Investigate the impacts of pressure ulcers in acute ward patients
• Recognise the instruments that are used to classify PU status

Chapter 2:

Introduction

Methodology is a crucial chapter of dissertation. It helps the author to select the optimal ways or the steps which will be important in conducting the research towards the achievement of the research aims and objectives. According to Saunders and Rojon (2014), research methodology mainly highlights the philosophy underlying specific research approach. Chapter mainly aims to highlight the steps that the author will be using while conducting thematic analysis of the systematic review of the qualitative research. The approaches and the steps which are selected will be critically evaluated with detailed justification behind the reason for selection and the strengths of that specific approach in comparison to other research approaches.

The methodology of the systematic review will be based mainly be based on the research question and the type and design of the overall study will be reflected throughput the body of the systematic review and its methodology (Gough et al. 2017). As stated earlier in the Introduction chapter, the main aim is to determine the rates of prevalence of PU in acute care units. Therefore, in order to achieve the aim of the research, the author will follow objective rather than highlighting subjective realities.

Qualitative research

The main mode of the study selected by the author for this systematic review was qualitative research. Qualitative research deals with the study and understanding of the complex phenomenon via thematic analysis. It initiates via observation and then collection of data and thus helping to recognize the pattern of data (via themes) and thereby generating new theories about the present phenomenon (Ross, 2012).

Research philosophy

The main research philosophy selected for the qualitative research is interpretivisim. According to Bergh and Ketchen (2011), intrepretivism research philosophy is selected over positivism research philosophy in qualitative research because it helps to provide in-depth analysis of the small data via the use of themes.

Research approach

The research approach selected for this qualitative research is inductive research approach. Inductive research approach helps in the generation of new theory from the emerging information in comparison to deductive research approach which is based on the existing theory (Crowther and Lancaster 2012). Inductive research approach will help the research to compare the prevalence rate in pressure ulcers and this will help to generate new theory on the occurrence of pressure ulcers in different body parts.

Research design

The researcher selected descriptive type research design for this qualitative research. According to Ellis and Levy (2012), descriptive type research design helps in research to describe the relationship between the cause and effect. This is best suited in comparison explanatory and exploratory research design as these two research design do no provide scope of comparative analysis.

Literature search

The first step of the qualitative methodology for systematic review is the search of the literary articles in the electronic databases in an organised and in a methodological manner. Searching article in an organised manner will help the researcher to highlight relevant yet authentic studies which are already published online in esteemed scientific journals. The search of the articles was conducted in the electronic databases via the use of keywords.

Keywords

In the domain of conducting systematic review, Polit and Beck (2014) highlighted that before initiating literature search in the electronic databases, it is important to highlight proper keywords. Polit and Beck (2017) also highlighted that the keywords must be selected in such a way that it comprehensively covers the main concept of the research. The PICO framework was used for framing a clinical question, in relation to the systematic review. The PICO acronym has four components namely, P- population/patient; I- intervention; C- comparison; O- outcome. There was no intervention or comparison in regards to the clinical question being investigated. Thus, the research question was divided into the following two components:

Source: Created by author

The below mentioned table highlights the main keywords which are used by the author in order to search literatures from the electronic databases. The table also contains proper thesaurus terms that were used by the author in order to increase the number of hits in the database search.

Source: Created by author

Bibliographic Aids

According to Parahoo (2014), search of the literature is important in order to avail quick access to the information related to the research questions which are available online. The main medium selected for the collection of data includes online databases. Preliminary search of the relevant research articles were done via the use of the electronic databases like PubMed, MEDLINE, Cochrane and Ovid Full Text Nursing Plus and Cinhal. These specific electronic databases were selected for the search of the literary articles because the articles presented in these databases are mostly associated with the scope of the systematic review. According to Parahoo (2014), before initiating a systematic review of literature, it is crucial important to conduct a detailed search of the literary articles which are available online as reviews or meta-analysis or narrative review. This helps to mitigate the chances of getting duplicate work and thereby helping to make a novel research question. By taking this concept into consideration, the author conducted the search of literary articles in Cochrane Database for Systematic Review with the keywords which are highlighted in the above mentioned table. The search of the articles provided negative or zero hits. This signifies that there are no other reviews based on the presence of pressure ulcers which are published online in the form of systematic review. According to Holloway and Wheeler (2010) conducting a preliminary search in the Cochrane databases helps to highlight the research gap and thereby helping to figure out a novel research questions with an unique research approach.

Inclusion and Exclusion Criteria

According to the opinion stated by Aveyard (2014), having a distinct and clear plan for conducting research for the literary articles highlights that the search protocol have a specific focus on the aim of the search and no additional time is given to scrutinize the irrelevant information. Coughlan et al. (2013) further stated that formulation of the inclusion and exclusion criteria of the research helps to side-pass the unwanted wasted on time in search between irrelevant articles which falls beyond the scope of the research. Polit and Beck (2014) stated that selection of inclusion and exclusion criteria of the research while conducting systematic review must be done strategically. Proper selection of the inclusion and exclusion criteria helps to mark the boundaries for the review of literature. This selection approach also helps to reduce the number of irrelevant hits obtaining from the online database search of the literary articles. Parahoo (2014) stated that inclusion and exclusion criteria must be justifies. For example, exclusion criteria which is too specific lead to omit many relevant research articles which are otherwise helpful for the research and selecting inclusion criteria too board increases the overall time for screening of the literary articles.

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Justification between inclusion and exclusion criteria

Initially primary research articles were selected as the main inclusion criteria because Parahoo (2014) stated that results of the primary research articles are if high validity in comparison to the secondary research articles where reviewer bias can tamper the overall quality of the research. However, selecting only primary data for conducting literature review decreases the number of hits available for the research hence a revised inclusion criteria was selected and this includes both the secondary and primary research. Justification against this is cited by Coughlan et al. (2013) who stated that inclusion of secondary research articles helps to increase the provision of getting a summative overview of the prevailing trend in research. Initially the year wise filter was selected for the last five years 2013 to 2018. However, this five years window again decrease the overall search hits and 10 years window was selected in order to provide a detailed insight for the prevalence rate of pressure ulcer during the last 10 years. Both qualitative and quantitative data research articles were selected under the inclusion criteria in order increase the number of hits and this parameter was kept unchanged. Only peered reviewed journals were kept under the inclusion criteria as Polit and Beck (2014) stated that peered reviewed journals help to increase the overall strength of the systematic review. English was selected as the as the main language for the selection of article because it is the international language worldwide (Polit and Beck 2014).

Revised inclusion and inclusion criteria

Source: Created by author

Search Strategy

The search strategy used for the search of the literary articles were conducted by the combination of keywords highlighted below

Search Outcomes

Initially, the search was conducted in the Google Scholar. According to Gough et al. (2012, in order to conduct a complete search removal of the publication bias is important. Publication bias is defined as a tendency to incorporate studies with positive results in comparison to the studies which contain negative results. Thus in an attempt to include published trials Google scholar was used as universal electronic database. The outcomes obtained from the Google scholar is highlighted below

Figure: Screenshot of Google Scholar (Keywords: Prevalence, Pressure Ulcers and Hospital)

Source: Google Scholar (2008 to 2018)

Figure: Screenshot of Google Scholar

Source: Google Scholar (2008 to 2018)

The number of hits obtained from the broad keyword search (Keywords: Prevalence, Pressure Ulcers and Hospital) were 17,300 hits. The number of hits obtained via specific search results with quotes (“”) and via the use of Boolean search indicators (Keywords combination: "Pressure Sore" OR "Pressure ulcer" AND "Prevalence" OR "Occurrence" AND "Hospital" OR "inpatient" were 15,700 (time frame 2008 to 2018). Thus it can be said that the outcome obtained from Google Scholar was huge and this indicated that there were gamut literature published online which coincided with the scope of the research question drafted from the systematic review. However, accessing gamut data manually was not feasible. So in order to stringent the search further electronic databases were used. Betanny-Saltikiv (2012) highlighted that this kind of approach promotes further refinement in the literature search. Use of the limiters as indicated by the inclusion and exclusion criteria and the use of Boolean operators helped to obtained specific search.

According to Robband Shellenbarger (2014), use of Boolean operators is important in order to establish relationship with the keywords. In this systematic review, two types of Boolean operators were used by the researcher and these are AND/PR. The use of Boolean operators like AND/OR helps to obtain combination of different keywords (Polit and Beck 2014). Moreover, use of Boolean operators also assisted the researcher to save potential time via reducing the number of obtained hits. The search results obtained via Boolean operators are limited and this assisted the author to scrutinise the relevancy of the search results obtained manually.

Snowball Technique

The hits obtained via search of the articles in the electronic databases are comprehensive as they are updated regularly. However, while conductive systematic review of literature, it is important to use numerous other alternative methods for the search of the literary articles. Aveyard (2014) highlighted that using electronic databases for the search of the literary articles is not exhaustive as some significant literatures might side-pass from the hits obtained due to selection bias of the inclusion and exclusion criteria. Taking this concept into consideration, the after the articles were selected through electronic databases, the selected articles were reviewed. As a part of the review process, the reference lists of the selected articles were scanned. Any additional articles, which coincided with the scope of the research and the inclusion criteria, were included in the search results. This approach is known as Snowball Technique as highlight by Greenhalgh and Peacock (2005). This process helps the researcher to spot any unidentified research. According to Betanny-Saltikiv (2012), Snowball Technique helps to avoid the keywords and database bias.

The search of the articles was stopped when literatures arising from the database search were found to be redundant. Saumure and Given (2008) stated that this stage is known as “data saturatiaon”. At this point the literature search must be stopped in order to obtain rounded perspective. The overall search highlighted 50 main articles which were selected for the further analysis.

Quality Assessment

Quality Assessment was done in an ordered manner. The quality assessment was initiated via the removal of the duplicates from the search results. After removal of the duplicates, selected 50 articles were reviewed on the basis of their title. Parahoo (2014) highlighted that title of the literature should be considered perfect if it clearly describes aim to the study and study approach. The title of the articles which failed to satisfy these criteria was excluded from the research. The total number of articles which are obtained after the title scrutiny was 30. These 30 articles were scanned on the basis of their abstract and filtered out 17 odd articles. The rest articles were analysed full-text. In the full-text analysis, the selection bias, confounding bias, allocation bias and reporting bias along with sample size were taken into detailed notice. Of them confounding bias is of prime importance. Confounding bias generates when the nature of the participants both experimental and placebo or the control and the intervention groups are not identical at the time of selection. Confounding generally rise when another factor produces observed outcome rather than the investigated scope of the study. According to Parahoo (2014), poor sample size results in generating biased results. The full-text analysis highlighted 12 articles which were included in the final systematic review. Quality assessment however, fails to in-corporate source bias. It mainly analysed whether the design of the study aligns with the purpose of the study purpose and whether the sample size is specified and whether the methods of data collection is properly described (Boland, Cherry, and Dickson, 2014).

Figure- PRISMA Flow Chart

Source- Author

Conclusion

Thus from above discussion it can be concluded that research will use 12 research articles to conduct systematic review of literature with qualitative approach via using descriptive type research design, inductive research approach and interpretivism research philosophy. These 12 articles which were used for the generation of systematic review were selected from the esteemed electronic databases via the use of proper keywords along with inclusion and exclusion criteria.

Chapter 3:

Despite the mounting evidence of literature which have investigated the underlying factors that contribute to pressure ulcer (PU) among patients, admitted to acute wards and significance of PU, the health event is a matter of major concern. This chapter on literature review aims to scrutinize all the available evidences that represent substantial data on the prevalence of PU in critical care units, across different hospitals. The prime objective of the literature review is to recognise, evaluate and combine accessible knowledge that is produced by rigorous scientific research. Literature review is often termed as ‘research done on research’, with the aim of providing an overview and drawing conclusions from the obtainable findings.Hence, conduction of a literature review serves an essential platform for future research prospects. This literature review was conducted in the form of a systematic review. The procedure refers to the rapid collection of literature in relation to a certain clinical area (pressure ulcer prevalence), or a given policy. The primary aim of the review was to accumulate as much data as possible, and map results related to prevalence of the condition accordingly. This review was conducted based on a methodological framework(Treadwell et al. 2011).

Such a review comprises of different stages of data collection and assimilation. While the primary aim of stage 1 is to clarify the objective and purpose, thus linking the research question with them, stage 2 helps in balancing feasibility of the study with the richness and breadth of the entire process. An iterative technique was employed in stage 3 for selecting studies that were appropriate to the research question. This was conducted in a way that any other person undertaking the same selection would possibly end up with similar results. Stage4 comprised of data collection,followed by thematic analysis in stage 5. This was followed by taking into consideration the implications of the research findings to medicine practice and health care policies. The search process was entirely based on the research question and was plannedin careful manner. The essential problem of subject that was intended to be investigated was defined initially, followed by identification of the key concepts such as,‘pressure ulcer’,‘prevalence’,‘incidence’, ‘rate’, ‘hospital’. This was followed by selection of suitable electronic databases and performing the search process. Below given are the initial results of the studies that were evaluated based on their quality, reliability, and relevance to the research question:

A retrospective study had been conducted to investigate the prevalence of PU across Dutch general hospitals, since the year 2001. The primary objective of the researchers was to investigate the impact of different factors such as, prevention strategies of PU, patient characteristics, and structural quality indicators that were implemented by hospital wards and institutions for an apparent reduction in the prevalence rate of the condition from 2001-2008. The researchers collected data from the Dutch National Prevalence Survey of Care Problems (Also referred to as the LPZ database) from the year 2001 to 2008, with the aim of exploring the existing variations in characteristics of patients, the prevention strategies and the indicators. Health indicators wereassessedduring two different time periods namely 2005-2008, wherePU was evaluated as an external health quality indicator and during 2001-2004, where it functioned as an internal indicator. Upon comparing the results from 2001-2004, the authors found that there were fewer participants who reported hemiparesis/CVA (OR 0.485), surgery that lasted more than 2 hours (OR 0.637), infectious or contagious diseases (OR 0.861), and those who were at risk for Braden scale scores (OR 0.844). However, high prevalence was found for patients who reported diabetes mellitus (OR 1.693), corresponding to the 2005-2008 group. On comparing the results, the researchers also found that the hospital wards required more special mattresses or beds (OR 2.216) and specialised questions that were attached to wheelchairs (OR 2.277) during the second time period (2005-2008). This second time frame was also supported by an increase in information related to repositioning of patients, prevention of malnutrition and or dehydration in them, prevention of PU and information on its appropriate treatment. Further investigation suggested that more Dutch hospitals disseminated information leaflets and pamphlets on PUs (OR 5.894), prevention guidelines (OR 4.625), and formed committees related to its management during 2005-2008 (OR 2.503). An increase was also seen and the number of PU wound care nurses who were recruited at different wards during the time period (OR 2.434). This made the researchers conclude that the high prevalence of PU across Dutch hospitals after the year 2004could be attributed to differences that existed in characteristics of patients, and an improvement in the structural quality indicators and prevention strategies for PU (Amir, Meijers and Halfens 2011).

The increase in use of data related to prevalence and incidence of PU as indicators of quality of care and their effectiveness in formulating prevention protocols were identified by another group of researchers. The researchers tried to investigate the dilemma that was associated with measurement of the incidence and prevalence rates and suggested that there existed confusion over the definitions, the uses and implication of the terms. Although used interchangeably, the term incidence referred to the total number of new cases that were reported within a certain period of time in relation to a particular disease. On the other hand, prevalence referred to the total number of people alive with a certain disease during a particular period of time that was being investigated. The researchers also suggested that they often encountered difficulties in conducting studies on the incidence and prevalence of PU, in relation to different aspects namely, (1) collection and recording of data, (2) definition of the population being study, (3) identification of PUs, and (4) subsequent classification of PUs. The researchers also elaborated on the need for increasing awareness on the perils related to interpretation, evaluation and comparison of the incidence and prevalence rates. Some of the major indicators that were identified by them as effective prevention strategies were, a reduction in PU incidence and prevalence, decrease of treatment costs, presence of a prompt and effective monitoring or assessment, decreased risks of adverse effects of PU on the quality of life, and reduced litigation risks. Furthermore, the authors also illustrated that pressure also should be classified according to etiology, reverse staging, deep tissue injury, and non-blanchable erythema (Baharestani et al. 2009).

Another cross-sectional study was conducted in the year 2004 to determine the prevalence rates of PU across French hospitals. The researchers carried out the survey over a period of one week, across all public hospitals that were enlisted in the French National Public Hospital directory, of which 29 university hospitals were excluded. All patients, except those who were admitted to the outpatient, emergency, and accident departments were included in the study, following which questionnaires were sent to nurses, in order to determine the prevalence rates. Analysis of the questionnaires resulted in 93.5% response rates from an approximate 37307 inpatients, who were admitted to 1170 wards, present across 1149 hospitals.The mean age of all the respondents was an estimated 72.3 years, and 62% of them were women. 3314 patients reported confirmed presence of one PU in them, which resulted in a prevalence rate of 8.9 %. Records were obtained for a total of 4991 PUs and 64% of the patients reported only one PU. A minimum of two connected diseases were reported by 55% of the patient. Upon assessing the patients who reported one PU, the most common regions of ulcer formation were found to be the sacrum and the heels, with rates of 29% and 53%, respectively. Heel PU were frequent among patients who had obliterative arterial disease. Conversely, patients who reported incontinence in urine or fecal matter reported sacral PU, more commonly than others. Severe lesions were found among patients with multiple sites of PU. These findings made the researchers conclude that there was a stability or saturation in the prevalence of Pus, across inpatients in French hospitals, since a similar study was undertaken 10 years earlier, which also had a prevalence rate of 8.9 % (Barrois et al. 2008).

Similar cross-sectional study was conducted across two Swedish County Councils, in order to determine the prevalence of hospital acquired PUs. The entire study comprised of data collection conducted across a single day, on 1192 patients who were aged more than 18 years. Following conduction of a descriptive statistical analysis, the researchers found that 14.29% was the overall prevalence of PU among the patients, of which 11.6% was found among patients with HAPU, and 3.3% among those who had community acquired PUs. Majority of the cases of PUs were hospital acquired, with the prevalence of 78% and most of them were categorised to stage 1 that corresponded to non-blanchable erythema. 26% and 18% HAPU belonged tocategory 2 and 3, respectively that corresponded to partial thickness of skin loss, or full thickness of skin loss. Moreover, the most severe locations of HAPU were the sacrum, heels and the hips (32.6%, 37%, and 3.0%).Of the 11 cases of PUs that belonged to category 4, nine were located in the heels. This made the authors draw the conclusion that an increase in age, longer hospitalization period, less physical activity, reduction in sensory perception and problems associated with friction or shear were the major contributor factors to the high rates of HAPU among the patients (Gunningberg, Stotts and Idvall 2011).

Gunningberg et al. (2013) also conducted the first national survey on the prevalence of PU in municipality settings and County Councils in Sweden. They focused their study on the fact that only few countries in the Europe had effectively conducted PU prevalence researches that acted as a benchmark for evaluating the efficacy of the care that was being provided to patients in different hospital settings. The authors employed a cross-sectional study design that invited all municipalities and County Councils to help in the determination of the prevalence rates in the year 2011. A specific day was selected for collecting information from the PU survey that encompassed questions on age, gender, risk assessment, observation of skin, PU location, PU categories, and prevention strategies. After entering the collected data in the SALAR national database, an estimated 16,466 people were found to participate in the survey. The entire PU prevalence was 16.6% (2737 patients) for categories 1-4. A total of 2737 patients had reported cases of 3276 PUs. 11% (291 patients) of them provided responses that suggested the likely onset of PU, before they were admitted to the hospital units. The prevalence rates of PU differed from 17.8% in county hospitals to 15.5% in university hospitals. Furthermore, approximately 50% PU cases belonged to the category 1. The rates ranged from 9-31% in 21 different counties. Heels and sacrum were identified as the most affected regions. Of the 18,592 participants from the municipalities, 14.5% was the overall PU prevalence (2693 patients). Moreover, prevalence rate varied from 12.3%-21.9% for special housing and short-term care, respectively. Sacrum, feet and heels were the most affected regions among people in the municipality settings as well. At-risk people had a proportion of 26.1-34.7%. Furthermore, most person at-risks were not receiving bed repositioning (50.2–57.5%) or pressure relieving mattresses (23.3-27.9%).

Another study aimed to provide an estimate related to the costs that were associated with treatment of Pus, in the UK as per prices in the year 2011. The authors used resources with theapplication of a bottom-up methodology that was based on all the daily resources, which were required for delivering care protocol that reflected a good clinical practice. This approach was utilised by the authors for estimating costs of treatment, per episode of PU care for each patient,suffering from PUs that were of different levels of complication and severity. Findings from the authors suggested that the cost of treatment variedfrom £1214, for category 1 that corresponded to non-blanchable erythema to £14108, for category 4PU that was concomitant with full thickness tissue-loss, associated with exposed tendons, muscles, and bones. The average daily treatment costs varied from £43 to £374 for patients, and the presence of complications that needed additional diagnostic tests, increase in the length of stay in hospitals, and expensive pressure relieving surfaces, acted as significant factors in increasing the treatment costs. This made the authors suggest that PUs represented a significant rate burden to the patients and healthcare providers in the UK. These costs showedlikelihood to increase in future practice, with an increase in age of the population (Dealey, Posnett and Walker 2012).

da Silva Cardoso et al. (2010) also conducted a similar cross-sectional study to investigate the prevalence of PU across Brazilian hospitals. They based their study on previously conducted epidemiological research that assessed the incidence and prevalence of the condition in hospitals and long-term care units. Following approval from the Research Ethics Committee of the São Paulo Hospital (UNIFESP-EPM), the prevalence of PU was measured at two different time frames among all patients who had been admitted to the São Paulo Hospital, with 752 beds. The researchers primarily focused on acute care wards namely, intensive care, surgical, medical, and emergency units. On collecting information on the prevalence rates on June 16 and October 20, in the year 2004. Results collected on the first day emphasized on the presence of PU among 43 hospitalised patients among the total population of 376, thus indicating a prevalence rate of 11.4%. Conversely, data collected on the second day provided evidence for PU among 35 of 340 patients. This indicated a prevalence rate of 10.3%. The total number of days since hospitalization ranged from 1-224 days, with a mean average of 36 days. Further analysis made by the researchers suggested that the condition of the patients diagnosed with PU was the major factor that was evident in both the patient populations. Furthermore, most of the patients reported presence of a single PU (61.5%) and 47% of those were present in the sacral region. 32.7% PU prevalence was found in patients admitted to the ICU, on both the days. In addition, 8.7% PU was prevalent in the medical unit on the second day, and 22.7% in emergency department on the first day, respectively. These expected results made the authors recognize the need of formulating specific PU prevention protocols, in future practice.

Another study was conducted with the aim of determining the factors that played a role on the effects of PU on health-related quality of life of all patients (HRQoL). The researchers included adult patients having diagnosed with different categories of PU in any location, based on their stay in hospitals, community or rehabilitation centres. A purposive sampling method was adopted by the researchers for gaining an insight into the diversity and range of PU population that including severity, age, grades, location and experiences. Following collection of data by face-to-face interviews, results suggested that the age of the participants ranged from 22-94 years, with a mean age of 62.2 years. 56% of the participants were men and 19 had chronic disorders. The responses suggested that PU patients displayed an adherence to treatment only if they were assured of the effectiveness of the treatment in improving their PU condition. Continued hospitalization made the PU patients feel restricted and prevented their participation in leisure or social activities. Moreover, inconsistencies in management of PU also contributed to feelings of worry and anxiety among the patients. Inconsistent usage of different healthcare terminologies, differences in the time that the staff spent on wound care, and reduced patient satisfaction, when compared to burden of treatment were some of the major complaints made the patients (Gorecki et al. 2012).

Bernardes and Caliri(2016) conducted another cross-sectional study for recognizing PU point prevalence in different emergency units of a hospital. The researchers collected data on a single day, by showing adherence to the international guidelines and used the Braden Scale for assessing the PU risk in each patient. The age of the patients ranged from 20-90 years, with a mean age of 54.01 years. Distribution of the patients as per the prevalence of pressure ulcer was 16%, 3%, 4%, in the infirmaries, emergency rooms, semi-intensive units, respectively. Highest point prevalence of PU was reported in the ICU (75%), followed by 55.56% in the semi-ICU. Category 2 ulcers were found more among the patients (42.86%). This prevalence was followed by category 1 and category 3 ulcers, with a prevalence of 42.86% and 20.24%, respectively. Category 4 ulcers and subjective deep tissue injuries were found among 3.57% and 5.95% of the participants. Furthermore, most PU were found in the calcaneus region (28.57%), and sacral region (22.61%). Moreover, PU point prevalence was found to be 35.29% in the hospital after 4 patients reporting category 1 ulcer were excluded from the data findings. Besides, patients being diagnosed with PU reported increased length of hospitalization, when compared to their non-ulcer counterparts. The difference of p<0.0001 was statistically significant.The mean and median of PU patients was found to be higher for the total diagnosis. However, this difference failed to show a statistical significance (p=0.065).

Another study was conducted with the aim of determining the prevalence of PU among hospitalized patients in a tertiary public hospital of Jordan, in order to formulate effective strategies for avoiding harms and minimizing healthcare costs. The authors adopted a cross-sectional study design that was conducted over a period of four weeks in two different medical wards of the selected AlBashir hospital. The researchers calculated the prevalence rate as the total number of patients who were diagnosed with PU, divided by the assessed patients. 190 participants were included in the research, of whom 123 were identified to stay an an increased risk of development of PU. Over a period of five years, 30 PU cases were identified among the patients. Of these identified cases, 53% were men, and 75% of the patients were aged more than 60 years. Furthermore, the prevalence rate was approximately 24%. 8 cases (27%) reporred category 1 PU, followed by 13 patients (43%) for category 2, and 6 patients (20%) for category 3 pressure ulcers. In addition, 1 patient (3%) reported category 4 PU. Reports from 2 patients also reported mixed categories of the condition. Highest prevalence of PU was chiefly found in the sacral region(43%=13 cases), followed by the heel region (24%= 7 cases), hip trochanters (10%= 3 cases), calf (3%= 1 case), and multiple region (20%= 6 cases).Over a time frame of 4 weeks, the researchers could identify 29 new cases of PU. Furthermore, older people were found at an increased risk of PU development, when compared to their younger counterparts. However, the researchers failed to draw a significant difference between the prevalence rates based on gender (47% and 53%, p<0.6) (Alja'afreh and Mosleh 2013).

An exhaustive review was conducted by different researchers to discover the incidence, prevalence, costs, and risk factors of PU among persons having suffered spinal cord injury (SCI), in the developing world. The authors conducted a PubMed search of relevant scholarly articles that were published in English between the year 1998 and August 2014. They used search terms as ‘pressure ulcers’, and ‘spinal cord injury’ for retrieving important articles. This made them obtain 938 article hits. This was followed byreviewing the abstracts of pertinent titles, which when considered relevant were followed by a thorough analysis of the full texts. 10 scholarly papers were found to report a prevalence of PU 26.7 –46.2%. The mean prevalence rate was found to be 35.2%. A single article cited a prevalence rate of 30% that referred to a population paraplegic persons in Brazil. 37.5% prevalence was found among participants enrolled in a cross-sectional study conducted in Nepal that comprised of home visits of SCI injured people suffering from complete or incomplete paraplegia. The authors identified low educational attainment as a major risk factorfor PU development in patients who belonged to developed nations. Further analysis of the data findings suggested that developing nations also had low educational levels on an average, which in turn acted as a significant barrier to the condition (Zakrasek, Creasey and Crew 2015).

Keelaghan et al. (2008) conducted a study among patients who had been recently admitted to hospital units, with the purpose of investigating and comparing the prevalence rates of pressure ulcers. Comparisons were drawn between patients who were newly hospitalized across different nursing homes, with recently admitted ones from non-nursing home settings. They conducted secondary analysis of a study that was conducted across two inner city hospitals held in Philadelphia, between the years 1998 and 2001. All of the study participants were aged at least 65 years and had been admitted to emergency department in either of the two hospitals. The nurses also determined the presence of PU among the patients (categories 1–4) by conducting a visual skin assessment. This assessment was performed on the third day, after the patients were admitted to the hospital units. The nurses also collected data followinginterview,clinical examination, and review of medical records. 26.2% was the prevalence of already existing pressure ulcers during admission among people who were present in nursing homes, compared to 4.8% among patients who had been admitted to other living situations (OR= 5.5, 95% CI; 4.3–7.1). Following adjustment for the confounding variables, the link between admission of patients from nursing homes and prevalence of PU on admission showed a significant reduction (OR=1.51, 95% CI; 1.03–2.23). These results indicated provided evidence for the fact that admission of patients from a nursing home acted as a potential marker for risks of pressure ulcer.

An earlier study conducted by Fogerty et al. (2009) had provided evidence for a significantly high risk of PU diagnosis following hospital discharge of African Americans. These patients were found to belong to the higher age groups, and had already been diagnosed with specific medical disorders. The key objectives of the researchers were to (a) examine the demographics that were related to increased odds ratio (OR) among African Americans and (b) definepresence of medical risk factors among the African Americans. They queried the 2003 Nationwide Inpatient Sample database. Patients diagnosed with PU were recognized by release diagnoses, with the use of ICD?9 codes 707.0–707.09. African Americans demonstrated an elevated incidence for 28 recognized CCS risk factors (OR>2) for PU. The diagnosis of PU was found to occur more among African Americans, who belonged to the younger age group. Following conduction of a sub-analysis, the researchers failed to produce any significant difference in African Americans having pressure ulcers.

Another 3 year unit-specific analysis was also conducted to determine the prevalence of PU, in addition to results of the 2008 – 2009 International Pressure Ulcer Prevalence Survey. The key purpose of this cross-sectional, observational cohort study was to conclude findings from the International Pressure Ulcer Prevalence Survey (IPUP) that was conducted in the United States from 2008-2009. Additionally, the researchers also focused on data that was collected previously during 2006-2007for reporting unit-specific and general prevalence rates of PU, among patients admitted to acute care facilities. The overall prevalence and rates of PUwas found to be 13.5% and 6%, in the year 2008 (N = 90,398). Results that corresponded to the year 2009 were12.3 and 5% (N = 92,408). Furthermore,the overall prevalence rates in 2008 and 2009 were also found to be highest (22%) in long-term acute care. Rates of facility-acquired ulcers were maximum in adult patients present in intensive care units and fluctuated from 9.2%-12.1% forgeneral cardiac care and medical ICU units, respectively, in the year 2008. Corresponding results for 2009 varied from 8.8% (CCU) to 10.3% (ICU). Besides, 3.3% ICU patients acquired severe FA ulcers that were categorized to category 3, category 4, deep tissue injury, and eschar/unable to stage. An estimated 10% ulcers (n = 1,631) were recognized as device-related. The sacral or coccyx region (17%) and ear (20%) were the most affected areas. The findings made the authors conclude that the prevalence rates of PU were significantly low in 2008-2009, compared to 2006-2007 (Catherine VanGilder et al. 2009).

Similar study was also conducted by Shahin, Dassen and Halfens(2008) to assess the prevalence rate of PU across patients who were admitted to intensive care units. The authors conducted an exhaustive study of electronic databases such as, PubMed and CINAHL, for retrieving scholarly articles that were published from 2000-2005. Some of the key words that were used by the researchers were ‘pressure ulcer’, ‘decubitus ulcer’, ‘pressure sore’, ‘bed sore’, ‘incidence’, and ‘prevalence’. Findings of the review suggested that the prevalence of PU ranged from 4% in ICUs across Denmark, to an estimated 49% in Germany. The incidence rate was found to vary between 38-124%. Wide differences were observed in the incidence and prevalence of pressure ulcer among patients admitted to the intensive care units. Furthermore, the review also suggested that the sacrum and the heels were the most commonly affected parts of the body (25.2% and 39.4%, respectively). Besides, results presented in the scholarly articles suggested that the highest prevalence (56.9%) of PU was found among patients who had acquired some form of infection (commonly sepsis). Some of the most common factors that were identified to play a crucial role in the prevalence rates were length of hospitalization, age, mobility status and presence of moisture.

Owing to the fact that pressure ulcers have been recognized as a significant problem in healthcare facilities and patients, authors of another study attempted to evaluate the results of nine surveys that were conducted between the year 1989 to 2005, for assessing the prevalence rates of PU. During all of the nine surveys that were conducted from 1989-2005, all the clinical teams present in the participating facilities, were predominantly located in the US. Some of the surveys were conducted across healthcare facilities in Saudi Arabia, Canada, and Australia after 2003. The researchers primarily assessed the patients who had been admitted on specific study dates. The prevalence rate for nosocomial and overall PU ranged from 5.6% and 9.2% in 1989 to 10% and 15.5% in 2003 and 2004, respectively. The maximum prevalence of 8.5% nosocomial PU and 27.3% overall PU was acknowledged in the long-term acute care. Most frequently, PU were found located among patients at the heels (23.6%), sacrum (28%), and the buttocks (17.2%). The PU were more generally measured as category 1 and category 2 (>70%). However, patients having a darker skin tone (n = 162,296 in 2004 and 2005) reported a prevalence rate of 13% category 1 PU, in contrast to38% patients with lighter and 32% patients with medium skin tone. An estimated 48% of all the patients who had been diagnosed with PU and 48% of them who had nosocomial pressure ulcers were found to stay at no risk or mild risk (Braden scale scores>14) (VanGilder, MacFarlane and Meyer 2008).

Amir et al. (2013) also conducted a cross-sectional study with the aim of exploring the quality of PU care among patients who had suffered stroke and were admitted to a stroke-specialised hospital in Indonesia. The researchers included all the patients who were present on the day of prevalence measurement and used two questionnaires namely, the Dutch National Prevalence Measurement of Care Problems (LPZ) and the European Pressure Ulcer Prevalence Study Minimum Data Set for assessing the prevalence rates. Upon analyzing the responses of the aforementioned two questionnaires, the authors found that there was a high rate of prevalence of PU in the Indonesian hospital that included and excluded Category 1 (28% and 17%, respectively). More than half of all families and patients (56%) received proper education on PU prevention strategies and 74% of them reported that they were repositioned. However, this repositioning rate was irregularly managed by the families and nurses. Patients having category 1 PU did not receive any treatment. Treatment of category 2 PUs were done using 0.9% NaCl solution, for cleansing the wound, without application of dressings. Anti-microbial gauze dressings were used for treating category 3 PU. Category 4 PU was not reported among any patient.

Chapter 4:

Results

The procedure of thematic synthesis was used to combine the studies that contained information on prevalence of pressure ulcer (PU), followed by identification of key themes, with the aim of exploring the research objectives. This thematic analysis examined and recorded specific patterns within the data that were collected from the scholarly articles, and were considered essential for description of the phenomenon being investigated.

Theme 1: Following NPUAP and EPUAP classification pattern

The US National and European PU advisory panel have proposed the classification pattern for categorising PU, depending on their severity, with the help of clinical tools. 10 studies classified PU into different stages that have been proposed in the aforementioned two assessment tools. The study conducted by Amir, Meijers and Halfens (2011) used the EPUAP classification system for categorising PU that was found among patients enrolled in the Dutch General Hospitals. However, the major drawback of the study was that the researchers excluded category 1 PU, while determining prevalence of the condition among the patients, every year. Another study conducted by Barrois et al. (2008) use the NPUAP classification system for categorising an approximate 3238 cases of PU, among French hospital inpatients. Results of the study indicated that there were 32% cases of stage 1, 13% stage 2, 18% stage 3, and 18% stage 4 PU, respectively. Moreover, the classification system was also used for grading the types of ulcer among patients who reported only one such PU. Stage 1 and 3 PUs corresponded to 31% and 19% prevalence, respectively. While stage 2 PU that caused damage to the epidermis was found among 16% of the inpatients, those that resulted in granulation tissue were prevalent among 20% of them. The EPUAP Classification system was used, following a modification with the CALNOC prevalence procedure, in another study that determined PU prevalence in Swedish County Councils. Results presented by the researchers suggested that the overall prevalence of PU based on the classification system was 8.2%, 3.3%, 2.0 %, and 1.3%, respectively for category 1, 2, 3, and 4. The total overall prevalence of PU was found to be 14.9%, among all the patient, which included both community acquired and hospital acquired PU (Gunningberg, Stotts and Idvall 2011). Similar study was also developed with the use of EPUAP classification data, and made the researchers conclude that category 1 PU was found among 8.1% of the total participants (n=18592). While category 2 PU was found among 3% of the participants, category 3 and 4 were found in 2% and 1.3%, respectively of all people, included in the study (Gunningberg et al. 2013). In another study the in NPUAP Staging system was followed for grading PU, and results obtained from the cross-sectional studies suggested that 32.1% and 47% of the people were classified into stage 1 and stage 2 PU categories. Stage 3 and 4 were found among 13.4% and 2.2% of the patients (da Silva Cardoso et al. 2010).

The NPUAP PU Assessment tool was also used in a study conducted in AlBashir hospital of Jordan, where 27% had stage 1, 43% had stage 2, 20% had stage 3, and 3% patients reported stage 4 PU, respectively. Moreover, results from the study indicated that stage 1 and stage 2 PU were more prevalent among females, when compared to their male counterparts. On the other hand, stage 3 was found in equal proportion in both males and females (Alja'afreh and Mosleh 2013). Although the study conducted by Keelaghan et al. (2008) reported the prevalence of the different stages of PU among the nursing home residents who had been transferred to hospital, adequate information was not present, regarding which assessment tool was used by the nurses for determining the same.

In another research the stage 1 classification tool was excluded from the final findings, since the researchers argued that stage 1 PU was associated with subsequent data problem and substantial errors. Overall prevalence of PU in all US Healthcare facilities was 13.5%, 13.7%, 13.50%, and 12.3%, respectively in the year 2006, 2007, 2008, and 2009, respectively. Furthermore, the overall preference in acute care units was 13.3%, 13.4%, 13.10%, and 11.9% for the corresponding years from 2006 to 2009 (Catherine VanGilder et al. 2009).

The study that reported findings from the first International PU Prevalence™ Study followed the NPUAP classification system and categorised PU prevalence in four different stages from the year 1989 to 2005. While prevalence of stage 1 ranged from 39 % to 34%, those for stage 2 and stage 3 range from 39% to 37% and 14% to 7% respectively. Stage 4 ulcer prevalence was found to range from 8% to 7%, from 1989 to 2005 (VanGilder, C., MacFarlane and Meyer 2008). The EPUAP-NPUAP PU classification system was also used in a study conducted in Indonesia, where the prevalence of PU including category 1 was found to be 28%, while that excluding category 1 was 7%. Moreover, upon classifying the frequency of PU based on these category, category 1 (57%) was found to be the most prevalent, followed by category 2 (29%) and 3 (14%). None of the patients reported presence of category for PU wounds.

Theme 2: Methodological quality of the studies

Differences were observed between the studies that were included in the review, based on their characteristics and their methodological quality. While most of the studies were based on cross-sectional observations, some also utilised retrospective data for determining the prevalence of PU and their outcomes on the selected population. A cross-sectional approach was employed in nine of the included studies, for assessing the prevalence rate of PU among members of the target population. Barrois et al. (2008) adopted a cross-sectional research approach for assessing the rates of PU in the year 2004, across different French hospital and primarily used a methodology where data was analysed from a representative subset of a population at a specific point of time. The study conducted across the Swedish County Councils by Gunningberg, Stotts and Idvall (2011) and Gunningberg et al. (2013) also focused on cross-sectional study designs, where all participants from the County Councils and Municipalities were invited for determining the presence of PU among them. Both of these cross-sectional studies is involved collection of data across one day, with the use of different surveys that contained questions on risk assessment, gender, age, location of PU, its categories, prevention, strategies and skin observation. Similar cross-sectional design was also adopted across Brazilian hospitals for determining the incidence and prevalence of PU in long-term care units, and the data were collected with the use of a paper-based instruments, the records of which related on statistical analysis using chi-square test, Fisher's exact test, student's T test, and analysis of variance (da Silva Cardoso et al. 2010). Alja'afreh and Mosleh (2013) and Bernardes and Caliri (2016) also adopted this observational research design for recognising the point prevalence of PU in emergency units of different hospitals, and tertiary public hospital in Jordan, respectively.

The research that was based on concluding findings from the US based International PU Prevalence Survey (IPUP) also adopted a cross-sectional and observational cohort design for determining the overall prevalence of PU in the years 2008 and 2009. The quality of care that was provided to patients having suffered stroke, diagnosed with PU was also determined by another cross-sectional study conducted by Amir et al. (2013) in Indonesia. Therefore, it can be suggested that most of the studies had high methodological quality, owing to the advantages of a cross-sectional approach namely, the ease of gathering much needed information, cost-effectiveness of the design, collection of data on multiple variables within a snapshot of time, and ability to utilise the outcomes or findings for creating new theories. The study conducted by Amir, Meijers and Halfens (2011) utilised the retrospective approach where the primary aim of the research is to evaluate exposure to certain suspected risk factors of production factors, in relation to the outcome, specifically PU that was established at the beginning of the research. The primary advantage of conducting this kind of longitudinal cohort study is that it provides clarity regarding the temporal sequence of whether a certain exposure preceded the outcome that is being investigated, and facilitates calculation of incidence of a particular disease, with respect to the absolute risk relative risk and attributable proportion. However, measurement of incidence is not the primary focus of this systematic review.

One major disadvantage that can be attributed to the methodological quality of those scholarly articles that had employed retrospective approach is that it often becomes difficult to recognise an accurately exposed cohort and a corresponding comparison group in such studies. In addition, differential losses might also have added to bias in the results of the retrospective studies. A similar retrospective design was also adopted in two other articles that presented findings from a secondary analysis of data conducted in Philadelphia hospitals during 1998 and 2001, and nine surveys that were conducted between 1989-2005 (Keelaghan et al. 2008; VanGilder, MacFarlane and Meyer 2008).

The inclusion and exclusion criteria were not clearly defined in all of the studies. While the retrospective study by Amir, Meijers and Halfens (2011) clearly stated that adult patients (≥ 18 years old) in all acute care units were considered eligible to participate, the study by Barrois et al. (2008) included all placement except those who are admitted to the accident on emergency department. Patients belonging to the psychiatric, maternity/obstetric, skin, rehabilitation, and ENT units were excluded from the first study, based on expectations of low prevalence of PU cases in those units. Gunningberg, Stotts and Idvall (2011) also included patients aged ≥18 years, who were admitted before midnight to critical care, geriatric, medical-surgical or gero-psychiatric units, the day the study was conducted and excluded those from maternity, psychiatric or hospice units. However, Gunningberg et al. (2013) only mentioned that adult patients who had been admitted to the hospital on the day of data collection, prior to 7:00 a.m. were included in the study. Adult patients who had earlier been diagnosed with PU and who had developed the condition upon admission to Brazilian hospitals were considered to meet the eligibility criteria for another study that excluded psychiatric, obstetric, and paediatric wards from the data collection procedure (da Silva Cardoso et al. 2010). Similar inclusion and exclusion criteria were also defined by Bernardes and Caliri (2016) who included adult patients admitted on the data collection day and excluded those who were present in burn units. Alja'afreh and Mosleh (2013) and Keelaghan (2008) failed to provide accurate description regarding the inclusion and exclusion criteria that was followed during the data collection procedure. Although no exclusion criteria was provided by Amir et al. (2013) they clearly stated that all stroke patients who had been staying in the ICU, CVCU, and neurological units were included in the research. Thus, it can be stated that most of the studies included in the review were able to report adequately only the inclusion criteria that was followed. Adequate information on obtaining informed consent was also presented in the articles.

Theme 3: Location of the PU

The localised injuries of PU are most commonly found in sites that overlay the heels, sacrum, hips, coccyx, knees, elbows, and ankles. Barrois et al. (2008) stated that maximum prevalence of PU was found in the heels (53%) and the sacrum (29%) among the patients with obliterative arterial disease, and urine or fecal matter incontinence, respectively. Similar findings were reported by Gunningberg, Stotts and Idvall (2011) that the maximum prevalence of PU was found in the heels (37%), followed by the sacrum (32.6%) and the hips (3.0%). These results were consistent to the data presented in another study, where the sacrum (5.7%), foot (1.8%), and heels (4.9%) were identified to be the most affected regions, among people in hospital settings. The value of corresponded to 3.5%, 3.5% and 4.7% for the regions, among patients who were present in home or municipal settings (Gunningberg et al. 2013). In the words of da Silva Cardoso et al. (2010) 47% PU was found in the central region among patients, who had only one such ulcer in their body. Maximum cases of PU were found to occur in the calcaneus region (28.75%), followed by the sacrum (22.61%) in a cross-sectional study that was conducted across emergency hospital. Furthermore, the heels and the sacral plant were associated with maximum deep tissue injury (Bernardes and Caliri (2016).

These findings were consistent with study carried out by Alja'afreh and Mosleh (2013) in Jordan, where highest prevalence was found in the sacrum (43%), followed by the heels (24%), calf (3%), and hip (10%). PUs were most commonly found in the sacrum (39.2%), heels (19.6%), ischium (14.6%), and trochanter (5%), among residents of a nursing home who had been transferred to a hospital (Keelaghan et al. 2008). Analysis of a 3 year-unit specific research made the researchers conclude that PUs were most prevalent in the sacral region (17%) and ear (20%) among all the patients. These findings were consistent with those presented by Shahin, Dassen and Halfens (2008) who identified the heels and sacrum to be the most affected regions of the body (39.4% and 25.2%, respectively). VanGilder, MacFarlane and Meyer (2008) also provided exhaustive evidence for the fact that the sacrum (28%), heels (23.6%) and buttocks (17.2%) were primarily affected among patients being diagnosed with PU.

Discussion

Impacts of pressure ulcer

Pressure ulcers are considered as a significant health problem in most parts of the world, not only due to the financial constraints that they put on the patient and the healthcare providers, but also in terms of the pain, human suffering, loss of productive time, disfigurement, and changes in body images that follow the condition. From the articles discussed above it can be stated that PU is widely prevalent among people who are admitted to acute units in all hospitals, which in turn creates an impact on their overall wellbeing, health related quality of life (HRQoL), length of hospitalization and health care costs. A retrospective population-based study was conducted with the use of the minimum Data Set Health Assessment among long-term care residents, in Ontario who had been subjected to these assessments from May 2004- November 2007. Analysis of the results suggested that an estimated 9% of the total 16531 LTC residence had been diagnosed with PU that corresponded to Stage 2 or higher degree. 0.26 ± 0.13 and 0.36 ± 0.17 were the mean ± SD MDS-HSI scores, for all the residents, with or without PU. Furthermore, the factors that were associated with the highest prevalence comprised of female gender, increase in age, and previous presence of PU, recent fracture in the hip, presence of multiple comorbid conditions, incontinence, end stage disease, and clinical depression. All of the mentioned factors contributed to a low health related quality of life among all the LTC residents, who had been diagnosed with ulcer, when compared to their known non-ulcer counterparts (Thein et al. 2010).

The findings presented by Lala et al. (2014) suggested that presence of PU among 381 individuals resulted in a reduction of daily activities to some extent (65.3%) among the people. PU was also found to reduce ability of all individuals who had suffered from spinal cord injury to actively participate in 19 of the 26 enlisted daily and community activities. Moreover, the findings also suggested that individuals who had been diagnosed with one or two PU reported more dissatisfaction with their disability and incapability to take part in activities of daily living, when compared to those people who did not have any PU (p=0.0077). Pus increased prevalence were also correlated with a significant number of consultations with nurses, family, physicians, wound care nurses, specialists, and occupational therapist, thereby providing evidence for the high healthcare costs that are associated with the condition. Iizaka et al. (2010) also conducted a study to investigate the impact that nutrition related factors and nutritional status created on the severity and development of PU that were acquired in home settings. The data collected by the researchers established a strong correlation between malnutrition and higher rates of ulcer, following and adjustment of the other risk factors (OR-2.29, 95% CI; 1.53-3.44). Besides, after assessing the nutritional status of all the enrolled patients, the researchers established an association between adequate dietary intakes with lower odds for developing the condition. Severity of PU was also considered to be a major manifestation of malnutrition among patients who were present in home settings (OR= 1.88, 95% CI; 1.03-3.45).

Results from another retrospective observational study that was conducted among 3198 patients who were aged more than 75 years at a German university hospital suggested that 7.1 % of them had a quiet PU during their stay in the hospital. Of these, 7.3% were classified into categories 1 and 2. While the mean age for all the patients was 81.6 years, those for PU patients 83.2 years. The impacts of PU were associated with an increased overall stay in hospitals (19.0 vs 9.9 days) and excess length of stay (.6 vs 0.3 days). A statistically significant association was established between hospital acquired PU and the increase in the length of hospitalization among the affected patients, when compared to those who had acquired ulcer at the time of hospital admission (p=0.0011) (Theisen, Drabik and Stock 2012). According to Pieper (2012) PU prevalence was considered as a second diagnosis for an estimated 300,000 patients and accounted for more than $43,180 costs related to hospitalization. Data findings established the fact that facility associated pressure ulcers were responsible for an increase in length of stay, subsequent increase in risk of developing health complications, and resulted in a delay in the recuperation of all patients. Besides, the data presented in this study were also able to establish the fact that hospitalization is most often required for severe PU, due to the need for surgical repair or debridement for sepsis treatment.

Nursing knowledge and attitude on pressure ulcer

One major consideration that needs to be taken into account from the thematic analysis is that all nursing professionals should hold adequate knowledge and a positive attitude towards prevention of PU in all patients whom they deliver care. Results presented in a cross-sectional study conducted across Belgian hospital suggested that the prevalence of category 1-4 PU among 2105 patients was approximately 13.5% (n=284). However, as much is 30% of all the patients (n=625) were found to be at a risk (presence of PU and or Braden score <17). The findings suggested that only 87 of the 625 patients (13.92%) had received adequate prevention strategies when they were seated or present in bed. The mean attitude and knowledge score among the nurses working in the Belgian hospitals were 71.3% and 49.7%, respectively. The authors failed to establish any independent correlation between nursing knowledge and application of appropriate intervention strategies. Hence, the findings provided enough evidence to suggest that knowledge among the nurses working in Belgian hospitals on PU and its treatment was quite inadequate (Beeckman et al. 2011). These findings were consistent with those presented by Demarré et al. (2012) who conducted similar study across Belgian nursing homes and stated that only 6.9% of the nursing home residents, found at risk demonstrated adequate compliance to the prevention strategies. The mean knowledge scores were 28.7% for all nursing assistants, in comparison to 29.3% of the nurses. Significant differences were also observed in their overall attitude scores, with a total score of 74.5%. The nursing professionals were found to display a positive attitude towards prevention of PU, when compared to nursing assistants (78.3% vs 72.3%, respectively). This made the authors conclude that positive attitude among nursing professionals acted as a significant predictor for showing compliance with the prevention guidelines on PU, which were provided to all the residents who were identified at an increased risk of development of the condition.

On assessing the knowledge and attitudes towards prevention of PU among patients, admitted to intensive care units (ICUs), researchers of a particular study found that the means scores for attitudes were 34 ± 4. The research findings made the authors identify that 48.6% of the nursing professionals were able to correctly categorise PU based on their severity, with the use of assessment scales. However, the enrolled nurses demonstrated less capability of correct categorisation of the condition. Preventive measures that were most commonly known to the nursing staff were adequate nutritional support (36.1%) and pressure relief systems (97.3%). In addition, some of the major barriers that were reported by the nurses that impeded the delivery of appropriate care services to PU patients were severity in illness of the patient (28.9%), lack of proper time (57.8%), inadequate access to pressure relieving mattress and other equipment (35.5%), and poor knowledge (38%). These findings also highlighted on the fact that increasing the knowledge among nursing professionals would serve as an essential step towards prevention of PU (Strand and Lindgren 2010).

The results were in accordance to the findings presented by Iranmanesh et al. (2011) that elaborated on the fact that the nursing professionals enrolled for the study could correctly provide answer to 54.36% of the questions that were administered to them. The results of the study showed that the category of PU evaluation had 83·35% correct answers, highest in comparison to other categories. This insufficiency in the level of knowledge about PU among the nursing professionals therefore calls the need for increasing an awareness and creating provisions for adequate training and education. These would help them identify the underlying factors and pathophysiology associated with the condition and implement appropriate intervention strategies in their future practice.

Approximately half of the nursing staff demonstrated good knowledge (54.4%) and 14.4% of them manifested adequate practice on prevention of PU, in another study that was conducted in Northwest Ethiopia. Significant correlation was established on knowledge on PU prevention with work experience (OR = 4.8, 95% CI; 1.31-10.62), formal training experience (OR = 4.1, 95% CI; 1.29-9.92), and educational status (OR = 2.4, 95% CI; 1.39-4.15). Moreover, satisfaction with the leadership exhibited by nursing seniors, inadequate equipment and facility for pressure relief and shortage of staff were associated with reduced practice and poor attitude towards the condition among nurses (Nurut al. 2015).

Upon conducting a similar cross-sectional multicenter study across four hospitals situated in Jordan, the researchers found that experience of all the participants (nursing assistants and registered nurses) were significant factors that created a positive attitude among them regarding the prevailing condition. An increase in the number of years of professional experience was significantly correlated with enhancement of positive attitude. However, showing similarity with the previously discussed study, lack of time management (83.6%), severity of patient conditions (68.6%) and inadequate nursing staff (86.2%) acted as major barriers to the practice.

Nursing implications and preventive strategies in pressure ulcer

According to Chou et al. (2013), PUs are associated with substantial health burden but it is preventable. The review of the literature highlighted that PU significantly affect the health-related quality of life (HRQoL) of the patients. So in order to improve HROoL, the first attention that comes into consideration in nursing implication include therapy plan for the prevention and cure of pressure ulcers. The systematic review conducted by McInneset al. (2015)highlighted that use pressure-relieving support surfaces like beds, mattresses, seat cushions can be used to prevent the occurrence of pressure ulcers in elderly patients who are suffering from chronic illness and are bedridden for a prolong period of time. McInnes et al. (2015) mainly stressed over the use of high-specific foam mattresses in comparison to the standard foam mattresses available in hospital for the prevention of pressure ulcers. However, the study failed to highlight relative merits of higher-specific low pressure constant and alternating-pressure support surfaces in reduces the chances of developing pressure ulcers. McInnes et al. (2015) further recommended that the nursing professionals must use foams for the pressure reliefs in order to treat high-risk patients in the operating theaters. In relation to the use pressure mattress, Chouet al. (2013)stated that advanced static support surfaces are more effective in comparison to the standard mattress for the prevention of ulcers among the higher-risk population. However, Gillespie et al. (20114) highlighted that thought the use of foam mattresses might be regarded as an effective means of controlling pressure ulcers especially in the hips and the low-backside of the body but it at times turn out to be cost. It that case, one of the effective intervention proposed by the Gillespie et al. (20114) include repositioning. Gillespie et al. (20114) highlighted that bed sores or the pressure ulcers mainly results from rubbing or friction over the weight bearing bony points of the body like the heels, elbows and the hips. Repositioning can be regarded as an important cost effective strategy that can use used alongside with other effective preventive strategies in order to relieve pressure and thereby relieving pressure ulcers. Repositioning mainly involves moving the person in different position in order to redistribute the pressure from any specific part of the body. However, Gillespieet al. (20114)failed to highlight any particular position which is effective in comparison to others towards preventing PU. Callet al. (2015)highlighted the use of proper wound dressing in preventing PU. Call et al. (2015) stated that use of wound dressing helps to reduce the amplitude of shear stress and friction damaging the skin of the patient’s a risk. The use of wound dressing mainly causes re-distribution of pressure based upon the effect of Poisson ratio and greater area of deflection and thereby providing greater load redistribution. Other preventive strategy of pressure ulcers include use of antibiotic, negative pressure wound therapy and reconstructive surgery (Bhattacharya and Mishra 2015).

The study conducted by Gorecki et al. (2012) highlighted that the patient only accepts to adhere to the treatment only if they are assured about the effectiveness of the treatment in improving their overall condition from debilitating PU. Moreover, inconsistent management of PU also contributes to the generation of anxiety, depression and loss of hope. Moreover, patient also feels restricted as occurrence of PU limits their social activities which further increase the level of depression and a sense of social isolation. Inconsistent use of complex healthcare terminologies increases the confusion about the overall therapy plan and thereby decreasing the overall healthoutcome (Gorecki et al. 2012). So it is the duty of the nursing professionals to explain the concept of treatment of pressure ulcer to the patient’s before in clear and understandable language. According to Hibbard and Greene (2013) proper explanation of the care plan to the patient equates to patient activation along with understanding of one’s role in the care process and this increases the adherence to the treatment along with patient engagement which leads to the overall increase in the therapy outcome. This concept is extremely significant during the process of skin grafting. Proper explanation to the patient about the necessity of skin grafting in treatment PU increases patient participation in the care process. A successful skin grafting not only provides therapeutic benefits but also helps to increase the health related quality of life of the patients along with increase in the overall self-esteem(Lourenco et al. 2014). Salomé, Blanes and Ferreira (2014) tested the efficacy of skin-grafting along with nursing counseling with patient with venous leg ulcers and found to record improved outcome in comparison to the compression therapy done by Unna’s boot.

Taking into consideration of the high rate of occurrence of PU in the acute ward, it is better to conduct risk assessment in order to denote the high risk patients for PU. Moore and Cowman (2014) stated that the use of pressure ulcer risk assessment tools helps in comprehensive assessment process in order to identify patients who are at risk of developing pressure ulcer. Moore and Cowman (2014) mainly stressed over Braden risk assessment toll over successful risk assessment of PU. Moore and Cowman (2014) are of the opinion that risk assessment tool helps to provide standard results in comparison to other tools which are denoted to be unstructured. However, detection of at risk patients does not reduce the risk of developing PU. Only proper application of the nursing interventions like pressure bed or repositioning along with proper mental counselling helps in reducing the occurrence and chornicity of PU. Sving et al. (2014) state that the chances of developing PU increases with age however, nursing professionals plays less significant role in determining the high risk patients and this increases the overall prevalence rate of PU. So the healthcare leaders must come forward in establishing routines of different evidence-based practices in PU prevention and at the same time registered nurses need to assume their best responsibility at the bed-side (Sving et al. 2014).

Limitations

However, there were some limitations in the review. One major limitation is related to the fact that the review did not adequately report on RCTs that might have predisposed the assessment and thematic analysis to bias. It is usually difficult to ascertain as to which elements of quality assessment are extrapolative of valid outcomes and which checklist is able to best assesses the quality of the papers. Small sample size was another major limitation. Owing to the fact that only 12 articles were included in the thematic analysis, it might have affected reliability of the results. Thus, it might have resulted in settling down for less conclusive results, owing to higher variability. Not performing a meta-analysis by combining the prevalence data obtained from the 12 studies was another significant limitation. This would have facilitated increasing the precision of the prevalence effects and analysing the differences that existed in the results among the included studies.

Chapter 5:

Thus from the detailed analysis conducted in the literature review in relation to the prevalence of PU, it can be concluded that the prevalence rate of pressure ulcer is significantly higher in the acute wards and it is a major health concern. The main target group of population for PU are the patients suffering from diabetes mellitus and is patients who belong to the category of older adults. The increase in the rate of occurrence of PU with diabetes indicated that delay in wound healing and poor nutritional backup increase the prevalence rate of PU. Among male and female, the female gender is more prone in getting affected with PU due to their high tenderness in skin. Increase in age increases the tendency of developing chronic diseases which demands prolong bed rest or at times forces the patients to become bed-ridden all these increase the total amount to time spent while lying over the bed. Increase in the bed rest time causes increase in friction of the skin of the body over the surface of the bed, leading to the development of PU. Main the parts of the body which carriers the maximum body load like the hips, heels, sacrum and the elbows are the main target for PUs. Patient with frequent obliterative arterial disease have higher chances of developing heel PU. Whereas patients with urine or fecal matter complications have high reported cases of sacral PU which is one of the most common form of PU. Apart from these main pressure points of the body, PUs, also leads to the formation of severe lesions through the body. The review of literature also highlighted that there are no strict of clear values of the reported cases of PU under the hospital ward and the main reason highlighted against this is difficulties in conducting studies over incidence and prevalence and difficulty in defining the population which is being studied. The main modes of studies which are attempted in order to detect the prevalence rate of PU include cross-sectional study. It was regarded as an important approach in determining the PU in the French hospital; ward. In this cross-sectional studies mainly used representative subset of a population at any definite point of time in order to access the rate of prevalence of PU. The main mode of data collection used for detecting PU include paper-based instruments and records because these mode of data collection can be easily related with the statistical analysis via the use of chi-square test. Apart from corss-sectional study design, retrospective approach is also found to be effective in detecting the rate of occurrence of PU as this type of study design help to evaluate the exposure of suspected risk factors behind the development of PU. The main risk factor underlying the prevalence of PU revealed the occurrence of PU is mainly hospital acquired and most of these are characterised under stage 1 non-blanchable erythema rest hospital acquired PUs belong to category 2 and 3 and these indicates partial thickness or skin loss or full thickness of skin loss respectively. Thus on visualizing the prevalence story of PU, it can be stated that the vulnerability of developing PU mostly increases with age, the tenure of hospitalization, lack of adequate physical activity, decrease in the overall sensory perception and increase in the rate of friction or shear of the skin with the surface of the bed.

The analysis of the papers in relation to pressure ulcer highlighted that the pressure ulcers cause pain increases human suffering along with the loss of productive time and change in the overall image of the body and all these lead to decrease in the overall health related quality of life of the patient along with an increase in the rate of hospitalization and increase in the overall healthcare cost. Loss of productive time is mainly attributed with the lack of proper physical activity. Lack of proper physical activity decreases the scope of performing daily living activities which decreases the overall self-esteem of the individual. This decrease in self-esteem is mostly profound among the people who are suffering from the spinal cord injury as their chronicity of PU are higher in comparison to others. The prevalence of PU is also co-related with the significant number of consultations with the nurses, family members, healthcare professionals and other wound care nurses and thus leading to an overall hike in the health care cost. It is obvious that development of PU increases the overall stay in the hospital which further increases the overall healthcare cost.

Delay in healing of the PU and lack of proper treatment of PU is mainly attributed towards the lack of proper risk assessment tool for the detection of the high risk patients with PU along with lack of proper knowledge of the nursing professionals tin treating PU effectively. Thematic analysis highlighted that the attitude and knowledge score among the nursing professionals who are working in the acute care unit are considerably poor in treatment PU. Nurses also showed inadequate complication to the prevention strategies towards PU. The nursed lack positive attitude and proper bedside knowledge in treating PU among the hospital patients. Their lack of knowledge increases the overall prevalence rate of pressure ulcers in the acute ward of the hospitals. ICU wards nurses at times failed to correctly categorise PUs and demonstrate less capability of proper therapy plan for the PU. Due to their lack of knowledge they are unable to explain the therapy plan to the patient properly in easy language which are understandable to the patients. This lack of knowledge and failure in explaining the patient about the impending therapy and expected outcome decreases the overall participation of the patient in the therapy plan. Lack of patient consent in the therapy plan decreases the overall therapy outcome. It recommended that increase in knowledge of the nursing professionals about the therapy planning under the training of the doctors or the physicians help in improving the overall health related outcomes and thereby helping to improve the overall quality of life.

Proper nursing education towards the prevention of the pressure ulcer must be directed towards the utilization of the proper nursing interventions in treating PUs. Some of the popular nursing interventions that are found effective in treating PUs include use of support surfaces like beds, seat cushions and mattresses. This pressure surfaces like the foam mattresses helps in the redistribution of the pressures throughout the body and thus helping to reduce the chances of developing PUs. However, the use of foam or the pressure mattress are at times creates financial constraints and thereby leading to an increase in the overall healthcare cost. So an effective alternative of pressure mattress is repositioning of the patients, Repositioning also helps to decrease rubbing or friction of the skin surface bearing body points of body and thus decreases the chance of encountering PU. However, most effective location of prepositioning are not highlighted in the studies and is usually done in a trial and error method. So use of repositioning is recommended along with the use of the pressure mattresses. Use of wound dressing is also found to provide effective results in treatment of PU and thus regarded as an important nursing intervention under the prevention strategies of PU. Wound dressing helps to decrease the amplitude of the sheer stress and the friction which damages the skin. Use of wound dressing helps in re-distribution of pressure and thus providing greater load distribution and decreasing the severity or the chances of occurrence of PUs.

However, before the application of any particular therapy plan, proper risk assessment of the patients must be conducted. Here risk assessment means the chances of developing PU among the high risk patients. The main risk assessment tool that is used to identify the high risk patient of PU is Braden risk assessment tool. It is one of the most structured tools that help in identifying the high risk patients of PU. However, detection of at risk patients does not help in reducing or chances of developing PU. Proper application of non-pharmacological and pharmacological interventions will help in successful prevention of PU. Of pharmacological preventive strategy of PU, there are use of antibiotic therapy and skin grafting. The analysis of the results highlighted that the use of proper skin grafting surgery use to improve the severity of PU along with an improvement of self-esteem of the patient. However, it is the duty of the nursing professionals to make the patient understand the importance of the therapy and its expected outcomes. Explaining the therapy process clearly to the patient helps to increase the overall patient participation in the care plan and hereby helping to increase the overall health outcomes. However, explanation must be done in simple langue so that it becomes easier for the patients to understand the overall prognosis of the therapy and the disease. For these proper nursing training about the required interventions for the prevention of PU is important. Optimal application of the non-pharmacological and the pharmacological interventions for the prevention of PU helps to decrease the prevalence rate of PU along with an improvement of HROoL of the patients.

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