The Risk Factors Of Pressure Ulcers

Published Date: 02 Nov 2017

Abstract

The purpose of this study was to enumerate the causes, treatment, prevention and the risk factors of Pressure Ulcers (PUs) and to briefly give a critical analysis of Literature review. The process leading to pressure ulcer formation and early detection of individuals who are at risk of developing it for prompt prevention are key areas in this study.

Methods: The methods adopted in this dissertation involved various strategies: selecting a review topic and searching the literatures used. It also involved gathering, reading and analysing the literatures, as well as critical examination of the management, treatment and risk factors of pressure ulcer care in people with learning disabilities.

On this basis, certain number of research articles were examined, some of which were undertaken online with the aid of computer and electronic databases. Computer databases were used because they offer access to varieties of information, which could not be obtained manually and they are quite current.

Findings and Conclusions: This study went further to research the effect of age and nutrition on the persistence and spread of pressure ulcer in individuals exhibiting learning disabilities. Finally, having given a critical analysis of the literatures, it discussed the findings as well as the various ways of preventing and managing the existing cases as well as improving and maintaining the wellbeing of the pressure ulcer patients with learning disabilities. These include the mentally and physically challenged persons with ulcer, who due to underlying health conditions such as diabetes and catheterisation could not avoid staying in one position for too long, with emphasis on people with learning disabilities.

CHAPTER ONE

INTRODUCTION

Pressure ulcers have been observed to have a devastating effect on people with learning disabilities, it is said to have affected them financially, physically and psychologically (Spilsbury et al. 2007). In addition, its effect on the quality of life of the patients often leads to unending pain (Spilsbury et al. 2007; MEP Ltd, 2009; NHS for Scotland, 2009).

According to (Spilsbury et al., 2007), pressure ulcer (PU) is also known as pressure sore, pressure damage, pressure injuries or bed sore. (Spilsbury et al., 2007) further described PU as the affected part of the skin that has become an open wound, which occurs gradually due to a reduction of or discontinued flow of blood to that part of the body as a result of an inserted pressure on the affected area.

This inserted pressure on the body, which may eventually contribute to PU is mainly as a result of maintaining same position for a longer period of time, when sitting or lying down (RCN, 2005).

(Stephen-Haynens, 2011), also described PU as a localised scrape on a particular part of the skin or the underlying tissue, in most cases over a bony area, which is brought about by an increased pressure on that part of the body, it was also noted that friction which is the rubbing of the body on other surface such as sliding up and down on a bed or chair can also promote pressure ulcer. (Lyder, 2010 & Guy, 2012) in their Journal explained that pressure ulcer could further be defined based on the severity of the damage done to the affected part of the body. The epidermis and the dermis layers of the skin might have been scrapped or become swollen with fluid inside the elevated or raised area (Lyder, 2010 & Guy, 2012). Furthermore, Pressure ulcer in some other cases may cause redness of the skin due to exerted pressure. This abnormal redness of the skin has been shown to be due to expansion of the blood vessels underneath the skin, according to (www.merckmanuals.com/home/heart_and_blood_vessel_disorders.html). (Barbanel, & Hagisawa, 2001), observed in their studies that the red colouration on the skin, often remain over a long period on relieving the pressure.

In view of the fact that Pressure ulcer has been widely noted to reduce the quality of life of the sufferers (Dorner et al, 2009), this topic is very important and relevant to a very large extent for Nurses and other carers involved with the treatment and management of PUs in individuals with learning disability. Among the many reasons for studying this particular topic are as follows: Having established that pressure ulcers are a major cause of morbidity, mortality and a healthcare burden globally and that many of the cases may be avoidable (Whittington et al, 2004); it follows that solutions needed to be sought aimed at reducing it, if at all, its prevalence. According to statistics, it has been estimated that the total cost of treating pressure ulcers is top at one quarter of the total care cost of treating people with Spinal cord injury (SCI) (Bogie et al. 2000; Jones et al. 2003). Furthermore, in the United States alone, reports from the work of (Bogie et al. 2000; Jones et al. 2003) indicated an estimated cost of care for pressure ulcers at about 1.2 to 1.3 billion dollars annually. Whereas, prevention of pressure ulcer, could cost less with roughly one-tenth of the above estimated amount (Bogie et al. 2000; Jones et al. 2003).

Looking at PUs from the perspectives of treatment and management, it has been observed that both treatment and management require a huge cost to yield effective result, and it could also be preventable (Soban et al; White-Chu 2011). It has also be found that It is very important to concentrate more efforts on minimising the occurrence of PUs, rather than spend a huge resources on treatment, which might not yield the desired result (European Pressure Ulcer Advisory Panel [EPUAP], 2005).

Pressure ulcers pose a grave consequence on the wellbeing of the patient, although, its treatment, prevention and management are a major priority within the clinical and policy agenda. It is very important that patients are educated on the impact of PUs on health and quality of life, using simplified pictorial representation and signs to get them informed about Pressure ulcer, at the same time;(NMC 2008), it is their right to make informed decision when they have capacity about their care and treatment in conjunction with the healthcare provider (Spilsbury et al, 2007; NICE clinical guideline, 2005).

(Plaum et al, 2006), in their questionnaire research on Pressure ulcer, discovered the possibility of patients having a combination of deficiency of sensory experience as well as memory loss. The above combination of health challenges tended to increase the probability of having PUs (Plaum et al, 2006).

This study will further discuss common risk factors for developing pressure ulcers, its prevention and management with respect to people with learning disability (Guy H 2012, Vanderwee et al, 2007).

This study intends to find out the probable effects of nutritional deficiency, such as protein (NPUAP, 2009), on the persistence and spread of pressure ulcer in individuals with learning disability, as they are known to generally have poor eating patterns because some of them find swallowing difficult (The Caroline Walker Trust, 2007).

The knowledge gained here will go a long way in improving the practise of the Learning disabilities nurse who may also be having the challenge of managing pressure ulcer.

This study will summarise the various ways to curtail the emergence as well as the ways to improve the physical and psychological wellbeing of learning disability patients with pressure sores. According to the International guidelines on Pressure ulcer prevention, prevalence and Incidence (MEP Ltd, 2009: page 8); the results of PUs prevalence and incidence research could be used for enlightenment purposes, aimed at reducing PUs Occurrence, and therefore improving clinical practice. It is very important to understand the consequences and pitfalls of the prevalence and incidence of PUs.

Lastly, it is very important for all healthcare practitioners, managers, payers and financiers involved in the development, implementation and assessment of PU prevention protocols (Fletcher et al, 2011).

Therefore, the overall aim of this study also involved a strategy geared towards the reduction of PUs as well as management of the number of patients who already have PU in people with learning disability.

1.4. Research questions:

What are the possible causes of pressure ulcers in individuals with learning disability?

What are the various treatments and preventive measures for persons with learning disability who are having pressure ulcers?

What are the common risk factors for development of pressure ulcers in people with learning disability?

How can pressure ulcers be managed in persons having learning disability?

CHAPTER TWO

METHODS

The methods adopted in this dissertation involved various strategies: Selecting a review topic and searching the literatures used. This was followed by gathering, reading and analysing the literature followed by the review of references and evidence based approaches.

Having selected the topic the next step was identification of the appropriate and related information and relevant materials. This method was in agreement with (Cronin et al. 2007). In their study, they discovered and applied a particular orderly approach that was sequential and capable of generating reliable and beneficial information unlike the traditional review.

All the literature searches were undertaken online with the aid of computer and electronic databases. The reason for using computer databases is that they offer access to varieties of information, which cannot be obtained manually. Keyword searches were generally applied method of selecting appropriate literature (Cronin et al. 2007). However, keywords, which have to do with the review/assessment, evident based and management of pressure ulcers, were used.

Databases of particular relevance to the selected topic, which are very useful for Nursing (Parahoo, 2006), aided the search for related Journals which included: British Nursing Index Nursing Journals in English Language

Cumulative Index of Nursing and Allied Health Literature (CINAHL) and related publications. This according to (Polit and Beck, 2009), offers an important, reliable and up-to-date electronic databases for Nurses and other healthcare professionals. More importantly, CINAHL databases is known to have offered professionals and students more recent clinical evidence based practice in Nursing and other branches of medicine. Medical Subject Headings or subject headings:

Pubmed/MEDLINE

Google scholar

The essence of using numerous databases was to harvest a large catalogue of research materials including those directly linked to the field of learning disability practice:

Journal of Learning Disabilities

Journal of Intellectual Disabilities.

Journals of wound care and management.

Generally, Journals are much more up-to-date than books, which were probably written decades ago since information is dynamic and prone to changes with time and discoveries. Therefore, maximum period of 10 years was placed on the age of the works and journals used in this work except in some circumstances where recent materials were not found. The search strategy aimed to identify all articles that examined patient reports about the impact of PUs and PU interventions on Health Related Quality of Life (HRQL). Data extraction involved the reading through each of the published articles and identifying their findings in the form of statements by the author supported by patient reported data. The extracted patient reported data produced (Gorecki et al 2009). Moreover, specialist Journals were also hand-searched.

The internet played a crucial role for web sites on pressure ulcer publications.

Eligibility: Both exclusion and inclusion criteria were used for the primary and final selection for reporting the impact of PUs and interventions respectively on Health related quality of life (HRQL); this examines and evaluates the patient for probable interventions. (Gorecki et al., 2009).

The critiquing procedure in the third chapter was carefully fashioned out following the method used by Boswell & Cannon (2011) in their work on research critique procedure. The discussion chapter drew out relevant and applicable conclusions from the literature review. This was summarily followed by recommendations for good learning disabilities nursing practice, having considered some barriers to the practice of LD nursing.

CHAPTER THREE

CRITICAL REVIEW OF THE LITERATURE

This chapter is specifically devoted to generate a detailed critical analyses and evaluation of all available evidence from the selected articles for the research questions identified in the preamble and the primary research. The framework enumerated in chapter two aimed to serve as guarding principles.

3.0.0 The aim of critiquing a research report:

It enables the reader to determine the quality of the study having objectively evaluated the entire content that was presented (LoBiondo-Wood and Haber, 2006). Moreover critiquing research also evaluates the strengths of an article as well as its limitations (Boswell and Cannon, 2011). It is very essential to critically evaluate research findings before recommending them for use in nursing practice. In order to simplify the procedure and reflect the main themes of the literature, the chapter has been organised into sub-sections.

3.1.1 Formation of Pressure ulcers:

Pressure ulcer, which is also known as decubitius ulcer (A.D.A.M. Medical Encyclopaedia, 2012), ischemic ulcer, bedsore or skin sore, can be defined as localised injury on surface of the skin or to the epidermis layer of the tissue usually over an area covered with bones due to pressure or pressure combined with friction" (NPUAP 2007).

3.1.2 Causes and predisposing factors:

Pressure ulcer is formed by a process which is somehow complex, although numerous research works have been carried out, not much is understood about the process (Regan et al 2012).

The primary cause of pressure ulcers is the externally applied pressure over a prolonged period affecting the bony part of the skin. Due to the applied pressure, there is a decrease in blood supply to the soft tissue. The shear force hampers the smooth flow of blood to the skin by stretching and contorting the blood vessels (Collier & Moore, 2005).

Bob Gate, (2007), in his book ‘Learning Disabilities, Towards Inclusion’ indicated that skin breaks down easily and fast when an individual is left is a position for too long a time without any attempt to change the position either by the patient or nursing intervention can lead to pressure ulcer formation (Bob Gate, 2007).

(Defloor, 1999), noted that Pressure ulcers have the tendency to occur in any part of the body, and especially in some areas where there has been exertion of body weight or pressure such as shear or frictional forces where the body rubs against another object (Defloor, 1999, Ohura et al., 2007). Furthermore, among other probable risk factors that could predispose an individual with learning disability to develop pressure ulcer are immobility (Livesley, & Chow, 2002), or reduced activity, neurological deficits, incontinence, nutritional deficiency and age (Livesley, & Chow, 2002).

Patient mobility which is the movement of patient from one position to another within a short period of time can help to relieve pressure on a particular area of the body, as a result it can also help to prevent pressure ulcer formation, thereby maintaining good posture, frequent changing of sleeping or sitting position (NICE 2003, RCN 2005).

According to Stockton & Flynn, (2009), the commonest and most consistent predisposing factors are immobility (Gorecki et al., 2009); reduced activity and moisture or urination i.e., incontinence. In the light of this, it has been observed that certain group of people with learning disability are much more likely to develop pressure ulcer than others examples are:

• the elderly and individuals with learning disability usually with reduced mobility or those who are confined to their bed.

• those with severe/acute illness who might spend most of the day lying in bed for treatment.

• those who have had accidental damage to their spinal cord and as such could not feel any pain in the area i.e. neurological deficits

A number of other factors collectively contribute to pressure ulcer formation. These factors could be intrinsic such as in exceptional cases where one has been diagnosed or has a history of previous accidental record, surgery, poor nutritional condition where the body is know to lack some nutrient that supports the body. (Livesley and Chow 2002, Consortium for Spinal Cord Medicine 2000, Garber et al. 2007, Fleck & Sprigle 2007, Reger et al. 2007).

In a research carried out by (Chen et al. 2005), they reported that the increasing pressure ulcer prevalence in recent years could not be explained by ageing, years of injury or different demographics.

3.1.3 Roles of microorganisms:

In a related development, Bowler and Davies (1999), in their work on wound infection, observed that mixed growth of bacteria which can survive in the absence of oxygen constitute about 30% of the total number of microorganisms identified in the wounds (Bowler and Davies 1999).

Further experimental evidence has shown that S. aureus is the most common and prevalent potential harmful bacteria. Brown and Smith (1999), reported that decubitus ulcers or bedsore developed because of continued skin pressure over the bony parts; and that these pressure cause the skin to break down as a result, local tissue ischemia, necrosis, and those in the sacral region become vulnerable to faecal contamination. Approximately 25% of all individuals having decubitus ulcers are reported to be having underlying Osteomyelitis. In addition, bacteraemia, which is bacteria in the blood is also said to be common (Brown and Smith, 1999).

According to (Consortium for Spinal Cord Medicine 2000), Pressure ulcers are regarded as serious, life lasting secondary complication of spinal cord injury (SCI) and this has a downward impact on the quality of life as it tend to affect their social activities, their physical and psychological part of life is also affected in people with learning disability and it is capable of negatively affecting their overall quality of life. According to Healthcare professionals, the initial sign indicating that pressure ulcer may be forming is usually discoloration of the skin, which may get progressively worse and eventually lead to an open wound. The most susceptible body parts to pressure ulcers are sacrum, elbow, knees, and ankles.

Although preventable in most cases, pressure ulcers may still disrupt rehabilitation, prevent individuals with Learning disability from going about their daily community activities, therefore interfering with the potential to affect the community reintegration. Furthermore, the occurrence of a pressure ulcer can result to extended re-hospitalisation for some individuals (Consortium for Spinal Cord Medicine 2000, Jones et al. 2003).

3.1.4 Inevitability of PUs:

Are there any unavoidable situations for PU formation? In a write-up by Bedfordshire and Hertfordshire TVN Forum (2010); NPUAP (2010); a pressure ulcer can be said to be unavoidable under any of the following situations; such as a situation where all risk assessments and preventive care have been implemented and further re-evaluated, yet a pressure ulcer still occurs. The other situations involving a life-threatening event or when the patient has had an end-of-life skin changes. Furthermore, in patients with mental capacity bluntly refused preventive interventions; and when the patient has been in a collapsed state, without the knowledge the health professionals.

Pressure ulcers are expensive to treat and it also have a negative effect on the individuals affected by it (Moore et al., 2011). Due to the huge costs involved with the treatment of pressure ulcers, Krause et al. (2001), stated that more attentions have been concentrated on remedy and prevention, creating awareness to public health other than any other type of secondary condition associated with SCI. Krause et al. (2001), noted that, in spite of the attention given to the prevention and awareness, pressure ulcers still remains a reoccurring issue in people with SCI (Krause et al. 2001).

Defloor (1999), observed that applied pressure is a key factor to the development of pressure ulcer and amongst other factors, there is also share or frictional factor and many more others. Furthermore, among other probable risk factors that could predispose an individual to develop pressure ulcer are reduced mobility, hygiene in aspect of incontinence and poor nutritional or dietary needs as well as ageing (Fisher et al, 2004).

According to Stockton & Flynn (2009), the commonest and most consistent predisposing factors are immobility, reduced activity and moisture or humidity i.e., incontinence. In the light of this, it has been observed that certain group of people are much more likely to develop pressure ulcer than others examples are: the elderly those with reduced or no mobility, such as people with other conditions that prevents them from being mobile such as severe/acute illness, People needing intensive care admission in hospital and those with neurological deficits, such as patients with spinal cord injuries (SCI), (Regan et al 2012).

Among the hospitalised elderly people especially those with learning disabilities, Pressure ulcer is one of the most common secondary illnesses Cuddigan et al. (2001); in their studies on Prevalence, Incidence, and Implications for the Future discovered from statistical analysis, that in United States healthcare settings, Pressure ulcer remains a prominent challenge (Cuddigan et al. 2001). Whittington & Briones (2004), in their study on National prevalence and incidence study: 6-year sequential acute care data. Adv Skin Wound Care submitted that pressure ulcers (Pus) are a major cause of morbidity, mortality and healthcare burden globally.

It has been estimated that 1.3-3.0 million adults have pressure ulcers. The cost implication of this for treating each individual ranges between $500 to $40,000 to heal each case (Cuddigan et al. 2001). They opined that the incidence rate depend on each clinical setting, and largely on the severity of the illness, as well as prevailing factors.

Furthermore, pressure ulcers in elderly persons have also been linked with increased mortality rates, because pressure ulcers can now stand as a good indicator of the standard of care, it follows that failure to prevent or heal them can be taken as poor service provision (Cuddigan et al. 2001).

In a related development, Clarkson (2007), in a clinical review titled "Are pressure ulcers an act of nursing negligence?" observed that under some circumstances, it mighty be said to be as a result of the negligence of carers in nursing homes who ought to provide adequate care to patients but ignore patients.

Apart from the negative situations and seemingly irreparable skin damage which pressure ulcer often presents for patients, it has also been observed evidentially to be expensive to treat patients stay especially in cases of extended hospitalization in people with one or more challenges, (Graves et al. 2005).

3.1.5. Risk factors for developing pressure ulcer.

Reduced mobility or immobility: This refers to a situation in which an individual is confined either to a position perpetually or with minimal movement due in part to their condition and body weight. This stationary position usually builds up pressure, which if exerted over a bony prominence, increases tremendously (Thomas, 2001). When pressure is built up, there is a prolonged reduction in the rate of blood flow to other tissues. The reduction in blood flow to the tissues causes deprivation of oxygen supply, leading to the death of the tissues (Thomas, 2001). Continuous generation of pressure especially at the point of the bone produces a warning signal in the form of pain (Moore, 2006; EPUAP and NPUAP, 2009), which usually triggers movement. According to Schoonhoven et al, (2002), in their work on incidence of pressure ulcer due to surgery; they observed that in an acute hospital setting, it is possible for the patient’s situation to change more often than not, depending on their reason for admission. Furthermore, certain conditions that are only associated with acute settings such as surgery, intensive care unit admissions and prolonged periods of intravenous feeding are found to be related to the risk for pressure-ulcer development.

3.1.6 Lack of sensation:

This happens when the individual, i.e. with learning disability, no longer respond to the stimulus of pain. This situation occurs when there is injury to the Spinal cord, leading to its severe damage (Nursing Times 2012). When there is damage to any part of the body, the patient mighty be confined to a position over a long period, without being aware of any wound developing. This invariably leads to pressure ulcer being developed there (Nursing Times 2012).

3.1.7 Skin marking:

Due to aging, all organs in the body such as the heart, kidney, brain and even the entire skin begin to lose function. The skin may fail at this point in an individual’s life (Sibbald et al, 2009). This is particularly evident likely towards the end of life and may result in irreparable skin damage (Bedfordshire and Hertfordshire TVN Forum, 2010; NPUAP, 2010). Since skin change is an inevitable terminal event due to morphological changes leading to decline in function of the immune system (Jos et al. 2013; Sibbald et al, 2009).

An important early warning sign of risk for the development of pressure ulcer is indicated by colour change in conjunction with pressure damage. (Bethell, 2003) noted that there is a visible circular pink or red blanching mark which is an indication that pressure damage is about to occur. Failure to notice this may further increase the risk of pressure damage.

Furthermore, a number of physiological illnesses such as cellulitis, necrotising or dead skin infections, bruising, dermatological disorders and incontinence-associated dermatitis may cover up the redness which look like sunburn (Fogerty et al, 2008).

3.1.8 Nutritional status:

Apart from the fact that malnourishment, lowers the body’s immune defence system, undernourished people are at increased risk of developing pressure ulcer (EPUAP and NPUAP, 2009), although the evidence base behind this is not robust (Mathus-Vliegen, 2004). In the Journal titled "Eating well: children and adults with learning disabilities Nutritional and practical guidelines- The Caroline Walker Trust" by Crawley, (2007); it is of the author’s opinion that eating and drinking well gives satisfaction and are pleasure to the eater’s life. Moreover, eating well brings about sound mind. The individual is able to think aright and make meaningful contribution to the society.

In addition, people with learning disabilities have been observed to also have higher probability of developing nutrition-related illness (Crawley, 2007). Therefore, nutritional status of the individual with learning disability determines largely, the chance of having pressure ulcer. This could come in form of overweight or loss of weight. Dorner et al. (2009) noted in their paper that increased body protein level speeds up rate of healing of wounds.

Maintaining a good habit of eating food that are rich with a balance diet and good fluid intake with help to support the body with the nutrients and vitamins that the body needs and this will help to prevent skin breakdown and damage. In the event that a patient is observed to be lacking some nutrients, it is advisable that supplements are introduced or a referral to a dietician could be ideal as Nurses have a duty of care to all their patients (NMC 2008, NICE 2003).

Impact of nutrition or effect of malnutrition:

Two papers were selected from the research articles that were pooled together to make this dissertation, for critiquing purposes Zwifelhofer, (2007) titles the first of the papers by (Crawley, 2007) Eating well: children and adults with learning disabilities Nutritional and practical guidelines, and the second paper. Having gone through both papers critically, bearing in mind the procedure for critiquing research articles as designed by (Boswell & Cannon 2011).

From the preamble, it is quite clear that paper one did not start by giving the purpose of the study. Rather it began by giving the summary and recommendation, which should have been the last aspect of the study. on the other hand , paper two started by introducing the term hydration arising from consumption of fluids to make the body of the individual robust, before going to other relevant topics of importance to the main title. Furthermore, paper one was of immense benefit to the theme of this work as it explained the effect of malnutrition on individuals having learning disabilities. it is therefore relevant to the main topic of this dissertation. The design was well framed in sequential order.

However, this paper did not give qualitative analytical evaluation of the importance of eating well among the various age groups and across gender divide. It merely talked about the essence of eating well and the nutritional values of the various classes of food among young children and adults under 65 years of age with learning disabilities. It further emphasise the need for family members to make it a point of duty to persuade their sick ones to eat as much as possible the various foods that make up a balanced diet. Mention was not made of the sex of the persons involved and their age ranges. This paper did not estimate the number of people with learning disabilities that were experimented. However, it enumerated the impact of learning disabilities on the general quality of life on the patient and how learning disabilities affect their reasoning, memories and social behaviours. On the other hand, paper two was grossly deficient on most relevant parameters needed to make the paper of immense benefit to this work. It was only able to apply statistical analysis to explain daily fluid intakes as against daily fluid loss in people with learning disabilities.

In addition, none of the two papers gave a comprehensive literature review, and there was no definite submission on the subject; learning disabilities/

These papers do not look to be ideal for research materials in nursing.

There were no research questions in both papers. No target population were mentioned in paper two.

3.1.9 Compromised vascular supply:

According to Guy (2011), an already compromised vascular supply due to ill health or ageing will sudden lead to a drop in blood pressure therefore makes the place weak and liable to ulcer developing. Moreover, shear force hinders blood flow to the skin by stretching and contorting blood vessels (Collier and Moore, 2005) In addition, the type of surface on which the patient sits, lies or leans influences the risk of pressure ulcer. (Norton et al, 2011). Their findings appeared to be quite reliable as it was also mentioned on Norton et al (2011) report.

3.1.10 Neglect

Another very important factor that can lead to developing pressure is neglect. This may happen in the case of individuals who lack mental capacity (PDNDPU, 2012).

3.2.0 CRITIQUING THE RESEARCH SOURCES

This second part of the chapter aims to provide critical analysis and evaluation of methods adopted for some of the selected articles for the research themes enumerated in the preamble and the reviewed literature. Following the guidelines of the framework highlighted in the first half of this chapter, it will be organised into sub-sections according to the main themes of the research.

3.2.1 What are the possible causes of pressure ulcers in people with learning disability?

Two research articles were selected randomly from the Literatures for critiquing in each of the themes of this study. Regan et al., (2010), and Ohura et al., (2007). Having gone through both papers, it is quite clear that the purpose of each paper was precise and explanatory. While Regan et al., (2010) starts by clearly defining pressure ulcer, before sequentially explaining the process leading to its development as a result of an injury to the spinal cord. Ohura et al., (2007) clearly defined shear force and then diagrammatically explained it in clear language. Both articles are very relevant to the study and are quite necessary. They will both improve the knowledge and practice of nursing profession. Research design: Regan et al., (2010), in their study were found to be guided by relevant and necessary framework and theory. However, none of the two papers has an abstract that is a summary of the work done. This did not make it clear to the aim of both studies. Data collections were not reflected in both papers, because while Regan et al., (2010), work is a review of past studies, Ohura et al., (2007) mainly explained shear force and its impact. Both aimed to study individuals with pressure ulcers who also have learning disability.

Both researchers centered their work around people with Learning disability alongside with possible other illness such as spinal cord injury which is a long term disability and share pressure which is and after effect that occurs as a result of immobility of the patient that could lead to pressure ulcer (Moore and Cowman, 2011). Their both approach and data analysis tend to improve the trustworthiness of their research as it cuts across a vast generality of other research works as they all discuss the numerous functional unit which support pressure ulcer formation (Stekelenburg et al, 2008).

Literature review:

In the area of literature review, only (Regan et al., 2010), gave a comprehensive review. Both articles employed older papers as old as 30 years. The sources are majority in both cases. (Regan et al., 2010), included well-organised introduction and summary but that was lacking in (Ohura et al., 2007). It seemed that the hypothesis does not reflect the purpose of the studies in both cases and they are of little relevance to the study. Strengths and Limitation: Both papers stressed the causes of pressure ulcers. While (Regan et al., 2010), emphasised PUs in spinal cord injury; and the research cuts across gender, but the age range was 27- 47year olds. This did not consider the elderly aged above 60 years. On the other hand, Ohura et al., (2007), enumerated the importance of shear force in causing pressure ulcers, but gender and age were not considered as being important. However, due to the age range involved in the research, the quantitative nature of the study can not be generalized to all male gender.

3.2.2 What are the various treatment and preventive measures in people with learning disability?

In tackling this question, two articles have been taken for critiquing from the preamble; Spilsbury et al., (2007) and Dorner et al., (2009). Having read both papers critically, it was discovered that going by the procedure for critiquing the research papers was met to a large extent by Spilsbury et al., (2007). On the other hand, Dorner et al., (2009) did not meet up to expectations. With respect to clarity of purpose; while Spilsbury et al., (2007), was clear relevance and of immense benefit to the nursing profession, the second paper Dorner et al., (2009), did not show much benefit. Comparing their literature reviews, only Spilsbury et al., (2007), met the criteria that included introduction and summary, comprehensive in nature, time range of = 5 years and its level of organisation. Furthermore, while gender and age range covering the young and the elderly (33 - 92 years) were considered in the case of Spilsbury et al., (2007), the second article Dorner et al., (2009) was not specific on this, instead the term patient was used all through. However, both papers were specific on their target population. The targeted population in both cases was the individuals with pressure ulcer whose quality of life was already diminishing exponentially by the impact of the pressure ulcers. Nevertheless, both papers reflected the purpose of the study as regards treatment and prevention of Pressure ulcers. Spilsbury et al., (2007), sought and obtained ethical approval from the Committees in charge of Multi-centre Research, Local Research Ethics and the Research governance and management departments of the participating centers, while Dorner et al., (2009), sought the approval of the National Pressure Ulcer Advisory Panel board.

Limitations:

Spilsbury et al., (2007); noted that this study cannot be interpreted to be applicable on a larger population. In addition, the impact of the condition in relation to the length of time they had suffered the chronic condition are not distinguishable. In the case of Dorner et al., (2009), they failed to demonstrate the efficacy of amino acid in the treatment of pressure ulcers. They opined that further research would be required.

All the above studies and researches have relevant importance in the Nursing practice as they serve as evidence based report towards the awareness, management, treatment and prevention of pressure ulcer in people with learning disability of various ages.

CHAPTER 4

DISCUSSIONS

This chapter aims to generate useful and applicable conclusions from the literature review and further give a critical analysis of the implications for nursing practice. It will also give recommendations for Learning disabilities practice.

An important step towards Prevention of pressure ulcers is the recognition of the risk factors for its development (Regan et al. 2009).

Both the patient and the healthcare system are adversely affected by the persistence, spreading and delay in the healing process of PUs (Livesley & Chow 2002). Furthermore, it has been proved that PUs and its intervention have a huge impact on the overall quality of life of the individual patients and burden on the caregivers who have to spend quality time caring, repositioning and monitoring the progress of the healing (Gorecki et al. 2009).

However, prevention is often better than cure, since treatment of PUs have always proved cumbersome (Zeller et al. 2006). To achieve this; it is important to maintain the skin by moisturizing it as often as possible especially morning and night when the patient retires to bed. In addition, there is need to minimise the pressure around the spot (Zeller et al. 2006).

4.0 ROLE OF AGE AND LEARNING DISABILITIES ON PRESSURE ULCERS (PUs):

Old people with learning disabilities who are bedridden or use wheelchairs are invariably at risk for developing pressure ulcers (Spilsbury et al. 2007).

(Guinningberg and Stotts 2008) observed that the patients who most often developed ulcers were the elderly, at-risk for ulcers, incontinent and those inextended hospitalisation. It is essential to guide older and physically challenged individuals against developing pressure ulcers by paying them more attention especially those with acute admission (Guinningberg and Stotts 2008).

Moreover according to the Centre for Disease Control and prevention (CDC), People with disabilities also need health care and health programmes for the same reasons like everyone else; to stay well, active, and as part of the community. It is very common for people with disabilities to present their health report as being good, very good, or excellent (CDC). For people with disabilities, health problems relating to a disability, which are also called secondary conditions including pain, depression, and other greater risk illnesses.

4.1 Nutrition:

Food and drink are very essential for the maintenance of the body systems. Food is important for energy, repair of wear and tear as well as proper functioning of the immune system (Crawley, 2007). In addition, it has been observed that old individuals with PUs need more daily protein intake than those without it, for healing and body defence (Thomas, 2001). It is the responsibility of Learning disabilities nurses to see to the safety of their patients as well as themselves (Davies & Jenkins, 2011).

4.2 INCONTINENCE:

If a physically and mentally challenged person frequently urinates or opens the bowel randomly, the service provider can only contain this by applying pampers to make the beddings neat. However, due to this inability to control the rate of defecation and urine passage, the skin is further prone to ulceration (DLF 2006) pg 5.

4.3 PREVENTION AND TREATMENTS:

In order to assess the degree of damage before commencing treatment or to determine the potential risk of developing pressure ulcer, an assessment tool such as Waterlow scale is employed (Webster et al 2011; Bolton, 2007; Sharp and McClaws, (2006). In the opinion of (Regan et al. 2012), prevention is regarded very important on daily basis.

European Pressure Ulcer Advisory panel (EPUAP 2000) are of the opinion that it is much better and preferable to prevent PUs with minimal cost instead of the huge cost of its treatment. The use of pressure ulcer assessment tools are necessitated by the increasing number of potential risk factors (Agency for Healthcare Research and Quality. Clinical Practice Guidelines 2002).

(Lyder 2010) stressed the importance of prompt identification of individuals who are at risk in order to quickly prevent its development. According to this article, over 100 risk factors have been established. Some of the physiologic risk factors include diabetes mellitus, peripheral vascular disease, cerebrovascular disease, sepsis, etc. In addition, other preventive measures that should be considered in the interest of the mentally challenged individuals are; provided adequate balanced diet rich in vitamins, A, C, E and Zinc (NPUAP, 2006 pg 3). In addition, care staff should avoid dragging them on the bed when during repositioning, as this is capable of causing bruises to occur. on the fragile skin (NPUAP, 2006 pg 3).

Furthermore, since it is generally believed that prevention and management of PUs in people with learning disabilities is very challenging (Stephen-Haynes, 2011), there is need to periodically organise education awareness for the patients and their care providers (Stephen-Haynes 2011).

Other important ways to prevent PUs are; changing position frequently or by assisted repositioning if immobile, use of pressure relieving mattresses and constant inspection of the skin (NICE, 2005).

4.4 TREATMENT WITH ANTISEPTICS:

Unlike antibiotics, Antiseptics are poisonous chemical agents that are used topically to wounds and intact skin. They are especially useful for treating wounds that are heavily contaminated with a variety of bacteria that are failing to heal, with or without clinical signs of infection (Phillips and Davey. 1997). The most commonly used topical antiseptic agents include iodine-releasing agents such as povidone iodine. Pressure ulcer is best treated without further cross infection if the service providers endeavour to carry out laboratory check up from time to time

4.5 MANAGEMENT OF PRESSURE ULCERS:

There is no rigid rule about how pressure ulcers should be managed. The clinicians and nurses and other caregivers concerned can make decisions based on their discretions (RCN Clinical Guidelines, 2005).

The healing process of pressure ulcer can be achieved, if the service provider, i.e. the Nurse on duty is aware of the performance parameters of the various dressing categories or individual products and matches the attributes to the patient’s wound. However, it should be understood that dressings alone do not induce the healing process, until the causative factor of the wound has been addressed simultaneously, like taking proper care of the wound through treatment, good blood supply, improved dietary needs and patients positive ability towards treatment (Krasner, 2012). It is also very important to change the dressing products as the wound treatment improves.

Selection of appropriate dressing products for pressure ulcer optimises the local wound healing environment, reduces the pain and suffering and tends to improve the quality of life of the individual, as well as improve daily activities. On the other hand, if the dressing products are inappropriate, it can cause the wound status to deteriorate by presenting wound margin maceration, increased risk of deep infection, skin stripping. It may as a result, influence the cost as more resources will be spent on subsequent treatment that may be needed to achieve a healing process (Krasner, 2012). Stromgren et al., (2001) in their findings, noted that because of advanced chronic conditions such as neurological, cardiac, or respiratory diseases as well as malignancies, wound care could complicate care, thereby increasing the cost of care, and even threaten the quality of life for the patients. In view of the problems targeted by nurses in caring for dying patients, wound care is often mistreated. Nevertheless, Health care nurses need to understand the critical issues facing patients nearing the end of their lives, especially those who have surgical wounds, complicating wounds such as pressure ulcers and malignant wounds (Stromgren et al., 2001).

4.6 Challenges in Prevention and Treatment:

Patients Refusal: "There are times when patients just want to maintain the same position over a long period, or may refuse to use a pressure-relieving mattress. At this point, nurses should first consider the patients’ mental capacity" (Mental Capacity Act 2005).

An individual’s level of mental incapacitation is measured by considering a range of questions to determine their ability to make decisions according to their ability. The mental Capacity Act recommends that patients be given the opportunity to change their decision and agree to interventions continually. If a pressure ulcer occurs under these circumstances, it would be deemed an unavoidable one (Hertfordshire Tissue Viability Nurses Forum, 2010).

According to Bowler et al, (2001); while it is true that bacteria are known to be responsible for wound infections, there are widespread controversies relating to the exact mechanisms by which the bacteria cause infection and also their significance in non-healing wounds that fail to exhibit clinical manifestation. Robson (1999); observed that their quantity is a critical factor in determining the probability of the wound healing process.

Nevertheless, others have reported that microorganisms do not necessarily play a huge role in wound healing or slow healing. (EWMA MEP Ltd, 2005), opined that; not all wounds become infected because of the hygienic nature of the environment. The level of the immunity of the host determines the chance that such a wound would eventually become infected by harmful bacterial.

4.7 Mode of treatment:

since pressure ulcer (PU) is chronic wound that affects mostly individuals who are incapacitated due to age or an underlying illness (Lyder, 2003), its treatment typically involves multiple treatment procedures simultaneously; such as support surface and dressings. Nutritional supplements are very essential (NPUAP, 2009). It has been observed that most individuals with learning disability obviously have diet problems according to (Dorner et al, 2009).

4.8 Recommendations:

A number of people with learning disability have a high probability of developing diabetes, especially those with eating disorder as they have tendency to gain much weight with higher blood glucose (RCN, 2009). On the other hand, those who have challenges in swallowing would most likely have much of their weight reduced and are deficient in the protein necessary for healing the process (RCN, 2009). In both cases, their wounds are going to remain or have delayed healing.

It is therefore recommended that all persons with learning disabilities who have Pressure ulcers are to be encouraged to feed well and eat moderately.

They should be treated with dignity and encouraged to see themselves as being important like everyone else (RCN, 2009).

Moreover, there should be good communication between the LD patient with PUs and the healthcare providers. Every decision taken in respect of the patient’s treatment and care must be communicated to their families (RCN, 2005).

4.9 Strengths:

As the saying goes, prevention is better than cure. Therefore, prevention of pressure ulcer is very crucial and the first step in the process of pressure ulcer prevention, is the risk assessment. One of the steps to be taken in conjunction with the clinician’s physical examination of the skin is its assessment with the aid of an assessment tool. Assessment also assists to trigger care interventions that prevent development of pressure ulcers. The followings are some possible strengths or merits of the tools and their use.

They are useful educational tools to demonstrate to staff, carers and pressure ulcer patients. Assessment tools help to provide useful guides to determining an individual’s risk of pressure ulcer development.

4.1.0 Weaknesses:

According to (Anthony et al, 2010), risk assessment tools have some possible weaknesses, such as User subjectivity; here the risks might not be clearly defined. This may prompt the assessors to either over- or underestimate the risk. In addition, the factors described in the tool might not necessarily be related to the risk being assessed (Anthony et al, 2010). It is also possible that the tools for assessments were not tested for their reliability and validity.

Sense of judgments may differ at times, according to (Baath et al 2008); it is possible for two nurses using the same tool to record different scores, even under the same condition.

Furthermore, due to low sensitivity, the tool may not accurately predict people with an existing pressure ulcer as being at risk. In addition, (Moore and Cowman, 2010) in their research observed that those assessed as not being at risk may go on to develop a pressure ulcer (negative Predictive value), and also using the tool may not reduce the incidence of pressure ulcers. (Anthony et al, 2010) concluded that the interrater might not be 100% reliable.