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Pressure ulcers - role of the nurse to improve patient safety: prevalence, risk factors, classification and documentation in patients undergoing hip surgery
Sophiahemmet University.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Pressure ulcer is a common complication in hip fracture surgery and convalescence. Earlier prevalence studies have demonstrated a lower prevalence in Southern Europe than in Northern Europe. In patients with hip fractures, specific risk factors for developing pressure ulcers, apart from those included in standardised risk assessment are not fully understood. Correct classification of Category I pressure ulcers is a prerequisite for planning preventive measures. It is also mandatory for the reliability of prevalence studies. Until now subjective tests such as finger-press test and visual assessment have been utilised in clinical practice. An objective method has hitherto been lacking. Planning and delivering good nursing care to patients who are at risk of, or already have, manifest pressure ulcers should be built on proper documentation. Degree of documentation of pressure ulcer prevalence and risk factors in patients with hip fractures versus elective hip replacement surgery has hitherto not been investigated. Scrutiny of medical records for these diagnoses and identification of potential differences should therefore be of interest.Aim: - To investigate prevalence and incidence of pressure ulcers upon arrival and at discharge from hospital, and to identify potential intrinsic and extrinsic risk factors for the development of pressure ulcers in patients admitted for hip fracture surgery. To establish the inter-rater reliability between blanching and non-blanching erythema, assessed by two independent assessors. The secondary purpose was to investigate potential correlations between risk factors and pressure ulcers. - To explore if a non-invasive objective method could differentiate between blanching/nonblanching erythema in the sacral area of patients undergoing hip fracture surgery. - To investigate the degree of documentation regarding risk assessment, preventive measures taken, prevalence and severity of pressure ulcers, in patients undergoing surgery for hip fractures or elective hip replacements at admission and during hospital care at an orthopaedic unit.Results: The prevalence of pressure ulcers in Southern Europe was lower compared to Northern Europe. Specific risk factors such as dehydration (p=.005), moist skin (p=.004), pulmonary disease (p=.006) and diabetes (p=.005) were identified. The finger-press test and visual assessment of Category I pressure ulcers were both unreliable methods with low interrater reliability. The proportion of patients with persistent discoloration differed significantly between the assessors from Day 1 to Day 5 (p = .013). Reflectance spectrophotometer used was proven to deliver high precision regarding classification of non-blanchable erythema (Category I pressure ulcers). Documentation of pressure ulcers, risk assessment, body mass index and prevention at admittance was unsatisfactory in patients undergoing hip surgery.

Place, publisher, year, edition, pages
Stockholm: Karolinska Institutet , 2012. , 91 p.
Keyword [en]
Hip fracture, Pressure ulcers, Classification, Reflectance spectrophotometer, Nursing documentation
National Category
Nursing
Identifiers
URN: urn:nbn:se:shh:diva-1201ISBN: 978-91-7457-690-0 (print)OAI: oai:DiVA.org:shh-1201DiVA: diva2:573097
Public defence
2012-03-30, Erforssalen, Sophiahemmet Högskola, Valhallavägen 91, Ingång R, Stockholm, 14:00
Opponent
Supervisors
Available from: 2012-11-29 Created: 2012-11-29 Last updated: 2016-06-09Bibliographically approved
List of papers
1. Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study: intrinsic anc extrinsic factors
Open this publication in new window or tab >>Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study: intrinsic anc extrinsic factors
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2008 (English)In: International Wound Journal, ISSN 1742-481X, Vol. 5, no 2, 315-28 p.Article in journal (Refereed) Published
Abstract [en]

Pressure ulcers (PU) in patients with hip fracture remain a problem. Incidence of between 8.8% and 55% have been reported. There are few studies focusing on the specific patient-, surgery- and care-related risk indicators in this group. The aims of the study were: - to investigate prevalence and incidence of PU upon arrival and at discharge from hospital and to identify potential intrinsic and extrinsic risk factors for development of PU in patients admitted for hip fracture surgery, - to illuminate potential differences in patient logistics, surgery, PU prevalence and incidence and care between Northern and Southern Europe. Consecutive patients with hip fracture in six countries, Sweden, Finland, UK (North) and Spain, Italy and Portugal (South), were included. The patients were followed from Accident and Emergency Department and until discharge or 7 days. Prevalence, PU at discharge and incidence were investigated, and intrinsic and extrinsic risk indicators, including waiting time for surgery and duration of surgery were recorded. Of the 635 patients, 10% had PU upon arrival and 22% at discharge (26% North and 16% South). The majority of ulcers were grade 1 and none was grade 4. Cervical fractures were more common in the North and trochanteric in the South. Waiting time for surgery and duration of surgery were significantly longer in the South. Traction was more common in the South and perioperative warming in the North. Risk factors of statistical significance correlated to PU at discharge were age >or=71 (P = 0.020), dehydration (P = 0.005), moist skin (P = 0.004) and total Braden score (P = 0.050) as well as subscores for friction (P = 0.020), nutrition (P = 0.020) and sensory perception (P = 0.040). Comorbid conditions of statistical significance for development of PU were diabetes (P = 0.005) and pulmonary disease (P = 0.006). Waiting time for surgery, duration of surgery, warming or non warming perioperatively, type of anaesthesia, traction and type of fracture were not significantly correlated with development of PU.

National Category
Nursing
Identifiers
urn:nbn:se:shh:diva-102 (URN)10.1111/j.1742-481X.2008.00452.x (DOI)18494637 (PubMedID)
Available from: 2010-03-02 Created: 2010-02-25 Last updated: 2014-09-12Bibliographically approved
2. Category I pressure ulcers: how reliable is clinical assessment?
Open this publication in new window or tab >>Category I pressure ulcers: how reliable is clinical assessment?
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2011 (English)In: Orthopedic Nursing, ISSN 0744-6020, E-ISSN 1542-538X, Vol. 30, no 3, 194-205 p.Article in journal (Refereed) Published
Abstract [en]

finger-press tests and visual observation alone were not reliable methods to discriminate between blanching and nonblanching erythema. Forty-seven percent of the patients had a risk score 20 or fewer (high risk for pressure ulcers). Forty-four patients (56%) had pressure ulcers at discharge.

Keyword
Pressure ulcers, Assessment, Hip fractures
National Category
Nursing
Identifiers
urn:nbn:se:shh:diva-788 (URN)10.1097/NOR.0b013e318219ae77 (DOI)21597349 (PubMedID)
Available from: 2011-08-12 Created: 2011-08-12 Last updated: 2014-12-01Bibliographically approved
3. Objective evaluation by reflectance spectrophotometry can be of clinical value for the verification of blanching/nonblanching erythema in the sacral area
Open this publication in new window or tab >>Objective evaluation by reflectance spectrophotometry can be of clinical value for the verification of blanching/nonblanching erythema in the sacral area
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2014 (English)In: International Wound Journal, ISSN 1742-4801, E-ISSN 1742-481X, Vol. 11, no 4, 416-423 p.Article in journal (Refereed) Published
Keyword
Blanching/nonblanching erythema, Category I, Hip fracture, Pressure ulcer, Reactive hyperaemia, Reflectance spectrophotometry
National Category
Nursing
Identifiers
urn:nbn:se:shh:diva-1078 (URN)10.1111/iwj.12044 (DOI)23521782 (PubMedID)
Note

Early detection of non blanching erythema (pressure ulcer category I) is necessary to prevent any further skin damage. An objective method to discriminate between blanching/non blanching erythema is presently not available. The purpose of this investigation was to explore if a non invasive objective method could differentiate between blanching/non blanching erythema in the sacral area of patients undergoing hip fracture surgery. Seventy-eight patients were included. The sacral area of all patients was assessed using (i) conventional finger-press test and (ii) digital reading of the erythema index assessed with reflectance spectrophotometry. The patients were examined at admission and during 5 days postsurgery. Reflectance spectrophotometry measurements proved able to discriminate between blanching/non blanching erythema. The reliability, quantified by the intra-class correlation coefficient, was excellent between repeated measurements over the measurement period, varying between 0·82 and 0·96, and a significant change was recorded in the areas from day 1 to day 5 (P < 0·0001). The value from the reference point did not show any significant changes over the same period (P = 0·32). An objective method proven to identify early pressure damage to tissue can be a valuable tool in clinical practice.

Available from: 2012-06-20 Created: 2012-06-20 Last updated: 2014-12-08Bibliographically approved
4. Poor documentation of risk factors and prevention strategies for pressure ulcers in orthopedic inpatients
Open this publication in new window or tab >>Poor documentation of risk factors and prevention strategies for pressure ulcers in orthopedic inpatients
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(English)Manuscript (preprint) (Other academic)
National Category
Nursing
Identifiers
urn:nbn:se:shh:diva-1196 (URN)
Available from: 2012-11-29 Created: 2012-11-29 Last updated: 2014-12-01Bibliographically approved

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