Preserving Skin Integrity in Geriatric Patients

1. Preserving Skin Integrity in Geriatric Patients

2. Problem Statement: • Hospital acquired pressure ulcers have a higher incidence of occurring in the geriatric population, which affects not only increased health care costs but also impacts their quality of life; can skin barriers, if applied early upon admission, decrease the incidence of pressure ulcers?

3. Clinical Significance: • Scope of problem (incidence, geriatric patients at higher risk, etc) • Increased Health Care Costs • (put bullet points here from Jim)

4. Clinical Significance: • Pressure Ulcer impact on quality of life • Impacts physical functioning affecting mobility, daily routines and ADLS • Psychological well-being impacts mood, anxiety, loss of independence, and increase self-conscious. • Psychosocial aspect of pressure ulcers can discourage social actives with families as well as create feelings of isolation.

5. Causes of Pressure Ulcers • Pressure • Shear • Friction • Moisture at the skin surface

6. Age related physical changes • Increased fragility of blood vessels and connective tissue • Loss of fat and muscle leading to decreased capacity to dissipate pressure • Decrease bladder and bowel control • Decrease in mobility and activity • Decrease in sensory perception • Changes in nutritional status

7. Review of the Literature • Nicholas et al. (2012) authored an article “Which medical device and/or which local treatment for prevention in patients with risk factors of pressure sores in 2012. Towards development of French guideline for clinical practice.” • Systematic review of the literature • Relevance – helped to narrow down what methods of prevention had been studied and were unsuccessful and which interventions had potential to answer the gap in knowledge that was being researched.

8. Review of the Literature • Nicholas et al. (2012) continued: • Article conclusion – “it would be interesting, on hospital admission, to institute nursing care in conjunction with the application of dressings to the skin’s bony prominences so as to weaken shearing forces”

9. Review of the Literature • Walsh et al. (2012) authored an article “Use of Sacral Silicone Border Foam Dressing as One Component of a Pressure Ulcer Prevention Program in an Intensive Care Unit Setting”. • This article described a quality improvement initiative and did not include a control group. • This study described the application of a soft silicone foam dressing in the ICU to prevent pressure ulcers.

10. Review of the Literature • Walsh et al. (2012) continued: • They reported the incidence of pressure ulcers in the ICU declined from 50 patients in 2009 to 13 patients in 2010 after the initiation of applying the silicone border dressing. • Relevance – This article addressed part of the clinical question that skin barriers can reduce the incidence of pressure ulcers

11. Review of the Literature: • Cubit, McNally & Lopez (2012) authored an article “Taking the pressure off in the Emergency Department: Evaluation of the prophylactic application of a low shear, soft silicon sacral dressing on high risk medical patients. • A non-randomized controlled study • A silicon sacral dressing (Mepilex) was applied to the sacrum while in the Emergency Department. • Mepilex is a soft silicon dressing that is easy to apply and remove which molds to the skin surfaces and according to the authors aids in reduction of friction and shearing forces on the sacral area.

12. Review of the Literature • Cubit et al. (2012) continued: • Authors pointed out that a Stage II pressure ulcer is often related to issues of shearing, friction and changes in microclimates. • Patients spent on average 7.5 hrs in the ED prior to admission to the medical unit and the authors hypothesized that this contributed to the start of pressure ulcers • High risk medical patients in this study included geriatric patients

13. Review of the Literature • Cubit et al. (2012) continued: • Results – 1 of the 51 patients in the intervention group developed a pressure ulcer. In the known group 6 of the 58 patients developed a pressure ulcer • Study was conducted during January – May in 2010 • Article answered our clinical question that it was possible to decrease the incidence of pressure ulcers by applying a skin barrier early on admission.

14. Review of the Literature • Santamaria et al., (2013) authored an article “A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients; the border trial. • A randomized controlled trial • Study involved applying a silicone dressing (Mepilex) to both the sacrum and heels in the Emergency Department. • The trial contained 219 patients in the intervention group and 221 in the control group at the beginning of the study. At the end of study there were 161 in the intervention group and 152 in the control group. The difference due to the number of patients discharged from the ICU prior to the first pressure ulcer assessment.

15. Review of Literature • Santamaria et al. (2013) continued: • Trial took place between April 2011 and December 2012. • Results: 5 patients in the intervention group developed pressure ulcers compared to 20 patients in the control group • Authors concluded that there was a statistical and clinically significant benefit for the application of the Mepilex dressing in the prevention of sacral and heel ulcers. • Article answered our clinical question that it was possible to decrease the incidence of pressure ulcers by applying a skin barrier to the skin on admission.

16. Review of the Literature • Cost of Mepilex Border Sacrum $5.00 each • Average cost to treat a pressureulcer $50,000.

17. Conclusion • Put bullets here from Jim, • Per syllabus it should also include: “how literature extends an understanding of the clinical problem and contributes to evidence based practice.

18. References Brown, T., & Kitterman, J. (2013). Developing a cost-effective pressure-ulcer prevention program in an acute care-setting. Wound Care Advisor 2(5), 31-35. Cubit, K., McNally, B., & Lopez, V. (2012). Taking the pressure off in the emergency department: Evaluation of the prophylactic application of a low shear, soft silicone sacral dressing on high risk medical patients. International Wound Journal, 10, 579-584. doi:10.1111/j.1742-481x.2012.01025.x  Gorecki, C., Lamping, D., Brown, J., Madill, A., Firth, J., & Nixon, J. (2010). Development of a conceptual framework of health-related quality of life in pressure ulcers: A patient-focused approach. International Journal of Nursing Studies, 47, 1525-1534. doi:10.1016/j.ijnurstru.2010.05.014

19. References Kwong, E., Pang S., Aboo, G., & Law, S. (2009). Pressure ulcer development in older residents in nursing homes: influencing factors. Journal of Advance Nursing 65(12), 2608-2620 Nicholas, B., Moiziard, A., Barrois, B., Colin, D., Michel, J., Passadori, Y., & Ribinik, P. (2012). Which medical device and/or which local treatment for prevention in patients with risk factors of pressure sores in 2012 towards development of french guideline for clinical practice. Annals of Physical and Rehabilitation Medicine, 55, 482-488. Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassilious, T., DeVincentis, S., Ng, A., Manias, E., Liu, W., & Knott, J. (2013). A randomized controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The border trial. International Wound Journal. 1-7. doi:10.1111/iwj. 12101

20. References Walsh, N., Blanck, A., Smith, L., Cross, M., Andersson, L., & Polito, C. (2012). Use of a sacral silicone border foam dressing as one component of a pressure ulcer prevention program in an intensive care unit setting. Journal Wound Ostomy Continence Nursing, 39(2), 146-149. doi:10.1097/WON.0b013e3182435579