Pressure Ulcer Development in Older Residents in Nursing Homes Report

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The purpose of this article by Kwong, Pang, Aboo Law (2009) is to assess the pressure ulcer incident and influencing factor of development on older residents in nursing homes in Hong Kong. Despite having previous studies done on the elderly in various healthcare settings, there were no investigations done on interactive effects among older nursing home residents (Kwong, Pang, Aboo Law, 2009).

The article written by Graves, Birrell, Whitby (2005) mentioned that pressure ulcer is a common and serious health issue which all institutions are concerned about as it causes pain, delay recovery and worst death due to infection. It has shown that pressure ulcer alone can contribute in prolonging the stay than what was hypothesised based on admission diagnosis (Graves, Birrell, Whitby, 2005) which is inline with the purpose of Kwong, Pang, Aboo Law (2009)’s article and it helps in supporting the study that pressure ulcer is a serious health concern as it alone can affect a patient’s duration of stay and condition.

Braden Scale is an effective instrument that can predict and prevent the development of pressure ulcers by measuring the intensity, duration of pressure and skin tolerance. (Bergstrom, Braden, Laguzza, Holman, 1987). Kwong, Pang, Aboo Law (2009) uses information by Bergstrom, Braden, Laguzza, Holman(1987) on Braden Scale as Kwong, Pang, Aboo Law (2009)’s article uses questionnaires that contained the chinese version of Modified Braden Scale(MBS) for assessment and identifying the influential factors of development.

An article which was written by Okuwa, et al.(2006) has studied the estimation and identified the risk factors of lower-extremity pressure ulcers in bedfast patients as it is a significant issue for bedfast patients whose age are 65 and older (Okuwa, et al. 2006). Kwong, Pang, Aboo Law(2009) uses Okuwa, et al. (2006) article as it used a similar format and it is inline with the purpose of identifying the factors of development.

Research design Data collection

The research team uses a prospective cohort design and conducted a non-experimental design as a Research Assistant (RA) did not intervene in the development of pressure ulcers. Non-probability sampling method were used specifically purposive sampling as Kwong, Pang, Aboo Law (2009)’s article had criteria in order to participate. Sample size were residents of the four private for-profit nursing nursing home at eastern district of Hong Kong. The research team constructed a questionnaire to obtain quantitative data by incorporating various instruments such as demographic and clinical data collection form, health status form, pressure ulcer risk form, skin assessment chart and human resources form. Subsequently verified by a panel of one gerontology and two wound care specialist for validity.

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Data collection

Prior to the data collection at the four nursing home, the RA was trained by the research team to ascertain the accuracy of the data collection as data was collected concurrently in the four nursing home. Criteria to participate in the study were age 65 or above, present in the nursing homes on the days of data collection and willingness to participate. A total of 504 residents in the nursing home, however 22(4.37%) were under the age of 65, 47% (9.33%) rejected the involvement and 89(17.66%) were not present due to hospitalization(n=36) or went out (n=53). Overall, there were 346 residents participated and throughout the Kwong, Pang, Aboo Law (2009)’s article there were no internal dropout.

In each time slot according to the individual nursing home, the RA conducted screening on each participant for initial assessment on the skin to categorize into two groups; with and without pressure ulcers. Subsequently,visited the participants for skin assessment every two days for four week till case were closed. It closed when participants were not present or completed four week of assessment. Within four week of data collection period, the research team made several unannounced visits to each home to observe the RA in data collection and to ascertain the accuracy.

Data analysis Results

A quantity of data were then derived and analysed using the Statistical Package for Social Science version 15.

Results

From the initial assessment, 318 (91.91%) did not present any pressure ulcers. However, in subsequent assessment, 80(25.16%) had developed first pressure ulcer with the average of nine observation days. Among 346 participants, 100(28.9%) has either developed new or first pressure ulcers and the dominant formation were stage 1 and area which was prone to develop was coccyx(41%) and sacrum(12%).

Factors such as mode of feeding, activities of daily living, severity of impairment, cognitive function, bedfast, chairfast,nurses working in the nursing home and comorbidities including pneumonia, gastric ulcer renal failure, stroke and dementia were statistically significantly which means there's a greater probability of pressure ulcers development.

The accident rate (25.16%) of first pressure ulcer in Kwong, Pang, Aboo Law (2009)’s article were on the higher side as compared to previous study and this is due to financial. Most of the nursing home residents were unable to afford high service care despite receiving Comprehensive Social Security Allowance by Hong Kong government thus nursing home had to charge at a low fee and managed by cutting the cost of labour. The nursing home employed nursing assistants who were under educated and untrained to provide necessary care and thus resulting in higher risk of pressure ulcer formation especially bedfast and chairfast residents who were in a higher risk of developing pressure ulcers as compared to ambulatory residents.

Recommendation

When conducting future studies on various types of nursing homes for validation, identify risk factors in the development of pressure ulcers in bedfast and chairfast elderly, record the preventive nursing interventions performed and create multi-dimensional pressure ulcer prediction tools for nursing home settings.

Limitation

It was held in four private for-profit nursing homes, thus limiting its generalizability as some residents were able to participate however left the homes; hence might have affected the pressure incident data. Result could have been affected as worker was aware of the purpose of study and might had tried to amend to protect the reputation of the nursing home.

Conclusion

The study confirmed that the four private for-profit nursing homes has high pressure incidences due to insufficient supply of community support service, elderly residents with comorbidities and homes with no nurse but only nursing assistant. Pressure ulcer can be prevented with appropriate nursing tools and intervention.

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