9. bed sore education program


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9. bed sore education program

  1. 1. Effectiveness of Bed Sore Prevention Training Programme in ICU/CCU at B. P. Koirala Institute of Health Sciences Mehta RS*1 , Rai HK*2, Bhatta N*3, Bhattari B*4, , Shrestha R*5. B.P. Koirala Institute of Health Sciences Email: ramsharanmehta@hotmail.comAbstract:Critically ill patients are at high risk for pressure ulcers. Bed bound patients with pressure ulcersare almost twice as likely to die, as are those without pressure ulcer often untreated. Mostcommonly affected sites are trochannteric, ischial, heal and sacral. Pressure ulcer can cause painand loss in economic productivity and also can result in huge expenditure for patients as well ashospitals.The objective of this study was to evaluate the effectiveness of bedsore prevention educationprogramme among the nurses working in ICU / CCU units of BPKIHS. The single group pre-testpost –test Quasi-experimental design was used to conduct the study. After pre-test educationintervention session was arranged in three sessions and an education material was provided to theindividual nurses. After 3 months of education intervention post test was taken and findings wereanalyzed using SPSS 12.5 software.It was found that most of the (90%) subjects were of age group of 20-25 years, unmarried (76%),and provide bedsore care (96.7%) to their assigned patients. In comparison to practice scoredifference there is more post tests score difference in knowledge components like, pressure soreassessment tool (66.7%), pressure distribution mattress (43.3%), frequency of back care (36.7%)and concentration of Betadine solution for dressing (53.4%).It can conclude that the knowledge and practice related to bedsore prevention and care amongnurses is satisfactory. There is no association between mean scores of pre-test and post-test inknowledge (p=0.788), where as there is association between mean practices scores of pre-testand post-test (p= 0.050). In-service education on pressure assessment tools and recent conceptsare essential to bust-up the knowledge. Finally the education intervention program is veryeffective for nurses in the management and care of bedsore.Note: 1* Ram Sharan Mehta, Associate Professor, Medical-Surgical Nursing Department, Email: 2 3ramsharanmehta@hotmail.com , * Hari Kumari Rai, ICU-Incharge, * Dr Narendra Bhatta, Additional 4Professor, Department of Internal Medicine * Prof. Dr. Bal Krishna Bhattari, HOD, Department of 5Anesthesia and critical care unit, * Rosy shrestha, Nursing Officer 1
  2. 2. Introduction: Bedsores results from the impairment of blood flow and from mechanical stress tothe skin and tissue over the bony area that has been under pressure for a prolonged period.Critically ill patients are at high risk for pressure ulcers. Pressure ulcers not only cause sufferingto the patients but also increases the workload on health care professionals. Pressure ulcers havebeen viewed as negligence, especially nursing care. It is assumed that pressure ulcers arepreventable but high prevalence of pressure ulcers among indoor patients have variouscontradicting factors including patients medical history, present environment and past eventswhich predisposes them to develop pressure ulcers. 1In USA 9% of all hospitalized and 20-40% of all nursing home patients, develop pressure sore.Incidence is 43/100,000 population every year; 65% of elderly with femoral fractures; 33% ofcritical care patients and a 60% prevalence among quadriplegic patients.1More than 10% nurses reported that they assess the areas for any decoloration, swelling anditching, early one fifth of them (20%) had no knowledge as how to assess the pressure pointsfor ulcers.2More than 100 risk factors have been identified in the literature. Some physiologic risk factorsinclude diabetes mellitus, peripheral vascular disease, cerebrovascular disease, sepsis, andhypotension. It has been hypothesized that these physiologic risk factors place the patients at riskbecause of impairment of the microcirculatory system.3Some of the preventive steps to reduce the prevalence of pressure included: change of side orposition (95%); removal of wrinkles from the bed sheet (60%) and use of cushions or air rings(55%). More than 50% nurses reported care of back as a preventive step. In addition,cleanliness (35%); and massaging (25%) also help in the prevention of pressure ulcers.Although care of pressure points is a fundamental care activity but many of nurses are unableto adopt preventive measures dues to lack of time and low priority given to prevention ofpressure ulcers in the clinical practice.2Objectives of the study: 1. To assess the knowledge and Practice regarding bed sore prevention and care among the nurses working in ICU/CCU at BPKIHS. 2. To provide the training programme on prevention and care of Bedsore. 3. To find out the effectiveness of Bed Sore Prevention Training Programme among the Nurses working in ICU/CCU at BPKIHSResearch design and methodology: It was quasi-experimental single group Pre-test post-testeducational interventional research design conducted among the nurses working in ICU/CCUwhere the more clients are susceptible to develop bedsore. Total enumerative sampling techniquewas used to select all the nurses working in ICU/CCU for more than 3 months and the pre-testingwas done to assess the knowledge about the bed sore, its prevention and care. The pre-testingwas done on 19th and 20th April 2009.The information collected in the first phase from the nurses regarding their knowledge profileand practice was used as pre-test and after the intervention of training programme the 2
  3. 3. information collected was used as post-test. The education intervention programme was carriedout during the period of 26th April 2009 to 30th April 2009. The post-test data was collected after3 months of education intervention programme i.e. on 30th and 31st July 2009. The difference inknowledge and practice was determining the effectiveness of the training intervention. Threedays teaching learning session was arranged for all the nurses. The education interventionpackage prepared is provided individual nurses. The theoretical as well as practical knowledgewas imparted on them. The subjects were fully oriented about the purpose of study and theirconsent was obtained prior to data collection. The validity of the tool and the package wasestablished with the concerned experts from the nurses, doctors and researchers.Results: Most of the subjects (90%) were of age group of 20-25 years, unmarried (76%), stay inBPKIHS Quarter (70%), mean ICU experiences of 13.2 months, and mean nursing serviceexperience in BPKIHS was 16.53 months. Most of the subjects (96.7%) provide bed soreprevention and care activities to their assigned patients and most of them (90%) were satisfiedwith service provided to assigned patients; where as only 13.3% nurses had only received bedsore training program.In some of the areas like: common terminology, common sites of bedsore occurrence, high riskpatients & skin as first degree defense line. The pretest and post-test score is same. Themaximum difference in knowledge after post test was found in, pressure that altered skinintegrity (63.4 %), pressure sere assessment tool (66.7 %), pressure reduction mattress (43.3 %),low BP. As risk of bed sore (40 %), concentration of Betadine for dressing (53.4 %) and massagethe skin where it is tight over bones (59.9 %). There are not many differences in score ofpractices after education interventions in most of the components. The areas where raises inscores in practices are, applying nursing process while providing bedsore care (10%), use ofassessment scale (13.3%), systematic assessment of bed ridden patient (40%), and always keepthe skin dry (7%).There is association between the knowledge score in pre-test and post-test in the componentslike: Causes of pressure ulcer (p=0.004), Effects of moisture on Skin (p=0.002), Causes ofaltered skin integrity (p=0.000), Manifestations of bed sore (p=0.000), First stage pressure(p=0.000), legal issues related to bedsore (0.000), Risk of pressure ulcer (p=0.000), Frequency tochange position in chair (p=0.001) and Definition of Eschar (p=0.000). There is no associationin the components like: Bedsore terminology (p=1.000), Factors causing bedsore (p=0.250), andcauses of skin injury (p=0.344) at 5% level of significance .The details are mention in table – 1.There is association between pre-test and post-test practice scores in the components like: Use ofbedsore assessment scale (p=0.001) but there is no association between applying nursing process(p=0.500), Provide back massage (p=0.250) and Record observed skin condition (p=1.000) at5% level of significance. The details are depicted in table – 2.There is no association between the pre-test and post-test mean knowledge score (p=0.788) butthere is association between mean practice score (p=0.050) at 5% level of significance. Thedetails are depicted in table – 3. 3
  4. 4. The overall evaluation of education program result is highly satisfactory that is 80% werestrongly agree and 20% were agree that programme helped in care of bed ridden patients.Focus Group Discussion: Focus group discussion was also arranged on 29th May 2009 from 2-4 pm at meeting room of ICU. Total 11 nurses were present in the FGD. The FGD was facilitatedby moderator (Principal Investigator), a reporter and the participants. After all the necessarypreparations the discussion was started using a pre-set guideline.Most of the nurses reported that the incidence of bed sore patients in ICU is 1-2 per months, andamong those bedsore developed patients it’ was found that majority of clients developed it outside ICU before admission. Most of the nurses (about 70%) reported that their level ofsatisfaction regarding bedsore prevention and care is very high. The main results of thediscussion are as follows:Main causes of bedsore in ICU are: Patient developed Bedsore before admission, or nutritionstates of the patients, obese patients, continence patient, prolonged ICU admitted patients andintubated and restlessness patients.Problems in providing care to the bedsore patients in ICU are: Availability of inadequate air-mattress, availability of Air-filling machine, High work load of ICU nursing staffs, Inadequateadjustable beds, Inadequate service of physiotherapists, Not availability of fixed protocol ofdressing and Not using bedsore assessment tool.How to improve the bedsore care in ICU: Availability of all adjustable beds in ICU, Availabilityof adequate number of air-mattresses and air-filling machine, Improve nutritional status ofclients by supplying adequate nutrition and dietetic services and develop & utilization of bedsoreprotocol.Discussions: Most of the subjects (90%) were of age group of 20-25 years, unmarried (76%),living in BPKIHS Quarter (70%) and having ICU experiences of more than 6 months (63.3%);most of the nurses (96.7%). Most of the nurses (93.7%) frequently provide care to the bed riddenadmitted patients usually and fully satisfied (90%); where as 13.3% received informal trainingon bed sore. Bed sore is one of the common problems among critically ill patients admitted inICU. The study conducted by Marum6 reported that, the pressure sore is common problem and itsprevalence ranges from 2.4 to 23%. Incidence rate are similar. In elderly the prevalence ofpressure sore is 66%, similar findings were reported by Nayak 7 also, Which is similar to oursetting.Knowledge related to bedsore prevention and care: There is in crease in knowledge onbedsore prevention and care in the components like: pressure that altered skin integrity (63.4%),pressure sore assessment tool (66.7%), Low BP a risk of bedsore (40%), definition of Eschar(56.6 %) and concentration of Betadine for dressing (53.4%). Study conducted by Vati 3 in Indiareported that most of the nurses (67.5%) inspect skin for pressure ulcer regularly which is similarto this study. Similar findings were reported by WOCN 2. The study conducted by tweed 4among ICU nursing staff had a high level of knowledge of pressure ulcers before any educationalintervention with pass rate of 90% for the baseline test, which is similar to this study. 4
  5. 5. Practices related to bedsore prevention and care: After education intervention program thereis not incensement in score like: Identity potential risk of skin integrity provides notorious diet asper need of client and many other components. In pre test most of the respondents had adequatepractice score. There is incensement in score after post-test in some components like: systematicassessment of bed ridden patient (40 %), keeping the skin dry (7.1%), use of bedsore assessmentscale (13.3%) and inspection of skin condition regularly (3.3%).Study conducted in India by Vati 3, reported that position change (95%), making bed tidy (60%),back care (50%) and massages (75%) are common practices for bedsore prevention which issimilar to this study. The study conducted in Turkey by Ozdemir 9 reported that nurses did notconsistently use the risk-evaluation scale, documentation properly and not train auxiliarypersonnel properly. She concludes that critical care nurses don’t consistently provide preventivecare for pressure ulcer, which is the contradictory to this study.Association between Pre-test and post-test Knowledge scores: There is association betweenthe knowledge score in pre-test and post-test in the components like: Causes of pressure ulcer(p=0.004), Effects of moisture on Skin (p=0.002), Causes of altered skin integrity (p=0.000),Manifestations of bed sore (p=0.000), First stage pressure (p=0.000), legal issues related tobedsore (0.000), Risk of pressure ulcer (p=0.000), Frequency to change position in chair(p=0.001) and Definition of Eschar (p=0.000). There is no association in the components like:Bedsore terminology (p=1.000), Factors causing bedsore (p=0.250), and causes of skin injury(p=0.344) at 5% level of significance.Association between Pre-test and post-test Practice scores: There is association between pre-test and post-test practice scores in the components like: Use of bedsore assessment scale(p=0.001) but there is no association between applying nursing process (p=0.500), Provide backmassage (p=0.250) and Record observed skin condition (p=1.000) at 5% level of significance.Association between Pre-test and post-test, Knowledge and Practice scores: There is noassociation between the pre-test and post-test mean knowledge score (p=0.788) but there isassociation between mean practice score (p=0.050) at 5% level of significance.Evaluation of education intervention programme: Most of the respondents (80%) werestrongly agree that programme helped in care of bedridden patients; where 20% reported agreebut non of them reported strongly disagree and disagree. The study conducted by Thomas 8,reported that preventing pressure ulcer requires broad range of interventions, none of which havehad rigorous research evaluation. Medical personnel need to be informed immediately of eithersuspicion of sores or actual sores.Conclusions: Pressure ulcers remain a major health problem for adults across all health caresettings. Many gaps still remain in the understanding of preventing and healing pressure ulcers.Pressure ulcers remain a multi-factorial, complex, and dynamic problem and physicians remainintegral to the prevention and management of this common health care issue. Among this cohortof critical care staff nurses, knowledge and practice scores on pressure ulcer prevention and carewere good. There is no association between knowledge and practice among the nurses regardingbedsore prevention and care. 5
  6. 6. References: 1. Guideline for prevention and management of pressure ulcers. Wound, Ostomy, and Continence Nurses Society; 2003:52. 2. Vati J, chopra S, Walia I. Nurses Role in the management and prevention of pressure ulcer. Nursing Journal of India. May 2004. 3. Clough NP. The cost of pressure area management in an intensive care unit. J Wound Care. 1994; 3:33–35. 4. Tweed C, Tweed M. Intensive care nurses knowledge of pressure ulcer: Development of an assessement tool and effect of and educational programme. Am. J. Crit. Care. 2008: 17: 338-346. 5. Bostrom J, Kenneth H. Staff Nurses knowledge and prevention about prevention of pressure sores. Dermatol Nurss 1992; 4(5):365-8. 6. Marum RV, Ooms ME, Ribble MW, Eijk JT. The Duch pressure sore assement score or the Norten Scale for identifying at-risk nursing home patients?. Age and Ageing. 2000; 29: 63-68. 7. Nayak D, Srinivasan K, Jagdish S, Rattan R, Chatram VS. Bedsores: top to bottom and bottom to top. Indian J. Surg..2008; 70: 161-168. 8. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired ulcers and risk of death. J Am Geriatr Sco. 1996; 7:48-56. 9. Ozdemir H, Karadag A. Prevention of pressure ulcers: a descriptive study in three intensive care units in Turkey. J. wound Ostomy Continence Nurs. 2008; 35(3): 293-300. 6
  7. 7. Table 1 Association between pre-test and post-test knowledge score among the subject using MacNemar Chi-Square test (p=0.05) n=30 KnowledgeCharacteristics Categories Pee- Post- P-Value Remarks test test Incorrect 0 2Bedsore Terminology 1.000* NS Correct 2 26 Incorrect 0 3Factor causing bedsore 0.250* NS Correct 0 27 Incorrect 1 4Definition of bedsore 0.388* NS Correct 8 17 Incorrect 0 9Causes of pressure ulcer 0.004* S Correct 0 21 Incorrect 0 10Effects of moisture on skin 0.002* S Correct 0 20 Incorrect 1 19Causes of altered skin integrity 0.000* S Correct 0 10 Incorrect 1 2Contributing factors of pressure sore 1.000* NS Correct 1 26 Incorrect 1 22Manifestations of bedsore 0.000* S Correct 0 7 Incorrect 0 24First stage bedsore 0.000* S Correct 1 6 Incorrect 1 12Legal issues of bedsore 0.000* S Correct 0 17 Incorrect 0 24Bedsore assessment tools 0.000* S Correct 0 6 Incorrect 0 7Criteria of risk assessment 0.333* NS Correct 3 20 Incorrect 1 10Special devices of bedsore 0.039* S Correct 2 17 Incorrect 0 21Pressure redistribution mattress 0.000* S Correct 0 9 Incorrect 1 26Frequency of back care 0.000 S Correct 1 2 Incorrect 2 7Causes of skin injury 0.344* NS Correct 3 18 Incorrect 0 26Risk of pressure ulcer 0.000 S Correct 0 4 Incorrect 2 5Position on bed 1.000* NS Correct 6 17 Incorrect 11 15Position change in chair 0.001* S Correct 1 3 Incorrect 1 18Definition of Eschar 0.000* S Correct 0 11 * = Binomial Distribution is used, as the cell value is less than 5 7
  8. 8. Table 2 Association between pre-test and post-test Practice score among the subject using MacNemar Chi-Square test (p=0.05) n=30 Practices Characteristics Categories Pre- Post- P-Value Remarks test test No 0 2Apply Nursing Process Yes 0 28 0.500* NS No 8 14Use of Assessment Scale 0.001* S Yes 1 7 No 0 2Maintain Turning Schedule 1.000* NS Yes 1 27 No 0 1Provide Nutritious Diet 1.000* NS Yes 2 27 No 0 0Provide Back Massage 0.250* NS Yes 3 27 No 3 4Record Observed Skin condition 1.000* NS Yes 3 21 * = Binomial Distribution is used, as the cell value is less than 5 Table 3 Association between pre-test and post-test Knowledge and Practice Mean score among the subject using Pearson Chi-Square test (p=0.05) N=30 Pre-test Post-testCharacteristics/ SD/ SD/ P-value RemarkVariables Mean Mean Value Range Value Range 2.931/ 2.426/Knowledge 18.4 25.8 0.788 NS 12-25 21-31 1.87819/ 1.779/Practice 22.7 23.6 0.050 S 18-25 18-26 8