A Systematic

Review of Repositioning and

Turning of Patients: Effects on

Skin Breakdown and Pressure

Ulcers

Danielle Avery, Courtney Ball, Jill

Cutting, Taysha Demetro, and Krista

Tincher

Importance of Skin Breakdown

and Pressure Ulcer Prevention

• The incidence of pressure ulcer development and treatment has been an increasingly important issue with doctor and nursing staff , hospital management and medical insurance organizations.

• The practice of turning and repositioning has been used by nursing staff for several years based on an assumption this alleviates skin pressure especially on bony prominences.

Repositioning and Turning to

prevent Pressure Ulcers

• Turning patients regularly to reduce pressures and prevent pressure ulcers is considered a standard of care (Peterson et al 2010).

• Pressure ulcers are thought to develop when soft tissues are compressed between bony prominences and a firm surface for prolonged periods of time (Black & Hawks, 2009).

Search Strategy

• Randomized Controlled Clinical Trials

• CINAHL, Google Scholar, Electronic

Journal Center and Cochrane Databases

were used.

• Terms searched: Repositioning

patients, turning patients, pressure ulcers,

and skin breakdown.

Purpose of Research

• Review the effect of repositioning

and turning on skin breakdown and

the incidence of pressure ulcers

• Increasing important patient,

hospital and insurance related

healthcare topic

• Create systematic review of

relevant trials related to

repositioning and the development

of pressure ulcers

Research Studies

Total of 8 studies of varied design.

Two reviews. One narrative and one systemic.

Six clinical studies. All were quasi-experimental and

quantitative in design.

Three studied the effects of hospital policies.

Three studied body dynamics and pressure ulcer

development.

Review Results

Sonenblum & Springle, 2011

Complex variables – no single support works for all

people.

Sitting is a “dynamic activity.”

Repositioning is the most common and most

expensive way to prevent pressure ulcers.

No solid evidence for turns every 2 hours. Some

may need more frequent turns!

Those in wheelchairs are taught to shift their own

weight periodically.

Review Results

Chiang and Winkelman, 2010

No recommendations about frequency of position

can be made.

Studies typically had small sample sizes and

“inconsistent” time frames.

The mattress type is important.

Turns may not relieve sacral pressure if HOB is

elevated.

Individual patient variables are important!

Clinical Study Results

Three studies on hospital procedure

ALL three studies utilized nurse specialists on

pressure ulcer prevention to help staff.

Found that prior prevention protocols were not

utilized consistently.

Found inconsistencies in documentation.

Staffs lacked time and support to implement patient

repositioning and conduct thorough assessments.

Clinical Study Results

Three studies on effects of positioning on patients.

One study of 269 patients over 65 years old found

no connection between frequent repositioning and

pressure ulcer formation (Amr et al, 2010).

The second study with 14 healthy adults and a

sensor array pad found that conventional side to side

turning may not relieve pressure in the perisacral

area (Peterson et al., 2010). See image below.

Clinical Study Results

Three studies on effects of positioning on patients.

A third study with 230 nursing home residents with

wheelchair cushions, found that the type of cushion

and wheelchair maintenance was important

(Allegretti et al., 2010).

Common Results

The type of support matters.

Time for pressure ulcer development varies

depending on the patient‟s personal

characteristics.

Consistent documentation of skin assessments is

important.

Thorough skin assessment makes a difference.

Study Weaknesses

Common weaknesses noted:

It would be unethical to do a study where turns were

intentionally done less often than current standard of

care practices.

Inconsistent medical documentation.

Small sample sizes and limited study time.

Variables in patient conditions.

Current Practice

In the United States, traditional belief is that repositioning every two hours helps prevent skin breakdown and pressure ulcers

Origins of this practice are unknown (Winkelman & Chiang, 2010)

Scientific support of this belief is difficult to identify (Sprigle &

Sonenblum, 2011)

Despite unknown origins or scientific support, practice has been

accepted and adopted Use of Braden Scale to identify the level of skin breakdown risk

http://www.vnaa.org/vnaa/GeneralcontentPages/HTML/Braden_Risk.pdf

Newer Trends

Current research suggests that combining a

regular turning schedule with additional

interventions could help decrease incidence of

skin ulcers and pressure ulcers in at risk patients

Additional Interventions

Change in support surfaces

Appropriate Bed Surfaces per patient need (Ackerman,

2011)

Skin Protection Cushions for wheelchairs (Brienza et al.,

2010)

Pressure-Relieving Air Mattresses (Courtney et al., 2006)

“In general, creating successful support surfaces is challenging because of the differences in individual risk factors…” (Sprigle & Soneblum, 2011)

Additional Interventions

Protocol Changes

Skin Care Resource Nurse (Ackerman, 2006)

Standardized Assessments (Courtney et al., 2006)

Consistency in Charting and Documentation

Increased Education

Low percentages of patients who are actually turned

every two hours suggests lack of knowledge

Interventions should be used together rather than as

substitutions for each other

Special Considerations

Elderly Patients Majority of patients with pressure ulcers are older (Gunningberg &

Stotts, 2008)

Tend to be weaker, with more co-morbidities, fewer reserves to fight

skin breakdown

Mechanically Ventilated Patients Manual turning addresses many different issues

Can cause cardiovascular compromise

Oxygenation can be impaired

Suggestions for Future Research

The imperative question ??????

What is the exact cause and/or reason a patient

has developed a pressure ulcer or skin

breakdown?

? Who, What, Where, How, Why,

and When ? Who…study patients of different ages?

What…study the exact cause of pressure ulcers and

skin breakdown?

Where…study multiple floors of different hospitals?

How…the researchers would investigate the nurses?

Why…to determine the most frequent reasons (why

and how)?

When…study over a period of 3- 6 months?

The Study

What do the researchers want to find?

• Ackerman, C.L. (2011). „Not on my watch:' treating and preventing

pressure ulcers. MEDSURG Nursing,20(2), 86-93.

• Allegretti, A., Brienza, D., Geyer, M.J., Holm, M., Karg, P., Kelsey, S.,

Kusturiss, M., Schmeler, M., & Zanca, J. (2010). A randomized

clinical trial on preventing pressure ulcers with wheelchair seat

cushions. Journal of the American Geriatrics Society, 58(12), 2308-

2314.

• Amr, S., Baumgarten, M., Hawkes, W.G., Margolis, D., Miller, R.R.,

Shardell, M., & Shayna, R.E. (2010). Frequent manual

repositioning and incidence of pressure ulcers among bed-

bound elderly hip fracture patients.Wound Repair and Regulation,

10-18.

References

• Black, J.M. & Hawks, J.H. (2009). Medical-Surgical nursing: Clinical

management for positive outcomes. St.Louis, MO: Elsevier

Saunders.

• Chiang, C.L. & Winkelman, C. (2010). Manual turns in patients

receiving mechanical ventilation.Critical Care Nurse, 30(4), 36-44.

• Courtney, B.A., Ruppman, J.B. & Cooper, N.M. (2006) Save our skin:

Initiative cuts pressure ulcer incidence in half. Nursing

Management April, 36-45.

• Gunningberg, L. & Stotts, N.A. (2008). Tracking quality over time:

what do pressure ulcer data show?. International Journal for Quality

in Health Care, 20(4), 246-253.

• Peterson, M.J., Schwab, W., Van Oostrom, J.H., Gravenstein, N. &

Caruso, L. J. (2010) Effects of turning on skin-bed interface

pressures in healthy adults. Journal of Advanced Nursing 66(7),

1556-1564. doi: 10.1111/j.1365-2648.2010.05292.x

• Sprigle, S. & Sonenblum, S. (2011). Assessing evidence supporting

redistribution of pressure for pressure ulcer prevention: a

review. Journal of Rehabilitation Research and Development, 48(3),

203-213.