A Systematic A Systematic Review of Repositioning Review of Repositioning and Turning of Patients: and Turning of Patients:

Effects on Skin Effects on Skin

BreakdownBreakdown and Pressure and Pressure UlcersUlcers

Danielle Avery, Courtney Ball, Danielle Avery, Courtney Ball, Jill Cutting, Taysha Demetro, Jill Cutting, Taysha Demetro,

and Krista Tincherand Krista Tincher

Importance of Skin Importance of Skin Breakdown and Pressure Breakdown and Pressure

Ulcer PreventionUlcer Prevention• • The incidence of pressure ulcer The incidence of pressure ulcer development and treatment has been development and treatment has been an increasingly important issue with an increasingly important issue with doctor and nursing staff , hospital doctor and nursing staff , hospital management and medical insurance management and medical insurance organizations.organizations.• • The practice of turning and The practice of turning and repositioning has been used by repositioning has been used by nursing staff for several years based nursing staff for several years based on an assumption this alleviates skin on an assumption this alleviates skin pressure especially on bony pressure especially on bony prominences.prominences.

Repositioning and Repositioning and Turning to prevent Turning to prevent

Pressure UlcersPressure Ulcers• • Turning patients regularly to Turning patients regularly to reduce pressures and prevent reduce pressures and prevent pressure ulcers is considered a pressure ulcers is considered a standard of care (Peterson et al 2010).standard of care (Peterson et al 2010).• • Pressure ulcers are thought to Pressure ulcers are thought to develop when soft tissues are develop when soft tissues are compressed between bony compressed between bony prominences and a firm surface for prominences and a firm surface for prolonged periods of time (Black & prolonged periods of time (Black & Hawks, 2009). Hawks, 2009).

Search StrategySearch Strategy

• • Randomized Controlled Randomized Controlled Clinical TrialsClinical Trials

• • CINAHL, Google Scholar, CINAHL, Google Scholar, Electronic Journal Center and Electronic Journal Center and Cochrane Databases were Cochrane Databases were used.used.

• • Terms searched: Terms searched: Repositioning patients, turning Repositioning patients, turning patients, pressure ulcers, and patients, pressure ulcers, and skin breakdown.skin breakdown.

Purpose of ResearchPurpose of Research

• • Review the effect of Review the effect of repositioning and turning repositioning and turning on skin breakdown and the on skin breakdown and the incidence of pressure incidence of pressure ulcersulcers

• • Increasing important Increasing important patient, hospital and patient, hospital and insurance related insurance related healthcare topichealthcare topic

• • Create systematic review Create systematic review of relevant trials related to of relevant trials related to repositioning and the repositioning and the development of pressure development of pressure ulcersulcers

Research StudiesResearch Studies

Total of 8 studies of varied design.Total of 8 studies of varied design. Two reviews. One narrative and one Two reviews. One narrative and one

systemic.systemic. Six clinical studies. All were quasi-Six clinical studies. All were quasi-

experimental and quantitative in design.experimental and quantitative in design. Three studied the effects of hospital policies.Three studied the effects of hospital policies. Three studied body dynamics and pressure ulcer Three studied body dynamics and pressure ulcer

development.development.

Review ResultsReview Results Sonenblum & Springle, 2011Sonenblum & Springle, 2011

Complex variables – no single support works for all people.Complex variables – no single support works for all people. Sitting is a “dynamic activity.”Sitting is a “dynamic activity.” Repositioning is the most common and most expensive way Repositioning is the most common and most expensive way

to prevent pressure ulcers.to prevent pressure ulcers. No solid evidence for turns every 2 hours. Some may need No solid evidence for turns every 2 hours. Some may need

more frequent turns!more frequent turns! Those in wheelchairs are taught to shift their own weight Those in wheelchairs are taught to shift their own weight

periodically.periodically.

Review ResultsReview Results Chiang and Winkelman, 2010Chiang and Winkelman, 2010

No recommendations about frequency of position can No recommendations about frequency of position can be made.be made.

Studies typically had small sample sizes and Studies typically had small sample sizes and “inconsistent” time frames.“inconsistent” time frames.

The mattress type is important.The mattress type is important. Turns may not relieve sacral pressure if HOB is Turns may not relieve sacral pressure if HOB is

elevated.elevated. Individual patient variables are important!Individual patient variables are important!

Clinical Study ResultsClinical Study Results

Three studies on hospital procedureThree studies on hospital procedure ALL three studies utilized nurse specialists on ALL three studies utilized nurse specialists on

pressure ulcer prevention to help staff.pressure ulcer prevention to help staff. Found that prior prevention protocols were not Found that prior prevention protocols were not

utilized consistently.utilized consistently. Found inconsistencies in documentation.Found inconsistencies in documentation. Staffs lacked time and support to implement patient Staffs lacked time and support to implement patient

repositioning and conduct thorough assessments.repositioning and conduct thorough assessments.

Clinical Study ResultsClinical Study Results Three studies on effects of positioning on patients.Three studies on effects of positioning on patients.

One study of 269 patients over 65 years old found One study of 269 patients over 65 years old found nono connection between frequent repositioning and connection between frequent repositioning and pressure ulcer formation (Amr et al, 2010).pressure ulcer formation (Amr et al, 2010).

The second study with 14 healthy adults and a The second study with 14 healthy adults and a sensor array pad found that conventional side to side sensor array pad found that conventional side to side turning may not relieve pressure in the perisacral turning may not relieve pressure in the perisacral area (Peterson et al., 2010). See image below.area (Peterson et al., 2010). See image below.

Clinical Study ResultsClinical Study Results

Three studies on effects of positioning Three studies on effects of positioning on patients.on patients. A third study with 230 nursing home A third study with 230 nursing home

residents with wheelchair cushions, residents with wheelchair cushions, found that the type of cushion and found that the type of cushion and wheelchair maintenance was important wheelchair maintenance was important (Allegretti et al., 2010).(Allegretti et al., 2010).

Common ResultsCommon Results

The type of support matters.The type of support matters. Time for pressure ulcer development Time for pressure ulcer development

varies depending on the patient’s varies depending on the patient’s personal characteristics.personal characteristics.

Consistent documentation of skin Consistent documentation of skin assessments is important.assessments is important.

Thorough skin assessment makes a Thorough skin assessment makes a difference.difference.

Study WeaknessesStudy Weaknesses

Common weaknesses noted:Common weaknesses noted: It would be unethical to do a study It would be unethical to do a study

where turns were intentionally done where turns were intentionally done less often than current standard of care less often than current standard of care practices.practices.

Inconsistent medical documentation.Inconsistent medical documentation. Small sample sizes and limited study Small sample sizes and limited study

time.time. Variables in patient conditions.Variables in patient conditions.

Current PracticeCurrent Practice In the United States, traditional belief is that In the United States, traditional belief is that

repositioning every two hours helps prevent skin repositioning every two hours helps prevent skin breakdown and pressure ulcersbreakdown and pressure ulcers

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

Scientific support of this belief is difficult to Scientific support of this belief is difficult to identify identify (Sprigle & Sonenblum, 2011)(Sprigle & Sonenblum, 2011)

Despite unknown origins or scientific support, Despite unknown origins or scientific support, practice has been accepted and adoptedpractice has been accepted and adopted

Use of Braden Scale to identify the level of skin Use of Braden Scale to identify the level of skin breakdown riskbreakdown risk

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

Newer TrendsNewer Trends

Current research suggests that Current research suggests that combining a regular turning combining a regular turning schedule with additional schedule with additional interventions could help decrease interventions could help decrease incidence of skin ulcers and incidence of skin ulcers and pressure ulcers in at risk patientspressure ulcers in at risk patients

Additional InterventionsAdditional Interventions Change in support surfacesChange in support surfaces

Appropriate Bed Surfaces per patient need Appropriate Bed Surfaces per patient need (Ackerman, 2011)(Ackerman, 2011)

Skin Protection Cushions for wheelchairs Skin Protection Cushions for wheelchairs (Brienza et al., 2010)(Brienza et al., 2010)

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

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

Additional InterventionsAdditional Interventions

Protocol ChangesProtocol Changes Skin Care Resource Nurse Skin Care Resource Nurse (Ackerman, 2006)(Ackerman, 2006)

Standardized Assessments Standardized Assessments (Courtney et al., 2006)(Courtney et al., 2006)

Consistency in Charting and DocumentationConsistency in Charting and Documentation Increased EducationIncreased Education

Low percentages of patients who are Low percentages of patients who are actually turned every two hours suggests actually turned every two hours suggests lack of knowledge lack of knowledge

Interventions should be used together Interventions should be used together rather than as substitutions for each other rather than as substitutions for each other

Special ConsiderationsSpecial Considerations

Elderly PatientsElderly Patients Majority of patients with pressure ulcers are Majority of patients with pressure ulcers are

older older (Gunningberg & Stotts, 2008)(Gunningberg & Stotts, 2008) Tend to be weaker, with more co-morbidities, fewer Tend to be weaker, with more co-morbidities, fewer

reserves to fight skin breakdownreserves to fight skin breakdown

Mechanically Ventilated PatientsMechanically Ventilated Patients Manual turning addresses many different issuesManual turning addresses many different issues Can cause cardiovascular compromiseCan cause cardiovascular compromise Oxygenation can be impaired Oxygenation can be impaired

Suggestions for Future Suggestions for Future Research Research

The imperative question ??????The imperative question ??????

What is the exact cause and/or What is the exact cause and/or

reason a patient has developed a reason a patient has developed a pressure ulcer or skin breakdown?pressure ulcer or skin breakdown?

? Who, What, Where, ? Who, What, Where, How, Why, and When ? How, Why, and When ?

Who…study patients of different ages?Who…study patients of different ages? What…study the exact cause of pressure What…study the exact cause of pressure

ulcers and skin breakdown?ulcers and skin breakdown? Where…study multiple floors of different Where…study multiple floors of different

hospitals?hospitals? How…the researchers would investigate the How…the researchers would investigate the

nurses?nurses? Why…to determine the most frequent Why…to determine the most frequent

reasons (why and how)?reasons (why and how)? When…study over a period of 3- 6 months?When…study over a period of 3- 6 months?

The Study The Study

What do the researchers want to What do the researchers want to find?find?

• • Ackerman, C.L. (2011). ‘Not on my watch:' treating Ackerman, C.L. (2011). ‘Not on my watch:' treating and preventing and preventing pressure ulcers. pressure ulcers. MEDSURG MEDSURG NursingNursing,,2020(2), 86-93.(2), 86-93.

• • Allegretti, A., Brienza, D., Geyer, M.J., Holm, M., Allegretti, A., Brienza, D., Geyer, M.J., Holm, M., Karg, P., Kelsey, S., Karg, P., Kelsey, S., Kusturiss, M., Schmeler, M., & Kusturiss, M., Schmeler, M., & Zanca, J. (2010). A randomized Zanca, J. (2010). A randomized clinical trial on clinical trial on preventing pressure ulcers with wheelchair seat preventing pressure ulcers with wheelchair seat cushions. cushions. Journal of the American Geriatrics Journal of the American Geriatrics SocietySociety, , 5858(12), 2308-(12), 2308- 2314.2314.

• • Amr, S., Baumgarten, M., Hawkes, W.G., Margolis, Amr, S., Baumgarten, M., Hawkes, W.G., Margolis, D., Miller, R.R., D., Miller, R.R., Shardell, M., & Shayna, R.E. Shardell, M., & Shayna, R.E. (2010). Frequent manual (2010). Frequent manual repositioning and repositioning and incidence of pressure ulcers among bed-incidence of pressure ulcers among bed- bound bound elderly hip fracture patients.elderly hip fracture patients.Wound Repair and Wound Repair and RegulationRegulation, , 10-18.10-18.

ReferencesReferences

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

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

Saunders.Saunders.

• • Chiang, C.L. & Winkelman, C. (2010). Manual turns Chiang, C.L. & Winkelman, C. (2010). Manual turns in patients in patients receiving mechanical ventilation.receiving mechanical ventilation.Critical Critical Care NurseCare Nurse, , 3030(4), 36-44.(4), 36-44.

• • Courtney, B.A., Ruppman, J.B. & Cooper, N.M. Courtney, B.A., Ruppman, J.B. & Cooper, N.M. (2006) Save our skin: (2006) Save our skin: Initiative cuts pressure Initiative cuts pressure ulcer incidence in half. ulcer incidence in half. Nursing Nursing ManagementManagement April, April, 36-45. 36-45.

• • Gunningberg, L. & Stotts, N.A. (2008). Tracking Gunningberg, L. & Stotts, N.A. (2008). Tracking quality over time: quality over time: what do pressure ulcer data what do pressure ulcer data show?. show?. International Journal for Quality International Journal for Quality in Health in Health CareCare, , 2020(4), 246-253.(4), 246-253.

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

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

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

1556-1564. doi: 10.1111/j.1365-1556-1564. doi: 10.1111/j.1365-2648.2010.05292.x2648.2010.05292.x

• • Sprigle, S. & Sonenblum, S. (2011). Assessing Sprigle, S. & Sonenblum, S. (2011). Assessing evidence supporting evidence supporting redistribution of pressure for redistribution of pressure for pressure ulcer prevention: a pressure ulcer prevention: a review. review. Journal of Journal of Rehabilitation Research and DevelopmentRehabilitation Research and Development, , 4848(3), (3),

203-213.203-213.