A great deal of time and energy continues to be devoted to the prevention and treatment of pressure sores. Statistics compiled by the Stop Pressure Sores in Florida campaign estimated that "500,000 persons nationally suffer from decubitus ulcers . . . Some 3.5 million persons in the US are considered at risk of getting pressure sores, 165,000 in Florida alone."1 Fowler states "an estimated 30% of nursing home residents develop pressure sores. "2 Although the literature abounds with information on preventing and treating pressure sores, there remains no simple solution to this relentless problem.
Escalating healthcare costs have resulted in heightened consumer awareness of cost for essential services. In this era of cost containment, health professionals are responsible for examining healthcare practices over which they have control or influence for cost and effectiveness. One example of such a practice is the wide variety of treatments currently used to heal pressure sores.
Both intrinsic and extrinsic factors that cause prolonged compression on an area encourage the development of pressure sores.3 Examples of factors contributing to skin breakdown are immobility, metabolic conditions, peripheral-vascular impairment, paralysis, malnutrition, and incontinence. Nursing care of clients with potential or actual pressure sores includes prevention and management.
This study addressed both these nursing components. It was designed to evaluate whether adherence to prescribed prevention guidelines for clients who were determined to be at risk resulted in improvement in their risk status. The second purpose was to compare the effectiveness of hydrocolloid occlusive dressing with povidoneiodine therapy in the treatment of pressure sores.
Review of the Literature
Nursing literature expounds on the multiple factors that contribute to the development of pressure sores. Prevention of pressure sores depends on how well these contributing factors are eliminated, diminished, or counteracted. Localized ischemia due to pressure is the primary factor contributing to the development of pressure sores.4 Relief of pressure on bony prominences can be accomplished by using specialized mattresses and good turning protocols.
Assessing the skin frequently, improving a client's nutritional status, maintaining clean, dry skin, and teaching prevention guidelines all facilitate the prevention of pressure sores. Tooman and Patterson5 encouraged the use of Ensure®, a liquid nutritional supplement, three times daily for all clients who had pressure sores, and improvement in the sores was evident in 20 days. Maintenance of clean, dry skin is of utmost importance since incontinence has been identified as a factor that may increase the risk of an immobile client developing pressure sores.2,4
Patient education is identified, however, as one of the most important factors in the prevention of pressure sores. Prevention guidelines need to address what can be done to eliminate, diminish, or counteract the contributing factors that lead to the development of pressure sores. Subjects to be taught to clients and families include skin management activity and nutritional guidelines. Patient teaching is more effective when both verbal and written methods are used.2-6
An informal survey of local home health agencies in the community revealed that povidone-iodine and hydrocolloid occlusive dressing (HCD) were two of the most common treatment modalities for pressure sores. HCD is a semisynthetic, relatively oxygen impermeable occlusive dressing. It consists of a pliable, water resistant outer layer and an inner layer containing hydroactive particles that interact with wound fluid.7 The composition of this dressing allows for prolonged use and easy application.
Studies by Galub, Friedman, and Yarkony3,7,8 indicate a marked improvement in the healing of pressure sores through the use of HCD. It was determined that the longer the period of application, the greater the ulcer response to HCD. Galub7 reports that a lack of oxygen may, in fact, stimulate capillary growth. The promotion of granulation tissue is cited as a distinct advantage of hydrocolloid dressing.8
Povidone-iodine as a treatment modality for pressure sores was selected for study because of the frequency of use in many healthcare settings in southeast Florida, despite the virtual absence of research support. Documentation of povidone-iodine as an effective treatment modality for pressure sores is limited. Studies have determined that the topical application of povidone-iodine to manage infections associated with pressure sores and burns was effective.9,10
Study Methods and Procedures
Based on the literature review, the first hypothesis stated there would be a significant difference between the initial Norton score and the score recorded following adherence to prevention guidelines by clients identified as being at risk. The Norton scale consists of five categories measuring observable data that can be assessed in a few moments time. These categories include physical condition, mental condition, activity, mobility, and incontinence. A score of 14 or below indicates that the client is at risk for developing pressure sores. The second hypothesis tested whether there would be a significant difference in the degree of effectiveness of HCD over povidone-iodine in the treatment of pressure sores.
The sample consisted of clients from two home health agencies who met the inclusion criteria of having either a Norton score of 14 or less, or an existing pressure sore. Twenty-one subjects, 15 females and 6 males, were obtained by convenience sampling. All clients lived at home and were at least 65 years of age. Ages ranged from 67 to 96 with an average age of 83 . Eleven subjects had pressure sores and the remaining 10 were at risk on the Norton scale, but did not have pressure sores.
The sample for the first hypothesis included all 21 subjects. Subgroups for the second hypothesis consisted of 5 subjects from one home health agency with a total of 1 1 pressure sores treated with povidone-iodine, and 6 subjects from the second agency with a total of 10 pressure sores treated with HCD. The length of time in the study ranged from 1 to 12 weeks, with an average inclusion of 6.4 weeks.
A Norton scale score was obtained on the initial visit to establish a baseline score and at 1-week intervals to assess the client's potential for developing pressure sores. After the initial Norton score was completed the nurse instructed all at-risk clients and their families in the prevention guidelines. These guidelines addressed skin management, activity, and nutrition. Instructions were both verbal and written. A pamphlet, titled "Prevention Guidelines," was developed from the literature review with input from enterostomal therapists and registered nurses at the home health agencies used in this study.
Each client was visited weekly by the same nurse. The weekly visit included reinforcement of the teaching program and reassessment on the Norton scale.
CHANGE IN SIZE OF PRESSURE SORES BEFORE AND AFTER TREATMENT
Weekly Norton scores were graphed. Data collection extended over a period of 3 months at each agency.
The treatment protocols for povidone-iodine and HCD were developed in the same manner as the prevention guidelines. Each treatment procedure was demonstrated to participating staff, and copies of the procedure were distributed and discussed.
Instructions for treatment application were written in lay terminology to facilitate proper understanding by the client and family members. The investigators made random home visits with the home health nurses to determine compliance with designated protocol.
The first step in the treatment of a pressure sore was to obtain a baseline assessment of the area. Each ulcer was identified on a flow sheet according to location, stage, appearance, size, drainage, and odor. Direct measurement of the pressure sore was done by determining the sore diameter and depth using a wound size measurement scale.
CHANGE IN NORTON SCORE BEFORE AND AFTER TREATMENT
Each pressure sore was evaluated on a weekly basis. Subjects were treated with pov idone- iodine or HCD depending on the home health agency involved.
Results and Discussion
Data were analyzed using SPSS on the UNIVAC 1100. The chi-square test for contingency was used to evaluate whether there was a significant change in the Norton scale score of at-risk clients after having been taught prevention guidelines. The results did not support the research hypothesis that there would be a significant difference between the initial Norton score and the score recorded following adherence to prevention guidelines by clients identified as being at risk.
The one-way analysis of variance was used to determine if there was a significant difference in the means of the two treatment groups. Although statistical results did not support the hypothesis that there would be a significant difference in the degree of effectiveness of HCD overpovidone-iodine in the treatment of pressure sores, interesting patterns did emerge.
The pressure sores treated with HCD showed a decrease in size approximately twice that of povidone-iodine. The chi-square test for contingency revealed a trend that indicated HCD was better than povidone-iodine in effecting this change.
Although the sample size was too small to generalize findings to the total population, the statistical pattern indicated a trend that HCD may be more effective in the treatment of pressure sores than povidone-iodine.
Table I shows the difference in the size of the pressure sores prior to treatment and at the end of the study. Three sores treated with povidone-iodine decreased in size and 8 remained the same. Of the pressure sores treated with HCD, 6 decreased in size, 2 remained the same, and 2 increased in size.
Table 2 demonstrates the change in Norton score for all subjects: those treated with povidone-iodine, those treated with HCD, and those in the atrisk category. The trend was that the Norton score either remained the same or improved. None of the 10 at-risk subjects developed a pressure sore during the 12-week period.
The importance of client teaching cannot be overlooked. Families and clients must be taught options, costs, advantages, and disadvantages of treatments. This approach places increased responsibility for health care on the consumer, promotes independence, and enhances commitment to achieving health goals. Professional caring requires that the client be the focus of holistic care.
More than ever, healthcare professionals are being required to be more responsible and accountable for highquality, yet economical, health care. Nurses must take advantage of opportunities to identify and market nursing resources. When the physician asks nurses for input regarding treatment modalities for pressure sores, nursing resources should not be ignored.
In early studies on pressure sores it was said, "The avoidance of pressure sores is usually considered to be the concern of nurses and the occurrence of pressure sores regarded as a serious reflection on their skill."11 Continuing research on pressure sores has demonstrated quite clearly the complexity of this nursing problem. This study brought to light, however, the question of whether good nursing care alone could heal pressure sores. It is frequently said that good nursing care prevents pressure sores; could it also heal existing sores? The time is ripe for nursing to recognize the many nursing resources that should be used in the design and implementation of quality, cost-effective nursing care.
- 1. Arjemi C: Statewide drive to eradicate decubitus ulcers launched in South Rorida. Florida Nursing News, February 23, 1985; 1,4.
- 2. Fowler E: Pressure sores: A deadly nuisance. J Geranio! Nurs 1982; 8(12>:680-685.
- 3. YarkonyG.LukancC, Carle T: Pressure sore management: Efficacy of a moisture reactive occlusive dressing. Arch Phys Med Rehabil 1984; 65(10):597-600.
- 4. Reddy MP: Decubitus ulcers: Principles of prevention and management. Geriatrics 1983; 38<7):55-6l.
- 5. Tooman T, Patterson J: Decubitus ulcer warfare: Product vs process. Geriatric Nursing 1984; 5(3):166-167.
- 6. Andberg M, Rudolph A, Anderson T: Improving skin care through patient and family training. Topics in Clinical Nursing 1983; 5(2):45-54.
- 7. Galub J: Wound dressing technology revives old concept: Don't expose wound to air. Nursing Homes 1983; 32(51:32-35.
- 8. Friedman SJ, Su WPD: Management of leg ulcers with hydrocolloid occlusive dressing. Arch Dermatoi 1984; I20(10):1329-1336.
- 9. Lee B, Trainor FS. Thoden WR: Topical application of povidone-iodine in the management of decubitus and stasis ulcers. J Am Gerialr Soc 1979; 27(7): 302-306.
- 10. deKock M: Topical bum therapy comparing povidone-iodine ointment or cream plus aserbine, and povidone-iodine cream. Journal of Hospital Infection 1985: 6<supplement): 127-1 32.
- 11. Norton D, McLaren R. Exton-Smith AN: An Investigation of Geriatric Nursing Problems in Hospital. National Corporation for the Care of Old People, London, 1962, p 236.
CHANGE IN SIZE OF PRESSURE SORES BEFORE AND AFTER TREATMENT
CHANGE IN NORTON SCORE BEFORE AND AFTER TREATMENT