Ebp Case Study Emcc.docx

Turning Patient with Physical Immobility Every 2 Hours

Introduction Pressure ulcers, commonly referred to as pressure sores, bed sores, pressure damage and decubitus ulcers, are areas of localised damage to the skin that caused by a combination of factors including pressure, shear forces, friction and moisture (Wain & Laing, 2016). Turning the patient every 2 hours becomes a practice that has been used in order to prevent pressure sores on the area receiving pressure (Makic, Rauen, Watson, & Poteet, 2014). Although the research evidence has been found to be limited, this intervention is still being used because it gives good results in preventing pressure ulcer (Miles, Nowicki, & Fulbrook, 2014).

Case study : Mrs.R is 70 years old; Body Weingt:80 kg; Body Height:158 cm, admitted to hospital due to decreased consciousness after falling in his room. When assessed by the nurse HR:90 times/min, RR:19 times/min, T:36.4ºC, BP:150/124 mmHg, GCS E1M1V1, Braden Score 10, BMI 32,12, has a history of uncontrolled hypertension. After examination by the doctor, the client is diagnosed with ICH and need bed rest. After being treated for 4 days in the ICU, the nurse who was bathing Mrs.R found that there was a reddish skin on the sacrum.

Assessment Nurse should perform a full-body skin assessment within 8 hours of admission and during every shift. Based on Braden Score assessment, Mrs.R has a high risk (score of 10) to have pressure ulcer due to decreased consciousness (E1M1V1) that caused the client to

experience physical immobility, decreased ability to respond pressure and inability to reposition. In addition to the Braden Score assessment, the nurse also needs to examine other risk factors found on Mrs.R. Mrs.R age is 70 years old, this fact increase the risk of pressure ulcer because of decreased quality of skin integrity. In addition, Mrs.R is obesity and this will make the client experience pressure on certain body parts if not repositioned. Mrs.R has experienced bed rest and can’t perform her daily activities. Mrs.R‘s husband and her daughter always come tovisiting Mrs.R. In addition, the Mrs.R‘s husband also said that his youngest daughter always comes to their house to tidy up the house and cook since Mrs.R was hospitalized.

Pathophysiology First, longstanding hypertension leads to hypertensive vasculopathy causing microscopic degenerative changes in the walls of small-to-medium vessels, which is known as lipohyalinosis. Then the vessel rupture, the hematoma causes direct mechanical injury to the brain parenchyma. Finally, the hematoma can continue to expand in up to 38 percent of patients during the first 24 hours (Caceres & Goldstein, 2012). Hematoma that found in the brain parenchyma interferes the work of the brain as the central nervous system that regulates the physiological function and ultimately leads to a decrease in consciousness that makes the client immobilized (Caceres & Goldstein, 2012). This condition make Mrs.R has high risk to pressure ulcer because she can’t do repositioning by herself. Pressure ulcers result when increased pressure on the skin and subcutaneous tissues exceeds the local capillary pressure, which compromises blood flow and results in ischemia and decreased oxygen delivery (Peterson, Gravenstein, Schwab, Oostrom, & Caruso, 2013). Healthy

capillary pressures typically range from 10 to 30 mm Hg (Tayyib, Coyer, & Lewis, 2013). When pressures exceed capillary pressure, tissue hypoperfusion, accumulation of metabolites, and impairment of tissue reperfusion may occur, all of which can damage the tissue. It is well established in animal and human studies that not only is the magnitude of pressure a factor for tissue damage but the duration is important as well-the greater the pressure, the less time it takes until damage occurs (Peterson, Gravenstein, Schwab, Oostrom, & Caruso, 2013). The pressure is very large around the sacrum, the coccyx, and ischiatuberosity, so it is not surprising that pressure ulcers develop in this area.

Nursing Management According to Makic, Rauen, Watson, & Poteet (2014) since 1900, nurses are encouraged to reposition clients as often as possible to prevent damage to skin tissue under . According to current practice standards, frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. Makic, Rauen, Watson, & Poteet (2014) state that this repositioning should be done every 2 hours. Why should be done every 2 hours? According to Zulaikah, Kristiyawati, & Purnomo (2016) in bedrest patient, reposition is done every 2 hours because this period can reduce the occurrence of hypoxia in the tissues. If not immediately repositioned then clients will experience reactive hyperemia that can cause tissue damage within 1-2 hour intervals (Potter & Perry, 2012). Among patients at high risk of pressure ulcers, those repositioned at least every 2 hours had a lower rate of incident pressure ulcers than those repositioned less frequently (Miles, Nowicki, & Fulbrook, 2014). It should be noted that there are other factors that can also affect the effectiveness of repositioning every 2 hours such as the client's health condition, nutrition,

activity and type of bed used (Makic, Rauen, Watson, & Poteet, 2014). In fact, certain types of beds can extend the repositioning time without increasing the incidence of pressure ulcers (Manzano, et al., 2014).

Conclusion Clients with physical immobility and loss of consciousness require nurse assistance to be able to reposition in order to prevent injuries. As a nurse we should always undertake a thorough assessment, especially in assessing the risk of injury. If the client has a high risk of pressure ulcers, then the most effective intervention to prevent the occurrence of pressure ulcers is repositioning the client every 2 hours (Miles, Nowicki, & Fulbrook, 2014). However, it should be considered that the physical condition, the medical condition and the type of bed used may also affect the repositioning time (Manzano, et al., 2014). Therefore, repositioning every 2 hours is an intervention that must be given to Mrs.R because Mrs.R has a high risk for pressure ulcers.