Prevention of pressure ulcers: nurses’ sole responsibility

Prevention of pressure ulcers: nurses’ sole responsibility Pressure ulcer is a major health problem. According to previous 10 years nationwide studies, 10% to 15% of the general population suffers from chronic pressure ulcers. In addition, Reddy, Gill and Rochon (cited in Walton-Geer, 2009) approximated 60,000 patients every year will die from hospital acquired pressure ulcers and the treatment of these wounds costs approximately $11 billion per year. These findings are significant in some areas such as patients in intensive care units, critical care units and nursing home residents. These situations cost patient in terms of suffering, impaired quality of life, reduced independence and even increased morbidity and mortality. The patients delay in hospital discharge and decrease the efficiency and efficacy of health services. The health industry is also concerned about lack of sources, work force hours to manage the problem. Various industries and government agencies are disconcerted to either treat these ulcers in early intervention or encou rage prevention (Lippincott Williams Wilkins, 2007). However, a good quality care is important in preventing these sores and nurses come at front to provide this care. In identifying the nurses attitude towards care and perception of barriers in that case may solve this situation. Search strategy The literature search was conducted by using the databases- Cinahl, Pro Quest, Pub med and Waiariki library catalogues. These databases identified the published studies, nursing journals and conference proceedings. The search engine used the terms for search were pressure ulcers and nursing, nurse and bedsores, nurse and hospital, pressure ulcer and patient, and nursing management and decubitus ulcers to search out the articles. The articles only written in English were retrieved for review. This literature review is based on the prevention strategies. Prevention and management of pressure ulcer is of major concern in health care system. Most of the studies revealed the appropriate knowledge of nurses for prevention. The gaps could be in the lack of performance in their practice. The hospital routines for early assessment and culture may be responsible for nurses to practice efficiently. Despite of increasing expenditure neither incidence nor prevalence is reducing. The attitude and supervision towards care of patient are significant review in whole populations generally. The search was wide to find the reliable material and needed to exclude some for relevance. The search boundaries were elaborated for nursing practice and attitude. The access to literature was sometimes limited to abstract only. Eighteen published articles were reviewed for possible inclusions in the final review. Among those ten articles were taken from previous conducted researches, three were the literature reviews and two relevant articles were based on life story of patients. One textbook and two non-research articles were kept for background information. The first line of defense in preventing the pressure ulcer development is the nurse practitioners behavior towards patient, nursing care by using various devices, patients status for devolving risk factors and hospital polices for further improvements. All ages were viewed as inclusion criteria with high-risk abilities. Four articles were more than ten years old and excluded to gather current knowledge for practice. One study was excluded because of emphasize was put on various positions of the patient that are inefficient for critical care units to take efforts in rising out of bed and were not valid. Two researches based studies were included to asse ss nurses knowledge in prevention and treatment strategies that were mainly researched for assessing the nurses knowledge about pressure ulcers and impact on practical decision-making skills and utilizations of various devices. The research literatures on pressure ulcer development filled the education and reliability assessment of nurses. One group of researchers created the longitudinal examination of hospital registered staffing to improve the quality of care and revealed the limited support for quality with number of registered nurses. These variations in favor of care presents a cross comparison of results, at best. Another research study revealed the influence of handling technique, and patients weight and disability that causes serious back injuries to nurses. One research supported computers for prevention and treatment of pressure ulcers at LCD hospital was included because the system reminds documentation to nurses. One life story article included tells about the negligenc e in care that leads towards the death of a woman, because of bone deep bedsores that remained untreated in last six months of her life. The selection criteria in three researches have been taken for use of preventive devices that underline the risk of pressure ulcers early assessment at time of admission. The potential inclusion admits a risk assessment tool, Braden scale in predicting pressure sore risk in hospitalized patients. However, two included studies exposed issues regarding the lack of clinical trials for effectiveness and the quality improvement implementations in nursing homes that associated with organizational culture. As the review included all ages, hospitalized and outside patients, one study assures about the sitting behavior of people lead towards building the risk of pressure ulcers. Nurses knowledge and attitude In 2004, Moore agreed the development of pressure ulcer is linked to nurses attitude, education and competence. Education increases awareness of the problem and gives a pathway for developing and maintaining competency. Thus, the successful prevention is dependent on staff knowledge, skill and attitude. This argument was underlined the content and quality of education, a major concern in decision-making. Hulland (cited in Moore, 2004) was able to identify nurses action, beliefs and opinion on pressure ulcer prevention and treatment. Anthony (cited in Moore, 2004) also agreed, however, nurses have good knowledge for prevention, still usage is inappropriate in practice. Maylor and Torrance (cited in Moore, 2004) supported the value of the attitude of nurses for preventive practices of pressure ulcers in clinical practice. Ousey (2010) accented the need of evidence-based education for whole staff involved in care of pressure ulcers. Another study by Wiechula in 1997 described the focus of quality improvement ought to on the appropriate education program that contains the instructions and guidelines of current and evidence based practice. The education program should include the etiology and risk factors along with risk assessment tools and application in demonstrating the positioning for prevention of pressure ulcers. In this study, the stress was also put on the accurate documentation and monitoring. Another cross-sectional study by a group of researchers explored the comparison between the knowledge among past time and present time nurses. The sample was large (n=522 nurses in 2003 compared with n=351 nurses in 1991), with written questionnaire method. The authors identified the knowledge of nurses in 2003 is better and nurses know the usefulness of preventive measures. However, the raised issue was again the knowledge did not come in practice in the organizations that monitored pressure ulcers (Hulsenboom, Bours Halfens, 2007). Comparing the views of all autho rs, one group of researchers conducted a one-time survey. Fifteen nurses were subjected to check the use of system increase their knowledge and skills. The study resulted in no effective knowledge about pressure ulcers and decision-making skills in practice (Zielstorff et al, 1997). Among various researches, one study by Smith and Waugh in 2009 uncovered the nurses knowledge of pressure ulcer prevention and treatment along with the perception of barrier in providing effective care. After using the Pieper Pressure Ulcer Knowledge Test among 96 nurses, the study revealed the nurses knowledge was higher significantly but the barrier such as the weight of patient, patients refusal, unavailability of equipments, not having enough time and staff was significantly considerable. Nevertheless, Mark, Harless, McCue and Xu in 2004 found limited support for enduring the belief that improvement in registered nurse staffing improves the quality of care. In addition, Skotte and Fallentin in 2008 s upports the barrier by assessing the low back load on health care workers while using preventive techniques such as repositioning and use of friction reducing devices that is higher than patients weight and disability. Pulkkinen (2009) explores this argument in an article about a health care workers second-degree criminal mistreatment. The evidence shows that the treatment for bedsores was not provided to Harrison and ultimately because of gangrene infection of bone deep ulcers, he died. Use of appliances in practice In 1997, Wiechula described the assessment of risk is important to consider causative and contributing factors that can eliminate the negative effects. This skin care assessment of patient should be at the time of admission, after change in condition and for long-term patients at regular intervals. Specifically, to relieve pressure, attempt should be put on positioning and turning frequently. The major concern was preventing contact on between prone areas and support surface by using devices such as pillows and foams and use of alternating pressure mattress for high-risk patients. Ousey (2010) explored the early detection and effective documentation of pressure ulcers is a key component of quality care if the nurses can identify risk development behavior appropriately. The study assures manual repositioning and pressure relieving support surfaces are important in preventive measures. The early detection includes the assessment within six hours of admission in hospital and in communit y settings; it should be at first visit of practice nurse. However, Wiechula in 1997 outlined, turning of patient every 2 hours is a reliable and cheap method of prevention. Schoonhoven (cited in Ousey, 2010) disputed the effectiveness of preventive measures in some patients. Based on this notion, Ousey agreed the pressure ulcer tool will be helpful for high-risk individuals if practice with professional jugdement. Stotts and Gunningberg in 2007 supported one evidence-based article for use of Braden scale, a good assessment tool. Considering the reliability and validity, Braden scale is affective to practice with the difference in patients culture. In the matter of devices in care of pressure ulcers, the Australian Medical sheepskin is a new pressure-relieving device is effective in relieving pressure with moisture absorbing capacities (Mistiaen et al, 2008). Gardner, Frantz, Bergquist and Shin (2005) explored another perspective study for measuring the wound healing is pressure ulc er scale for healing. When the workers apply this evidence-based tool at weekly intervals, it provides accuracy in differentiating healing of pressure ulcer from non-healing in tracking changes in pressure ulcer status. This study outlined the use of PUSH score can achieve changes during extended follow-ups during the time when pressure ulcers take more than 3 months to heal. As explained by Wiechula in 1997, massage on bony prominences ought to avoid and the ring shaped devices are ineffectiveness in practice. Ousey (2010) agreed the view of not rubbing the skin vigorously to prevent the damage of superficial and deep tissues. Interestingly, one cross-sectional study unveiled the use of these preventive devices and documentation is suboptimal even for high-risk patients. In practice, the documentation and preventive devices are important for all patients who are at risk and having pressure ulcers to note the status of patients. A research nurse to ascertain the use of pressure ulce r devices examined the patients. After examination, 68% patients were documented for pressure ulcers. Among those 15% of patients had preventive devices and 51% receive those were at high-risk. In multiple analyses, the type and stage of pressure ulcer were not associated with high-risk patient but the use of preventive devices (Rich, Shardell, Margolis Baumgarten, 2010). Similarly, Moore (2004) identified the use of pressure relieving devices are not as much helpful in reducing the prevalence of pressure ulcers without nurses positive attitude. Hospital policy The cost of treatment of pressure ulcers can be enormous and significantly run out the health system resources. According to Posnett Franks (cited in Ousey, 2010) the estimated cost for the treatment of pressure ulcer is between 1.8 billion pounds to 2.6 billion pounds annually. In 2009, Walton-Geer gave views on for the improvement in patient care the interventions should be initiated on evidence-based practice. Patients status AHCPR (cited in Wiechula, 1997) recommended the important link of malnutrition with the development of pressure ulcers. Wiechula (1997) indicated, on admission nutritional assessment should also be monitored such as weight changes, loss of appetite and decreased dietary intake. Patients with poor hygiene and skin moisture degrade the integrity of skin that further helps in developing sores. One literature review supported the components of Braden scale such as nutrition, sensory perception, evidence of moisture, activity level and mobility status are the most important predictive of developing risk of pressure ulcers. It is apparent in the study that the risk increases with the susceptibility of tissue tolerance and poor peripheral circulation that relates with poor nutritional status (Schultz, 2005). Ousey in 2010 outlined some intrinsic and extrinsic factors responsible for pressure ulcer development. Intrinsic factors included patients age, mobility, incontinence, medication, anem ia, thin skin, nutritional status and disease condition. The considered extrinsic factors were friction, moisture, poor handling and changing position. The stress was also put on initial assessment of all patients to improve nutritional intakes. Williams et al (cited in Ousey, 2010) considered poor nutrition and decreased tissue perfusion, the main cause of pressure ulcer development. Bain and Ferguson-Pell in 2002 considered the knowledge of sitting behavior of patients outside the hospital especially for wheel chair users who sit continuously for long time. The study tested the use of remote monitoring pressure distributing logger that keeps the record of sitting behavior after testing its feasibility. Phytochemical Method Silver Nanoparticles: Synthesis Phytochemical Method Silver Nanoparticles: Synthesis Phytochemical Method Silver Nanoparticles: Synthesis and Characterization The study of green synthesis of nanomaterials offers a valuable contribution to biomedicine at nanobiotechnology. This study focuses on the green synthesis of nanosilver from O. sanctum leaf extract and loading the nanosilver onto cotton fabrics and assessing their physical and biological properties. In this study, O. sanctum leaf extract was used as reducing agent for the synthesis of silver nanoparticles. When the silver nitrate solution was mixed with leaf extract, the color changes occur immediately in silver nitrate solution. Initially, the leaf extract was green, which turned yellowish brown on adding the silver nitrate solution. The color changes indirectly indicate the formation of silver nanoparticles. The color change was noted by virtual observation of O. sanctum leaf extract incubated with an aqueous solution of AgNO3. It started to change color from watery to yellowish brown at 4 h and dark pink at 24 h after incubation (Figure 1). It is due to the reduction of silver ions; this exhibits the formation of silver nanoparticles (Table 1). The color of the extract changed to intense brown along with threads after 24 h of incubation, and there was no significant change afterward. S.No. Time interval Colour change 1 0 min Dark green 2 10 min Pale green 3 30 min Reddish green 4 1hr Red 5 2 hrs Red 6 4 hrs Reddish brown 7 8 hrs Reddish brown 8 16 hrs Brown Threads 9 24 hrs Brown Threads Table 5. 1. Effect of leaf extract of O.sanctum on colour changes in silver nitrate solution at different time interval Biosynthesis of nanoparticles by time-dependent absorption spectrum The continuous formation of silver nanoparticles was investigated using UV-Vis spectroscopy, which has proven to be a useful spectroscopic method. The presence of silver nanoparticles was confirmed at a range of 200–600 nm. In UV-Vis spectra, silver nanoparticles can be shown by a SPR peak at around 400 nm, but a small shift (blueshift or redshift) in the wavelength of the peak could be related to obtaining —silver nanoparticles in different shapes, sizes, or solvent dependences. After 24 h of incubation, a typical peak of ÃŽ »max at 421 nm was obtained due to the SPR of silver nanoparticles (Figure5. 2). After the reaction time on adding of leaf extract reached 4 h, obtained silver nanoparticles showed a UV-Vis absorption peak, a characteristic SPR band for silver nanoparticles, centered at 400 nm (Figure 5.2). Figure 2, the intensity of the SPR peak increased with the increase in the reaction time, which indicated the continued reduction of the silver nitrate ions, whereas the increase of the absorbance value with the reaction time indicated the increase in concentration of silver nanoparticles. When the reaction time reached 12 h, the absorbance was increased and ÃŽ »max value was slightly blueshifted to 435 nm. At reaction time of 24 h, the absorbance value was also increased and blueshifted to 435 and 421 nm, respectively. At the end of the reaction (24 h), the absorbance value was considerably increased and there was no significant change in ÃŽ »max value (421 nm), compared with that at 12-h reaction time. FTIR spectroscopy analysis of biosynthesized silver nanoparticles FTIR measurements of the biosynthesized silver nanoparticle samples were carried out to identify the possible interactions between silver and bioactive molecules, which may be responsible for synthesis and stabilization (capping material) of silver nanoparticles. These were also to identify the possible biomolecules responsible for capping and efficient stabilization of the metal nanoparticles synthesized by leaf extract. Figure 5.3 shows the FTIR spectra of aqueous silver nanoparticles prepared from O. sanctum leaf extract. The presence of the signature peaks of amino acids supports the presence of proteins in cell-free filtrate as observed in spectral analysis. The silver nanoparticle sample shows peaks at 3313.48, 3193, 2976.90, 2883, 1670, 1452, 1338, 1196.78, and 1112.75 cm−1 (Figure 5.3). The peaks corresponding to protein and silver nanoparticles were found commonly present in the nanoparticles synthesized by leaf extract. X-ray diffraction analysis The crystalline nature of silver nanoparticles was studied with the aid of XRD as shown in Figure 5.4. The dry powders of the biosynthesized silver nanoparticles were used for XRD analysis. The diffracted intensities were recorded from 20à ¯Ã¢â‚¬Å¡Ã‚ ° to 80à ¯Ã¢â‚¬Å¡Ã‚ ° at 2à ¯Ã‚ Ã‚ ± angles. Many strong Bragg diffracted peaks observed at 27.82, 32.25, 46.22, and 76.63 corresponding to 126, 199, 131, and 24 height of the face-centered cubic pattern of silver were obtained. The average grain size of the silver nanoparticles formed in the bio-reduction process was determined using Scherrer formula and it suggested that the synthesized silver nanoparticles were crystalline. The size of the silver nanoparticles was found to be 26 nm, and it was determined using the width of the (126) Bragg’s reflection. In addition, yet some unassigned peaks were also observed suggesting the crystallization of biophase occurs on the surface of silver nanoparticles. Fluorescence spectral analysis Fluorescence spectroscopy is a type of electromagnetic spectroscopy which analyzes fluorescence from a sample. Figure 5.5 shows fluorescence emission spectrum from silver nanoparticles, dispersed in double distilled water. Fluorescence spectral analysis of silver nanoparticles used in the experiment was carried out to confirm the fluorescence emitted from the nanoparticles. A strong maximum at 431 nm wavelength and a quantum yield was 666.450 mV appeared in the fluorescence emission spectrum of O. sanctum leaf extract mediated silver nanoparticles. Potentiometry analysis of biosynthesized silver nanoparticles The biosynthesized silver nanostructure was shown and confirmed by the characteristic peaks observed in zeta potential, which will help to measure the diameter of nanoparticles with corresponding average zeta potential values, and also used for suggesting higher stability of silver nanoparticles. The reduction of silver ions to form nanoparticles was also monitored using a potentiometer. The large negative potential value could be due to the capping of polyphenolic constituents present in the extract. Figure 5.6 shows the results of time-dependent zeta potential analysis from 0 to 24 h of incubation period. A pointed reduction in the potential could be observed on 4 h of interaction, further indicating the formation of nanoparticles at this stage. The potential decrease from an initial value of 0.436 V for silver ions to 0.153 V at the end of 11 h (Figure5.6) was observed, after which the decrease in potential was gradual, decreasing up to 0.048 V at the end of 24 h. Zeta potential analysis of synthesized silver nanoparticles The zeta potential analysis was used to measure the electrophoretic mobility of the silver nanoparticles. The complex zeta potential is a parameter that is used to learn the surface charges and stability of nanoparticles. The zeta potential charges significantly affect the particle distribution and agglomeration of nanoparticles. The high zeta potential value indicates a high electric charge on the surface of the nanoparticles. It describes strong repellent forces among the particles, which prevent aggregation and lead to stabilization of the nanoparticles in the medium. The zeta potential of the nanoparticles formulated was only measured in systems that did not sediment after overnight equilibration. The alteration in zeta potential with a moment in time is shown in Figure 5.7. It can be observed that there was charge stabilization from 11 to 16 h, with the charge stabilized at around −57 mV. The zeta potential was −62 mV for the 14 h interacted samples, which further decreased to −35 mV for the 24 h interacted samples. SEM analysis of silver nanoparticles The morphology of silver nanoparticle was observed using a SEM instrument. The shape and size of silver nanoparticles were analyzed after 24 h of incubation using SEM as shown in Figure 5.8. In general, the nanoparticles were spherical with varying size ranged from 7 to 28 nm. Most of the nanoparticles were combined, with only a few of them scattered, as observed under SEM. The biosynthesized silver nanoparticles were mostly spherical. These were used to characterize the morphology, size, and distribution in aqueous suspension and were prepared by dropping the suspension onto a clean glass plate and allowing water to completely evaporate. It was evident that the ends of silver nanoparticles are brighter than the middle, suggesting the particles are encapsulated by biomolecules such as proteins in the Basil leaf extract (Figure 5.8). EDS analysis of silver nanoparticles The EDS spectrum (Figure 5.9) clearly identified the elemental composition of the synthesized nanoparticles, which suggests the presence of silver as the ingredient element. The vertical axis shows the counts of the X-ray and the horizontal axis shows energy in keV. The strong signals of silver correspond to the peaks in the graph confirming presence of silver. Biosynthesized silver nanoparticles typically show an optical absorption peak at 3.2 keV due to SPR. However, other elemental signals along with silver nanoparticles were also recorded, which were not observed for the biosynthesis of many other nanoparticles. TEM was used to visualize the size and shape of silver nanoparticles. Figure 5.10 shows the typical TEM micrograph of the synthesized silver nanoparticles. It is observed that most of the silver nanoparticles were spherical. A few agglomerated silver nanoparticles were also observed in some places, thereby indicating possible sedimentation at a later time. It is evident that there is variation in particle sizes, and the average size was estimated to be 26 nm and the particle size ranged from 8 to 45 nm. The natural products, namely glycosides, flavanones, and reducing sugars, are the main constituents of the O. sanctum leaf extract