CHAPTER ONE

1.     INTRODUCTION

• Background

Pressure ulcers (PU’s) have been recognized as a major health problem within the healthcare system (Tubaishat et al,2014).It is estimated that three million people are affected by PU’s, representing a major challenge to health care providers (Bran dies et al, 2001) pressure ulcers threaten the well-being of patients and have been identified as one of the five most common causes of harm to patients.(Abou El Enein N et al, 2001).Pressure ulcers affect all age groups but are more common among immobile and geriatric patients, as well as patients with severe acute neurological conditions (Kruger E et al, 2013).

In the United States of America (U.S.A) and Europe the prevalence of PU’s range between 10.5% to 22% in acute care settings. (Leijon S et al, 2013). In an attempt to reduce PU prevalence, the U.S.A and Europe have readily available guidelines from Panels dealing specifically with PU’s, namely; The National Pressure Ulcer Advisory Panel (NPUAP) in the U.S.A and the European Pressure ulcer Advisory Panel (EPUAP) in Europe (2016). The NPUAP serves as an authoritative voice for PU prevention and treatment through public policy, education, and research (National Pressure ulcer Advisory Panel 17 march 2017). Through the Panel’s collaboration with many Organizations, and it has designed a model for addressing PU prevention and treatment and has become an internationally recognized panel. The EPUAP serves a similar function to the NPUAP, and the two panels have collaborated to develop new, evidence-based guidelines on PU prevention and management.

In the U.S.A, the total cost of treating a grade four PU for 19 patients, is estimated at $129,248 annually (Brem H et al, 2010). The cost of treating a single patient can range from $20,90 to $151,00 per pressure ulcer. (Agency for Health care Research Quality October 2014). In Europe, the cost of treating PU’s is estimated to be between £1.4 and £2.1 billion annually (Bennet G et al, 2004). The financial burden incurred as a result of PU’s further increases costs due to litigation, with an average malpractice lawsuit settlement amounting to roughly $250,000 in the U.S.A (Leaf Healthcare 2014). Pressure ulcers have been reported to increase hospital stay by about seven days (Anthony D. 2004). This increase in hospital stay can add $43,180 in costs to a hospital stay.

Pressure ulcers are common in high and middle-income countries but the subject is rarely researched in low income countries (Jonsson A et al, 2010). Although there is little published data about PU’s in low income countries the problem of PU’s is more extensive in developing countries due to the lack of medical resources. There is paucity of data on PU prevalence or incidence in South Africa. (Pather D. et al, 2012). However, studies conducted in two countries in sub-Sahara African (Nigeria and Ethiopia) revealed a PU of 4.2% and 16.8% respectively (Adegoke B. et al, 2013and Gedamu H. et al, 2014). Therefore, research on PU prevalence in South Africa is imperative to bridge the gap in the literature.

The treatment of PU’s affects nursing staff workload and the time spent by nurses in managing PU’s is equivalent to 90% of the total cost in grade 1 and grade 2 PU’s. Apart from financial burden, PU’s are also associated with human suffering (Van Rensburg G, et al, 2014). Patients experience pain, limited movement, and some on how PU’s have affected their family and social lives due to the added care that they needed (Hopkin S A. et al,2006).

Pressure ulcers have been recognized universally as a preventable patient safety problem and are used as a measure of quality nursing care in health institutions worldwide. Pressure ulcer development is a phenomenon that is complex and the factors contributing to PU development relate to external factors and/or a patient’s condition (Lindgren M. et al,2004). Some of the risk factors associated with PU development includes; immobility, poor nutritional status, reduced sensation, age, moisture (often caused by incontinence), as well as circulation issues (Coleman S. et al, 2013). The prevention of PU’s includes the use of a combination of strategies such as foam-based mattresses, sheepskins, and other high technology pressure support surfaces which have been found to be more effective than standard hospital beds (Mclnnes E, et al 2011). Furthermore, a combination of repositioning and the use of pressure-alleviating surfaces have been found to be more effective than using a single strategy (Reddy M, et al 2006).

The National Department of Health in South Africa adopted the National core standards (NCs) in 2009.The purpose was to improve service delivery and quality of care in all health institution in the south African setting importance to PU’s is Domain 2 (patient safety , clinical governance, and care) (south Africa National Department of Health 2011). This domain sets out the standards pertaining to quality nursing care, ethical practice, reduction, of unintended harm to patients, prevention, and management of adverse events, clinical management, and infection prevention and control standards.

In  Cameroon, the incidence rate ranges from 1% to 3% and higher rates are noted in intensive care units where patients are mobile and have severe systemic illnesses. In the study of( Vander Wee et al, study 2010), only 10% of patients at risk developing pressure ulcer received adequate treatment (Spoelhofet a, 2009). Prevention PU begins by identifying high-risk individual, systematic examination of skin using bed and chair support surface, changing posture, mobility and nutritional support(Strauss et al,2013).

The pressure ulcer Assessment Tool (PUKAT) is a 26- items questionnaire designed by Beckman et al to access nurse’s knowledge on the prevention and management (Beckman et al 2008). Low knowledge on PU prevention negatively affects preventive care strategies. The review of literature suggests that a nurse’s knowledge on PU prevention and management is limited and that this lack of knowledge can negatively influence their performance, control and prevention  of PU requires integrity of patients skin and prevent complications of bedsores , patient need to receive support and advise from health professionals (Williams et al 1988).Pressure ulcer management depends on ulcer infection and associated complications. Frist and Second degrees are generally managed by conservative approaches such as elimination of ulcer creating pressure, ulcer care and improvement of patient’s nutritional status while third- and fourth-degree ulcer are treated by surgical intervention such as debridement of necrotic, infectious tissues defect which is situated on bony prominence (Williams et al 1988).

Most PU’s are preventable and a core indicator of quality of care. Poor implementation of evidence -based methods and insufficient equipment in clinical practice are common problems (Gunningberg L.et al 2001). Nurses should possess good knowledge, positive attitudes, as well as evidence – based practices in preventing  PU’s. While a multi-disciplinary approach is required in the prevention of  PU’s nurses are the appropriate practitioners to lead prevention teams since they are primarily concerned with coordinating the nursing aspect of care (Yap T et al 2013).

• Problem statement

Globally, pressure ulcer remains the third most costly problem after cancer and cardiovascular diseases, the mortality rates from this sores  are 2 to 6 times as much as other diseases with 60,000 deaths annually due to the complication (Goreckic. Et al 2009).

In Africa, Pressure ulcer remains a major problem affecting approximately three million adults and have longed been a concern of prolonged hospital stay and poor healing performance due to few number of workers on duty who hardly have time to make up patients bed and positioning those critically ill patients (Lawrence P. et al 2015). A systematic review of 31 studies found out that pressure ulcer significantly limits many aspects of an individual’s wellbeing including general health, physically, social, financial and psychological quality of life. So, the burden of pressure ulcer goes beyond increasing health care cost to loss of life (Qaddumi J. et al, 2014). The pain and discomfort of pressure ulcer delays rehabilitation, prolong illness and timing of discharge and also contribute to disability and death. These dramatically raise health care cost as a result of the need for supplies and nursing care (Samuriwo R. 2012). Therefore, laying more emphasis on the prevention and management of bedsores is a necessity.

• Goal

The goal of this study is to determine nurses’ knowledge, altitudes, and practices of pressure ulcer prevention and management in Mount Mary Hospital Buea.

• Research Questions

• What is the knowledge of nurses on pressure ulcer?
• What are the measures used by nurses to manage pressure ulcer?

• Research objectives
  • General objectives

To assess the knowledge of nurses in Mount Mary Hospital on pressure ulcers and to evaluate the measures of prevention and method of management

• Specific objectives

• To assess the knowledge of nurses in Mount Mary Hospital on pressure ulcers.
• To evaluate the measures of prevention of pressure ulcer.
• To assess the method of management of pressure ulcer.