Older adults’ knowledge of pressure ulcer prevention: a prospective quasi-experimental study Irene Hartigan
MSc, RNT, H.Dip, BSc, RGN
Lecturer, School of Nursing and Midwifery, University College Cork, Cork, Ireland
MSc, BSc, RNT, RGN
Lecturer, School of Nursing and Midwifery, University College Cork, Cork, Ireland
CNM, RNP, RM, RGN
Clinical Nurse Manager and Registered General Nurse, St. Finbarr’s Hospital, Cork, Ireland
Submitted for publication: 2 August 2010 Accepted for publication: 7 January 2011
Correspondence: Irene Hartigan School of Nursing and Midwifery Brookfield Health Science Complex University College Cork Cork Ireland Telephone: 00 353 21 4901623 E-mail: [email protected]
H A R T I G A N I . , M U R P H Y S . & H I C K E Y M . ( 2 0 1 1 ) Older adults’ knowledge of pressure ulcer prevention: a prospective quasi-experimental study. International Journal of Older People Nursing doi: 10.1111/j.1748-3743.2011.00274.x Aim. To test an evidence base patient education leaflet to evaluate older adults’ knowledge of pressure ulcers and prevention strategies. Background. The increasing population of older adults living in the community managing chronic health conditions are at risk of pressure ulcer development. Education leaflets are a useful adjunct to reinforce healthcare professional’s verbal information to promote healthy lifestyles choices. However, little is known of the effectives of pressure ulcer prevention educational leaflets for older adults. Methods. A quasi-experimental uncontrolled pre-test, post-test study of participants’ knowledge of pressure ulcer and preventative strategies was conducted. Community dwelling older adults (n = 75) were recruited to this study. Older adult’s knowledge was measured pre- and postdistribution of an education intervention. A risk assessment scale was recorded to identify whether this cohort of older adults were actually at risk of developing pressure ulcers. Conclusion. The results indicate that an education leaflet enhanced patients’ knowledge relating to pressure ulceration. Printed education materials increase knowledge and understanding which may lend to older adults adopting healthy behaviours. Implications for practice. An education leaflet can help older adults and their carers to be more empowered as active participants in reducing the incidence of pressure ulceration.
Key words: chronic health conditions preventative strategies, health literacy, nursing, older adults, pressure ulcers
Introduction The prevention of pressure ulcers is not a new issue in older adult nursing. Worldwide pressure ulceration continues to 2011 Blackwell Publishing Ltd
be a persistent source of burden to patients and healthcare professionals. Economically, pressure ulcers are catastrophic for health care. Pressure ulcers have a significant impact on health1
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related quality of life and cause substantial burden to patients (Fox, 2002; Bennett et al., 2004; Hobbs, 2004; Briggs & Flemming, 2007). The prevalence of pressure ulcers from a sample of 5000 hospitalised patients in five European countries ranged from 8% in Italy to 22.9% in Sweden (Clark et al., 2004). Similarly in Ireland, a recent point prevalence study of pressure ulceration in three university teaching hospitals was 18.5% (Gallagher et al., 2008). Pressure ulcers contribute greatly to older adults’ morbidity, mortality and reduce their quality of life especially those who are nutritionally compromised, immobile, incontinent and cogitatively impaired (Bergquist, 2003; Brillhart et al., 2006; Santamaria et al., 2009). Pressure ulcers are a non-communicable condition and known worldwide to be preventable and avoidable in many cases (Allman, 1997; Whitfield et al., 2000; Lyder et al., 2002). Yet, they continue to cause both physical and psychological suffering for patients in hospitals and at home (Collins, 2001; Brillhart, 2006; Madhuri et al., 2006). Although individuals of any age can develop pressure ulcers, they are more common in certain patient groups such as older people (Whittington & Briones, 2004). It is expected that by 2030, one in four Irish people will be over 65 years of age (McDermott-Scales et al., 2009). Coupled with people living longer and the expected rise in chronic health conditions such as cardiovascular disease (Yazdanyar & Newman, 2009), hyperlipidaemia (Aslam et al.,2009), obesity (Chapman, 2008), diabetes and mobility problems (Cigolle et al., 2009), many of these conditions are major predisposing risk factors for the development of pressure ulcers (Department of Health and Children, 2007). The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) (2009) identify four factors that impact on an individual’s risk of pressure ulcer development namely nutritional indicators, skin moisture, advanced age as well as perfusion and oxygenation. Health literacy has the potential to promote healthy lifestyles behaviours. Nurses are well placed to provide education that meets the individual needs of specific groups such as older adults. McKenna and Scott (2007) stipulate that patient’s knowledge, behaviour and attitudes are influenced by the provision of information. Providing pressure ulcer information in the form of patient education may influence patient’s self-management of their own healthcare.
Literature review The development and availability of health information literature relating to chronic health conditions promotes awareness which in turn can empower patients to maximise 2
their health (Mancuso, 2008). Knowledge and education programs have been shown to reduce the incidence and severity of pressure ulcers (Leary, 1990; Moody et al., 1998; Bergquist & Frantz, 1999; Lyder et al., 2002; Robinson et al., 2003; Hobbs, 2004). Consequently, there is a growing demand from patients to be provided with verbal, written, pictorial or digital/multimedia information that supports and enables patients to self-manage and make informed health choices for themselves (Johnson et al., 2003). Health literacy is characterised by the Joint Committee on National Health Education Standards (EPUAP Review 2002) as the individual’s capacity to obtain, interpret and understand basic health knowledge and to apply this knowledge to enhance their own health. The predominant mediums for dissemination of health literacy are verbal and written formats which have been proven to be successful in improving knowledge, reducing hospital admissions and increasing satisfaction in the provision of patient and carer education (Johnson et al., 2003; Wolf et al., 2005). A Cochrane review identified 23 studies that examined the effectiveness of printed education material in improving patient outcomes. Of these, 12 studies were randomised controlled studies comparing two groups of patients. This Cochrane review highlighted that printed educational material is a common method for disseminating information to patients. Despite many limitations to the studies mentioned in this review, printed educational material demonstrated an effect (Farmer et al., 2010). Printed educational material has also been used for the provision of important aspects of cancer care. A systematic review of randomised control trials identified 10 studies that evaluated methods of educating cancer patients or their families. Written information featured as the most common educational intervention method and had a significant effect on knowledge amongst cancer patients (McPherson et al., 2001). Several qualitative studies have demonstrated that providing written information to patients improves patient confidence, decreases recovery time, reduces anxiety and improves adherence to treatment regimes (Gibbs et al., 1989; Devine & Westlake, 1995; Johnson, 1999; National Health and Medical Research Council, 2000; Johnson & Sandford, 2005). Printed education leaflets have also proven to be effective for reminding women to register for pap-smear screening for cancer prevention (Paul et al., 2003). The content and design characteristics of the pap-smear leaflet were not found to play a significant role in the effectiveness of the printed leaflet (Paul et al., 2003). The effect of printed education material in the prevention of pressure ulcers has not been examined, and little evidence exists regarding nurses’ contributions to health literacy (Mancuso, 2008). Nurses need to develop and provide education in a format 2011 Blackwell Publishing Ltd
Older adults’ knowledge of pressure ulcer prevention
that best meets the individual needs of specific groups, such as older adults. Clinical practice guidelines for the prevention and treatment of pressure ulcers have been developed in many countries around the globe; EPUAP in Europe, NPUAP in the USA, National Institute of Clinical Excellence (NICE) in the UK, the Scottish Intercollegiate Guidelines Network (SIGN) and National Best Practice and Evidence Based Guidelines for Wound Management in Ireland. The effectiveness of pressure ulcer prevention patient education programmes is not known, and it is unclear whether interventions such as providing written information are implemented in practice (Ardblaster, 1998; O’Brien et al., 2003). A recent study by Paquay et al., (2010) demonstrated adherence by nurses and patients to the Belgian Guidelines for prevention of pressure ulcers after an education programme. Despite the positive outcomes of this study, the effects were only short to midterm in duration. Thus, further research is proposed to examine older adults’ basic knowledge of pressure ulcers and their prevention, as well as determining the effectiveness of giving a pressure ulcer education leaflet to older adults.
Methodology Design This study was designed as a prospective quasi-experimental, uncontrolled pre-test, post-test study of pressure ulcer prevention education. The aim of this study was to use an evidence base patient education leaflet to measure the knowledge of older adults in relation to pressure ulcers and prevention strategies. The pressure ulcer prevention leaflet was given to an at-risk population over a 1-week period. Data collectors administered the pre- and post-tests. All data collectors, who were nurses, were instructed on the process of data collection.
Setting and sample The study setting was an assessment and treatment centre which is dedicated to older adults under the governance of the Irish Health Service Executive. Patients aged 65 years and over who live in their own homes are referred to the centre following discharge from acute or rehabilitation hospitals in the region. This centre has a vital role in supporting early discharge from the acute services and maintaining older people in their own homes. Nurses, doctors, physiotherapists, occupational therapists, speech and language therapists, clinical nutritionist and podiatrist provide prescribed profes 2011 Blackwell Publishing Ltd
sional services. Patients’ appointments are once weekly, and they attend the centre for appointments of 2–4 hours duration depending on the number of services they require. In this study, the convenience sample was recruited from this centre for older adults. According to the NICE guidelines (2005), this population is representative of an at-risk group for pressure ulcers firstly because they are older adults and secondly as they have recently been ill or suffered injury at an older age. All patients attending the assessment and treatment centre (n = 97) during a 1-week period formed the potential study population. Patients with a Mental Test Score (MTS) of seven or greater out of a total of 10 comprised the study population (n = 91). However, a further 16 patients declined to consent, resulting in a total of 75 older adults who agreed to participate in this study.
Intervention The intervention developed for this study is a patient education leaflet titled ‘Preventing Pressure Ulcers, a guide for patients and their carers’ (Appendix 1). Following a literature review, the content to include in this leaflet was determined and emanated from the principles of EPUAP and NPUAP (2009). The intervention leaflet begins with a definition of pressure ulcers, followed by a diagram of the body depicting the eight most likely areas to develop pressure ulcers. The leaflet also provides a selection of strategies the older person or carers can implement when alerted to the possibility of pressure ulcer development. The order and presentation of text and images were carefully chosen to emphasize preventative information and to attract the reader. Sentences were concise and personalised while bullet points were used to alert readers to actions, such as ‘Eat plenty of protein (e.g. meat, fish, eggs)’ and ‘Don’t rub or massage your pressure area’. This A4 size, Z folded leaflet was designed to be used as a guide for both patients and carers in their home. A review and critiquing process was conducted by an expert panel consisting of consultant geriatricians, doctors and nurses. Service-users, who were not study subjects but who attended the centre, were consulted to determine the readability and ability to understand the intervention by an older adult population. Suggestions received from both the expert panel and service users contributed to the final version of the intervention. The readability of the leaflet was calculated using the Flesch–Kincaid Grade Level (Flesch, 1974), which is built into Microsoft Word. The readability is calculated from the number of words, syllables and sentence length in the leaflet and the final score indicates comprehension difficulty. A typical score of 8.2 would indicate that the text is expected to be understandable by an average student 3
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in 8th grade in the USA which is equivalent to 6th Class in Primary School in the Republic of Ireland. The Preventing Pressure Ulcers, a guide for patients and their carers’ leaflet scored 5.5. This translates to a reading age of an 8–10 year old, indicating ease of reading and understanding of the content of the intervention.
Measurement instrument A patient knowledge of pressure ulcer prevention measurement instrument consisting of 13 questions was developed specifically for this study. This measured older adults’ knowledge of pressure ulcers and prevention strategies. From review of EPUAP and NPUAP (2009), content to be included in the measurement instrument was determined, and this contributed to its content validity. Each question included, directly mirrored the content and order of information in the education leaflet. Thus, the content of the instrument logically and comprehensively addresses items of interest. The relationship between the European guidelines and the measurement instrument demonstrates strong correlation between the gold standard of pressure ulcer information and the instrument establishing a degree of criterion validity. An expert panel consisting of consultant geriatricians, doctors, nurses and service users was approached to review the instrument. Specific members of the expert panel were invited to contribute as they had extensive international clinical and research expertise in caring for and educating older adults. This further contributed to the content and the construct validity of the measurement instrument as minor typographical changes were made and the number of questions were reduced by two. In addition, the panel was cognisant of how relevant and clear the instrument questions were and this informed face validity. Consequently, the 11 questions emanated from key sources pertaining to patients’ knowledge of pressure ulcer preventative strategies. Examples include ‘what foods might help to prevent developing a pressure ulcer?’ and ‘what parts of the body are at risk of developing a pressure ulcer?’ With the exception of the second question, which required a tick-box multiple closed response, remaining questions required the data collector to document the words given in response to each question by each participant.
ily returned consent forms during their appointment. Patients who decided not to participate in this study were informed that their care would not be comprised in any way. On patients’ next appointment, data collectors administered the pre-test instrument to those that had given consent and assured their anonymity and confidentiality. Demographic details including age, gender and primary diagnosis were obtained. The instrument was administered to each participant by a nurse data collector who sat with the older adult and asked each question individually and documented their responses verbatim. The data collector also conducted and documented a pressure ulcer risk assessment on each participant using the Medley scale (1987) (Appendix 2). This scale was chosen as it is the scale routinely used within this local health service and calculates the participant’s risk for pressure ulcer development. On completion of the pre-test instrument, participants were given the education leaflet and encouraged to read and learn about pressure ulcer prevention. Each participant was reminded that the same 11 questions would be asked again on their return appointment in 7 days. Thus, the time frame to read and learn from the leaflet was the same for all participants. The post-test instrument was administered by any one of the four nurse data collectors who again documented the patients’ responses.
Results The patients in this study were all older adults who were living at home with a chronic illness. Pre-test data were collected from 75 patients who consented to participate in this study. The post-test was not conducted on 19 patients as they did not return on their next appointment or where discharged from the assessment and treatment centre. Thus, 56 participants had data collected both at the pre- and posttest study times which allowed for comparison between data sets. The age range of participants was 66–99 years with a mean age of 79.9 (SD ± 6.5) years of which 64% were female. The majority of patients (92%) demonstrated full cognition as they achieved a score of 10 out of 10 on MTS while the remaining 8% had a score of seven or greater. Table 1 presents the gender distribution and primary
Table 1 Study sample characteristics
Data collection For the duration of 1 week, all older adults arriving to the assessment and treatment centre received a written invitation to participate in this study. A data collector provided detailed explanation of the study protocol, and participants voluntar4
Age category Male Female Primary diagnosis
66–75 7 10 Stroke
76–85 8 18 Congestive cardiac failure
>85 5 8 Atrial fibrillation
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Older adults’ knowledge of pressure ulcer prevention
Participants’ choice of words to describe the signs and symptoms of pressure ulcer formation is displayed in Table 3. These are presented in three categories. Overall, participants reported one or more sign of pressure ulcer formation. Figure 2 demonstrates that those who had no knowledge of signs of pressure ulcer formation in the presurvey increased in the post-survey results. It is also evident that there was an increase in the number of signs for pressure ulcer formation in the post-survey as each participant was able to recall a greater number of signs demonstrating an increase in knowledge. Participants were asked to identify how long does pressure need to persist when either sitting or lying for a pressure ulcer to occur? Table 4 identifies that 32% (n = 18) were unable to answer this question in the presurvey, and this only reduced to 11% (n = 6) in the post-survey. Participant’s knowledge of the duration of pressure for pressure ulcer formation ranged from 1 hour to several weeks. This implies that participants equate pressure ulcer formation to duration of sustained
50 45 40 35 30 25 20 15 10 5 0 Did not know what Knew what a PU Did not know what Knew what a PU a PU was was a PU was was
Figure 1 Knowledge of what is a pressure ulcer.
diagnosis of the study sample based on the following three age categories: 66–75, 76–85 and >85 years. Pressure ulcers had been previously experienced by 7% of the study sample. The Medley scale identified that 59% of participants were at low risk of developing a pressure ulcer, 38% of patients were at medium risk and 3% at high risk. The pre-test survey results identified that 32% (n = 18) of patients did not know what a pressure ulcer was or what it may look like. Whereas the post-test survey results identified that only 9% (n = 5) of patients did not know what a pressure ulcer was or what it may look like (Fig. 1). Table 2 displays a breakdown of participants’ knowledge of the most common sites for pressure ulcer development prior to and post the intervention. The post-test survey identified that the majority of patients could identify possible anatomical body areas where a pressure ulcer would be most likely to occur. There is an obvious improvement in knowledge of most common sites except for the hip. The buttock was known by the majority of participants as the area most at risk of pressure ulcer development at both the pre- and post intervention. Prior to receiving the leaflet, 77% (n = 43) of participants could identify what might cause a pressure ulcer and this increased to 89% (n = 50) post test. The key causes of pressure ulcers were reported as sitting or lying in the same position for too long, friction, dry skin, poor washing of the skin, wrinkled sheets, incontinence and being overweight.
Table 3 Signs and symptoms of pressure ulcer formation as identified by participants Change in skin tone
Change in skin sensation
Change in skin appearance
Redness Rash Rough surface
Numbness Tenderness Pain
Blister Swelling Break in the skin
No knowledge of signs
Identified 1 sign
Identified 2 signs
Identified 3 signs
Figure 2 Knowledge of signs of pressure ulcer formation.
Table 2 Knowledge of most common sites for pressure ulcer development Most common sites
2 (4%) 5 (18%)
14 (25%) 30 (54%)
2 (4%) 7 (13%)
6 (11%) 6 (11%)
34 (61%) 44 (79%)
11 (20%) 29 (52%)
2 (4%) 9 (16%)
15 (27%) 22 (39%)
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I. Hartigan et al. Table 4 Pre-test and post-test findings of pressure ulcer prevention knowledge No. of participants (%)
Did not know how long it took for a PU to develop Identified 1–12 hours for PU formation Identified 12–48 hours for PU formation Identified days to weeks for PU formation Did not know how to prevent PU when in chair Did not know how to prevent PU when in bed
8 6 28 12
5 14 24 5
(14) (11) (50) (21)
(9) (25) (43) (9)
PU, pressure ulcer.
pressure as opposed to the intensity of the pressure. When sitting in a chair, 21% (n = 12) of patients did not know how to prevent a pressure ulcer, whereas this figure reduced to 9% (n = 5) in the post-test survey data. The majority of patients 86% (n = 48) did not know what foods help prevent a pressure ulcer before receiving the education leaflet compared with 36% (n = 20) after receiving the leaflet. When asked who could give advice with regard to pressure ulcer prevention, 82% (n = 46) of participants identified both nurses and doctors as key information providers with 18% (n = 10) identifying carers and pharmacists.
Discussion WHO Europe (2006) advocates self-care in preventing and controlling non-communicable conditions. Despite worldwide acknowledgement that pressure ulcers are preventable and avoidable, older people continue to be at risk. Education of patients and caregivers must be the objective, especially for those who are at risk of developing pressure ulcers. Printed education materials increase awareness and knowledge. They also help individuals adapt healthy behaviours (Bull et al., 2001). EPUAP supports this opinion and advocates for studies to investigate the impact of individualised structured education programmes. The results of this study suggest that education leaflets are an effective method of delivering health literacy for older adults. Providing pressure ulcer education is necessary for prevention as it is assumed that greater awareness of pressure ulcers will prompt adults to reduce the risk factors for pressure ulcer formation. Research also demonstrates that patients only recall and comprehend 50% of verbal medical information from doctors (Bertakis, 1997; 6
Crane, 1997; Roter, 2000), and often communication levels are too complex for patients to understand (Farrell et al., 2008). Education leaflets contribute to participants’ confidence in managing their health and the perception that they can control their environment (McKenna & Tooth, 2006). However, education leaflets can only marginally influence a patient’s knowledge, attitude and behaviour. Changing patients’ attitude and behaviour regarding pressure ulcer prevention would require patients’ participation in activities that promote health and wellbeing, such as adopting healthy behaviours like increasing mobility and healthy eating (Lorig, 2001). Therefore, older adults take an informed active role in their own health by engaging with health professionals who provide both verbal and written health education. Despite this study determining an increase in knowledge of pressure ulcers, actual measures of preventative behaviours and attitude would have greatly informed the effectiveness of the education leaflet. It is assumed that older adults acquire pressure ulcers because they are old. However, the evidence demonstrates that issues such as poor mobility and inadequate nutrition have a more significant contribution to pressure ulcer formation than age alone (Mathus-Vliegen, 2004). Nurses are well placed to influence healthy lifestyle behaviours as they can provide education about and support of healthy living and illness prevention (Sheriff & Chenoweth, 2006). Given the rising numbers of older people, promoting individual responsibility builds on older adults self-care capacity and capability to make informed decisions in relation to preventing and managing common age-related illness such as pressure ulceration. The results of this study are encouraging, as they demonstrate the extent of pressure ulcer knowledge gained from providing people with an education leaflet. The sample in this study was representative of community dwelling older adults who are managing chronic health conditions at home yet at risk of developing pressure ulcers. The incidence of stroke, atrial fibrillation and congestive cardiac failure in this study sample concurs with national prevalence of coronary heart diseases on the island of Ireland (Balanda et al., 2010). According to various pressure ulcer risk assessment scales, coronary heart diseases are associated with greater risk of pressure ulceration. As the population of older adults is predicted to increase, interventions such as education leaflets need to be developed and empirically tested to reduce the physical and economic burden of pressure ulcers. Community dwelling older adults are at risk of pressure ulcer development, and these study findings demonstrate the effectiveness of a simple yet evidence base intervention that can help prevent pressure ulcers. Nurses have many opportunities 2011 Blackwell Publishing Ltd
Older adults’ knowledge of pressure ulcer prevention
when interacting with older adults to provide education on illness prevention and encourage a proactive approach to offset disability and achieve healthy well-being. Johnson and Sandford (2005) stipulate that education leaflets are a valuable adjunct to verbal information as they assist patients to remember key strategies. Education leaflets also aid reinforcement of healthy lifestyle choices and create greater body awareness. Development of the education leaflet ‘Preventing Pressure Ulcers, a guide for patients and their carers’ is an example of an effective nursing action directed at preventing pressure ulcers and promoting maximum well being of older adults. Education leaflets are a convenient means of delivering health literacy to older adults while they are simultaneously availing of other health services. Health literacy involves a person being able to understand basic health information so that they have options to make informed decisions about their own health. Healthcare professionals need to consider delivering verbal or written education in formats that concur with a patient’s ability to understand. This approach was implemented in developing the intervention as McKenna and Scott (2007) stipulate the need to tailor information to the target population, so content can be easily read and understood. Furthermore, Weinman et al. (2009) highlighted that many patients in the UK could not identify the location of key body organs. These issues informed the content of the leaflet in which a simple body diagram was included, clearly outlining anatomical body areas most at risk of pressure ulceration. Thus, the content of ‘Preventing Pressure Ulcers, a guide for patients and their carers’ provided older adults with education pertaining to prevention of pressure ulcers using diagrams and text. Furthermore, pressure relieving techniques were presented in words only in the leaflet to inform study participants that increased duration and intensity of pressure on the at-risk body parts significantly contributes to pressure ulcer formation. Presenting this concept in word format alone did not impact on participants’ knowledge. Therefore, we would recommend that this is an area needing revision to clearly demonstrate that the association between the duration and intensity of pressure creates a greater risk of pressure ulcer formation. The inclusion of a diagram and/or equation would be a suggestion to improve the explanation of the physics of pressure ulcer formation. Empowering patients through various health literacy sources is positively correlated with happiness (Angner et al., 2009). Other technological mediums are also available such as web learning, but this can be overwhelming as the quantity and quality of web interface is dependant on the technological ability of the older adult as well as the resources to support this technology. Designing and developing other 2011 Blackwell Publishing Ltd
mediums such as education leaflets can enhance nurses’ contribution to health literacy research (Hobbs, 2004). The low cost of designing and printing the education leaflet further suggests that this is an optimal choice for educating older adults who may want to learn in their own time and at their own pace (Bernier, 1993). Health literacy should include a variety of delivery formats that compliment individual patient capacity to understand and interpret the education. This education leaflet is one example of a providing and reinforcing education to older adults at risk of pressure ulcer development.
Limitations of the study Results of this study are confined to a small population of older adults attending an assessment and treatment centre; hence, the results are not generalisable. Participant’s education levels were not collated as years of education are a poor predictor of older adults reading ability (McKenna & Scott, 2007). To enhance future study findings, actual literacy skills should be measured to determine the reading ability of participants (Wilson & McLemore, 1997). The study findings did demonstrate an increase in patients’ knowledge; however, the knowledge retention interval was relatively short (1 week) suggesting that knowledge needs to be examined over longer time intervals and amongst diverse populations. A longitudinal study would estimate the effects of education over time. Furthermore, recruiting a control group would further enhance the study findings. This study could, however, be used as a pilot project to a randomised control trial as further reliability and validity testing of the study instruments needs to be established.
Conclusion Providing education for patients and carers is a responsibility of healthcare professionals and should be a consistent objective to improve health outcomes for the increasing population of older adults who are at risk of pressure ulcers. The increase in chronic health conditions and the effects of ageing on the skin increases older adults risk of pressure ulcers. Pressure ulcers reduce patients’ quality of life because of the pain and suffering which is associated with their exclusion from participating in everyday social activities. The EPUAP supports educating older adults and suggests it should be achieved through structured, organised, comprehensive education programmes. Providing preventative education leaflets can empower patients to actively participate and take responsibility for their own health and thus reduce the incidence of pressure ulcers. 7
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Implications for practice • ‘Preventing Pressure Ulcers, a guide for patients and their carers’ could be introduced as an approach to reach beyond the clinical environment and into the homes of older adults at risk of pressure ulcers. • Timely and readable communications between patients and nurses can improve health care outcomes for older adults. • Education leaflets are a useful adjunct to reinforce health lifestyle choices. • Nurse needs to be able to determine patients’ actual health literacy abilities when providing information to ensure they have the capacity to understand. • Recognising patients’ health literacy can be a challenge as it can be influenced by a number of factors such as formal education, ethnicity and cognitive decline.
Acknowledgements The contributions of the older adults attending the Assessment and Treatment Centre at St. Finbarr’s Hospital, data collectors and Consultant Geriatricians are greatly appreciated by the authors.
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Appendix 1 Assessment & Treatment Centre
St. Finbarr’s Hospital Tel: 021- 492 3298
Preventing Pressure Ulcer
What is a pressure ulcer? A pressure ulcer is an area of skin, which has become damaged due to lying or sitting in the one position for too long. It can also be caused by friction on the skin due to sliding down or across the bed. Most pressure ulcers are preventable. Pressure ulcers are most likely to develop on parts of the body, which take your weight and where the bone is close to the surface. The areas most at risk are: 1. Heels 2. Ankles 3. Knees 4. Hips
5. Bottom 6. Base of Spine 7. Elbows 8. Shoulders
A guide for patients and their carers
How can I avoid Pressure Ulcers? If you are in a chair, Make sure the chair is a good fit. Try to move e very 15 minutes. Lift your bottom off the seat by pushing up on the arms of the chair or you could try rolling from cheek to cheek for a short while. You can get a special cushion to relieve pressure. Ask your nurse, doctor or occupational therapist if you need one. If you are in bed, aim to turn or be turned every 2–4 hours. When on your side place a soft pillow between your knees to relieve pressure. Keep the bottom sheet of your bed smooth and free from creases. Avoid dragging your bottom over the bed, especially when transferring to a chair. Special pressure relieving equipment will be used in hospital. The public health nurse is able to advise on special mattresses available for home.
What to look out for? Check your skin for signs of damage at least once a day. Look for skin that doesn’t return to its normal colour after you have taken the weight off it. For areas that are hard to see, use a mirror or ask your carer to look for you. Never lie on skin that is darker or more red than usual.
You are more likely to get a pressure ulcer if: • You have to stay in bed • You are in a wheelchair • You spend long periods in an armchair • You have difficulty moving • You are elderly or weak • You have a serious illness • You are incontinent • Your skin sensation is poor because you are diabetic or have had a stroke • You have a bad heart or poor circulation • You are not eating a balanced diet or drinking enough
Remember: • Change your position regularly • Keep your skin dry and clean • Eat plenty protein (e.g. meat, eggs, fish etc.) and fresh fruit & vegetables Don’t: • Don’t massage or rub your pressure areas • Don’t drag yourself over damp or creased bedclothes • Don’t try to dress or manage pressure ulcers without seeking the help of a nurse or doctor.
Carers: - where pressure ulcer s tend to develop are difficult to see so the older adult may ne ed you to look at the skin to check it is not red or broken. • If there is any sign of redness, which does not disappear within 1–2 hours, talk to your Public Health Nurse, General Practitioner or Day Hospital staff.
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Older adults’ knowledge of pressure ulcer prevention
Appendix 2 Modified Medley risk assessment tool Activity-ambulance Ambulant without assistance Ambulant with assistance Chairfast (longer than 12 hours) Bedfast (longer than 12 hours) Mobility range of motion Full active range of motion Moves with limited assistance Moves only with assistance Immobile Skin condition Healthy Rashes or abrasions Dehydrated-advanced age (65+) Oedema and or redness Pressure ulcer involved Predisposing disease None Chronic stable Acute or chronically unstable Terminal Level of consciousness Alert Lethargic/confusion Semi-comatose (responds to stimuli) Comatose (absence to response of stimuli) Nutritional state Good (TPN or naso gastric feeds) Fair (insufficient in take to maintain weight) Poor (eats drinks very little) Very poor (unable/refuses to eat, emaciated) Incontinence-bladder Total control/catherised Occasional (