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04/03/2017
Abstract
The purpose of this research was to determine if there was a difference in skin breakdown
between turning and repositioning every two hours and turning and repositioning every four
hours. A correlation between pressure ulcers, alternative measures, and the Braden scale is
discussed. ___ different sources were used, including quantitative studies, qualitative studies,
and an informative booklet on pressure ulcers. It was found that there was no significant
evidence in the difference in skin breakdown when turning the patient every two hours, three
hours, or four hours. Skin breakdown starts to occur when the patient is only turned every six
hours. There are alternative measures that can be taken to prevent skin breakdown, such as skin
Reposition Every Two-Six hours and the Effects of Pressure Ulcer Development
Pressure ulcers are a problem for nurses because they show that the patient did not
receive proper care. Preventative measures to reduce the occurrence of pressure ulcers include:
identifying those at risk, identifying nutritional needs, proper skin care, proper bedding or
cushions, and proper repositioning of a patient who is unable to reposition themselves ever two-
six hours. In dealing with preventative measures for pressure ulcers the following research
question was addressed: How does tuning and repositioning patients every two hours as
Literature Review
Introduction
In order to address this issue in health care, information was acquired via OhioLINK
databases. __ sources were reviewed for the data collection regarding turning and repositioning
patients every two hours and the development of pressure ulcers. Pressure ulcers, two and four
hour turns, skin care, supportive surfaces, nutrition, the Braden Scale, and Medicare will be
discussed
Pressure Ulcers
Pressure ulcers or bedsores are prevalent health issues that affect long term and acute care
settings. Pressure ulcers are injuries to the skin and tissues caused by prolonged pressure or
friction and shearing to an area. Pressure ulcers usually occur over bony prominences such as the
back of the head, elbows, tail bone, hips and the heels. People at risk for pressure ulcers are
usually those who have impaired nutrition, incontinent, confined to bed rest and/ or wheel chair,
or are unable to make frequent position changes. Although pressure ulcers are said to be
preventable, they are still a major issue that hospitals and long-term care facilities face daily.
EFFECTS OF TURNING AND REPOSITIONING 3
Treating pressure ulcers cost thousands of dollars and can result in longer hospital stays and even
death.
Pressure ulcers can form quickly and progress from one stage to the next. Pressure ulcers
are placed into four different categories based on their characteristics. Pressure ulcers that fall
into stage one are considered areas that have a nonblanchable redness of intact skin. “ This area
may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue”(Molnlycke Health
Care, 2015, p.2 ). Pressure ulcers in stage two are described as, “partial thickness loss of dermis
presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as
an intact or open/ ruptured serum- filled blister,” (Molnlycke Health Care, 2015, p.2). Stage three
pressure ulcers are categorized as full thickness skin loss, this stage occurs when, “subcutaneous
fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does no
obscure the depth of tissue loss. May include undermining and tunneling,” (Molnlycke Health
Care, 2015, p. 3). The depth of stage three pressure ulcers may vary depending on the location.
“The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue,” causing
the ulcer to be fairly shallow (Molnlycke Health Care, 2015 p. 3). Stage four pressure ulcers are
categorized as full-thickness skin and tissue loss, “Full thickness loss with exposed bone, tendon
or muscle. Slough or eschar may be present on some parts of the wound bed.” (Molnlycke Health
Care, 2015 p.3). Additionally, stage four ulcers, “often include undermining and tunneling”
(Molnlycke Health Care, 2015 p.3). As with stage three, in stage four the depth of the ulcer
depends on the location it is present. “Category/ stage four ulcers can extend into muscle and/ or
supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible”
(Molnlycke Health Care, 2015, p, 3). Because pressure ulcers are preventable, ulcers that fall
into stages three and four may not be covered by insurance and cost the hospital directly. There
EFFECTS OF TURNING AND REPOSITIONING 4
are also pressure ulcers that are unstageable, these are ulcers are usually, “full thickness tissue
loss in which actual depth of ulcer is completely obscured by slough ( yellow, tan, gray, green, or
brown) and / or eschar ( tan, brown, black) in the wound bed,” (Molnlycke Health Care, 2015,
p.4). Unstageable ulcers would need debridement of the slough or eschar in order to stage the
wound properly.
The traditional primary source for the widely accepted two hour turn and reposition
theory that many facilities have accepted as their policy came from a study dating back to 1962
(Norton, McLaren, & Exton-Smith, 1962). This theory states that it is recommended that patients
be turned and repositioned every two hours, unless otherwise ordered, especially if the patient is
immobile. Two hour turns have proven to be effective in preventing pressure ulcers, but this
research is outdated. This experiment was performed in 1962, which is over fifty years ago. New
studies current in evidence based practice has proven that there are several other means to
prevent pressure ulcers that are more effective, less time consuming to valuable health care staff,
and improve the patients sleep and quality of life. Many advancements since the sixties in the
development of pressure reducing mattresses, evidence of the importance of nutrition and proper
skin care also play a large role. It is not simply the frequency of the turn that effects the
development of skin breakdown, but the therapies and treatments that must be utilized in
repositioning a patient every two, three or four hours, as long as they are on a high foam density
mattress. In fact, the study found that “less frequent turning might increase sleep, improve
EFFECTS OF TURNING AND REPOSITIONING 5
quality of life, reduce staff injury, and save time for such other activities as feeding, walking, and
toileting.” This study was performed on 942 patients who were classified as having a moderate to
high risk of acquiring a pressure ulcer. Of the 942 participants in this study only nineteen
acquired superficial stage one ulcers at the turning intervals of two, three, and four hours; no
stage three, stage four or unstageable pressure ulcers developed. During the duration of the three
week study, study coordinators assessing the patients skin regularly were not aware of which
patients were being turned every two, three or four hours. Meaning there was no difference in the
results that would differentiate a two hour turn from a four hour turn. Another study by
Bergstorm conducted in 2013, the TURN study (Turning for Ulcer Reduction Study), also
“Turning at 3- and 4- hour intervals is no worse than the current practice of turning every
2 hours in the United States and Canadian LTC facilities. Two hour turning could expose
In fact, several other studies conducted in recent years support these results. The study,
“Repositioning for pressure ulcer prevention in adults (Review)”, conducted by Gillespie (2014)
found that “There was a statistically significant reduction in pressure ulcers of Category 2 and
Skin Care
Along with turns and repositioning there are many other alternative measures to prevent
pressure ulcers. Skin care is one of the most prevalent preventers of skin break down and
pressure ulcers. This is one of the most cost efficient and effective ways to prevent skin
breakdown. Dirty or wet skin leads to irritation of the skin. It can also lead to excess moisture on
the skin that can created more friction that will decrease skin integrity. According to Cooper
EFFECTS OF TURNING AND REPOSITIONING 6
(2013), “Moisture contributes to maceration, which may make epidermal layers more vulnerable
to break down from pressure.” Another great benefit from frequent cleansing of the skin is that
the nurse will be preforming multiple skin checks. (Mallah, 2015) The more often a health care
provider is checking the skin the earlier they can take note of an area that is at risk for
developing into a pressure ulcer. While frequent washing is a good thing, it can be detrimental if
done too often (Cooper, 2013). When the skin is washed too often it begins to become dry and
irritated. Dry skin puts the patient at risk for developing a pressure ulcer as well. This all comes
Support Surfaces
Support surfaces are also very important when trying to prevent pressure ulcers.
Everyone has some sort of force or pressure on a body part at any given time. In bed bound
patients, the areas that experience the most pressure are the bony prominences (Mallah, 2015).
The whole idea with the support surfaces is to redistribute the pressure on patients in a way that
benefits them the most. A study was done using three different support surfaces. The results
showed no major conclusion in regard to what type of support surface was used, however, the
usage of a support surface does help to prevent pressure ulcers compared to a normal mattress
(Cooper, 2013). Pressure reducing mattresses are another great example. A study that was done
comparing the effectiveness of pressure reducing mattresses and they found that they do reduce
the rate of pressure ulcers. The study showed that these mattresses are a good replacement for
two hour turns where the nursing hours are lower (Sving, 2014). This does not mean that turns
can be completely forgotten about, these support surfaces can just potentially lengthen the
amount of time between turns. The different types of mattresses do have a flaw, they do not
account for the patients heels. According to Cooper (2013), “patient’s heels are particularly
EFFECTS OF TURNING AND REPOSITIONING 7
prone to both pressure and shear. When in contact with the bed surface, heels are prone to
pressure ulcers.” This is an easy problem to fix by simply elevating the heels off the bed with a
Nutrition
Nutrition always comes to mind when thinking of pressure ulcers. CMS states that
weight loss, and difficulties with chewing and swallowing are important indicators that a patient
may be at risk for developing a pressure ulcer (Cooper, 2013). This is because if a person is
having a hard time eating they will become malnourished. If they are malnourished they are not
getting the proper amount of fat and protein to protect their body from breakdown. A recent
study shows that 65% of severely malnourished patients developed pressure ulcers whereas
slightly malnourished or properly nourished patients have not developed any pressure areas.
(Mallah, 2015). Preventative nutrition is two completely different things in nourished and
malnourished people.
Nourished patients do not need many supplemental vitamins and minerals. According to
Mallah (2015), patients do not benefit from the high protein high fat supplemental drinks or
foods that are commonly given for wound prevention and healing. The main goal in nourished
people is to ensure that they stay nourished. This can be done by monitoring their weight and
keeping track of the calories and amount of food they are taking in. They do not benefit,
Protein drinks are very important in malnourished patients. Cooper (2013) states, “A low
albumin level is an indicator of malnutrition (normal levels, 36–52 g/L). Prealbumin levels
(normal level, 16–35 mg/dL) may be a reflection of current nutritional status.” This can be
prevented by ensuring that they are eating the correct amount of food daily and monitoring their
EFFECTS OF TURNING AND REPOSITIONING 8
appetite. If that does not work, providing these patients with supplements that give them their
daily amount of protein, fat, vitamins and minerals will be sure to increase their daily levels.
Braden Scale
The Braden Scale was developed in 1987 and is used to predict patients’ risk for
developing pressure ulcers. It has been proven by many sources that it works effectively.
According to Choi, J., Choi, J., Kim, H. (2014), patient characteristics can be interpreted in
different ways depending on the nurse, which in return can potentially skew the Braden Scales’
reliability. The Braden Scale “rates patients on six risk factors: sensory perception, nutrition,
activity, mobility, skin moisture, and presence of friction, and shearing force” (pg. 337). If the
patient characteristic was, for example, “skin is often, but not always moist,” nurses can interpret
that meaning in several different ways (Choi et al., 2014). “Accurately and reliably assessing
pressure-ulcer risk with the Braden Scale has been shown to depend on a comprehensive
understanding of patient status and correct application of patient characteristics as defined for
each scale parameter” (pg. 338). Nurses need to be properly trained on how to interpret patient
characteristics and on how to use the Braden Scale in order for prevention of pressure ulcers to
occur. According to Demarre et al. (2014), there are many factors contributing to the
associated dermatitis, non-bleachable erythema and a lower Braden score (<17) were associated
with the development of superficial pressure ulcers” (Demarre et al., 2014, pg. 392). With
knowing now that these factors contribute to the development of pressure ulcers, it is especially
important to know how to properly use and interpret the Braden scale.
Medicaid
EFFECTS OF TURNING AND REPOSITIONING 9
Gammon et al. (2016), “Pressure ulcers are one of the most costly hospital-acquired conditions,
resulting in $11 billion per year in direct and indirect costs.” Medicare no longer pays for stage 3
pressure ulcers and the use of the Braden Scale, as well as turning patients every two hours is so
important. Since this change in Medicare reimbursement, there have been many studies done to
According to Wald, H., Richard, A., Vaughan, D., and Capezuti, E., (2012), prevention of all
hospital-acquired conditions has since been the focus of the 14 hospitals in their study. “Pressure
ulcer detection and documentation became a larger focus streaming from the policy change”
(Wald et al., 2012 p. 1). Turning and repositioning the patient every two to four hours, proper
Conclusion
When addressing how does turning and repositioning patients every 2 hours as compared
to every 4 hours effect the development of pressure ulcers in the health care setting, recent
studies have shown that there is not a significant difference between turning a patient every 2, 3
or 4 hours. It is not until you reach the 6 hour interval that damage begins. The traditional 2 hour
turn rule is outdated seeing as it was developed in the sixties. In the past fifty years evidence
based practice has allowed nursing the additional steps to prevent pressure ulcers form occurring
by ensuring the patients nutritional status is adequate, assessing high risk patients with the
Braden scale, new high density alternating pressure mattresses and advances in skin care that
References
Choi, J., Choi, J., & Kim, H. (2014). Nurses’ interpretation of patient status descriptions
on the Braden Scale. Clinical Nursing Research, 23, 336-346. doi: 10.1177/1054773813486477
Demarre, L., Verhaeghe, S., Hacke, A., Clays, E., Grypdonck, M., & Beeckman, D. (2014).
receive standardized preventive care. Journal of Advanced Nursing, 71, 391-403. doi:
10.1111/JAN.12497
Gammon, H., Shelton, C., Siegert, C., Dawson, C., Sexton, E., Burmeister, C., Gnam, G., &
Siddiqiu, A. (2016). Self-turning for pressure injury prevention. Wound Medicine, 12, 15-18. doi:
10.1016/J.WNDM.2016.02.005
Molnlycke Health Care. (2015). The pressure is on. Norcross, GA. (pp.1-6)
Wald, H., Richard, A., Dickson, V., & Capezuti, E. (2012). Chier nursing officers’