1. Effectiveness of Bed Sore Prevention Training Programme in ICU/CCU at
B. P. Koirala Institute of Health Sciences
Mehta RS*1 , Rai HK*2, Bhatta N*3, Bhattari B*4, , Shrestha R*5.
B.P. Koirala Institute of Health Sciences
Email: ramsharanmehta@hotmail.com
Abstract:
Critically ill patients are at high risk for pressure ulcers. Bed bound patients with pressure ulcers
are almost twice as likely to die, as are those without pressure ulcer often untreated. Most
commonly affected sites are trochannteric, ischial, heal and sacral. Pressure ulcer can cause pain
and loss in economic productivity and also can result in huge expenditure for patients as well as
hospitals.
The objective of this study was to evaluate the effectiveness of bedsore prevention education
programme among the nurses working in ICU / CCU units of BPKIHS. The single group pre-test
post –test Quasi-experimental design was used to conduct the study. After pre-test education
intervention session was arranged in three sessions and an education material was provided to the
individual nurses. After 3 months of education intervention post test was taken and findings were
analyzed using SPSS 12.5 software.
It was found that most of the (90%) subjects were of age group of 20-25 years, unmarried (76%),
and provide bedsore care (96.7%) to their assigned patients. In comparison to practice score
difference there is more post tests score difference in knowledge components like, pressure sore
assessment tool (66.7%), pressure distribution mattress (43.3%), frequency of back care (36.7%)
and concentration of Betadine solution for dressing (53.4%).
It can conclude that the knowledge and practice related to bedsore prevention and care among
nurses is satisfactory. There is no association between mean scores of pre-test and post-test in
knowledge (p=0.788), where as there is association between mean practices scores of pre-test
and post-test (p= 0.050). In-service education on pressure assessment tools and recent concepts
are essential to bust-up the knowledge. Finally the education intervention program is very
effective for nurses in the management and care of bedsore.
Note:
1
* Ram Sharan Mehta, Associate Professor, Medical-Surgical Nursing Department, Email:
2 3
ramsharanmehta@hotmail.com , * Hari Kumari Rai, ICU-Incharge, * Dr Narendra Bhatta, Additional
4
Professor, Department of Internal Medicine * Prof. Dr. Bal Krishna Bhattari, HOD, Department of
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Anesthesia and critical care unit, * Rosy shrestha, Nursing Officer
1

2. Introduction: Bedsores results from the impairment of blood flow and from mechanical stress to
the skin and tissue over the bony area that has been under pressure for a prolonged period.
Critically ill patients are at high risk for pressure ulcers. Pressure ulcers not only cause suffering
to the patients but also increases the workload on health care professionals. Pressure ulcers have
been viewed as negligence, especially nursing care. It is assumed that pressure ulcers are
preventable but high prevalence of pressure ulcers among indoor patients have various
contradicting factors including patients' medical history, present environment and past events
which predisposes them to develop pressure ulcers. 1
In USA 9% of all hospitalized and 20-40% of all nursing home patients, develop pressure sore.
Incidence is 43/100,000 population every year; 65% of elderly with femoral fractures; 33% of
critical care patients and a 60% prevalence among quadriplegic patients.1
More than 10% nurses reported that they assess the areas for any decoloration, swelling and
itching, early one fifth of them (20%) had no knowledge as how to assess the pressure points
for ulcers.2
More than 100 risk factors have been identified in the literature. Some physiologic risk factors
include diabetes mellitus, peripheral vascular disease, cerebrovascular disease, sepsis, and
hypotension. It has been hypothesized that these physiologic risk factors place the patients at risk
because of impairment of the microcirculatory system.3
Some of the preventive steps to reduce the prevalence of pressure included: change of side or
position (95%); removal of wrinkles from the bed sheet (60%) and use of cushions or air rings
(55%). More than 50% nurses reported 'care of back' as a preventive step. In addition,
cleanliness (35%); and massaging (25%) also help in the prevention of pressure ulcers.
Although care of pressure points is a fundamental care activity but many of nurses are unable
to adopt preventive measures dues to lack of time and low priority given to prevention of
pressure ulcers in the clinical practice.2
Objectives of the study:
1. To assess the knowledge and Practice regarding bed sore prevention and care among the
nurses working in ICU/CCU at BPKIHS.
2. To provide the training programme on prevention and care of Bedsore.
3. To find out the effectiveness of Bed Sore Prevention Training Programme among the
Nurses working in ICU/CCU at BPKIHS
Research design and methodology: It was quasi-experimental single group Pre-test post-test
educational interventional research design conducted among the nurses working in ICU/CCU
where the more clients are susceptible to develop bedsore. Total enumerative sampling technique
was used to select all the nurses working in ICU/CCU for more than 3 months and the pre-testing
was done to assess the knowledge about the bed sore, its prevention and care. The pre-testing
was done on 19th and 20th April 2009.
The information collected in the first phase from the nurses regarding their knowledge profile
and practice was used as pre-test and after the intervention of training programme the
2

3. information collected was used as post-test. The education intervention programme was carried
out during the period of 26th April 2009 to 30th April 2009. The post-test data was collected after
3 months of education intervention programme i.e. on 30th and 31st July 2009. The difference in
knowledge and practice was determining the effectiveness of the training intervention. Three
days teaching learning session was arranged for all the nurses. The education intervention
package prepared is provided individual nurses. The theoretical as well as practical knowledge
was imparted on them. The subjects were fully oriented about the purpose of study and their
consent was obtained prior to data collection. The validity of the tool and the package was
established with the concerned experts from the nurses, doctors and researchers.
Results: Most of the subjects (90%) were of age group of 20-25 years, unmarried (76%), stay in
BPKIHS Quarter (70%), mean ICU experiences of 13.2 months, and mean nursing service
experience in BPKIHS was 16.53 months. Most of the subjects (96.7%) provide bed sore
prevention and care activities to their assigned patients and most of them (90%) were satisfied
with service provided to assigned patients; where as only 13.3% nurses had only received bed
sore training program.
In some of the areas like: common terminology, common sites of bedsore occurrence, high risk
patients & skin as first degree defense line. The pretest and post-test score is same. The
maximum difference in knowledge after post test was found in, pressure that altered skin
integrity (63.4 %), pressure sere assessment tool (66.7 %), pressure reduction mattress (43.3 %),
low BP. As risk of bed sore (40 %), concentration of Betadine for dressing (53.4 %) and massage
the skin where it is tight over bones (59.9 %). There are not many differences in score of
practices after education interventions in most of the components. The areas where raises in
scores in practices are, applying nursing process while providing bedsore care (10%), use of
assessment scale (13.3%), systematic assessment of bed ridden patient (40%), and always keep
the skin dry (7%).
There is association between the knowledge score in pre-test and post-test in the components
like: Causes of pressure ulcer (p=0.004), Effects of moisture on Skin (p=0.002), Causes of
altered skin integrity (p=0.000), Manifestations of bed sore (p=0.000), First stage pressure
(p=0.000), legal issues related to bedsore (0.000), Risk of pressure ulcer (p=0.000), Frequency to
change position in chair (p=0.001) and Definition of Eschar (p=0.000). There is no association
in the components like: Bedsore terminology (p=1.000), Factors causing bedsore (p=0.250), and
causes of skin injury (p=0.344) at 5% level of significance .The details are mention in table – 1.
There is association between pre-test and post-test practice scores in the components like: Use of
bedsore assessment scale (p=0.001) but there is no association between applying nursing process
(p=0.500), Provide back massage (p=0.250) and Record observed skin condition (p=1.000) at
5% level of significance. The details are depicted in table – 2.
There is no association between the pre-test and post-test mean knowledge score (p=0.788) but
there is association between mean practice score (p=0.050) at 5% level of significance. The
details are depicted in table – 3.
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4. The overall evaluation of education program result is highly satisfactory that is 80% were
strongly agree and 20% were agree that programme helped in care of bed ridden patients.
Focus Group Discussion: Focus group discussion was also arranged on 29th May 2009 from 2-
4 pm at meeting room of ICU. Total 11 nurses were present in the FGD. The FGD was facilitated
by moderator (Principal Investigator), a reporter and the participants. After all the necessary
preparations the discussion was started using a pre-set guideline.
Most of the nurses reported that the incidence of bed sore patients in ICU is 1-2 per months, and
among those bedsore developed patients it’ was found that majority of clients developed it out
side ICU before admission. Most of the nurses (about 70%) reported that their level of
satisfaction regarding bedsore prevention and care is very high. The main results of the
discussion are as follows:
Main causes of bedsore in ICU are: Patient developed Bedsore before admission, or nutrition
states of the patients, obese patients, continence patient, prolonged ICU admitted patients and
intubated and restlessness patients.
Problems in providing care to the bedsore patients in ICU are: Availability of inadequate air-
mattress, availability of Air-filling machine, High work load of ICU nursing staffs, Inadequate
adjustable beds, Inadequate service of physiotherapists, Not availability of fixed protocol of
dressing and Not using bedsore assessment tool.
How to improve the bedsore care in ICU: Availability of all adjustable beds in ICU, Availability
of adequate number of air-mattresses and air-filling machine, Improve nutritional status of
clients by supplying adequate nutrition and dietetic services and develop & utilization of bedsore
protocol.
Discussions: Most of the subjects (90%) were of age group of 20-25 years, unmarried (76%),
living in BPKIHS Quarter (70%) and having ICU experiences of more than 6 months (63.3%);
most of the nurses (96.7%). Most of the nurses (93.7%) frequently provide care to the bed ridden
admitted patients usually and fully satisfied (90%); where as 13.3% received informal training
on bed sore. Bed sore is one of the common problems among critically ill patients admitted in
ICU. The study conducted by Marum6 reported that, the pressure sore is common problem and its
prevalence ranges from 2.4 to 23%. Incidence rate are similar. In elderly the prevalence of
pressure sore is 66%, similar findings were reported by Nayak 7 also, Which is similar to our
setting.
Knowledge related to bedsore prevention and care: There is in crease in knowledge on
bedsore prevention and care in the components like: pressure that altered skin integrity (63.4%),
pressure sore assessment tool (66.7%), Low BP a risk of bedsore (40%), definition of Eschar
(56.6 %) and concentration of Betadine for dressing (53.4%). Study conducted by Vati 3 in India
reported that most of the nurses (67.5%) inspect skin for pressure ulcer regularly which is similar
to this study. Similar findings were reported by WOCN 2. The study conducted by tweed 4
among ICU nursing staff had a high level of knowledge of pressure ulcers before any educational
intervention with pass rate of 90% for the baseline test, which is similar to this study.
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5. Practices related to bedsore prevention and care: After education intervention program there
is not incensement in score like: Identity potential risk of skin integrity provides notorious diet as
per need of client and many other components. In pre test most of the respondents had adequate
practice score. There is incensement in score after post-test in some components like: systematic
assessment of bed ridden patient (40 %), keeping the skin dry (7.1%), use of bedsore assessment
scale (13.3%) and inspection of skin condition regularly (3.3%).
Study conducted in India by Vati 3, reported that position change (95%), making bed tidy (60%),
back care (50%) and massages (75%) are common practices for bedsore prevention which is
similar to this study. The study conducted in Turkey by Ozdemir 9 reported that nurses did not
consistently use the risk-evaluation scale, documentation properly and not train auxiliary
personnel properly. She concludes that critical care nurses don’t consistently provide preventive
care for pressure ulcer, which is the contradictory to this study.
Association between Pre-test and post-test Knowledge scores: There is association between
the knowledge score in pre-test and post-test in the components like: Causes of pressure ulcer
(p=0.004), Effects of moisture on Skin (p=0.002), Causes of altered skin integrity (p=0.000),
Manifestations of bed sore (p=0.000), First stage pressure (p=0.000), legal issues related to
bedsore (0.000), Risk of pressure ulcer (p=0.000), Frequency to change position in chair
(p=0.001) and Definition of Eschar (p=0.000). There is no association in the components like:
Bedsore terminology (p=1.000), Factors causing bedsore (p=0.250), and causes of skin injury
(p=0.344) at 5% level of significance.
Association between Pre-test and post-test Practice scores: There is association between pre-
test and post-test practice scores in the components like: Use of bedsore assessment scale
(p=0.001) but there is no association between applying nursing process (p=0.500), Provide back
massage (p=0.250) and Record observed skin condition (p=1.000) at 5% level of significance.
Association between Pre-test and post-test, Knowledge and Practice scores: There is no
association between the pre-test and post-test mean knowledge score (p=0.788) but there is
association between mean practice score (p=0.050) at 5% level of significance.
Evaluation of education intervention programme: Most of the respondents (80%) were
strongly agree that programme helped in care of bedridden patients; where 20% reported agree
but non of them reported strongly disagree and disagree. The study conducted by Thomas 8,
reported that preventing pressure ulcer requires broad range of interventions, none of which have
had rigorous research evaluation. Medical personnel need to be informed immediately of either
suspicion of sores or actual sores.
Conclusions: Pressure ulcers remain a major health problem for adults across all health care
settings. Many gaps still remain in the understanding of preventing and healing pressure ulcers.
Pressure ulcers remain a multi-factorial, complex, and dynamic problem and physicians remain
integral to the prevention and management of this common health care issue. Among this cohort
of critical care staff nurses, knowledge and practice scores on pressure ulcer prevention and care
were good. There is no association between knowledge and practice among the nurses regarding
bedsore prevention and care.
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6. References:
1. Guideline for prevention and management of pressure ulcers. Wound, Ostomy, and
Continence Nurses Society; 2003:52.
2. Vati J, chopra S, Walia I. Nurses Role in the management and prevention of pressure
ulcer. Nursing Journal of India. May 2004.
3. Clough NP. The cost of pressure area management in an intensive care unit. J Wound
Care. 1994; 3:33–35.
4. Tweed C, Tweed M. Intensive care nurses knowledge of pressure ulcer: Development
of an assessement tool and effect of and educational programme. Am. J. Crit. Care.
2008: 17: 338-346.
5. Bostrom J, Kenneth H. Staff Nurses knowledge and prevention about prevention of
pressure sores. Dermatol Nurss 1992; 4(5):365-8.
6. Marum RV, Ooms ME, Ribble MW, Eijk JT. The Duch pressure sore assement score or
the Norten Scale for identifying at-risk nursing home patients?. Age and Ageing. 2000;
29: 63-68.
7. Nayak D, Srinivasan K, Jagdish S, Rattan R, Chatram VS. Bedsores: top to bottom and
bottom to top. Indian J. Surg..2008; 70: 161-168.
8. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired ulcers and risk of
death. J Am Geriatr Sco. 1996; 7:48-56.
9. Ozdemir H, Karadag A. Prevention of pressure ulcers: a descriptive study in three
intensive care units in Turkey. J. wound Ostomy Continence Nurs. 2008; 35(3): 293-300.
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7. Table 1
Association between pre-test and post-test knowledge score among the subject using
MacNemar Chi-Square test (p=0.05)
n=30
Knowledge
Characteristics Categories Pee- Post- P-Value Remarks
test test
Incorrect 0 2
Bedsore Terminology 1.000* NS
Correct 2 26
Incorrect 0 3
Factor causing bedsore 0.250* NS
Correct 0 27
Incorrect 1 4
Definition of bedsore 0.388* NS
Correct 8 17
Incorrect 0 9
Causes of pressure ulcer 0.004* S
Correct 0 21
Incorrect 0 10
Effects of moisture on skin 0.002* S
Correct 0 20
Incorrect 1 19
Causes of altered skin integrity 0.000* S
Correct 0 10
Incorrect 1 2
Contributing factors of pressure sore 1.000* NS
Correct 1 26
Incorrect 1 22
Manifestations of bedsore 0.000* S
Correct 0 7
Incorrect 0 24
First stage bedsore 0.000* S
Correct 1 6
Incorrect 1 12
Legal issues of bedsore 0.000* S
Correct 0 17
Incorrect 0 24
Bedsore assessment tools 0.000* S
Correct 0 6
Incorrect 0 7
Criteria of risk assessment 0.333* NS
Correct 3 20
Incorrect 1 10
Special devices of bedsore 0.039* S
Correct 2 17
Incorrect 0 21
Pressure redistribution mattress 0.000* S
Correct 0 9
Incorrect 1 26
Frequency of back care 0.000 S
Correct 1 2
Incorrect 2 7
Causes of skin injury 0.344* NS
Correct 3 18
Incorrect 0 26
Risk of pressure ulcer 0.000 S
Correct 0 4
Incorrect 2 5
Position on bed 1.000* NS
Correct 6 17
Incorrect 11 15
Position change in chair 0.001* S
Correct 1 3
Incorrect 1 18
Definition of Eschar 0.000* S
Correct 0 11
* = Binomial Distribution is used, as the cell value is less than 5
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8. Table 2
Association between pre-test and post-test Practice score among the subject using
MacNemar Chi-Square test (p=0.05)
n=30
Practices
Characteristics Categories Pre- Post- P-Value Remarks
test test
No 0 2
Apply Nursing Process
Yes 0 28 0.500* NS
No 8 14
Use of Assessment Scale 0.001* S
Yes 1 7
No 0 2
Maintain Turning Schedule 1.000* NS
Yes 1 27
No 0 1
Provide Nutritious Diet 1.000* NS
Yes 2 27
No 0 0
Provide Back Massage 0.250* NS
Yes 3 27
No 3 4
Record Observed Skin condition 1.000* NS
Yes 3 21
* = Binomial Distribution is used, as the cell value is less than 5
Table 3
Association between pre-test and post-test Knowledge and Practice Mean score among
the subject using Pearson Chi-Square test (p=0.05)
N=30
Pre-test Post-test
Characteristics/
SD/ SD/ P-value Remark
Variables Mean Mean
Value Range Value Range
2.931/ 2.426/
Knowledge 18.4 25.8 0.788 NS
12-25 21-31
1.87819/ 1.779/
Practice 22.7 23.6 0.050 S
18-25 18-26
8