The purpose of this study is to give a critical analysis of the Literature, and briefly enumerate the causes, treatment, prevention and the risk factors of Pressure Ulcers (PUs). The process leading to pressure ulcer formation and early detection of individuals who are at risk of developing it for prompt prevention are paramount in this study.

Methods: The methods adopted in this dissertation involved various strategies: selecting a review topic and searching the literatures to be used. Gathering, reading and analysing the literatures. It also involved critical examination of the various causes, treatment and preventive measures.

Furthermore, it is also intended to find out the various risk factors that could lead to its emergence. On this basis, a number of research articles was examined after which their literatures were critically analysed All the literature searches were undertaken online with the aid of computer and electronic databases. Computer databases are used because they offer access to varieties of information, which could not be obtained manually.

Findings and Conclusions: This study went further to find out the effect of age and nutrition on the persistence and spread of presure ulcer. Finally, having given a critical analysis of the literatures, it summarised the findings as well as the various ways to curtail the emergence as well as improving the wellbeing of the patients with essential pressure ulcer, ie, those who by reason of underlying health conditions such as diabetes and catheterized individuals, people with profound learning disability, who could not avoid staying in one position for too long.

CHAPTER ONE

INTRODUCTION

The impact of pressure ulcers on the quality of life of the people with learning disability cannot be overemphasised, as it can be devastating (Spilsbury et al. 2007; MEP Ltd, 2009; NHS for Scotland, 2009).

A pressure ulcer (PU) otherwise known as pressure sore, pressure damage, pressure injuries or bed sore (Spilsbury et al. 2007), is an area of the skin that has become abraded gradually due to a reduction or cessation of blood flowing through that part of the body. It is mainly as a result of continuous maintenance of same position when sitting or lying down for a long period of time, (RCN, 2005). It can also be described as a localised abrasion on the skin or the underlying tissue, in most cases over a bony prominence, due to the pressure or pressure in combination with deformation of the site; this can also be caused by friction. Based on the degree of damage, it can further be defined as partial-thickness of skin loss involving epidermis or dermis; mainly affecting the surface manifesting as a scratch, fluid-filled elevation of the skin or simply as a swollen crater (Lyder, 2010 & Guy, 2012). Furthermore, Pressure ulcer in some other cases can present as an erythematic or abnormal redness of the skin due to dilation of the blood vessels in the skin. (www.merckmanuals.com/home/heart_and_blood_vessel_disorders.html).

The reddened area remains as such for longer than 30 minutes after pressure is relieved (Barbanel, and Hagisawa, 2001).

In view of the fact that Pressure ulcer has been widely noted to reduce the quality of life in people with learning disability (Dorner et al, 2009), this topic is very important and relevant to a very large extent for Nurses and other carers involved with the treatment and management of PUs in individuals having learning disability.

Among the many reasons for choosing this particular topic are as follows: Having established that pressure ulcers are a major cause of morbidity, mortality and healthcare burden globally and that many of the cases are avoidable (Whittington et al, 2004); it follows that solutions need to be sought aimed at reducing it, if its prevalence.

Looking at PUs from the perspectives of treatment and management, it has been observed that both treatment and management are capital intensive, but it is also preventable (Soban et al; White-Chu, 2011). It is very important to concentrate more efforts at minimising the occurrence of PUs, rather than wasting resources on treatment, which might be counterproductive, especially in diabetic patients (European Pressure Ulcer Advisory Panel [EPUAP], 2005).

Pressure ulcers pose grave consequences on the wellbeing of people with profound learning disability, be that as it may, its treatment, prevention and management is a major priority within the clinical and policy agenda. It is very important that patients are educated on the impact of PUs on health and quality of life, at the same time; it is their right to make informed decision about their care and treatment in conjunction with the healthcare provider (Spilsbury et al, 2007; NICE clinical guideline, 2005).

In addition, the data generated could be used to estimate the total number of cases with PUs within a particular population (i.e. prevalence) and the rate at which new Pressure Ulcers are occurring in people in needing medical care. (Clark, 2007).

(Plaum et al, 2006), in their questionnaire research on Pressure ulcer discovered that it was possible for patients to have a combination of deficiency of sensory experience as well as memory loss. The above combination of health challenges tended to increase the probability of having PUs (Plaum et al, 2006).

This study will therefore discuss common risk factors for developing pressure ulcers in people with learning disability, its prevention and management (Guy H, 2012, Vanderwee et al, 2007).

This study will also find out effect on age, and nutrition on the persistence and spread of pressure ulcer. The findings will summarise the various ways to curtail the emergence as well as the ways to improve the wellbeing of the patients with pressure sores. According to the International guidelines on Pressure ulcer prevention, prevalence and Incidence (MEP Ltd, 2009: page 8); “the results of PUs prevalence and incidence studies could be used for enlightenment purposes, to reduce PUs occurrence, and therefore improve clinical practice”. It is very important to understand the consequences and pitfalls of the prevalence and incidence of PUs.

Lastly, it is essential for all healthcare practitioners, managers, payers and financiers involved in the development, implementation and assessment of PU prevention protocols (Fletcher et al, 2011).

The overall aim of this study a strategy geared towards the reduction of PUs as well as reducing the number of patients who have it. The need for identification and production of new antimicrobial agents that are selectively toxic, that is; being able to destroy the causative agent with little side effect on the host and broadly effective with a low propensity to induce resistance is very crucial (Bowler et al, 2001).

According to (Bowler et al, 2001); while it is true that microorganisms are known to be responsible for wound infections, there are widespread controversies relating to the exact mechanisms by which the microbes cause infection and also their significance in non-healing wounds that fail to exhibit clinical manifestation. (Robson, 1999); observed that the mass per unit volume of microorganisms is a critical factor in determining the probability of the wound healing. However, (Pallua et al, 1999) argued the fact that certain virulent microorganisms were isolated is evidential in delayed wound healing.

Nevertheless, others have reported that microorganisms “per se” play little or no role in wound healing or slow healing. (EWMA MEP Ltd, 2005), stated that; not all wounds become infected, being that, the susceptibility or resistivity of the host determines the chance of such a wound eventually becoming infected by bacterial pathogen. Although the role of Microbiology laboratory is incontrovertible, the necessity of carrying out wound culture and sensitivity testing must be critically considered in order to save in cost, labour, and avoid unnecessary disturbance to the patient, (Bowler et al 2001).

1.3 Mode of treatment: since pressure ulcer (PU) is a debilitating chronic wound that affects mostly individuals who are incapacitated as a result of age or an underlying illness (Lyder, 2003), or people with profound learning disability who spent longer time on a particular position, its treatment typically involves multiple treatment procedures simultaneously; such as support surface and dressings. Nutritional supplements are essential; since most individuals with learning disability have been known to have diet problems (Dorner et al, 2009). At successive stages of the treatment, different treatments are applied (Lyder, 2003).

CHAPTER TWO

METHODS

The methods adopted in this dissertation involved various strategies: Selecting a review topic and searching the literatures to be used. Gathering reading materials and analysing the literature followed by the review of references.

Having selected the topic the next step was identification of the appropriate and related information. This method was in agreement with (Hek and Langton 2000). In their study, they discovered and applied a particular orderly approach which was sequential and capable of generating reliable and beneficial information unlike the traditional review.

All the literature searches were undertaken online with the aid of computer and electronic databases. The reason for using computer databases is that they offer access to varieties of information, which cannot be obtained manually and sometimes quite recent. Keyword searches were the most common method of identifying literature (Ely and Scott, 2007). However, keywords which have to do with the review/assessment and management of pressure ulcers were used.

Databases of particular relevance to the selected topic, which are very useful for Nurses (Parahoo, 2006), aided the search for related journals which included: British Nursing Index Nursing Journals in English Language

CINAHL (Cumulative Index of Nursing and Allied Health Literature) and related publications. This according to (Polit and Beck, 2006), offers an important, reliable and up-to-date electronic databases for Nurses and other healthcare professionals. More importantly, CINAHL databases offer both staff and student Nurses the most recent and best available evidence-based clinical practice.

Medical Subject Headings or subject headings:

Pubmed/MEDLINE

Google scholar

The essence of using numerous databases was to harvest a large catalogue of research materials including those directly linked to the field of learning disability practice:

Journal of Learning Disabilities

Journal of Intellectual Disabilities.

Journals of wound care and management.

Generally, Journals are much more up-to-date than books which were probably written decades ago since information is dynamic and prone to changes. Therefore, maximum period of 10 years was placed on the age of the works and journals that were used in this work except in some rear cases where no recent materials were found in relation to the subject matter. The search strategy sought to identify all published and unpublished research investigating patient reports about the impact of PUs and PU interventions on HRQL. Data extraction involved the reading through each of the published articles and identifying their findings in the form of statements by the author supported by patient reported data, the extracted patient reported data produced (Gorecki et al 2009). Moreover, specialist Journals were also hand-searched.

The internet played a crucial role for web sites on pressure ulcer publications, as well as books from my local area and the university library.

Eligibility: Both exclusion and inclusion criteria were used for the primary and final selection for reporting the impact of PUs and interventions respectively on Health related quality of life (HRQL), including symptoms and patient evaluation of interventions. (Gorecki et al 2009).