The Prevalence, Epidemiology, and Financial Problems of Pressure Ulcers

Abstract

The present research paper analyzes the prevalence, epidemiology, and financial problems related to pressure ulcers. One of the primary questions is whether a special program of nursing care can decrease the rate of bedsores’ development in the emergency department. The research is conducted at two levels, where each of them presents two perspectives – mathematical and scientific. The first level analytical research question assesses the statistical data pertaining to pressure ulcers’ treatment and prevention.

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The scientific view of the first level considers the epidemiology of the medical problem. The second level of research topics considers financial burdens as well as specific populations that are most affected by pressure ulcers. These questions are addressed by reviewing existing scholarly literature and evidence-based guidelines found through databases and Boolean search. The collected data about statistics reveal that multiple factors, including patients’ age, BMI, race, gender, and comorbidities impact their risk of developing bedsores.

As for the epidemiology, the number of affected persons ranges from 1 to 3 million, and emergency units encounter more than 2 million patients with pressure ulcers annually. Bedsores are a financial burden in healthcare, and their treatment may cost more than prevention initiatives. Finally, it is established that older people and persons with limited mobility are at the highest risk of developing pressure ulcers. Healthcare organizations should implement a program that focuses on pressure ulcer prevention. Otherwise, nurses should be educated about various cultural specificities of working with patients from different backgrounds in order to ensure adherence to recommendations.

Introduction

Pressure ulcers, also known as bedsores, are among the most prevalent types of injuries in long-term care institutions, especially in intensive care units. This variety of damage occurs when an area of skin stays in contact with a surface for extended periods. The flow of blood to the portion of the skin becomes interrupted, which leads to damage and potential cell death in the skin, as well as underlying tissue. In addition, bedsores can occur due to shear between the skin and another surface as they move relative to each other. This variant of damage is enabled by long periods of friction, which tends to make surface areas more vulnerable to injuries. All types of pressure ulcers can lead to further complications, including cellulitis, infection, and sepsis.

Due to their tendency to host immobile or unconscious patients, long-term care institutions and intensive care units often have high rates of pressure ulcer occurrences. Furthermore, the protocols for preventing bed-sores or recognizing and addressing them before the damage becomes severe are still not developed or unified across various institutions. As pressure ulcers are both dangerous to patients and expensive to treat once they reach an advanced stage, the development of adequate prevention and early detection guidelines is vital.

The goal of this research is to investigate the issue and the current approaches to its treatment from a variety of angles, including bedsore epidemiology, statistics, financial and cultural connotations, ethical concerns, and other matters. It is possible that a detailed inquiry that investigates the issue from multiple points of view will assist researchers in determining effective approaches that were not attempted, or combined, before.

Topic Description

The topic of assistance to those patients of intensive care units who suffer from pressure ulcers is the urgent task of modern nursing. In order to avoid this problem, it is necessary to develop an effective and accessible program of assistance, which will prevent the development of this ailment and involve the use of appropriate procedures. As Swafford, Culpepper, and Dunn (2016) argue, pressure ulcers “are a costly and largely preventable complication occurring in a variety of acute care settings” (p. 152). Therefore, suitable interventions implying the use of specific preventive protocols are necessary.

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Purpose Identification

One of the main goals of work in this direction is to determine whether a special assistance program can prevent the development of pressure ulcers in the emergency department where there are many immobile patients. This task is crucial for modern medicine and, in particular, nursing practice since additional complications arise because of such injuries. To study this problem, it is possible to research the statistics of medical facilities and the frequency of pressure ulcer developments in patients. The final goal is to present the new idea of ​​helping those at risk who are forced to rely on the nursing staff’s help. This purpose is realistic, and it is essential to use all the available resources for its implementation.

Problem Statement

The primary problem is whether a specific pressure ulcer protocol may be of good use for patients in the emergency departments or not. According to Behrendt, Ghaznavi, Mahan, Craft, and Siddiqui (2014), equipping with modern technology can lead to significant positive results. The use of a care mechanism should meet the needs of a specific group of patients and correspond with the standards of modern nursing practice. Certainly, not only patients but also medical personnel will benefit from this innovation since less work will be needed to eliminate dangerous consequences; therefore, the target population includes both caregivers and their wards.

Scientific and Mathematical/Analytical Perspectives of an Inquiry Paper

Pressure ulcers constitute a complicated but preventable healthcare issue that has a high prevalence. In order to approach this problem effectively, it is crucial to analyze the statistical data and investigate the possible methods of eliminating the issue. The present paper discusses level 1 and 2 research questions for the mathematical/analytical and scientific perspectives.

The first perspective involves such questions as “What are the statistical facts related to the prevention and treatment of pressure ulcers?” and “What is the cost and financial burden associated with the prevention and treatment of pressure ulcers?” The scientific perspective will investigate the questions “What are the epidemiological issues related to the prevention and treatment of pressure ulcers?” and “What populations and body systems are the most affected by pressure ulcers?” The paper will be divided by the levels of inquiry.

Level 1 Research Questions

The level 1 research question of the mathematical/analytical perspective is focused on the statistics of pressure ulcer prevention and treatment. The study by Gardiner et al. (2016) can be employed to find the answer to this inquiry. A population-based cohort study that scholars performed indicated that out of 242,745 hospital discharges within 2009 and 2010, 2.68% of patients experienced bedsores during their stay at a hospital (Gardiner et al., 2016). Such factors as gender, comorbidity, age, BMI, and race are reported to contribute to the development of pressure ulcers. The likelihood of bedsores increases if an individual has a negative interaction between the mentioned factors.

Another study analyzing the research question is focused on tracheostomy-related hospital-acquired pressure ulcers. In their research, O’Toole et al. (2017) note that there has been a decrease in bedsore incidence over the period between 2014 and 2015. In particular, the authors remark that the percentage of cases of pressure ulcers fell from 10.93% in 2014 to 1.29% in 2015 (O’Toole et al., 2017). Researchers note that the major reason for such a positive change is the introduction of a standardized care bundle. Also, scholars emphasize the importance of keeping a quality improvement protocol as a factor that can mitigate the problem and reduce its incidence.

The level 1 research question of the scientific perspective is concerned with the epidemiology of pressure ulcers. Lam et al. (2018) note that the annual number of people developing bedsores in the US varies between 1 and 3 million. Approximately 2.5 million cases are treated every year in emergency care units. What is more, about 60,000 people die yearly due to the complications they develop from pressure ulcers (Lam et al., 2018). The national incidence of the analyzed healthcare issue is 0-6% in rehabilitative care, 0-17% in-home care, and 2.3-23.9% in long-term care (Lam et al., 2018). Scholars mention that the detailed investigation of the problem’s epidemiology can help reduce the incidence.

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Pressure ulcers develop due to the immobility of a patient and are manifested through the damage of tissue. There are four stages of bedsores:

  1. sores are not open wounds yet,
  2. the skin breaks open and forms a painful ulcer,
  3. the sore progresses to the tissue,
  4. the ulcer damages muscles, and bones.

To reduce the likelihood of bedsore development, Lam et al. (2018) offer such strategies as the use of pressure-reducing beds, obligatory repositioning of patients, patient education, and checking the spots by highly-skilled wound care nurses. Early surgical interventions and enhanced and protocolized nutritional support are also recommended. Scholarly papers that have been found in databases with the help of Boolean search helped to answer level 1 questions of the mathematical/analytical and scientific perspectives.

Level 2 Research Questions

The level 2 research question of the mathematical/analytical perspective deals with the problem of the financial burden associated with the treatment and prevention of bedsores. Demarré et al. (2015) investigate this issue and mention that pressure ulcers impose a considerable financial burden. Scholars emphasize that high-quality nursing care can reduce expenditures while increasing patients’ conditions. Since the study involved the review of articles from various countries, including the USA, Demarré et al. (2015) suggest the estimated numbers in euros.

It is noted that both the prevention and treatment of bedsores are costly. Demarré et al. (2015) remark that the effect of pressure ulcer prevention cost ranges between €12.58 million and €240.94 across different settings and countries. Even the minimal number is a substantial burn on the healthcare system and the government. The total cost per one patient varies from €13.15 to €7 988.47 across different settings (Demarré et al., 2015). Therefore, the authors emphasize the importance of finding solutions to managing the incidence of pressure ulcers in order to reduce the financial burden imposed on the healthcare system.

The level 2 research question of the scientific perspective concerns the populations and body systems most frequently impacted by bedsores. Research by Coleman et al. (2013) offers relevant data on this issue. The body parts that suffer from bedsores are those that are under pressure. Therefore, the most vulnerable populations are elderly people and those who are immobile for a long time (Coleman et al., 2013). Scholars note that there is no single factor that could explain the risk of pressure ulcer development. Instead, Coleman et al. (2013) suggest that there exists a “complex interplay of factors” that intensifies the probability of bedsore (p. 975).

The primary risk factors, as identified by Coleman et al. (2013), are activity/mobility, skin/pressure ulcer status, and perfusion. Other risk aspects that can serve as predictors of bedsore development are age, nutrition, skin moisture, and hematological measures (Coleman et al., 2013). However, the three major factors should receive the most attention from the healthcare workers and caregivers.

Ethical and Cultural Perspectives of Pressure Ulcers

The profession of nurses is multifaceted so the scope of their work encompasses both practical and ethical questions. The field of wound medicine is not an exception since there, nurses often have to deal with vulnerable population groups and consider the ethical implications of each decision. The way pressure sores and ulcers are treated heavily depends on economic, social, and cultural factors and not only on the specifics of each case and available medical equipment.

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This paper presents level 1 and 2 research questions for the ethical and cultural perspectives of treating pressure ulcers. The first level deals with such questions as “How do ethical theories apply to the issue?” and “Which cultural values and/or norms influence the issue?”. The second level investigates the following questions: “What are the ethical issues of pressure ulcer research?” and “How do culturally defined family dynamics affect treatment?”.

Ethical Perspective of Inquiry

The ethical aspects of treating pressure ulcers in nursing practice may be explained through five ethical theories among which are egoism, deontology, care ethics, virtue ethics, and utilitarianism. Egoism might be seen as incompatible with nursing practice; however, one should avoid overworking and promote self-care among patients with this condition to lighten the workload. Encouraging patients to practice self-care aligns with the values of deontology and utilitarianism that call for transmitting all relevant information to a patient to bring about the best health outcome.

According to Beldon (2014), patients’ choices should be guided by a nurse who is responsible for informing them about the implication of their condition. At that, a nurse should take into account all the specifics of a patient’s situation to make treatment patient-focused and aligned with the principles of care ethics. Lastly, virtue ethics provide a framework within which it is encouraged that a nurse develops personal qualities that would enable them to provide services in the best way possible with regards to moral norms.

Pressure ulcer research should align with the main ethical principles of conducting a study. For a research nurse, it is crucial to recognize the heightened vulnerability of patients suffering from pressure sores and ulcers since they do not only experience pain but may also be self-conscious about their looks and body odor. A nurse cannot proceed with research unless he or she gains informed explicit consent from each participant. Research methodology cannot contradict the principle of nonmaleficence, that is if the invasion or other forms of treatment are involved, they should not pose a threat to a patient’s health and body integrity (Parahoo, 2014). Lastly, a research nurse should make sure that participation is confidential, and personal and sensitive information will not be disclosed.

Cultural Perspective of Inquiry

Treatment perspectives are often linked to a patient’s cultural values, norms, and background. For instance, elderly patients usually operate under the principle “doctor knows best” and maybe inactive in proceeding with the treatment plan. They may ignore self-care guidelines as to how they should move and treat their skin and let their condition worsen. On the other hand, young individuals are more outspoken and individualistic and may confront a doctor on the chosen treatment methods.

As for the cultural context, one should be aware of the differences in pain perception in various cultures. In some cultures, patients express greater stoicism towards pain, whereas, in others, sick people are outstandingly communicative when it comes to painful experiences (Pillay, Zyl, & Blackbeard, 2014). In this case, a patient that belongs to a “stoic” culture may be silent about their condition and not report it to the doctor. Another difficulty may arise when a nurse tries to assess such a patient’s level of pain. When introduced to the pain scale, they might hesitate to be honest about their sensations, and a medical practitioner might fail to prescribe an appropriate dose of pain medication.

As for the level 2 research question, some cultural family traditions may affect pressure ulcer treatment significantly. For instance, family dynamics are often culturally determined, and the roles of family members may have an impact on how a condition is treated. If in a particular culture, a woman is socially obliged to be obedient to her husband, he may try to overtake the treatment process and speak on his spouse’s behalf. He may also dictate who gains access to his wife’s body regarding skin examinations for sores and ulcers. In some societies, parents are very authoritarian, and they may ignore their child’s autonomy and silence him or her when they attempt to share their experiences.

When involved in the treatment process, family members play a number of roles. According to Lin, Pang, and Chen (2013), these roles include but are not limited to an information broker and a patient’s advocate. The researchers discovered that when confronted with the necessity to make an important health decision, patients saw their family as a whole and cared deeply about the well-being and mental state of each member.

However, there are two sides to this phenomenon as family members that actively transmit information and advocate for a patient’s needs may both amplify and limit his or her autonomy. It is suggested in the study that nurses and other medical practitioners should be aware of a family’s cultural background to know to what extent family members’ opinions will impact a patient’s decisions. Appropriate communication may prove to be beneficial for both families and medical staff.

Scientific and Mathematical/Analytical Perspectives of an Inquiry

Pressure ulcers constitute a complicated but preventable healthcare issue that has a high prevalence. In order to approach this problem effectively, it is crucial to analyze the statistical data and investigate the possible methods of eliminating the issue. The present paper discusses level 1 and 2 research questions for the mathematical/analytical and scientific perspectives.

The first perspective involves such questions as “What are the statistical facts related to the prevention and treatment of pressure ulcers?” and “What is the cost and financial burden associated with the prevention and treatment of pressure ulcers?” The scientific perspective will investigate the questions “What are the epidemiological issues related to the prevention and treatment of pressure ulcers?” and “What populations and body systems are the most affected by pressure ulcers?” The paper will be divided by the levels of inquiry.

Level 1 Research Questions

The level 1 research question of the mathematical/analytical perspective is focused on the statistics of pressure ulcer prevention and treatment. The study by Gardiner et al. (2016) can be employed to find the answer to this inquiry. A population-based cohort study that scholars performed indicated that out of 242,745 hospital discharges within 2009 and 2010, 2.68% of patients experienced bedsores during their stay at a hospital (Gardiner et al., 2016). Such factors as gender, comorbidity, age, BMI, and race are reported to contribute to the development of pressure ulcers. The likelihood of bedsores increases if an individual has a negative interaction between the mentioned factors.

Another study analyzing the research question is focused on tracheostomy-related hospital-acquired pressure ulcers. In their research, O’Toole et al. (2017) note that there has been a decrease in bedsore incidence over the period between 2014 and 2015. In particular, the authors remark that the percentage of cases of pressure ulcers fell from 10.93% in 2014 to 1.29% in 2015 (O’Toole et al., 2017). Researchers note that the major reason for such a positive change is the introduction of a standardized care bundle. Also, scholars emphasize the importance of keeping a quality improvement protocol as a factor that can mitigate the problem and reduce its incidence.

The level 1 research question of the scientific perspective is concerned with the epidemiology of pressure ulcers. Lam et al. (2018) note that the annual number of people developing bedsores in the US varies between 1 and 3 million. Approximately 2.5 million cases are treated every year in emergency care units. What is more, about 60,000 people die yearly due to the complications they develop from pressure ulcers (Lam et al., 2018).

The national incidence of the analyzed healthcare issue is 0-6% in rehabilitative care, 0-17% in-home care, and 2.3-23.9% in long-term care (Lam et al., 2018). Scholars mention that the detailed investigation of the problem’s epidemiology can help reduce the incidence.

Pressure ulcers develop due to the immobility of a patient and are manifested through the damage of tissue. There are four stages of bedsores:

  1. sores are not open wounds yet,
  2. the skin breaks open and forms a painful ulcer,
  3. the sore progresses to the tissue,
  4. the ulcer damages muscles, and bones.

To reduce the likelihood of bedsore development, Lam et al. (2018) offer such strategies as the use of pressure-reducing beds, obligatory repositioning of patients, patient education, and checking the spots by highly-skilled wound care nurses. Early surgical interventions and enhanced and protocolized nutritional support are also recommended. Scholarly papers that have been found in databases with the help of Boolean search helped to answer level 1 questions of the mathematical/analytical and scientific perspectives.

Level 2 Research Questions

The level 2 research question of the mathematical/analytical perspective deals with the problem of the financial burden associated with the treatment and prevention of bedsores. Demarré et al. (2015) investigate this issue and mention that pressure ulcers impose a considerable financial burden. Scholars emphasize that high-quality nursing care can reduce expenditures while increasing patients’ conditions. Since the study involved the review of articles from various countries, including the USA, Demarré et al. (2015) suggest the estimated numbers in euros.

It is noted that both the prevention and treatment of bedsores are costly. Demarré et al. (2015) remark that the effect of pressure ulcer prevention cost ranges between €12.58 million and €240.94 across different settings and countries. Even the minimal number is a substantial burn on the healthcare system and the government. The total cost per one patient varies from €13.15 to €7 988.47 across different settings (Demarré et al., 2015). Therefore, the authors emphasize the importance of finding solutions to managing the incidence of pressure ulcers in order to reduce the financial burden imposed on the healthcare system.

The level 2 research question of the scientific perspective concerns the populations and body systems most frequently impacted by bedsores. Research by Coleman et al. (2013) offers relevant data on this issue. The body parts that suffer from bedsores are those that are under pressure. Therefore, the most vulnerable populations are elderly people and those who are immobile for a long time (Coleman et al., 2013). Scholars note that there is no single factor that could explain the risk of pressure ulcer development. Instead, Coleman et al. (2013) suggest that there exists a “complex interplay of factors” that intensifies the probability of bedsore (p. 975).

The primary risk factors, as identified by Coleman et al. (2013), are activity/mobility, skin/pressure ulcer status, and perfusion. Other risk aspects that can serve as predictors of bedsore development are age, nutrition, skin moisture, and hematological measures (Coleman et al., 2013). However, the three major factors should receive the most attention from the healthcare workers and caregivers.

Ethical and Cultural Perspectives of Pressure Ulcers

The profession of nurses is multifaceted so the scope of their work encompasses both practical and ethical questions. The field of wound medicine is not an exception since there, nurses often have to deal with vulnerable population groups and consider the ethical implications of each decision. The way pressure sores and ulcers are treated heavily depends on economic, social, and cultural factors and not only on the specifics of each case and available medical equipment.

This paper presents level 1 and 2 research questions for the ethical and cultural perspectives of treating pressure ulcers. The first level deals with such questions as “How do ethical theories apply to the issue?” and “Which cultural values and/or norms influence the issue?”. The second level investigates the following questions: “What are the ethical issues of pressure ulcer research?” and “How do culturally defined family dynamics affect treatment?”.

Ethical Perspective of Inquiry

The ethical aspects of treating pressure ulcers in nursing practice may be explained through five ethical theories among which are egoism, deontology, care ethics, virtue ethics, and utilitarianism. Egoism might be seen as incompatible with nursing practice; however, one should avoid overworking and promote self-care among patients with this condition to lighten the workload. Encouraging patients to practice self-care aligns with the values of deontology and utilitarianism that call for transmitting all relevant information to a patient to bring about the best health outcome.

According to Beldon (2014), patients’ choices should be guided by a nurse who is responsible for informing them about the implication of their condition. At that, a nurse should take into account all the specifics of a patient’s situation to make treatment patient-focused and aligned with the principles of care ethics. Lastly, virtue ethics provide a framework within which it is encouraged that a nurse develops personal qualities that would enable them to provide services in the best way possible with regards to moral norms.

Pressure ulcer research should align with the main ethical principles of conducting a study. For a research nurse, it is crucial to recognize the heightened vulnerability of patients suffering from pressure sores and ulcers since they do not only experience pain but may also be self-conscious about their looks and body odor. A nurse cannot proceed with research unless he or she gains informed explicit consent from each participant.

Research methodology cannot contradict the principle of nonmaleficence, that is if the invasion or other forms of treatment are involved, they should not pose a threat to a patient’s health and body integrity (Parahoo, 2014). Lastly, a research nurse should make sure that participation is confidential, and personal and sensitive information will not be disclosed.

Cultural Perspective of Inquiry

Treatment perspectives are often linked to a patient’s cultural values, norms, and background. For instance, elderly patients usually operate under the principle “doctor knows best” and maybe inactive in proceeding with the treatment plan. They may ignore self-care guidelines as to how they should move and treat their skin and let their condition worsen. On the other hand, young individuals are more outspoken and individualistic and may confront a doctor on the chosen treatment methods.

As for the cultural context, one should be aware of the differences in pain perception in various cultures. In some cultures, patients express greater stoicism towards pain, whereas, in others, sick people are outstandingly communicative when it comes to painful experiences (Pillay, Zyl, & Blackbeard, 2014). In this case, a patient that belongs to a “stoic” culture may be silent about their condition and not report it to the doctor.

Another difficulty may arise when a nurse tries to assess such a patient’s level of pain. When introduced to the pain scale, they might hesitate to be honest about their sensations, and a medical practitioner might fail to prescribe an appropriate dose of pain medication.

As for the level 2 research question, some cultural family traditions may affect pressure ulcer treatment significantly. For instance, family dynamics are often culturally determined, and the roles of family members may have an impact on how a condition is treated. If in a particular culture, a woman is socially obliged to be obedient to her husband, he may try to overtake the treatment process and speak on his spouse’s behalf. He may also dictate who gains access to his wife’s body regarding skin examinations for sores and ulcers. In some societies, parents are very authoritarian, and they may ignore their child’s autonomy and silence him or her when they attempt to share their experiences.

When involved in the treatment process, family members play a number of roles. According to Lin, Pang, and Chen (2013), these roles include but are not limited to an information broker and a patient’s advocate. The researchers discovered that when confronted with the necessity to make an important health decision, patients saw their family as a whole and cared deeply about the well-being and mental state of each member. However, there are two sides to this phenomenon as family members that actively transmit information and advocate for a patient’s needs may both amplify and limit his or her autonomy. It is suggested in the study that nurses and other medical practitioners should be aware of a family’s cultural background to know to what extent family members’ opinions will impact a patient’s decisions. Appropriate communication may prove to be beneficial for both families and medical staff.

Conclusion

Pressure ulcers are a significant issue in long-term and intensive care units but in most cases, they can be prevented with a detailed thorough approach. The risk that a patient will develop bedsore can be evaluated based on factors such as gender, race, or BMI. Furthermore, the incidence of pressure ulcers can be reduced significantly through the introduction of a standardized care bundle. In addition, the literature suggests a variety of measures for the prevention and early detection of injuries. It should be noted, however, that these prevention approaches are potentially as expensive as the treatment of wounds after their occurrence.

The issue is exacerbated by the absence of clear risk factors for the development of the condition. Scholars suggest that nurses should pay particular attention to the patients’ mobility, skin status, and perfusion, but these indicators are not required or conclusive.

The second part of the paper investigates the ethical and cultural concerns surrounding research into pressure ulcers, both of which are particularly relevant because bedsores are often associated with vulnerable patient groups. A nurse should inform the patient of the details of his or her condition and obtain permission before proceeding with the inquiry. Furthermore, researchers should take personal factors such as the self-consciousness of patients into consideration while discussing the possibility of conducting research.

Moreover, the cultural norms of the patient and his or her approach to pain should be studied when collecting information about his or her perception of the condition. Lastly, the nurse should study the cultural relationship norms between husbands and wives, parents and children, or families as a unit in situations where those factors are applicable and act in a manner that aligns with those norms. Although the variety of factors makes the research a complex endeavor, observing ethical and cultural guidelines is vital to its success.

References

Beldon, P. (2014). The role of ethics in the wound care setting. Wounds UK, 10(3), 72-75.

Coleman, S., Gorecki, C., Nelson, E. A., Closs, J. C., Defloor, T., Halfens, R., … Nixon, J. (2013). Patient risk factors for pressure ulcer development: Systematic review. International Journal of Nursing Studies, 50(7), 974-1003.

Demarré, L., Van Lancker, A., Van Hecke, A., Verhaeghe, S., Grypdonck, M., Lemey, … J., Beeckman, D. (2015). The cost of prevention and treatment of pressure ulcers: A systematic review. International Journal of Nursing Studies, 52(11), 1754-1774.

Gardiner, J. C., Reed, P. L., Bonner, J. D., Haggerty, D. K., & Hale, D. G. (2016). Incidence of hospital-acquired pressure ulcers ― A population-based cohort study. International Would Journal, 13(5), 809-820.

Lam, C., Elkbuli, A., Benson, B., Young, E., Morejon, O., Boneva, D.,… McKenney, M. (2018). Implementing a novel guideline to prevent hospital-acquired pressure ulcers in a trauma population: A patient-safety approach. Journal of the American College of Surgeons, 226(6), 1122-1127.

Lin, M., Pang, M. S., & Chen, S. (2013). Family as a whole: Elective surgery patients’ perception of the meaning of family involvement in decision making. Journal of Clinical Nursing, 22(1-2), 271-278.

Parahoo, K. (2014). Nursing research: Principles, process and issues. London, England: Macmillan International Higher Education.

Pillay, T., Zyl, H. A., & Blackbeard, D. (2014). Chronic pain perception and cultural experience. Procedia – Social and Behavioral Sciences, 113, 151-160.

Silva, T. N., Freire, M. E. M., Vasconcelos, M. F., Silva Junior, S. V., Silva, W. J. C., AraújoI, P. S., & Eloy, A. V. A. (2018). Deontological aspects of the nursing profession: Understanding the code of ethics. Revista Brasileira Enfermagem, 71(1), 3-10.

Behrendt, R., Ghaznavi, A. M., Mahan, M., Craft, S., & Siddiqui, A. (2014). Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit. American Journal of Critical Care, 23(2), 127-133. Web.

Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155. Web.

Coleman, S., Gorecki, C., Nelson, E. A., Closs, J. C., Defloor, T., Halfens, R., … Nixon, J. (2013). Patient risk factors for pressure ulcer development: Systematic review. International Journal of Nursing Studies, 50(7), 974-1003.

Demarré, L., Van Lancker, A., Van Hecke, A., Verhaeghe, S., Grypdonck, M., Lemey, … J., Beeckman, D. (2015). The cost of prevention and treatment of pressure ulcers: A systematic review. International Journal of Nursing Studies, 52(11), 1754-1774.

Gardiner, J. C., Reed, P. L., Bonner, J. D., Haggerty, D. K., & Hale, D. G. (2016). Incidence of hospital-acquired pressure ulcers ― A population-based cohort study. International Would Journal, 13(5), 809-820.

Lam, C., Elkbuli, A., Benson, B., Young, E., Morejon, O., Boneva, D.,… McKenney, M. (2018). Implementing a novel guideline to prevent hospital-acquired pressure ulcers in a trauma population: A patient-safety approach. Journal of the American College of Surgeons, 226(6), 1122-1127.

O’Toole, T. R., Jacobs, N., Hondorp, B., Crawford, L., Boudreau, L. R., Jeffe, J.,… LoSavio, P. (2017). Prevention of tracheostomy-related hospital-acquired pressure ulcers. Otolaryngology – Head and Neck Surgery, 156(4), 642-651.

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