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PEMERIKSAAN HUBUNGAN ANTARA INSIDENSI
ULCER DEKUBITUS DI DUAJANGKA PANJANG PERAWATAN FASILITAS
DAN PROGRAM PENDIDIKAN
kepada Departemen Keperawatan
Universitas Negeri California, Long Beach
Dalam Pemenuhan Sebagian
Persyaratan untuk Gelar
Magister Sains
INI DIBERIKANOleh Donette Hylton
BSN, 1995, Universitas Loma Linda, Loma Linda, California

Agustus 2003
Direproduksi dengan izin dari pemilik hak cipta. Reproduksi lebih lanjut dilarang tanpa izin.
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Kami yang bertanda ANGGOTA KOMITE,
TELAH DISETUJUI SKRIPSI INI
SEBUAH PEMERIKSAAN HUBUNGAN ANTARA KEJADIAN
dekubitus borok DI DUA FASILITAS PERAWATAN JANGKA PANJANG
Oleh
Donette Hylton
ANGGOTA KOMITE
Bonnie Kellogg, RN, DR. P Keperawatan

/ - jika ** 0 3 MSN, RN, CS, ANP Nursing
Elaine E. White, RN., EdD. Keperawatan
DITERIMA DAN DISETUJUI ATASUNIVERSITAS.
SIKAPOnon E. Vogel, EdD. * Ronald E. Vogel ,: Dekan, Fakultas Kesehatan dan Layanan
Kemanusiaan
Universitas Negeri California, Long Beach
Agustus 2003
ABSTRAK
PEMERIKSAAN HUBUNGAN ANTARA INSIDENSI
ULCER DECUBITUS DI DUA FASILITAS PERAWATAN JANGKA PANJANG
Oleh
Donette Hylton
Agustus 2003
Penelitian ini dirancang untuk menentukan dampak dari program pendidikan untuk
sampel staf keperawatan terhadap kejadian dekubitus. borok di kohort warga
dari dua fasilitas perawatan jangka panjang. Catatan medis ditinjau dan
preassessment untuk kejadian ulkus dekubitus dan tahapan dilakukan menggunakanSessing
Skala. Program pendidikan, yang dikembangkan oleh Badan Kebijakan danPerawatan Kesehatan
Penelitian, dilakukan selama 7 hari untuk staf perawat. Perawat dalampelatihan
programdiberi pretest sebelum instruksi dan posttest setelah instruksi, untuk
menentukan pengetahuan. Tiga puluh hari setelah akhir program, postassessment
rekam medis diselesaikan untuk menentukan hasil. Studi ini melaporkan
peningkatanpengetahuan perawat ulkus dekubitus dan penurunan
kejadianulkus dekubitus setelah program pendidikan di kedua fasilitas.
Diproduksi ulang dengan izin dari pemilik hak cipta. Reproduksi lebih lanjut dilarang tanpa izin.
UCAPAN TERIMA
KASIH
Saya ingin menyampaikan terima kasih yang tulus dan mengucapkan kasih
terima kepadasaya
anggotakomite,California State University, Long Beach, Keperawatan staf Departemen,

dansaya,
keluarga untuk cinta mereka, dukungan, dan doa yang dirasakan di seluruh
proyek ini.
ii
i
DAFTAR ISI
Hala
man
UCAPAN TERIMA KASIH ................................................. .......................................... iii
TABEL ...... .................................................. .................................................. ................. vii
BAB
1. PENDAHULUAN ............................ .................................................. ............. 1
Bisul Dekubitus ...................................... .................................................. .. 1

Patofisiologi dan Faktor Risiko untuk Bisul Dekubitus ................... 2
Perawatan dan Tantangan Jangka
Panjang .............. ............................................. 5 Penilaian Integritas
Kulit .................................................. ................ 7
Pencegahan ................................ .................................................. ................ 7
Pertanyaan Penelitian ............................... .................................................. ... 8
Signifikansi Masalahnya ........ .................................................. .......... 8
Tujuan Penelitian ..................................... ................................................ 9
Kesimpulan .................................................. ............................................... 9
2. TINJAUAN PUSTAKA .................................................... .............................. 10
Long-T erm Care .............. .................................................. ........................ 11

Peran Praktisi Perawat Geriatrik (GNP) .................. ............................. 11
Penilaian ................... .................................................. ............................ 12
Penilaian Tambahan Ulkus Dekubitus ................ ......................... 16 Faktor
Gizi Terkait dengan Bisul Dekubitus .................. ................ 16
Insiden ................................ .................................................. .................. 17
Biaya Perawatan Ulkus Dekubitus. .................................................. ............
19 Pendidikan sebagai Tindakan Intervensi yang Efektif ...............................
... 20
Kesimpulan ............................................. .................................................. .. 22
3. KERANGKA TEORI ........................................... ..................... 23
Penerapan Kerangka Kerja dalam Studi Ini ...................... ........................ 25

Asumsi ........................ .................................................. ..................... 28
Batasan ........................... .................................................. .................... 28
iv
BAB Halaman
Definisi Ketentuan ............................................. ..................................... 28

Kesimpulan ........... .................................................. .................................... 29
4. METODOLOGI .......... ........... 30
Desain ..................................... .................................................. ................. 30

Variabel Independen .............................. .................................................. 30
Variabel Tergantung ............................................... ................................... 31
Intervensi V ariables ........... .................................................. ................... 31
Pilihan Sampel ............................ .................................................. ......... 31
Perlindungan Hak Asasi Manusia / Persetujuan
Diinformasikan ..................... 32
Pengaturan .......... .................................................. ............................................
. 33 Prosedur ... .................................................. ..............................................
33 Alat .. .................................................. .................................................. .....
35 Analisis Data .............................................. ..................................................
36
5. HASIL ............................................. .................................................. ........ 38
Pelaporan Data .......................................... ................................................ 38

Pendidikan Nilai Rata-Rata Program ................................................... ...........
39 Kesimpulan ..................................... .................................................. ..........
43
6. KESIMPULAN .................................... .................................................. ......... 44

Generalisasi Temuan ......................................... .................................. 49
Saran untuk Penelitian Lebih Lanjut. .................................................. .........
50 Kesimpulan ....................................... .................................................. ........
51
LAMPIRAN ........................................ .................................................. ..................... 52
A. SURAT PROPOSAL DAN RINGKASAN STUDI .................... ...... 53
B. BENTUK
PERSETUJUAN ........................................... ................................................ 56
C Garis Besar PROGRAM PENDIDIKAN ............................................... .. 63
D. SKALA SESI ........................................... ................................................ 65
E ALAT PENGUMPULAN KOLEKSI DATA ............................................. ....... 67
F. DECETITUS ULCER PRETEST DAN POSTTEST ..............................

69Diproduksi
dengan izin dari pemilik hak cipta. Reproduksi lebih lanjut dilarang tanpa izin.
DAFTAR
PUSTAKA
v
i
TABEL
TABEL Halaman
1. Klasifikasi dan Tahapan Pembentukan Ulkus Dekubitus ............................ 14
2. Distribusi Frekuensi Pasien Menurut Usia .................................. 41
3. Distribusi Frekuensi Pasien Menurut Jenis Kelamin ...... ....................... 41
4. Pola Kepegawaian di Fasilitas Studi ................... ............................................... 47

vii
BAB 1
PENDAHULUAN
Dalam bab ini, diskusi akan fokus pada ulkus dekubitus,kesehatan kritis yang
masalah perawatanmempengaruhi lansia di Amerika Serikat, misalnya, kualitas perawatan yang
ditawarkan di fasilitas perawatan jangka panjang, masalah yang dihadapi oleh penghuni fasilitas
ini. , dan
persiapan khusus staf perawat untuk menangani kondisi umum
ulkus dekubitus pada populasi ini. Lansia (didefinisikan sebagai pria dan wanita di atas 65
tahun) saat ini merupakan 10% dari populasi, dan proyeksi menunjukkan bahwa pada
tahun 2040, segmen ini akan terdiri dari 20% dari total populasi (Dacey & Travers,
1991; Spillman & Lubitz , 2000). Menanggapi fakta ini, dan kebutuhan tersirat untuk
peningkatan jumlah pasien yang membutuhkan perawatan geriatri, perawat praktik lanjut (yang
berpendidikan di tingkat master) memilih untuk pelatihan sebagai praktisi perawat geriatri untuk
memberikan perawatan kepada pasien usia lanjut ini. Perawat praktik lanjut ini dilatih untuk
menanggapi peningkatan risiko penyakit kronis pada populasi lansia, dan
kebutuhan terkait untuk dukungan fisik, psikologis, dan sosial.

Ulkus Decubitus
Decumbere adalah kata Latin, yang berarti “berbaring,” dari mana istilah
decubitus berasal. Istilah ini pertama kali digunakan oleh Hilanaus pada 1590 (Guggisberg,
Terumalai, Carron, & Rapin, 1992), dan masih umum digunakan lebih dari 400 tahun
kemudian.
Kasus-kasus pasien yang mengalamitekan ulkus, ulkus dekubitus, atau tempat tidur
luka pada(sinonim untuk luka yang timbul akibat tekanan dan geser kulit) sering
disebut sebagai indikator kurangnya kualitas perawatan pasien. Luka ini ditemukan terutama
pada
pasien dengan mobilitas terganggu, dan orang tua berisiko tinggi untukini
kondisi. Ulkus adalah luka yang disebabkan oleh kerusakan kulit atau selaput lendir,
yang dapat terjadi sehubungan dengan sejumlah penyakit kronis. Luka ini
berkembang di area yang tergantung pada tubuh, misalnya sakrum, iskium, trokanter,
dan tumit. Ada peningkatan insiden ulkus dekubitus pada lansia yang
tinggal di fasilitas perawatan jangka panjang (Lyder, 2003; Yarkony, 1994). Lyder dan Yarkony
mencatat bahwa pasien dengan dekubitus cenderung memiliki masalah kesehatan yang
membahayakan lainnya,
misalnya, imobilitas, asupan gizi yang buruk, infeksi, dan masalah mengunyah.
Semua masalah ini, jika tidak diselesaikan, berkontribusi pada pengembangandekubitus
ulkus. Bergantung pada tingkat keparahan atau stadium sakitnya, perawatan untukdekubitus
bisulbisa mahal dan berkepanjangan (National Pressure Ulcer Advisory Panel
[NPUAP], 1989).Patofisiologi dan Faktor Risiko untuk Ulkus Dekubitus
Mereka yang berisiko paling besar untuk ulkus dekubitus adalahcacat, inkontinensia, dan lanjut
usia
pasien. Pasien dengan penyakit kronis seperti edema, demensia, malnutrisi, dan
inkontinensia juga berisiko lebih tinggi. Ketika integritas kulit terganggu,
individu berisiko mengalami infeksi dan kerusakan jaringan lebih lanjut. Orang tuamungkin
jugamemiliki turgor kulit buruk, faktor yang akan membuat mereka lebih cenderung untuk
bisul tekanan. Tekanan muncul ketika seorang pasien tetap berada di permukaan yang keras.
tanpa mengubah posisi. Geser kulit disebabkan oleh pasien ditarik secara
tidak benar ke posisi yang berbeda tanpa drawsheets atau dengandigunakan

secara tidak benar
drawsheets yang(McCance & Huether,

2001).
Luka timbul sebagai akibat dari tekanan pada tonjolan tulang selama
berjam-jam, yang
akan mendistorsi kapiler dan menyumbat aliran darah ke tertentu daerah. Ketika
daerah
tersebut tidak hilang setelah beberapa jam, kapiler kemudian mengganggu

danplatelet
agregasiterjadi yang menyebabkan trombi kecil untuk menghalangi aliran darah. Ini
menyebabkan
nekrosis, karena darah dan oksigen tidak dapat mencapai jaringan dan
menjalankan
fungsinya (Lyder, 2003; McCance & Huether, 2001).
Sebuah penelitian dilakukan yang melibatkan 150 pasien berusia di atas

65 tahun, tinggal di
fasilitas keperawatan, yang didiagnosis dengan ulkus dekubitus. Tujuannya adalah

untuk
mengidentifikasi alasan pasien ini mengembangkan bisul dekubitus. Para peneliti

melaporkan
banyak alasan berbeda terkait dengan perkembangan ulkus tekan pada subjek,
termasuk
kemampuan fungsional yang berkurang, asupan makanan yang buruk, masalah

mengunyah, kadarserum yang kurang
albumindengan hidrasi dalam batas normal, dan kadar kolesterol yang rendah.
Disimpulkanbahwa hilangnya kemampuan untuk menyelesaikan aktivitas kehidupan

sehari-hari tanpa bantuan
dan malnutrisi pasien lanjut usia merupakan faktor risiko tinggi untuk
pengembangan
decubitus ulcers (Gilmore, Robinson, Posthauer, & Raymond, 1995).
Penelitian lain dilakukan untuk membangun hubungan antaradekubitus
ulkusdan perkembangan infeksi pada subjek usia lanjut. Studi internasional ini
dilakukan di dua fasilitas perawatan jangka panjang besar di Kanada.
Dilaporkan bahwa
organisme, termasuk anaerob, dan bakteri lain yang berpotensi patogen
tumbuh pada kultur situs dekubitus (Nicolle et al., 1994). Ada sejumlah besar
informasi yang melaporkan kejadian dan penyebab utama ulkus dekubitus di
fasilitas perawatan jangka panjang.
Praktisi perawat Geriatrik (GNP), dengan pelatihan khusus pascasarjana dan
pendidikan perawatan kesehatan untuk lansia, adalah para perawat yang profesionalpaling cocok
untuk merawat
populasi ini. Perawat ini dilatih untuk mengelola, mendiagnosis, dan mengobati penyakit kronis
dan
akut, sambil memenuhi kebutuhan klien lansia di bidang medis, sosial, dan
fungsional. Mereka memberikan perawatan dalam pengaturan yang berbeda, misalnya, rawat
pengaturanjalan,klinik rawat jalan, HMO, perawatan kesehatan di rumah, rumah sakit,

danperawatan jangka
fasilitaspanjang,seperti rumah jompo (Cora, Duquette, & Resnick, 2002). Meskipun ada
informasi yang dilaporkan terbatas tersedia pada ruang lingkup praktik GNP terkait dengan
perawatan di rumah jompo, GNP adalah bagian penting dari tenaga kerja yang memberikan
perawatan kepada
orang tua di lingkungan rumah.
Menurut Eliopoulos (1990), orang yang dilahirkan pada tahun 1986 dan setelahnya akan
mungkinhidup 27 tahun lebih lama daripada yang dilahirkan pada awal 1900-an. Penulis
menegaskan
orang berusia 75 dan lebih tua adalah segmen populasi yang tumbuh paling cepat.
Tingkat lansia yang menikah berbeda menurut jenis kelamin, dengan 79% pria lansia yang
menikah
dibandingkan dengan 40% wanita lansia. Ada rasio yang dilaporkan dari 3 wanita lansia
untuk setiap 2 pria lanjut usia (lebih dari 65 tahun) dan ini diperkirakan akan meningkat selama
dekade berikutnya (Arias, 2002). Banyak wanita tua bergantung pada suami mereka untuk
memimpin dalam urusan sehari-hari, seperti penggunaan pendapatan dankeuangan
dukungan, perbaikan rumah, dan transportasi. Dengan kematian pasangan mereka, dan
berkurangnya mereka keuangan basis, paralanjut usia ini wanita paling sering tidak dapat memenuhi
kebutuhan mereka, dan karena itu mungkin menemukan diri mereka berada pada posisi yang
sangat tidak menguntungkan secara finansial
(Eliopoulos; Mitka, 2002). Ketika ini terjadi, orang tua dapat mencari dukungan dari
anak-anak mereka yang menghadapi peningkatan pengasuhan anak dankeluarga lainnya
tanggung jawab. Meningkatnya masalah medis menambah masalah biaya hidup yang
dihadapi oleh para lansia, yang membutuhkan peningkatan perawatan dengan sumber daya yang
semakin menipis.umum
Jalan keluardari situasi ini adalah pelembagaan; dengan demikian, sekitar 5% lansia berakhir
sebagai
penghuni di panti jompo untuk perawatan masalah medis. Menurut Yang, Norton,
dan Steams (2003) dan Yoshikawa, Cobbs, dan Brummel-Smith (1990), lansia yang
tinggal di panti jompo berada pada risiko yang meningkat untuk hasil kesehatan negatif termasuk
masa hidup yang lebih pendek.
Perawatan dan Tantangan Jangka Panjang
Rumah jompo telah menjadi bagian utama dari industri kesehatan; sekitar 1,7
juta orang dewasa adalah penghuni panti jompo di Amerika Serikat. Meskipun ini
hanya mewakili 5% dari semua orang yang berusia 65 tahun ke atas, gambaran yang lebih benar
tentang tingkat
perawatan yang diberikan di panti jompo diperoleh ketika orang menganggap bahwa orang lanjut
usia
memiliki peluang 40% untuk dirawat di panti jompo setidaknya sekali selama
tahun-tahun menurun mereka (Yang et al., 2003; Yoshikawa et al., 1990).
Tuntutan dan tantangan utama yang dihadapi oleh dokter dan penyedia layanan kesehatan lainnya
untuk lansia termasuk berusaha menggabungkan kantor layanan rawat jalan
praktikdengan praktik kelembagaan panti jompo. Meskipun dokter harus mengakui
pasiendan melakukan 30 hari tindak lanjut kunjungan awal, praktisi asosiasi sering
5
digunakan (misalnya, asisten dokter dan perawat praktik lanjut) untuk melakukanrutin
kunjungandan mengevaluasi pasien dengan masalah akut (Yoshikawa et al., 1990).lanjutan
Perawat praktiktelah memainkan peran penting dalam penyediaan perawatan bagi pasien yang
tinggal
di panti jompo; Namun, dampak, kekuatan, dan asuhan keperawatan semakin
menurun di panti jompo karena pandangan pengusaha tentang keperawatan sebagai

menguntungkan
investasi yang. Pemilik panti jompo sering menerapkan anggaran, menggunakanbisnis
konsepbiaya per unit atau biaya per pasien. Konsep-konsep ini, dikembangkan tanpa
masukan perawat, diterapkan, yang berdampak pada penyediaan perawatan dan kualitas
perawatan
untuk lansia yang tinggal di panti jompo (Eliopoulos, 1990; Yang et al., 2003).
Saat ini, industri perawatan di rumah jompo dijalankan sebagai bisnis, menerapkan
konsep bisnis, mencari keuntungan sebagai garis bawah; untuk melakukan itu,
diperlukan anggaran. Staf umum panti jompo terdiri dariMedis
Direktur, Administrator, Direktur Perawat, Perawat Terdaftar (RN),Berlisensi
Perawat Kejuruan(LVN), dan Asisten Perawat Bersertifikat (CNA). Tigakemudian
anggota staf perawatbiasanya terlibat dalam perawatan sehari-hari pasien.yang
OfRNs rasiodibutuhkan, LVNs, dan CNA untuk jumlah pasien didirikan oleh
pemerintahfederal dan negara bagian California (Koalisi Warga Nasional untuk
Nursing Home Reformasi [NCCNHR], 1999). Karena banyak faktor, termasuk
beban kerja, gaji, dan tuntutan staf, ada masalah dengan penempatan staf-ini secara
lembagalembagatepat, dan itu berdampak negatif pada kualitas perawatan (Alexander,
2002; Ruppe, 2001; Yarkony, 1994).
Penilaian Kulit Integritas
Para ahli telah mengembangkan metode untuk menilai integritas kulit dan kerusakan,
untuk mengklasifikasikan tingkat keparahan atau stadium dari ulkus tekanan. Ada empat
tahappenekan
ulkus, dan tahap yang paling sedikit menyebabkan kerusakan pada kulit adalah tahap 1. Pada
tahap ini,
ada kemerahan yang tidak dapat terbakar pada kulit, sementara kulit tetap utuh. Tahap kedua
melibatkan hilangnya sebagian ketebalan kulit. Pada tahap ketiga, kehilangan kulit telah
meluas ke nekrosis, jauh ke dalam fasia. Tahap terakhir , atau tahap 4, melibatkan
kerusakan paling parah pada kulit, dan kerusakan jaringan. Ada nekrosis melalui
otot, tulang, dan struktur pendukung; dengan demikian, stadium 4 sangat menyakitkan (McCance
&
Huether, 2001). Tergantung pada tahap dekubitis, perawatannya bisa sangat
mahal. Yarkony (1994) menegaskan hingga 25% dari pasien di fasilitas perawatan jangka panjang
mengalami dekubitus.
Pencegahan
Pencegahan adalah pendekatan terbaik untuk menangani borok tekan, dan metode yang paling
efektif untuk perawatan. Metode pencegahan dimulai dengan mengenali pasien yang
berisiko dan termasuk identifikasi riwayat medis pasien dan penyakit saat ini
yang mungkin menempatkan mereka pada risiko (Shenaq & Dinh, 1990). Jika pasien harus
mengembangkan
tukak, penilaian lengkap dan dokumentasi untuk integritas dan risiko kulit,
tahap, area, apakah ulkus itu terjadi kembali, dan hasil kultur dimasukkan dalam
prosedur keperawatan standar. Setelah penilaian ini, keputusan dapat diambil untuk
perawatan yang sesuai (Hefley & Radcliffe, 1990; Rosenberg, 2002).sesuai
Perawatan yangtermasuk studi histopatologi pasien dan perbandingan dengan
ulkus kelompoklain untuk mengevaluasi solusi yang paling efektif untuk masalah tersebut (Vande
Berg
& Rudolph, 1995).
Pertanyaan Penelitian
Menurut Politic and Hungler (1995), pertanyaan penelitian adalah pertanyaan utama atau
pengontrol yang ingin dijawab seseorang dalam melakukan penelitian penelitian.
Pertanyaan penelitian berikut akan dijawab: Apakahpencegahan dekubitus

program pendidikan keperawatanyang dipresentasikan kepada staf keperawatan yang tidak
berlisensi akan mengurangi insiden
ulkus dekubitus pada pasien yang tinggal di fasilitas perawatan jangka panjang?
Signifikansi Masalah
Penelitian ini adalah penting untuk praktik keperawatan geriatri lanjut, karena
prevalensi ulkus dekubitus pada populasi geriatri yang tinggal diperawatan jangka panjang
fasilitasdan meningkatnya biaya untuk perawatan. Insiden mendukung kebutuhan besar
untuk pemeriksaan lebih dekat dari masalah ini (Campbell, 1997). Healthy People 2000 telah
menetapkan banyak tujuan bagi populasi AS untuk menjadi lebih kuat dan lebih sehat (Me
Ginnis & Lee, 1995). Tujuan utamanya adalah meningkatkan proporsi orang Amerika yang
akan hidup lebih lama dan lebih sehat dengan kualitas hidup. Salah satu tujuan kesehatan
masyarakat yang
diterapkan adalah pencegahan penyakit dan promosi kesehatan sebagai prioritas tinggi. Upaya ini
akan membutuhkan dukungan keluarga, komunitas, ilmu kedokteran, danperawatan medis
profesional(Allukian, 1993). Upaya yang efektif termasuk memberantas infeksi,
membalikkan jalannya beberapa penyakit kronis, dan meningkatkan kemampuan klien untuk
berfungsi di mana ada keterbatasan. Promosi kesehatan, perlindungan kesehatan, danpenyakit
pencegahanadalah fokus Presiden Bush dalam pidatonya di tahun 2003 bagi negara. Allukian
8
menegaskan kualitas layanan harus ditingkatkan melalui pengembangan dan
pembaruan
standar praktik, protokol, dan pedoman. Dia menyatakan studi lebih lanjut diperlukan
untuk
meningkatkan dan memastikan standar-standar ini diikuti. Ulkus dekubitus pada

pasien dengan
penyakit kronis adalah masalah penting untuk evaluasi karena hubungannya

dengan
penurunan kesehatan dan meningkatnya jumlah lansia.
Tujuan Penelitian
Tujuan
dari penelitian ini adalah untuk mengeksplorasi pengaruh pendidikan

terhadap staf keperawatan
di bidang pencegahan dan kejadian dekubitus pada subjek usia lanjut yang berada di
panti jompo.
Kesimpula
n
Bab ini mencakup diskusi tentang evaluasi masalahtekanan
perkembangansakit di antara klien lansia yang menerima perawatan saat

penghuni panti
jompo. Meningkatnya jumlah lansia dalam populasi yang tinggal di panti jompo
tanpa langkah-langkah pencegahan ulkus dekubitus menyebabkan biaya

perawatan meningkat.
Studi yang berbicara tentang pentingnya dan pentingnya penelitian untuk
praktik lanjut perawat geriatrik digambarkan. Pertanyaan penelitian untuk dijawab

dan
tujuan penelitian dipresentasikan.
BAB 2
TINJAUAN PUSTAKA
Sebuah survei studi penelitian yang berhubungan dengan ulkus dekubitus disajikan dengan
tiga fokus utama: (1) studi yang melaporkan kejadian ulkus dekubitus dijangka panjang
fasilitas perawatandan metode pengobatan, (2) studi penelitian yang menggambarkan biaya
perawatanulkus dekubitus dan efek ekonomi pada perawatan kesehatan, dan (3) studi yang
menguji pengaruh program pendidikan terhadap kejadian ulkus dekubitus pada
populasilanjut usia.
Di Amerika Serikat, banyak populasi lansia (orang berusia 60 tahun ke

atas) tinggal di fasilitas perawatan jangka panjang karena berbagai alasan; Namun, ketika mereka
berada di tempat tinggal, telah ditetapkan bahwa mereka biasanya rentan terhadap
banyakkesehatan yang
masalahterkait dengan pelembagaan - salah satu masalah kesehatan yang lebih umum adalah
ulkus dekubitus. Setiap tahun, biaya perawatan untuk ulkus dekubitus total sekitar
$ 1,3 miliar, dan banyak peneliti menyatakan bahwa implementasi yang tepat dariefektif
pencegahan dan strategi pengobatan dekubitus yangdapat secara signifikan mengurangi biaya ini
(Erwin, 1995). Komponen utama biaya, yang harus diperhitungkan dansecara luas
dipertimbangkan, adalah peningkatan waktu dan upaya oleh staf, dan tekanan yang dihasilkan
untuk
klien dan staf keperawatan. Biaya rumah sakit rata-rata untuk setiap pasien yang didiagnosis
dengan
tukak lambung diperkirakan sekitar $ 22.000 per tahun, selama kurang dari 20 hari
perawatan (NPUAP, 1989; Yang et al., 2003).
10
Perawatan Jangka Panjang
Sebuah studi 2 tahun (Januari 1999-Januari 2001), dilaporkan oleh minoritas stafdari
Divisi Investigasi KhususPemerintah Gedung Reformasi Komite,
melaporkan bahwa 30% dari panti jompo di Amerika Serikat dikutip untuk hampir 9.000
contoh pelecehan. Masalah utama pasien termasuk ulkus tekan yang tidak diobati,
perawatan medis yang tidak memadai, kekurangan gizi, dehidrasi, kecelakaan yang dapat
dicegah,tidak memadai
sanitasi yang, dan kebersihan. Dalam beberapa kasus, terjadinya pelecehan fisik dan seksual
memperburuk penyimpangan profesionalisme yang sudah serius, menyoroti perlunya
tindakan perbaikan yang mendesak dan komprehensif. Kekhawatiran utama yang diungkapkan
adalahini
fasilitasmenerima dana federal; dengan demikian, survei tahunan dibangun dan
spekulasi adalah bahwa tanpa survei ini, lebih banyak pelecehan tidak dilaporkan. Industri
panti jompo menyatakan masalah yang dilaporkan adalah karena kurangnya dana
(Ruppe, 2001).
Peran Praktisi Perawat Geriatrik (GNF)
Tinjauan literatur menemukan informasi yang dilaporkan terbatas mengenai peran
praktisi perawat lanjut usia (GNP) dalam fasilitas perawatan jangka panjang.
Namun, Karlin, Schneider, dan Pepper (2002) melaporkan penelitian yang melibatkan 36 GNP
yang memunculkan motivasi mereka untuk memilih bidang praktik ini, umur panjang
layanan mereka, dan negara afektif. Subjek penelitian adalah GNP yang tinggal di
Colorado atau Massachusetts dan dipekerjakan di fasilitas perawatan jangka panjang. Sebuah
survei
dilakukan dengan pertanyaan berdasarkan faktor-faktor yang berkaitan dengan kepuasan mereka
danutama
penghalanguntuk berlatih. Selain ini, Profil Moods Amerika diberikan
11
untuk mengukur suasana hati setiap subjek. Para penulis melaporkanyang paling
memuaskan pengalaman
dilansir GNPs adalah karena ekspresi penghargaan dari pasien danmereka.
keluarga Penangkal utama diidentifikasi sebagaitidak mencukupi staf yang dan

rekan-rekan dengan
citra negatif tentang fasilitas perawatan jangka

panjang.
Karlin et al. (2002) mencatat dampak berbagai faktor stres yang terjadi
dalam
proses upaya untuk memenuhi kebutuhan lansia dalam perawatan jangka panjang,
dan merupakan
pencegah utama terhadap retensi GNP dalam pengaturan perawatan jangka panjang.
Banyak pasien dalam
perawatan jangka panjang dengan luka tidak menerima perawatan yang tepat;
ini disebabkan oleh
kurangnya profesional kesehatan dengan keahlian dalam pengelolaan luka.
Gardner et al. (2001), dalam sebuah penelitian yang meneliti hubungan

antarakronis
penilaian lukadan telemedicine, telekomunikasi menegaskan bisa menjadi
jawabannya. Dalam penelitian mereka, sampel adalah 13 pengamatan luka

berpasangan.luka
Penilaiandilakukan melalui interaktif, telekomunikasi video dan dibandingkan

dengan
penilaian luka in-person ahli perawat untuk memeriksa perbedaan dalamakurat
penilaian yang, jika ada. Subjek berusia 62-82 tahun, dan meskipun 22luka
penilaianbenar-benar selesai, rekaman VHS menghasilkan hilangnya 9

penilaian. Secara keseluruhan, perjanjian 75% tercapai, dan perawat fasilitas dapat
memperkuat penilaian dan strategi pengobatan.
Penilaian
Sebuah studi yang mengeksplorasi waktu pemulihan aliran darah setelah

pengurangan tekanan dan
hubungannya dengan kerentanan pasien dilakukan dengan melibatkan 109 lansia

yang tinggal di panti jompo
. Waktu pemulihan aliran darah diukur menggunakan tekanan, suhu,
12
dan metode waktu (PTT). Prosedur ini melibatkan 10 menit tekanan tes stimulus
dan indeks tekanan yang digunakan untuk mengukur intensitas, durasi tekanan, dangeser
gayayang pasien terkena. Ditemukan bahwaaliran darah
waktu pemulihandan indeks tekanan berkorelasi dengan risiko mengembangkan dekubitus.
Dengan demikian, waktu pemulihan aliran darah bisa menjadi alat yang dapat diandalkan untuk
menguji kerentanan terhadap
dekubitus (Meijer, Germs, Schneider, & Ribbe, 1994). Dalam sebuah survei besar paraduka
direktur rumah, dilaporkan bahwa 24% orang yang meninggal memiliki setidaknyatahap 1
ulkus penekan, dengan tahap 2 ditemukan pada lebih dari tiga perempat dari kasus ini (Eckman,
1989). Yoshikawa et al. (1990) menegaskan bahwa jelas bahwa biaya akhir dari
perawatan yang tidak efektif untuk ulkus dekubitus untuk alasan apa pun adalah
kemungkinanpasien
kematian. “Di antara penghuni panti jompo yang gagal menyembuhkan ulkus dalam waktu 6
bulan, mortalitasnya enam kali lebih tinggi.”
Klasifikasi ulkus yang berbeda telah digunakan dalam penilaian pasien; Namun,
klasifikasi berikut saat ini lazim. Ada tigaditerima secara luas yang
kriteria yangdigunakan untuk mengklasifikasikan tahapan borok. Table 1 describes the

classifications, and
the stages of decubitus ulcer formulation correspond to tissue layers. The first stage
consists of skin redness that disappears on pressure; the skin and underlying tissues are
still soft. In the second stage, the skin shows redness, edema, and induration, at times
with epidermal blistering or desquamation. In the third stage, the skin becomes
necrotic, with exposure of the subcutaneous tissue but not to the fascia. In the fourth
stage, necrosis extends through the skin and fat to muscle; bone destruction begins,
13
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
TABLE 1. Classifications and Stages of Decubitus Ulcer Formation
Stage Description
Stage 1 Nonblanchable erythema of intact skin the heralding lesion of skin

ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or
hardness may be indicators.
Stage 2 Partial thickness skin loss involving epidermis, dermis, or both. The
ulcer is superficial and presents clinically as an abrasion, blister, or shallow center.
Stage 3 Full thickness skin loss involving damage to or necrosis of

subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents
clinically as a deep crater with or without undermining of adjacent tissue.
Stage 4 Full thickness skin loss with extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures (eg, tendon, joint capsule).
Note. Source: Agency for Health Care Policy and Research (1992).
14
with periosteitis and osteitis, progressing finally to osteomyelitis, with the possibility
of septic arthritis, pathologic fracture, and septicemia.

A study to explore treatment of elderly with decubitus ulcers at stage 3 focused
on 15 intensive care units and skilled nursing facilities located in urban areas; the
approximate census was 1,300 patients. Instructions for completion of the survey
were sent to each facility and monthly reports were rendered. The facilities reported
decubitus ulcers ranging in severity from stage 1 to stage 3. Estimates of patients with
decubitus ulcers were almost 25% in nursing homes. The most common sites were the
sacrum, ischium, trochanters, ankles, and heels (Yarkony, 1994). Nutritional intake,
mental state, mobility incontinence, contributing diagnoses, decubitus sizes and
locations, recurrence of decubiti sites, stages, dates healed, cultures taken and
reported, and treatments given for each subject were reported. It was reported that
establishing a standardization of treatment was impractical due to the variety and
combinations of treatments (Hefley & Radcliffe, 1990).
A classic longitudinal study to determine risk factors associated with the
development of stage 2-4 decubitus was reported in 1994. Subjects included patients
from 78 National Health Corps nursing homes with a total of 4,232 patients free of
decubitus on admission and at a 3-month follow-up. All issues pertaining to the
patient on record were evaluated for up to 21 months. Significant factors related to
stage 4 decubitus ulcers were divided into high and low incidence nursing home
categories. For the high incidence nursing homes, ambulation difficulty, fecal
incontinence, diabetes mellitus, and difficulty feeding one's self were factors related to
1
5
decubitus care. In the low incidence nursing homes, ambulation difficulty, feeding
one's self, and male gender were factors promoting development of decubitus ulcers at
stage 2 (Brandeis, Ooi, Hossain, Morris, & Lipsitz, 1994).
Additional Assessment of Decubitus Ulcers
Due to the increasing incidence of pressure ulcers and their impact on patients,
many risk assessment scales have been created for use by advanced practice nurses in
provision of care; however, they lack some important risk factors. Rosenberg (2002)
asserted, in addition, the current risk factors should include the following:
1. Patient and caregiver knowledge of the complexity of pressure ulcers so
proper skin care is considered a top priority in the prevention of pressure ulcers.
2. Knowledge and understanding of available risk scales and written material
on prevention must be available.
3. Patient and caregiver attitudes regarding prevention of pressure ulcers must
be assessed.
In order to assess these risk factors, in addition to the others, a Checklist for
Pressure Ulcer Prevention was developed by Rosenberg (2002). The checklist
consisted of patient physiological assessment, prevention strategies, caregiver

knowledge assessment, patient knowledge assessment, implications for practice, and
research.
Nutritional Factors Related to Decubitus Ulcers
In a study to identify clinical indicators associated with unintentional weight
loss and the relationship to decubitus ulcers in elderly residents of nursing facilities, a
16
total of 290 medical records and 265 patients with pressure ulcers were reviewed.
Two instruments were used to collect data, and indicators for the instruments were
specifically chosen to monitor clinical conditions for these two populations. There
were 24 indicators identified for unintentional weight loss, and those found to occur
most often were: reduced functional ability, intake of 50% of food or less, chewing
problems, and serum albumin levels less than 35g/l with normal hydration status. The
most frequent indicator for decubitus ulcers was those subjects with albumin levels
less than 35g/l with normal hydration status. Gilmore et al. (1995) used
documentation in the medical record as the valid indicator for both diagnoses. It was
reported that inappropriate dietary intake, disease, and disability increased the risk of
patients developing malnutrition and decubitus ulcers in long-term care facilities.
Incidence
Nicolle et al. (1994), in a prospective study of two long-term care facilities,
reported a prevalence initially of 2.6% and 1.6% decubitus ulcers in the elderly
population at the facility. These numbers occurred with an incidence of 3.4 and 4.8
decubitus ulcers per 100,000 resident days, respectively. An incidence of ulcer
infection was found to be 0.4 ulcers per 1,000 days. Surface swabs of the ulcers
produced 2.4% organisms, 14% anaerobes were isolated, 30% bacteria was isolated
from aspirations, and two-thirds of the organisms isolated were potentially pathogenic.
In a cohort study reported by Bergstrom, Braden, Kemp, Champagne, and
Ruby (1996), involving two skilled nursing homes, two tertiary hospitals, and two
Veteran Administration Medical Centers, 843 randomly selected patients (63% male,
1
7
79% White, with a mean age of 63 [+/-16 years]) participated in the study. This study
was conducted to describe the incidence of decubitus ulcers in different populations
and determine whether age, gender, and race were factors related to development of
decubitus ulcers. Complete assessments were done for decubitus, recording the site
and stage of ulcer sores using the Braden scale for predicting pressure sore risk.
Demographic characteristics, primary diagnosis, and preventative interventions were

also documented. For a maximum of 4 weeks, every 48-72 hours, clinical
observations were recorded. A total of 108 subjects developed decubitus ulcers from
the population of participants. Of the 108 subjects, the incidence reported was 8.5% in
the tertiary hospitals, 7.4% in the Veteran Administration Medical Centers, and 23.9%
in nursing homes. It was reported that lower Braden scale scores, older age, and
White race were related to decubitus ulcers. This finding supported the importance of
risk assessments as the basis of prescriptive decisions.
Ferrell, Artinian, and Sessing (1995) reported a study to evaluate the
effectiveness of a new observational tool and the Sessing scale to measure the
progression of decubitus ulcers, using the cohort sample method. The subjects
included 84 nursing home residents with decubitus ulcers. Strong relationships were
identified between changes in healing and changes in ulcer diameter measured by the
Sessing and Shea scale (p < .05). Reliability of both scales was reported with 50 of
the subjects. The Sessing scale was found to be simple to use and its indicators, for
example, granulation of tissue, drainage, and other factors, were reported as important
to researchers as the Shea stage or ulcer size. 18
The focus of this study was to examine the effectiveness of an educational
program on the incidence of decubiti in nursing home patients. Leshem and Skeiskey
(1994) examined the effectiveness of an educational program in a longitudinal study,
following patients in a long-term care facility for a period of 4 years. They reported
about 3.4% patients in the long-term care facility developed decubitus while 20% of
patients with decubitus ulcers were from acute care facilities. It was also reported that
59.7% of pressure ulcers in acute care facilities were assessed as stage 3 and 4, while
83% of decubitus ulcers found in patients from long-term care facilities were stage 1
and 2. Due to protocols for quality management, prevalence rates decreased from 7%
to 4% (Leshem & Skeiskey).Cost of Decubitus Ulcer Care
A retrospective research study to determine costs of decubitus ulcer treatment
was reported. The study was conducted in an 830-bed long-term care facility that
reported 81 patients with decubitus ulcers. The study examined decubitus ulcers and
treatment over a 1-year period following an established researched skin protocol. It
was reported that, over a year, the total cost of care was $30,079 per patient. Of this
cost, the original cost was $5.3 5/pressure ulcer/day and with implementation of the
skin protocol, cost of decubitus care was reduced to $3.74/pressure ulcer/day (Frantz,
Bergquist, & Specht, 1995).
Lyder (2003) stated there was an estimated 1.3 million to 3 million adults with
pressure ulcers in the United States, and the cost for each ulcer to heal was estimated
to be between $500 to $40,000 per person, dependent upon severity of the ulcer. The
19
incidence of decubitus ulcers in the clinical settings was approximately 38% in the
acute care hospitals, 23.9% in the long-term care facilities, and 17% of those receiving
in home care. It was stated that health professionals are aware that prevention is the
best answer; however, with the multiple indicators of risk and various assessment
tools, no one preventative measure has been evaluated or reported as a “best practice.”
It has been reported and substantiated that pressure ulcers develop from pressure to
sensitive areas of the body. Lyder stated use of support surfaces, optimal nutrition,
integration of adjunctive therapies to assist in wound healing, and surgery were
methods to manage wounds; however, it would be better for the economy to use valid
preventative programs as an intervention method.
Education as an Effective Intervention Measure
An 8-month prospective study was done to evaluate the effects of a
comprehensive pressure ulcer prevention program. This study involved 241 subjects,
who were residents of a 125-bed nursing home at the time the study began, or were
admitted during the study period. Assessments were completed on all the residents
over a 2-month period. The Agency for Health Care Policy and Research's (AHCPR)
guideline for pressure ulcers was used after staff education and the 2-month evaluation
of the patients. After the educational program was instituted, the incidence of pressure
ulcers in the patients decreased significantly. A cost analysis showed savings of
$230,000 for the prevention program versus treatment. This study concluded this
program, when used in long-term care facilities, reduced the cost of care and
decreased patients suffering with decubitus ulcers (Regan, Byers, & Mayrovitz, 1995).
20
Moody et al. (1988) conducted a study to test the hypothesis that an
educational program without new technology could have positive results, defined as
higher quality care and lower cost. The program was developed by a skin care team
consisting of physicians and nurses. The sample included 123 elderly patients; of this
number, 18 had decubitus after admission before the educational program was
instituted. After the program, a cohort sample, consisting of 105 patients, was
assessed; the results revealed 6 patients with decubitus. The stage or severity of the
decubitus was not rated. This study also reported a cost savings of $74,372. There are
many reported studies which examined the issue of decubitus ulcers with range from
susceptibility to treatment of decubitus ulcers. Xakellis, Frantz, and Lewis (1995)
conducted a study over a 3-month period to evaluate the cost of prevention and
intervention of decubitus ulcers. The subjects were 539 war veterans; 83% were male.
The results indicated that with diagnoses such as chronic obstructive pulmonary
disease (COPD), stroke, dementia, diabetes, heart disease, and para/quadriplegic the
risk factors for decubitus was high, requiring high cost interventions. During the
study, 8 of the subjects did obtain decubitus. A total of $132,114 was used and 97%
of the cost was found to be spent on 30% of the subjects. Also reported in the review
of literature that several complications may contribute to decubitus ulcers. Mekkes,
Loots, Van Der Wal, and Bos (2003), after conducting several research studies, noted
that 3-5% of the population over 65 years of age develop lower leg ulcerations. They
noted that some of the main causes were due to venous valve insufficiency, lower
21
extremity arterial disease, vasculitis, infection, and hypercoagulability. This stressed
the importance of proper risk assessment related to diagnosis.
Conclusion
In this chapter, a review select literature was reported that discussed the
problem of decubitus ulcers. According to the reported research studies, the best
approach to treatment of decubitus ulcers was prevention. As discussed in the studies,
the cost for treatment was high, as well as the incidence of decubitus occurring in the
elderly in nursing homes. The most tragic problem reported was the mortality rates of
patients with pressure ulcers.
Based on this literature review, it is evident that advanced practice nurses must
conduct research, educate, and assist in the prevention of this condition affecting the
elderly population residing in nursing homes. The reported study findings support the
efficacy of an educational program as a method to reduce the incidence of decubitus
ulcers. In addition, the reported studies support the need for educational programs
targeting acute care, long-term care, and in home care providers.
22
CHAPTER 3
THEORETICAL FRAMEWORK
The theoretical framework used in this study is Watson's care theory
developed in 1989. In this theory, the metaparadigm for nursing is concerned with
promoting and restoring health, and preventing illness. Advanced practice nurses use
the caring process to allow the patients to realize their inner strengths and self-healing
ability (Wesley, 1995). This theory allows the nurse to make sound nursing
judgements based on the use of the research process and the problem-solving
approach. In practice, this theory follows the same steps as scientific research
practice, which serves as the basis for the science of caring. These carative factors
include forming a humanistic-altruistic value system, instilling faith and hope,
cultivating sensitivity to oneself and to others, developing a helping-trust relationship,
and promoting expression of positive and negative feelings. Also involved are
systematically using the scientific problem-solving method for decision making,
promoting interpersonal teaching and learning, providing a supportive, protective, or
corrective mental, physical, sociocultural, and spiritual environment, assisting with
gratification of human needs, and, finally, allowing for existential-phenomenological
forces (Wesley).
This framework is appropriate to support this study due to its strong emphasis
on valuing the human being as a whole. It can be used with the nursing process to
2
3
guide practice and teaching to patients or staff, to change health practice behaviors.
The humanistic existentialist approach of this framework with the human being as its
central concern has been used widely in advanced practice nursing as a guide for
improving care, quality management, practice, and teaching. For the purposes of this
study, the framework was used for teaching nursing staff. Chipman (1991) described
the application of the caring theory as used to teach nursing students. The study
involved a Catholic school of nursing that changed its school curriculum to one based
on Watson's care theory. There were 26 second-year students who agreed to
participate. The purpose of the study was to clarify the meaning and purpose of the
caring theory in nursing practice. This qualitative study, “Caring: Its Meaning and
Place in the Practice ofNursing,” involved teaching the nursing students about the
Watson care theory and then collecting data the students identified as caring and
noncaring nursing behaviors. The results showed three areas of nursing behaviors
could be perceived as caring and giving of self, meeting patients' needs in a timely
fashion, and providing comfort measures for patients and their families (Chipman).
From (1995) reported a study involving RN students returning to college for
their BSN (Bachelor of Science in Nursing). This study was done in the home setting
where nursing students incorporated Watson's theory as a basis for their nursing
interventions with clients and families in the process of grieving. The purpose of this
clinical experience was to help students utilize the caring theory, when providing care
to patients and experiencing death in the home. From stated the students gained an
appreciation of the home setting, were able to acknowledge the dying process in the
24
home, feel comfortable with it, and were able to use the caring theory as a framework
for dealing with patient situations (From).
Application of Framework in This Study
In this study, the effect of education of staff in decubitus ulcers prevention and
incidence of decubitus ulcers was examined. Watson's caring theory was the
framework for this study and the application of the carative factors to practice was
explored.The first factor, forming a humanistic-altruiStic value system, involved
increasing staff capacity to view and appreciate the patient's individuality and
susceptibility to decubitus ulcers. After the educational program, the study assumed
the staff would have an increased appreciation for the importance of maintaining skin
integrity which served to focus their approach to include providing good pericare on
bladder and bowel incontinent clients, would turn clients every 2 hours for those that
were immobile, and change the sheets under the clients without pulling.
Factor 2, instilling faith and hope, involved teaching the staff to promote
wellness in their care to patients. After the program, the staff would not give
interventions only based upon the diagnoses, but they would use a holistic approach to
determine and meet the needs of the clients on all levels, for example, spiritual,
emotional, and physical needs.
Factor 3, cultivating sensitivity to oneself and to others, involved teaching the
staff to become self-aware and self-accepting to help their patients to follow the
example. The nurse would be more apt to pay attention to signs and symptoms of risk
25
factors of decubitus ulcers not only to educate the clients, but also their families,
friends, and the community at large.
Factor 4, developing a helping-trust relationship, in this study involved
teaching the staff to gain rapport with the patients, and allowed expression by the
patients of positive or negative outcomes of their decubitus. The popular saying
“knowledge is power” is relevant here as the clients would be involved in their plan of
care which means they were aware of their assessment, planning, interventions, and
ongoing evaluation of their decubitus ulcers.
Factor 5, promoting expression of positive and negative feelings, involved
teaching the staff to prepare the patient for negative as well as positive outcomes.
Staff were taught to look for changed behaviors that may result with better outcomes.
The staff would encourage the client-based outcomes of the healing potential. Signs
and symptoms of appropriate or inappropriate healing would be discussed and the

implications.
Factor 6, systematically using the scientific problem-solving method for
decision making, involved teaching the staff to decide on the treatment best for the
patient and if it was not effective, to try an alternative method of treatment. The
treatment that was chosen should be based upon many factors: the client's history
including physical, financial, and rehabilitation potential. The client, if possible,
should be involved at this level, for example, an egg crate mattress might be chosen
over the use of an air mattress. Reevaluation of any method would be appropriate
when outcomes were not met.
26
Factor 7, promoting interpersonal teaching-learning, involved teaching the
staff to identify early stages and institute measures to prevent further incidence of
decubitus. The program, using the team approach, allowed the staff on all levels to
notify their supervisor with any changes of skin status, for example, reporting the
occurrence of redness to prominent body sites in the client to the charge nurse who
then would obtain medical doctor orders for a topical ointment or treatment.
Factor 8, providing a supportive, protective, or corrective mental, physical,
sociocultural, and spiritual environment, involved teaching staffto acknowledge and

understand the patient's belief system, and use it to help promote healing of the person
as a whole. The staff would not consider the client as a decubitus problem, but a client
with needs involving many areas of his or her life, and allow the patient to feel
resolute with him or herself.
Factor 9, assisting with gratification of human needs, involved teaching the
staff to meet the patient's lower-order needs on the hierarchy of needs scale.
According to Wesley (1995), once basic needs are met, the patient has a better chance
for recovery. Maslow's hierarchy of needs states that if an individual has basic needs
such as hunger, thirst, security, and physical safety being met, the client can meet his
or her potential. According to Maslow, when the lower needs of the hierarchy are
fulfilled, then the higher needs can be met with socialization, such as belonging to a
group for clients with decubitus ulcers, and realizing that the ulcer should not be
viewed as the client identity, and the client is an individual with an ulcer, able to
express him or herself (Beck, Rawlins, & Williams, 1988).
27
Factor 10—the staff will now see the patient individually with all his or her
components coming together that makes him or her unique with his or her unique
healing process. Allowing for existential-phenomenological forces involves teaching

the staff to further understand the patient as a whole and relate his or her healing
process to his or her individuality (Wesley, 1995).
Assumptions
According to Polit and Hungler (1995), assumptions are theories that cannot be
tested but are presumed based upon relationships. The following assumptions apply to
the conduct of this study:
1) The staff will pay attention to the educational program about decubitus
prevention.
2) The staff will implement teaching strategies offered.
3) The staff have a basic knowledge about decubitus ulcers.
4) Record/charting will reflect accurate assessment of decubitus ulcers.
Limitations
The following will serve as limitations that will affect application of the
findings to a larger population. The study involves patients residing in two long-term
care facilities located in urban areas.
Definition of Terms
The following terms are unique to this study:
Decubitus Ulcers: Ischemic ulcers in normal skin as a result of pressure and
shearing forces (McCance & Huether, 2001).
28
Elderly: Men and women over 65 years old (Dacey & Travers, 1991).
Long-Term Care: A facility which provides care to patients, usually elderly,
who require skilled nursing care for a long period of time, sometimes till death
(Eliopoulos, 1990).
Nursing Staff: Persons that are involved in patient care—can include registered
nurses, nursing assistants, and licensed vocational nurses (Yang et al., 2003).
Topical Agents: A broad category of creams, lotions, and skin preparations
applied externally. Some topical agents may serve as moisture barriers, protecting the
skin from external sources of moisture (AHCPR, 1992).
Conclusion
In this study, Watson's caring theory was used to develop a decubitius
prevention educational program which would affect decubitus incidence. Application
of the different factors within the theory to this study assumes the staff had a focused
approach to skin care and treating each patient individually and holistically. The basic
parameters for the study applied to the caring theory were described. In addition,
variables limiting the ability of generalization were delineated.

29
CHAPTER 4
METHODOLOGY
In this chapter, the methodology and procedures used to conduct the study are
explained. The research design selection and justification thereof are discussed. The
independent and dependent variables are identified, and the sample selection and
setting for the study are delineated. Patients' consent and protection of rights are
addressed, and procedures and tools are defined and discussed in association with
validity and reliability of the tools used.Design
This study utilized a quantitative, quasi-experimental research design.
According to Polit and Hungler (1995), quantitative research is the method of using
numerical data and statistical findings to describe phenomena or to assess the extent
and reliability of the relationships among them. The educational program that was
implemented has been developed by the Agency for Health Care Policy and Research
(AHCPR) that consisted of a panel of nursing experts. The procedure of the study was
structured and evaluated utilizing statistical means.

Independent Variable
The independent variable, according to Polit and Hungler (1995), can be
defined as the treatment, action, or thing that is manipulated in a study to get desired
results. For this study, the independent variable is the educational program that will
30
be implemented for nursing staff. Other independent variables include the work
experience of the nursing staff socioeconomic status of patients, educational level of
staff and patients, and race and ethnicity of the cohort patient sample.
Dependent Variable
The dependent variable, according to Polit and Hungler (1995), is the result or
outcome of the study that is uncontrollable. For both groups participating in this
study, the dependent variable is the incidence and stages of decubitus ulcers in the
patient population 30 days after the program was presented to the staff. For the
nursing staff, in the educational program, the dependent variable is the difference
between the mean score on the competency test from the educational program at
pretest and posttest.
Intervening Variables
According to Polit and Hungler (1995), intervening variables are defined as

that element that occurs during the course of the study and is not part of the study, but
that affects the dependent variable. In this study, the intervening variables are the
elderly who may be discharged or leave the facility, and the preexisting physical
condition of the patients. The current treatment regimen in use at the facility for
decubitus may serve to reduce the severity of decubitus.
Sample Selection
In this study, the cohort sample was comprised of chart records of elderly
persons (ages 60 years and over). The sample included both men and women residing
in two long-term care facilities. The cohort sample included those patients with
31
decubitus ulcers rated stages 0 through 6 on the Sessing Scale and recorded in the
patient chart. According to Polit and Hungler (1995), a cohort sample may or may not
consist of the same members. This technique was necessary as some of the subjects in
the original sample may not be part of the final sample recorded 30 days after the
educational program. Persons with dementia or other psychological problems which
prevent their participation in the decubitus treatment regimen were excluded. Physical
condition of the clients and their diagnosis were not used as exclusionary criteria.
Protection of Human Rights/Informed Consent

The rights of participants were addressed and protected in the following
manner. Permission from the long-term care facilities where the studies took place
was obtained. A description of the study was given to the administrator and research
committee at the institutions. A letter and the proposal (Appendix A) were given to
the institution stating the dates, duration, education program, protocol, plans for
protection of the sample and institution, and requests for permission to conduct the
study at their institution. Data were reported as grouped data as it was not possible to
identify an individual subject and the specific institution with the incidence of
decubitus ulcers. In this manner, patient and institution anonymity was protected.
Nursing staff were given a page summary of the proposal, and a meeting was held
where specific questions were answered; the educational program was open to all
staff Those staff who completed the demographic data and competency scale as a
pretest were deemed as giving their consent to participate in the study as indicated by
32
completion of the data sheet and scale. Staff anonymity was also protected as the
scores on the pretest and posttest were reported as grouped data.
The proposal was presented to the Institutional Review Board (MB) at

California State University, Long Beach, for approval. In addition, the complete
proposal was presented and approved by the administrator and research committee at
the two urban nursing homes/long-term care facilities. Nursing staff, after discussion
regarding the study and obtaining consents of participants (Appendix B), took a test
(pretest) prior to instruction, and a posttest at the end of the class. Evidence of
consents was presented to the MB at California State University, Long Beach, for
their approval.
Setting
The study was conducted at two long-term care facilities, each with at least a
56-bed capacity located in San Bernardino County, California. Total staff in each
facility consisted of 30 persons per day. There were 6 nursing aides, 2 treatment
nurses, and 2 registered nurses assigned per shift. Staff also consisted of a skin care
team that included a doctor, a registered nurse, a licensed vocational nurse, and a
certified nursing assistant. The facilities had patients with decubitus ulcers diagnosed
as stage 1 and 2 using the Sessing Scale. The provision of nursing service was done
by team nursing.
Procedure
A chart review was conducted and an initial preassessment was completed to
note number of decubitus ulcers in patients and stages of the condition as included in
33
the patient's record using the Sessing Scale composed by Ferrell et al. (1995). The
educational program, developed by the AHCPR (1992), was given over a week period
to nursing staff including the skin care team. The educational program followed some
of the suggestions given by the AHCPR when conducting an educational program in
regards to pressure ulcers. The AHCPR's recommendations and the objectives that
were to be achieved at the completion of the program are in Appendix C. After
consents and the pretest were completed, a lecture was provided using overhead slides,
handouts, new material, and material currently used in the facility. The purpose and
importance of research was discussed, followed with graphic pictures of several stages
of decubitus ulcers. After a short discussion of what was being viewed, a lecture on
the prevention of decubitus ulcers was given with the following outline:
I. Definitions and synonyms of decubitus ulcers
II. Pathophysiology
III. Stages of classification with the Norton, Braden, and Sessing scales
IV. Prediction of decubitus ulcers
V. Proper skin care
VI. Proper skin assessment
VII. Dependant areas affected
VIII. Signs to report and document
IX. Proper selection of support equipment and positioning
X. Conclusion (posttest and discussion of answers)

34
After the program, a 30-day period was allowed to elapse before a chart review
postassessment of decubitus in the patient population applying the Sessing Scale was
conducted. The postassessment was conducted through a chart review of the Sessing
Scale, involving data collection, noting the amount of decubitus ulcers present and the
tags with the use of the Sessing Scale. In addition, demographic characteristics of the
sample were collected to identify the age, gender, and Sessing Scale ranking.
Tools
The Sessing Scale is competent to measure the stages of decubitus ulcers.
According to Ferrell et al. (1995), this observational scale is both reliable and valid
(Appendix D). The Sessing Scale was tested at the University of California, Los
Angeles, acute care facility using the Shea Scale to measure the validity and reliability
of each, and a moderate to strong relationship (r = 0.80, g < 0.0001) was found
between changes observed by the Sessing Scale and diameter measurements. This
scale was designed to identify stages 0-6 risks and was included in the patient record.
A data collection coding tool (Appendix E) was designed and used to
systematically record demographic data and decubitus ulcer rating utilizing the
Sessing Scale from a chart review. Reliability and validity of the tool was established
in the following manner: the coding tool was presented to a panel of experts in
nursing research for their review. One hundred percent agreement between the panel
members was used to establish face validity of the tool. According to Polit and
Hungler (1995), using a panel of experts is an acceptable method to establish face
validity. Reliability of the data collection tool was established through a field test.
35
According to Polit and Hungler, field testing is an acceptable method to establish
reliability of a tool. The tool was field tested utilizing a sample population of 10
charts to conduct a preassessment of decubitus in the sample subjects. The staff
educational program was devised by the AHCPR (1992) in a clinical practice manual
for guidelines for the prevention of pressure ulcers. The guidelines contained
materials for the professional and the patient and discussed procedures for prevention
and control. The program was established as reliable and proved valid by this
organization. To evaluate the knowledge level of the staff, a pretest and posttest
(Appendix F) of the knowledge level of decubitus prevention was administered before
the program was offered, and at the end of the program.
Data Analysis
Chart records of each patient with decubitus were reviewed and observed
stages as well as relevant demographic data were recorded. The initial mean score of
decubitus ulcers in all subjects before the class were noted. Likewise, the mean
Sessing score of subjects with decubitus ulcers at the end of the 30-day period were
recorded. A t test for significance between the mean Sessing stage scores in the
patient population at pretest and posttest was computed.
The mean score on the competence tool completed by the nursing staff as a
pretest and posttest was computed. A t test for significance between the mean scores
at pretest and posttest for the total population was computed. In addition, mean
Sessing stage scores pre- and posteducation program and level of significance were
reported by demographic information for patients.
36
This chapter discussed the methods and procedures implemented to complete
the study. The research design and independent, dependent, and intervening variables
were presented. The sample selection, protection of human subjects, setting, and
methods and procedures were delineated. The data collection tools with methods to
establish their reliability and validity were discussed.

37
CHAPTER 5
RESULTS
This chapter reports result of the investigation concerning the relationship
between the incidence of decubitus ulcers in the elderly after nurses have undergone
an educational program in the area of prevention and incidence of decubitus. This
study involved medical records of 120 patients residing in two long-term care facilities
located in San Bernardino County. The records of these residents with decubitus
ulcers were evaluated using the Sessing Scale. To measure risk and stages of
decubitus ulcers, initially the nursing staff was trained utilizing an educational
program developed by the AHCPR (1992) for a duration of a week. The assessment
of medical record reviews was completed 30 days after the educational program to
determine the patient outcomes.
Reporting of Data
1. Initial mean score of decubitus ulcers in patients before the class and after
the 30-day period was reported.

2. A t test for significance between the mean Sessing stage score at pretest and
30-day posteducational program Sessing stage mean score was computed and
reported.3. A mean score on the competency tool completed by the total population of
nursing staff at pretest and posttest was computed.
38
4. A t test for significance between the mean score at pretest and posttest for
the total population of caregivers was computed and reported.
5. Mean Sessing scores (pre- and posteducation program) with level of
significance were reported according to demographic information (age and gender) for
the patient population.
Educational Program Mean Score
The educational program developed by the AHCPR was given to all 35
persons comprising the nursing staff in both facilities. Provision for nurses to be
available for training without jeopardizing the health care of the patients was
considered and followed. The results of pre- and postassessment of all nurses'
knowledge in both facilities after the program in which they were taught to prevent
decubitus ulcers in the elderly indicated that the mean for postknowledge assessment
(M = 77.1, SD = 21.2) was greater than the mean score for preknowledge assessment
(M= 51.7, SD= 14.0), t(34) = 2.83, p = .001.
The data that were analyzed according to nurses' pre- and postknowledge per
long-term care facilities showed that nurses' postknowledge was greater than their
preknowledge in both facilities. The results of the Levene's test show variances for
the two groups were substantially different. For preknowledge, the t test for unequal
variances was not significant, t(33) = 1.52, p = .14, and for the postknowledge, the t
test for unequal variances was significant, t(33) = 2.34, p = .02.
Paired-samples t tests were conducted to evaluate whether there was
improvement of nurses' knowledge beyond the preassessment stage after nurses
39
received training through the educational program as compared between the facilities
and the results were found to be statistically significant. The results indicated the
mean for nurses in the facility with a patient census of 80 patients (preknowledge: M
= 57.00, SD = 12.51; postknowledge: M = 87.0, SD = 11.59) was the same for nurses
in the facility with 56 patients (preknowledge: M = 49.60, SD = 14.28;
postknowledge: M = 73.20, SD = 23.04). The mean difference was -30.00 between
the two ratings for preknowledge and postknowledge for nurses in the larger patient
census facility, which was significant, t(9) = -6.08, p = .001. There was a mean
difference of -23.00 for the two ratings preknowledge and postknowledge for nurses in
the smaller patient census facility, which was also significant, t(24) = -5.51, g = .001.
The overall analysis suggests that nurses in both facilities gained more
knowledge through the educational program and therefore were more equipped in
preventative decubitus ulcer care concerning the elderly.
The study required that a competency tool (Sessing Scale) be utilized to
measure the stages of decubitus ulcers. There were 120 elderly persons residing in
both long-term care facilities that comprised the sample of the study. These patients
were evaluated for the presence of decubitus ulcers rated stages 0 through 6 on the
Sessing Scale. Data on two demographic attributes—age and gender—were recorded
for each participant. The distribution of the participants' ages is shown in Table 2.
Table 3 reports the distribution of participants according to gender—male and female.
According to Table 2, 42.5% of the participants' age range was 84 years and
over while 27.5% were between 78 and 83 years old. Participants that were less than
40
TABLE 2. Frequency Distribution of Patients According to Age (N = 120)

Age Category Percent Number
<60 6.7 8 60-65 0.8 1 66-71 7.5 9 72-77 15.0 18 78-83 27.5 33 84+ 42.5 51 Total 100.0 120
TABLE 3. Frequency Distribution of Patients According to Gender (N = 120)
Gender Percent Number
Male 19.2 23 Female 80.8 97 Total 100.0 120
60 years formed 6.7% of the total sample. This finding indicates the greater
population of participants was above age 78 years.
As shown in Table 3, approximately 80.8% (n = 97) of the total sample of
participants from both long-term care facilities were female, while 19.2% (n = 23)
were male.
The data were collected and analyzed for all participants according to
incidence of decubitus ulcers—pre- and postassessment—in patients residing in both
long-term care facilities. An independent samples t test was conducted and the test
was significant, t( 119) = 5.46, p = .001. The mean of decubitus ulcers of residents at
predecubitus assessment was 0.7750 (SD = 1.31) and the mean at postdecubitus
assessment was 0.2417 (SD = .6217). The results indicated that the predisposition of
decubitus ulcers in patients at the postassessment was less severe as well as at the end
of the 30-day period of treatment and observation.
Further analysis was performed to show the relationship between demographic
data—age and gender—and incidence of decubitus ulcers in the patients. Independent
samples t tests and an ANOVA analysis were conducted to evaluate age in relationship
to occurrence of decubitus ulcers in the elderly. No significance was found in
reference to age. However, an independent t test was conducted for participants—male
versus females—pre- and postdecubitus and by long-term care facility.
The results indicated significance, t(46) = 2.22, p - .032. The implication was
that at one facility, the incidence of decubitus ulcers in predecubitus assessment was
lower in males than females. However, the results regarding postdecubitus assessment
42
approached significance, t(70) = -1.91, g = .062. This still indicated the male patients
at the one facility were lower in the incidence of decubitus ulcers in postdecubitus
assessment.
Conclusion
This chapter discussed the methodology and findings of the study. In addition,
the method to analyze the data was discussed. The letter, consent forms, and tables
have been included in the appendices to provide samples of the tools and consent
forms used in the study. A report of the data analysis for the findings was presented.
43
CHAPTER 6
CONCLUSION
This chapter includes a discussion of the literature compared with the findings
of this study, generalizations of the findings to the larger population of elderly, and
suggestions for further research in the area of decubitus ulcer prevention. According
to Arias (2002), the elderly in the United States comprise a substantial and rising ratio
of the total population. Based on present trends, extrapolations suggest that by the
year 2040 persons over 65 will make up 20% of the total population. In addition,
census data (Arias) reported that persons 75 years and over were the fastest growing
segment of the population and also that 70% of elderly males were married compared
to 40% of females. According to the census reports, skewed lifespans between
genders result in 3 elderly women for every 2 elderly men; the scope of health
problems associated with the aging of the population can be placed in perspective.
Eliopoulos (1990) asserted there will be an increase in persons aged 75 years
and older, with more females than males. The demographic characteristics of the
sample in this study support the work of Eliopoulos.
Elderly women typically depend on their husbands for financial support and, in
general, expect their husbands to take care of matters which are traditionally gender-
biased as was the case in their formative years decades ago. As widows, they are
often deprived of critical financial support leading to a sometimes real threat to their
44
well-being and lifestyle, in general. The first obvious solution was to seek assistance
from their offspring or siblings; however, many younger persons are themselves fully
occupied with child rearing and laying foundations for economic stability in a
socioeconomic ecology of rising national unemployment, collapse of corporate
megaliths, sluggish job creation, and stock market jitters. These factors place a heavy
burden on the 21st century family, and increase the stress level of the elderly
population.
The elderly, with little resources and support, are quite often summarily
institutionalized whenever health problems appear which further complicate matters.
According to Eliopoulos (1990), approximately 5% of the elderly are put in long-term
care facilities for medical problems.
The sample in this study reflects the projections of the 2000 census (Arias,
2002). The sample population included 120 subjects and 36 nursing staff. The largest
percentage of the sample were ages 84 and over, accounting for 42.5% (n = 51) noted
in Table 3. In addition, the females accounted for 80.8% (n = 87) of the sample as
indicated in Table 2. From the review of the chart records, many patients were
mentally challenged coupled with chronic illnesses which would support the
challenges faced by their older children and their ability to care for them at home.
These findings support the work ofDacey and Travers (1991), who asserted the
population will increasingly age, and need more care in the future.
Currently, long-term care facilities constitute an industry operated by health
service entrepreneurs where focus is on a bottom line of profit. Net profit
45
considerations seem to have supplanted the primary place of humanistic
considerations and primacy of patient welfare expected from the health care delivery
system, including nursing professionals. No institution can be successfully operated
without prudent financial management; however, there is a need for more involvement
from nursing staff in budget decisions. Yarkony (1994) reported that up to 25% of
patients in long-term care facilities have decubitus ulcers and indicated that problems
related to shortage of nursing staff also exacerbated the dilemma. This study supports
the incidence of decubitus ulcers reported by Yarkony.
Recommended nursing staff ratios in long-term care should be as follows:
100-bed facility should have at least 3 RNs, with 1 RN Supervisor 24 hrs/day, 1 LVN
to 15 patients during 7 am-3 pm shift, 1 LVN to 20 patients 3 pm-ll pm shift, 1
LVN to 30 patients 11 pm-7 am shift, CNAs 1 to 5 patients during 7 am-3 pm
shift, 1 CNAto 10 patients 3 pm-ll pm, and 1 CNAto 15 patients 11 pm-7 am
shift (Harrington et al., 2000). The facilities involved in the study seemed adequately
staffed. Table 4 reflects the number of staff available on each shift, which would
indicate that staff shortage would hardly be considered in these cases. However, it
might be considered that the presence of an RN on ail shifts could positively
contribute to better outcomes. Yarkony (1994) support the presence of an RN as
important to improve quality of care. It was also reviewed that an increase ofRNs to
LVNs could improve care due to the knowledge and expertise training of an RN
46
TABLE 4. Staffing Patterns in Study Facilities7A-3P

Shift
3P-11P 11P-7A
RNs (N = 120) Facility with mean patient census (80) 2 1 0 Facility with mean patient census (56) 1
'A 0
LVNs Facility with mean patient census (80) 4 2
RN Supervisor
on-call
2 Facility with mean patient census (56) 2 2 1
CNAs Facility with mean patient census (80) 14 8 5 Facility with mean patient census (56) 8 6 3
47
over the LVN (Kayser-Jones & Schell, 1997; Smith, 2001). The staffing patterns are
similar to the staffing patterns in other long-term care facilities and meet the minimum
recommendations reported by NCCNHR (1999).
As indicated by the results of the postknowledge in this current investigation,
the educational program as an intervention proved beneficial as the nurses who gained
knowledge of decubitus care, prevention, and treatment were better prepared and more
alert to signs and symptoms of decubitus ulcers. Therefore, the study results were
fewer incidences of decubitus after the 30-day period of observation. According to
Polit and Hungler (1995), administration of a pretest identical to the posttest may
promote learning and increase the posttest score attained by subjects.
These findings within this study seem to be supported by an investigation
conducted by Regan et al. (1995) where after an educational program (AHCPR) was
instituted, the incidence of pressure ulcers in patients decreased significantly. It is
critical, therefore, to attract nurses into the area of advanced practice geriatric nursing
and to provide continuous educational programs to upgrade the knowledge of these
nurses. The annual cost of care for decubitus ailments is approximately $1.3 billion.
Erwin (1995) draws attention to the potential benefits of prevention and treatment as a
method to reduce the cost of long-term health care.
Faced with the increasing numbers of elderly, and the increasing mean age of
this high-risk population, health care facilities have responded in a positive manner.
Long-term care facilities have responded to this critical and widely felt need in the
field of health care to provide professional care for the elderly that confers dignity in
48
their declining years. Nevertheless, there is a need to be more vigilant about care to
the elderly, those most at risk for pressure ulcers. Educational preparation for
caregivers, encouraging self-care, and other preventative measures are significant
means of achieving this goal. In this study, results showed that an AHCPR guide
training program administered to nursing staff in two long-term care facilities reported
greater mean scores for posttest knowledge assessment (after 30 days) than for pretest
knowledge assessment (M = 77.1, SD = 21.2 as against M = 51.7, SD = 14.0), t(34) =
2.83, p = .001. Application of this newly-gained knowledge should be reflected in
reduced incidence of decubitus ulcers, and study findings support this assertion.
Generalization of Findings
In order to strengthen this study, and broaden the generalizations of the
findings to the larger population of the elderly, there are many recommendations.
First, replicating the study and increasing the sample size would greatly enhance
generalization of the findings. According to the literature, elderly in acute care and in
home situations are also at risk. Findings of the study are also limited as subjects with
preexisting physical conditions that might affect ulcer development (such as cancers,
auto immune disorders, etc.) were not excluded from the sample. A stronger
relationship could be found with a study that grouped patients as to their diagnoses,
existing chronic illnesses, and the presence of decubitus ulcers. Joint Committee on
Accreditation of Healthcare Organization (JCAHO) standards of care for long-term
care facilities require ongoing programs of staff development. Decubitus prevention
with education to examine patient outcomes is effective.
49
The issue of infections associated with decubitus ulcers is another area
requiring further research. Nicolle et al. (1994) discussed finding anaerobes and
bacteria, with two-thirds of the organisms in decubitus ulcers as potentially
pathogenic. Leshem and Skelskey (1994) asserted there was an increased health risk
to elderly patients with infectious decubitus ulcers.
Suggestions for Further Research
Based upon the breadth of this study, its reported findings, and the reports of
others, the following recommendations for specific areas of future research are made:
Research supports preventative measures as the most cost effective means of dealing
with decubitus ulcers. However, the proper treatment and management of existing
decubitus ulcers to reduce the development of more serious outcomes is also
important. Other recommendations for future study are as follows:
1. Include patients with chronic illnesses, other demographic information, and
other diagnoses in the data collection coding tool.
2. Collect information as to ethnic identity, and compare ethnic identity with
the incidence of decubitus ulcers in the elderly.
3. Studies that consider specific skin care measures in relation to patient
outcomes.
4. Proper use of turning schedules for those patients at risk and the presence of
decubitus ulcers.
5. Studies that examine the cost of treatment and prevention of patients with
decubitus ulcers in long-term care facilities. 50
6. The elderly patient's stress level and the presence of decubitus ulcers.
7. The knowledge level of patients, and legal representatives, compared to the
incidence or development of decubitus ulcers.

Conclusion
The study involved a cohort sample of elderly patients, who were residents at
two long-term care facilities. The effect of an educational program on the incidence of
decubitus ulcers in the patient population and the knowledge level of the nursing staff
was reported. Findings support the use of the educational program as a method to
decrease the incidence of decubitus ulcers in the elderly. Education is one way of
empowering and advocating for the elderly in our society, specifically those in long
term care in relation to decubitus ulcers. The increase and length of the lifespan and
effect of technology seem to increase the potential population of elderly needing care
whether in long-term, acute settings, or in the home. According to the findings of this
study, proper educational programs that include decubitus ulcer preventive measures
and care will affect decubitus ulcer development and serious sequalae in the elderly
population.
51
APPENDICES
52
APPENDIX A
PROPOSAL LETTER AND SUMMARY OF STUDY

5
3
Doneite Hylton, RN
February 20, 2003
Mr.
Parker
Dear Mr. Parker,
I am a graduate Adult/Geriatric Nurse Practitioner student at CSULB and I am
working on a Thesis. This study I hope to conduct in your institution. The study is
entitled An Examination of the Relationship between the Incidence of Decubitus
Ulcers in a Long Term Care Facilities and an educational program. I would like your
institution to give me permission to conduct my study through a review of the chart
records at your establishment. Enclosed is information regarding the study for your
consideration. I will call your office to arrange a meeting with you to further discuss
my proposal, and hope I will receive approval.
Sincerely,
Donette C. Hylton
54
Study:
An Examination of the relationship between the incidence of decubitus ulcers
in long term care facilities and an educational program.
This study will be conducted over a two-month period. The projected date to
begin is February 15, 2003. The class will be conducted February 24, 26, 2003. The
data collection should be concluded April 18, 2003. The purpose of the study is to
explore the effect of education to nursing staff in the area of prevention on the
incidence of decubitus. It would be beneficial to the elderly population and the health
costs. The sample will consist of elderly patients men and women randomly picked
from your institution who have decubitus ulcers assessed at stages one and as two. The
subjects records will be assessed for the amount of decubitus present and the stage in
both the pre and post test using the Sessing scale. In between the data collection and
tests your nursing staff will receive education in the area of prevention and treatment
of decubitus ulcers. The results will then be analyzed. The subjects will remain
confidential with labeling such as (A) or (C). All human subject rights will be
respected. The cost to the subjects and institution is $0 and all data will be reported as
grouped. It will not be possible to identify individual patients or individual institution
data.
55
APPENDIX B
CONSENT FORMS
5
6
Informed Consent Form CSULB Department of Nursing Graduate Program Consent to be a
Research Subject
CONSENT TO PARTICIPATE IN RESEARCH
An Examination of the Relationship Between the Incidence of Decubitus Ulcers in Two Long Term
Care Facilities and Educational Program(Nursing Staff)
You are asked to participate in a research study conducted by Donette Hylton, RN who is a
graduate student in the Adult/Geriatric Nursing Practitioner program, from the Nursing
Department at California State University, Long Beach. The results will be used for contribution to
a thesis. You were selected as a possible participant in this study because you are part of the
nursing staff which work in the long term care facility that has agreed to participate in the study
and your overall work performance will be reflected as results in this study.
PURPOSE OF THE STUDY
This study is being conducted to explore the effect of education to nursing staff in the area of
prevention and the incidence of decubitus ulcers.
PROCEDURES
If you volunteer to participate in this study, you will do the following things: You will read this
consent form and sign appropriately. You will attend the inservice on decubitus ulcer prevention.
You will complete a quiz on decubitus ulcer prevention prior to and after instruction. Your score
for both quizzes will be evaluated to determine effective instruction. You will allow instruction to
positively influence your care.
POTENTIAL RISKS AND DISCOMFORTS
There is no potential risk or discomfort to the volunteer in this procedure. All information gathered
will be handled confidentially. These documents will be kept locked in a file cabinet and will be
reported as group data rather than individual.
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
This study may benefit all parties involved with regards to the decreased cost of care, quality of
care given and received, prevention, prediction, and decreased incidence of decubitus ulcers.
57
PAYMENT FOR PARTICIPATION
There will be no payment for participation in this study.

CONFIDENTIALITY
Any information that is obtained in connection with this study and that can be identified with you
will remain confidential and will be disclosed only with your permission or as required by law.
These documents will be kept locked in a file cabinet and the results of quizzes will be reported as
group data rather than individual.
PARTICIPATION AND WITHDRAWAL
You can choose whether to be in the study or not. If you volunteer to be in this study, you may
withdraw at any time without consequences of any kind. Participation or non-participation will not
affect your employment status, or any other personal consideration or right you usually expect. The
investigator may withdraw you from this research if circumstances arise which in the opinion of the
researcher warrant doing so.
IDENTIFICATION OF INVESTIGATOR
If you have any questions or concerns about the research, please feel free to contact: Donette C.
Hylton Dr. E. White (xxx) xxx-xxxx (562) 985-4111
RIGHTS OF RESEARCH SUBJECTS
You may withdraw your consent at any time and discontinue participation without penalty. You
are not waiving any legal claims, rights or remedies because of your participation in this research
study. If you have questions regarding your rights as a research subject, contact the Office of
University Research, CSU Long Beach, 1250 Bellflower Blvd., Long Beach, CA 90840; Telephone:
(562) 985-5314 or email to research®,csulb. edu.
58
SIGNATURE OF RESEARCH SUBJECT
I understand the procedures and conditions of my participation described above. My questions

have been answered to my satisfaction, and I agree to participate in this study. I have been given a
copy of this form.
Name of Subject
Signature of Subject/Date
STATEMENT and SIGNATURE OF INVESTIGATOR
In my judgment the subject is voluntarily and knowingly giving informed consent and possesses the
legal capacity to give informed consent to participate in this research study.
Signature of Investigator/Date
59
Informed Consent Form CSULB Department of Nursing Graduate Program Consent to be a
Research Subject
(Resident)
CONSENT TO PARTICIPATE IN RESEARCH
You were selected as a possible participant because you are a resident of a facility where a new trial
educational program for the nursing staff is being given. The program will be conducted by
Donette Hylton, RN who is a graduate student in the Adult/Geriatric Nursing Practitioner
program, from the Nursing Department at California State University, Long Beach. The results
will be used for contribution to a thesis.
PURPOSE OF THE STUDY
This study is being conducted to evaluate the difference that education, to the nursing staff of this
facility, may have to improve the quality of care you receive. The focus of the study is decubitus
ulcers, a frequent problem in long term facilities. The nursing staff will be educated on prevention
of decubitus ulcers, which may decrease the incidence of decubitus ulcers in your facility.
PROCEDURES
If you volunteer to participate in this study, you will do the following things: You will read this
consent form and sign appropriately. You will allow a review of your medical records to determine
the incidence of decubitus ulcers. An educational program will be provided to the nursing staff.
Then, you will allow another review of all your medical records to determine the relationship
between the educational program and the incidence of decubitus ulcers in this facility.
POTENTIAL RISKS AND DISCOMFORTS
There is minimal risk or discomfort to the volunteer in this procedure. The minimal risk may be
due to the embarrassment of the investigator reviewing your medical record. All information
gathered will be handled confidentially. These documents will be kept locked in a file cabinet and
will be reported as group data rather than individual.
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
This study may benefit you if you currently have a decubitus ulcer and or may have risk factors
that may predispose you to the development of decubitus ulcers. The
60
nursing staff will be provided with education that may improve the quality of care you currently
receive.
PAYMENT FOR PARTICIPATION
There will be no payment for participation in this study.
CONFIDENTIALITY
Any information that is obtained in connection with this study and that can be identified with you
will remain confidential and will be disclosed only with your permission or as required by law.
These documents will be kept locked in a file cabinet and the results will be reported as grouped
data rather than individual.
PARTICIPATION AND WITHDRAWAL
You can choose whether to be in the study or not. If you volunteer to be in this study, you may
withdraw at any time without consequences of any kind. Participation or non-participation will not
affect your resident status, or any other personal consideration or right you usually expect. The
investigator may withdraw you from this research if circumstances arise which in the opinion of the
researcher warrant doing so.
IDENTIFICATION OF INVESTIGATOR
If you have any questions or concerns about the research, please feel free to contact: Donette C.
Hylton Dr. E. White (xxx) xxx-xxxx (562) 985-4111
RIGHTS OF RESEARCH SUBJECTS

You may withdraw your consent at any time and discontinue participation without penalty. You
are not waiving any legal claims, rights or remedies because of your participation in this research
study. If you have questions regarding your rights as a research subject, contact the Office of
University Research, CSU Long Beach, 1250 Bellflower Blvd., Long Beach, CA 90840, Telephone:
(562) 985-5314 or email to research@csulb. edu.
61
SIGNATURE OF RESEARCH SUBJECT (AND) OR LEGAL REPRESENTATIVE
I understand the procedures and conditions of my participation described above. My questions

have been answered to my satisfaction, and I agree to participate in this study. I have been given a
copy of this form.
Name of Subject
Name of Legal Representative^ applicable)
Signature of Subject or Legal Representative Date
STATEMENT and SIGNATURE OF INVESTIGATOR
In my judgment the subject is voluntarily and knowingly giving informed consent and possesses the
legal capacity to give informed consent to participate in this research study.
Signature of Investigator/Date
62
APPENDIX C
EDUCATIONAL PROGRAM OUTLINE

6
3
Decubitus Ulcer Prevention
Program Objectives
Upon completion of this program the learner will be able to complete the following objectives:
1. Define Decubitus ulcers and list current synonyms.
2. List the risk factors for decubitus ulcers.
3. Discuss risk assessment tools and their application.
4. Describe appropriate skincare measures.
5. List the components of a complete skin assessment.
6. Describe the proper positions to prevent skin breakdown.
7. Discuss proper selection and use of support surfaces.
8. State each role's responsibility for prevention and care of skin.
9. Discuss some of the cultural issues that may impact decubitus prevention.
10. State rationale for undertaking research of decubitus ulcer issues.

64
APPENDIX D
SESSING SCALE
6
5
Sessing Scale
Stage Description
1. Normal skin, but at risk
2. Skin completely closed

May lack pigmentation or may be reddened
3. Wound edges and center are filled in

Surrounding tissues are intact and not reddened
4. Wound bed filling with pink granulating tissue

Slough and minimal necrotic tissue Free of necrotic tissue Minimum drainage and odor
5. Moderate to minimal granulating tissue

Slough and minimal necrotic tissue Moderate drainage and odor
6. Presence of heavy drainage and odor, eschar and slough Surrounding skin reddened or
discolored
7. Breaks in skin around primary ulcer

Purulent drainage, foul odor, necrotic tissue and/or eschar May have septic symptoms
Scoring: Assign the numerical value associated with the description that most closely matches the
observed pressure ulcer. The scale is scored by calculating the change in numerical values over
successive wound assessments over time. Positive scores indicate ulcer improvement and negative
scores indicating worsening ulcers.
Source: Ferrell (1997).
66
APPENDIX E
DATA COLLECTION CODING TOOL

67
Data Collection Coding Tool
Demographic Data Sessing Decubitus Ulcer Staging
A. 60-65 years
B. 66-71 years
C. 72-77 years
D. 78-83 years
E. 84 + years
Gende
r
Male
Female
By Donette Hylton
68
APPENDIX F
DECUBITUS ULCER PRETEST AND POSTTEST

69
Choose one correct answer for each of the following:
1. Decubitus ulcers can be defined as:

a. nonblanchable erythema of intact skin b. friction to skin with bony
prominences c. ischemic ulcers in normal skin d.
unrelieved pressure resulting in damaged skin
2. Which of the following areas is more likely to develop decubitus ulcers?

Sebuah. sacrum b. shoulder c.
buttocks d.
ear
3. Which of the following is not an appropriate decubitus ulcer assessment tool?

Sebuah. Norton scale b. Braden scale
c. Sessing scale
d. Age scale
4. The following are risk factors for decubitus ulcers except one:
a. level of consciousness b. age c. incontinence d.
nutrition
5. Decubitus ulcers can be caused by which of the following:

a. shearing b. friction c. moisture d. all of
the above
6. Which of the following is not an appropriate support device in positioning a
patient?Sebuah.
pillows
b. foam wedges
c. donut rings d.
sheepskin
7. The appropriate components of skin assessment is all of the following except:

a. color b. temperature c. moisture d.
pulses
70
8. Who is responsible for prevention of decubitus ulcers?
Sebuah. Charge nurse b. caregiver(not working at the facility) c.
bedside attendant d. Nurse manager
9. Prevention of decubitus ulcers starts:

a.' when nonblanchable erythema is present b. at admission c.
preparing for discharge d. loss of moblility
10. The best way to prevent decubitus ulcers is:

a. proper education b. proper positioning c. proper use of
support surfaces d. proper
nutrition
By Donette Hylton
7
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PEMERIKSAAN HUBUNGAN ANTARA INSIDENSI

ULCER DEKUBITUS DI DUAJANGKA PANJANG PERAWATAN FASILITAS

DAN PROGRAM PENDIDIKAN

kepada Departemen Keperawatan

Universitas Negeri California, Long Beach

Dalam Pemenuhan Sebagian

Persyaratan untuk Gelar

INI DIBERIKANOleh Donette Hylton

BSN, 1995, Universitas Loma Linda, Loma Linda, California

Nomor UMI: 1416761

Seluruh hak cipta. Edisi microform ini dilindungi dari

penyalinan tidak sah di bawah Judul 17, Kode Amerika

Perusahaan Informasi dan Pembelajaran

TELAH DISETUJUI SKRIPSI INI

SEBUAH PEMERIKSAAN HUBUNGAN ANTARA KEJADIAN

dekubitus borok DI DUA FASILITAS PERAWATAN JANGKA PANJANG

DAN PROGRAM PENDIDIKAN

Bonnie Kellogg, RN, DR. P Keperawatan

Elaine E. White, RN., EdD. Keperawatan

DITERIMA DAN DISETUJUI ATASUNIVERSITAS.

Universitas Negeri California, Long Beach

PEMERIKSAAN HUBUNGAN ANTARA INSIDENSI

ULCER DECUBITUS DI DUA FASILITAS PERAWATAN JANGKA PANJANG

DAN PROGRAM PENDIDIKAN

sampel staf keperawatan terhadap kejadian dekubitus. borok di kohort warga

preassessment untuk kejadian ulkus dekubitus dan tahapan dilakukan menggunakanSessing

Penelitian, dilakukan selama 7 hari untuk staf perawat. Perawat dalampelatihan

programdiberi pretest sebelum instruksi dan posttest setelah instruksi, untuk

menentukan pengetahuan. Tiga puluh hari setelah akhir program, postassessment

rekam medis diselesaikan untuk menentukan hasil. Studi ini melaporkan

peningkatanpengetahuan perawat ulkus dekubitus dan penurunan

kejadianulkus dekubitus setelah program pendidikan di kedua fasilitas.

anggotakomite,California State University, Long Beach, Keperawatan staf Departemen,

UCAPAN TERIMA KASIH ................................................. .......................................... iii

TABEL ...... .................................................. .................................................. ................. vii

1. PENDAHULUAN ............................ .................................................. ............. 1

Bisul Dekubitus ...................................... .................................................. .. 1

2. TINJAUAN PUSTAKA .................................................... .............................. 10

Long-T erm Care .............. .................................................. ........................ 11

Penerapan Kerangka Kerja dalam Studi Ini ...................... ........................ 25

Definisi Ketentuan ............................................. ..................................... 28

4. METODOLOGI .......... ........... 30

Desain ..................................... .................................................. ................. 30

5. HASIL ............................................. .................................................. ........ 38

Pelaporan Data .......................................... ................................................ 38

6. KESIMPULAN .................................... .................................................. ......... 44

LAMPIRAN ........................................ .................................................. ..................... 52

A. SURAT PROPOSAL DAN RINGKASAN STUDI .................... ...... 53

C Garis Besar PROGRAM PENDIDIKAN ............................................... .. 63

D. SKALA SESI ........................................... ................................................ 65

E ALAT PENGUMPULAN KOLEKSI DATA ............................................. ....... 67

F. DECETITUS ULCER PRETEST DAN POSTTEST ..............................

1. Klasifikasi dan Tahapan Pembentukan Ulkus Dekubitus ............................ 14

2. Distribusi Frekuensi Pasien Menurut Usia .................................. 41

3. Distribusi Frekuensi Pasien Menurut Jenis Kelamin ...... ....................... 41

4. Pola Kepegawaian di Fasilitas Studi ................... ............................................... 47

masalah perawatanmempengaruhi lansia di Amerika Serikat, misalnya, kualitas perawatan yang

persiapan khusus staf perawat untuk menangani kondisi umum

menanggapi peningkatan risiko penyakit kronis pada populasi lansia, dan

kebutuhan terkait untuk dukungan fisik, psikologis, dan sosial.

bisulbisa mahal dan berkepanjangan (National Pressure Ulcer Advisory Panel

[NPUAP], 1989).Patofisiologi dan Faktor Risiko untuk Ulkus Dekubitus

inkontinensia juga berisiko lebih tinggi. Ketika integritas kulit terganggu,