Running Head: EFFECTS OF TURNING AND REPOSITIONING 1

Effects of Turning and Repositioning on the Development of Pressure Ulcers

Stephanie L. Plyler, Tayona L. Johnson, Maggie M. Lauer, Jennifer M. Troutman

04/03/2017

NURS 3749: Nursing Research

Dr. Valerie O’Dell

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Abstract

The purpose of this research was to determine if there was a difference in skin breakdown

between turning and repositioning every two hours and turning and repositioning every four

hours. A correlation between pressure ulcers, alternative measures, and the Braden scale is

discussed. Nine different sources were used, including quantitative studies, qualitative studies,

and an informative booklet on pressure ulcers. It was found that there was no significant

evidence in the difference in skin breakdown when turning the patient every two hours, three

hours, or four hours. Skin breakdown starts to occur when the patient is only turned every six

hours. There are alternative measures that can be taken to prevent skin breakdown, such as skin

care, supportive surfaces, and nutrition.

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Reposition Every Two-Four hours and the Effects of Pressure Ulcer Development

Pressure ulcers are a problem for nurses because they show that the patient did not

receive proper care. Preventative measures to reduce the occurrence of pressure ulcers include:

identifying those at risk, identifying nutritional needs, proper skin care, proper bedding or

cushions, and proper repositioning of a patient who is unable to reposition themselves ever two-

six hours. In dealing with preventative measures for pressure ulcers the following research

question was addressed: How does tuning and repositioning patients every two hours as

compared to every four hours effect the development of pressure ulcers?

Literature Review

Introduction

In order to address this issue in health care, information was acquired via OhioLINK

databases. Nine sources were reviewed for the data collection regarding turning and

repositioning patients every two hours and the development of pressure ulcers. Pressure ulcers,

two and four hour turns, skin care, supportive surfaces, nutrition, the Braden Scale, and Medicare

will be discussed.

Pressure Ulcers

Pressure ulcers or bedsores are prevalent health issues that affect long term and acute care

settings. Pressure ulcers are injuries to the skin and tissues caused by prolonged pressure or

friction and shearing to an area. Pressure ulcers usually occur over bony prominences such as the

back of the head, elbows, tail bone, hips and the heels. People at risk for pressure ulcers are

usually those who have impaired nutrition, incontinent, confined to bed rest and/ or wheel chair,

or are unable to make frequent position changes. Although pressure ulcers are said to be

preventable, they are still a major issue that hospitals and long-term care facilities face daily.
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Treating pressure ulcers cost thousands of dollars and can result in longer hospital stays and even

death.

Pressure ulcers can form quickly and progress from one stage to the next. Pressure ulcers

are placed into four different categories based on their characteristics. Pressure ulcers that fall

into stage one are considered areas that have a nonblanchable redness of intact skin. “ This area

may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue”(Molnlycke Health

Care, 2015, p.2 ). Pressure ulcers in stage two are described as, “partial thickness loss of dermis

presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as

an intact or open/ ruptured serum- filled blister,” (Molnlycke Health Care, 2015, p.2). Stage three

pressure ulcers are categorized as full thickness skin loss, this stage occurs when, “subcutaneous

fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does no

obscure the depth of tissue loss. May include undermining and tunneling,” (Molnlycke Health

Care, 2015, p. 3). The depth of stage three pressure ulcers may vary depending on the location.

“The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue,” causing

the ulcer to be fairly shallow (Molnlycke Health Care, 2015 p. 3). Stage four pressure ulcers are

categorized as full-thickness skin and tissue loss, “Full thickness loss with exposed bone, tendon

or muscle. Slough or eschar may be present on some parts of the wound bed.” (Molnlycke Health

Care, 2015 p.3). Additionally, stage four ulcers, “often include undermining and tunneling”

(Molnlycke Health Care, 2015 p.3). As with stage three, in stage four the depth of the ulcer

depends on the location it is present. “Category/ stage four ulcers can extend into muscle and/ or

supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible”

(Molnlycke Health Care, 2015, p, 3). Because pressure ulcers are preventable, ulcers that fall

into stages three and four may not be covered by insurance and cost the hospital directly. There
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are also pressure ulcers that are unstageable, these are ulcers are usually, “full thickness tissue

loss in which actual depth of ulcer is completely obscured by slough ( yellow, tan, gray, green, or

brown) and / or eschar ( tan, brown, black) in the wound bed,” (Molnlycke Health Care, 2015,

p.4). Unstageable ulcers would need debridement of the slough or eschar in order to stage the

wound properly.

Two Hour Turns

The traditional primary source for the widely accepted two hour turn and reposition

theory that many facilities have accepted as their policy came from a study dating back to 1962

(Norton, McLaren, & Exton-Smith, 1962). This theory states that it is recommended that patients

be turned and repositioned every two hours, unless otherwise ordered, especially if the patient is

immobile. Two hour turns have proven to be effective in preventing pressure ulcers, but this

research is outdated. This experiment was performed in 1962, which is over fifty years ago. New

studies current in evidence based practice has proven that there are several other means to

prevent pressure ulcers that are more effective, less time consuming to valuable health care staff,

and improve the patients sleep and quality of life. Many advancements since the sixties in the

development of pressure reducing mattresses, evidence of the importance of nutrition and proper

skin care also play a large role. It is not simply the frequency of the turn that effects the

development of skin breakdown, but the therapies and treatments that must be utilized in

conjunction with turning and repositioning.

Four Hour Turns

According to Bergstorm (2013), there is no significant difference between turning and

repositioning a patient every two, three or four hours, as long as they are on a high foam density

mattress. In fact, the study found that “less frequent turning might increase sleep, improve
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quality of life, reduce staff injury, and save time for such other activities as feeding, walking, and

toileting.” This study was performed on 942 patients who were classified as having a moderate to

high risk of acquiring a pressure ulcer. Of the 942 participants in this study only nineteen

acquired superficial stage one ulcers at the turning intervals of two, three, and four hours; no

stage three, stage four or unstageable pressure ulcers developed. During the duration of the three

week study, study coordinators assessing the patients skin regularly were not aware of which

patients were being turned every two, three or four hours. Meaning there was no difference in the

results that would differentiate a two hour turn from a four hour turn. Another study by

Bergstorm conducted in 2013, the TURN study (Turning for Ulcer Reduction Study), also

supports this finding.

“Turning at 3- and 4- hour intervals is no worse than the current practice of turning every

2 hours in the United States and Canadian LTC facilities. Two hour turning could expose

residents to increased risk from friction during repositioning.” (Bergstrom 2013)

In fact, several other studies conducted in recent years support these results. The study,

“Repositioning for pressure ulcer prevention in adults (Review)”, conducted by Gillespie (2014)

found that “There was a statistically significant reduction in pressure ulcers of Category 2 and

above with 4-hourly repositioning compared with 6- hourly”.

Skin Care

Along with turns and repositioning there are many other alternative measures to prevent

pressure ulcers. Skin care is one of the most prevalent preventers of skin break down and

pressure ulcers. This is one of the most cost efficient and effective ways to prevent skin

breakdown. Dirty or wet skin leads to irritation of the skin. It can also lead to excess moisture on

the skin that can created more friction that will decrease skin integrity. According to Cooper
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(2013), “Moisture contributes to maceration, which may make epidermal layers more vulnerable

to break down from pressure.” Another great benefit from frequent cleansing of the skin is that

the nurse will be preforming multiple skin checks. (Mallah, 2015) The more often a health care

provider is checking the skin the earlier they can take note of an area that is at risk for

developing into a pressure ulcer. While frequent washing is a good thing, it can be detrimental if

done too often (Cooper, 2013). When the skin is washed too often it begins to become dry and

irritated. Dry skin puts the patient at risk for developing a pressure ulcer as well. This all comes

down to maintaining a perfect balance.

Support Surfaces

Support surfaces are also very important when trying to prevent pressure ulcers.

Everyone has some sort of force or pressure on a body part at any given time. In bed bound

patients, the areas that experience the most pressure are the bony prominences (Mallah, 2015).

The whole idea with the support surfaces is to redistribute the pressure on patients in a way that

benefits them the most. A study was done using three different support surfaces. The results

showed no major conclusion in regard to what type of support surface was used; however, the

usage of a support surface does help to prevent pressure ulcers compared to a normal mattress

(Cooper, 2013). Pressure reducing mattresses are another great example. A study that was done

comparing the effectiveness of pressure reducing mattresses and they found that they do reduce

the rate of pressure ulcers. The study showed that these mattresses are a good replacement for

two hour turns where the nursing hours are lower (Cooper, 2013). This does not mean that turns

can be completely forgotten about; these support surfaces can just potentially lengthen the

amount of time between turns. The different types of mattresses do have a flaw; they do not

account for the patients heels. According to Cooper (2013), “Patient’s heels are particularly
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prone to both pressure and shear. When in contact with the bed surface, heels are prone to

pressure ulcers.” This is an easy problem to fix by simply elevating the heels off the bed with a

pillow under the legs.

Nutrition

Nutrition always comes to mind when thinking of pressure ulcers. CMS states that weight

loss, and difficulties with chewing and swallowing are important indicators that a patient may be

at risk for developing a pressure ulcer (Cooper, 2013). This is because if a person is having a

hard time eating they will become malnourished. If they are malnourished they are not getting

the proper amount of fat and protein to protect their body from breakdown. A recent study shows

that 65% of severely malnourished patients developed pressure ulcers whereas slightly

malnourished or properly nourished patients have not developed any pressure areas. (Mallah,

2015). Preventative nutrition is two completely different things in nourished and malnourished

people.

Nourished patients do not need many supplemental vitamins and minerals. According to

Mallah (2015), patients do not benefit from the high protein high fat supplemental drinks or

foods that are commonly given for wound prevention and healing. The main goal in nourished

people is to ensure that they stay nourished. This can be done by monitoring their weight and

keeping track of the calories and amount of food they are taking in. They do not benefit,

however, from overloading them with vitamins and minerals.

Protein drinks are very important in malnourished patients. Cooper (2013) states, “A low

albumin level is an indicator of malnutrition (normal levels, 36–52 g/L). Prealbumin levels

(normal level, 16–35 mg/dL) may be a reflection of current nutritional status.” This can be

prevented by ensuring that they are eating the correct amount of food daily and monitoring their
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appetite. If that does not work, providing these patients with supplements that give them their

daily amount of protein, fat, vitamins and minerals will be sure to increase their daily levels.

Braden Scale

The Braden Scale was developed in 1987 and is used to predict patients’ risk for

developing pressure ulcers. It has been proven by many sources that it works effectively.

According to Choi, J., Choi, J., & Kim, H. (2014), patient characteristics can be interpreted in

different ways depending on the nurse, which in return can potentially skew the Braden Scales’

reliability. The Braden Scale “rates patients on six risk factors: sensory perception, nutrition,

activity, mobility, skin moisture, and presence of friction, and shearing force” (pg. 337). If the

patient characteristic was, for example, “skin is often, but not always moist,” nurses can interpret

that meaning in several different ways (Choi et al., 2014). “Accurately and reliably assessing

pressure-ulcer risk with the Braden Scale has been shown to depend on a comprehensive

understanding of patient status and correct application of patient characteristics as defined for

each scale parameter” (pg. 338). Nurses need to be properly trained on how to interpret patient

characteristics and on how to use the Braden Scale in order for prevention of pressure ulcers to

occur. According to Demarre et al. (2014), there are many factors contributing to the

development of pressure ulcers. “The admission to an internal medicine ward, incontinence-

associated dermatitis, non-bleachable erythema and a lower Braden score (<17) were associated

with the development of superficial pressure ulcers” (Demarre et al., 2014, pg. 392). With

knowing now that these factors contribute to the development of pressure ulcers, it is especially

important to know how to properly use and interpret the Braden scale.

Medicaid
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Prevention of pressure ulcers is a high priority in health care today. According to

Gammon et al. (2016), “Pressure ulcers are one of the most costly hospital-acquired conditions,

resulting in $11 billion per year in direct and indirect costs.” Medicare no longer pays for stage 3

or 4 hospital-acquired pressure ulcers, (Gammon et al., 2016), so that is why prevention of

pressure ulcers and the use of the Braden Scale, as well as turning patients every two hours is so

important. Since this change in Medicare reimbursement, there have been many studies done to

see the correlation between hospital-acquired conditions and Medicare reimbursement.

According to Wald, H., Richard, A., Vaughan, D., and Capezuti, E., (2012), prevention of all

hospital-acquired conditions has since been the focus of the 14 hospitals in their study. “Pressure

ulcer detection and documentation became a larger focus streaming from the policy change”

(Wald et al., 2012 p. 1). Turning and repositioning the patient every two to four hours, proper

hygiene and nutrition are all ways of preventing pressure ulcers.

Conclusion

When addressing how does turning and repositioning patients every 2 hours as compared

to every 4 hours effect the development of pressure ulcers in the health care setting, recent

studies have shown that there is not a significant difference between turning a patient every 2, 3

or 4 hours. It is not until you reach the 6 hour interval that damage begins. The traditional 2 hour

turn rule is outdated seeing as it was developed in the sixties. In the past fifty years evidence

based practice has allowed nursing the additional steps to prevent pressure ulcers form occurring

by ensuring the patients nutritional status is adequate, assessing high risk patients with the

Braden scale, new high density alternating pressure mattresses and advances in skin care that

contribute to the wellbeing of the patients. In conclusion, there is no significant difference

between turning a patient every 2 hours compared to every 4 hours.

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References

Bergstorm, N., Horn, S., Rapp, M., Stern, A., Barret, R., Watkiss, M., & Krahn, M. (2014).

Preventing pressure ulcers: A multisite randomized controlled trial in nursing homes.

Ontario Health Technology Assessment Series, 14, 1-32. Retrieved from

http://pubmedcentralcanada.ca/pmcc/articles/PMC4552218/

Choi, J., Choi, J., & Kim, H. (2014). Nurses’ interpretation of patient status descriptions on the

Braden Scale. Clinical Nursing Research, 23, 336-346. doi: 10.1177/1054773813486477

Cooper, K. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit.

Critical Care Nurse, 33,57-66. doi:10.4037/ccn2013985

Demarre, L., Verhaeghe, S., Hacke, A., Clays, E., Grypdonck, M., & Beeckman, D. (2014).

Factors predicting the development of pressure ulcers in an at-risk population who

receive standardized preventive care. Journal of Advanced Nursing, 71, 391-403. doi:

10.1111/JAN.12497

Gammon, H., Shelton, C., Siegert, C., Dawson, C., Sexton, E., Burmeister, C., Gnam, G., &

Siddiqiu, A. (2016). Self-turning for pressure injury prevention. Wound Medicine, 12, 15-

18. doi: 10.1016/J.WNDM.2016.02.005

Gillepsie, B., Chaboyer, W., McInnes, E., Kent, B., Whitty, J., & Thalia, L. (2014).

Repositioning for pressure ulcers prevention in adults. Cochrane Database of Systematic

Reviews, 4. doi:10.1002/14651858.CD009958

Molnlycke Health Care. (2015). The pressure is on. Norcross, GA. (pp.1-6)

Wald, H., Richard, A., Dickson, V., & Capezuti, E. (2012). Chier nursing officers’ prespective

on Medicare’s hospital-acquired conditions non-payment policy. Implementation Science,

7, 78. doi: 10.1186/1748-5908-7-78