[ANSWERED] The literature review describes and analyzes previous research on the topic or a gap in information that your project may fill

Literature Review

The literature review describes and analyzes previous research on the topic or a gap in information that your project may fill. This chapter, however, should not merely string together what other researchers have found. Rather, you should discuss and analyze the body of knowledge with the ultimate goal of determining what is known and is not known about the topic.

This section should contain a discussion of OTHER PEOPLE’s research. This is not the section to include information about your project. Do not include your own opinions or findings from your project. Begin by describing which databases you searched, search terms you used, how you narrowed your search, how you selected those references you will discuss in this section.

The Literature Review is what others have written that provide a foundation to the content of your project and support for the method you chose for delivery–does that help to expand it? A well-written Literature Review section demonstrates to the reader that you are expert in the problem and that you examined current, best practice to inform your project.

The Literature Review should begin with a paragraph that describes which databases you searched, which search terms you used, which strategies you used, and what you yielded. This shows the extent of your search. This section should be at least 10 pages and should have at least 30 sources. The content of this chapter should be separated with APA first and second level headings.

Expert Answer and Explanation

Literature Review

A literature review is an important section of any quality improvement project. A literature review helps a project manager understand existing studies and discuss the significance of a particular area or topic of study. In other words, conducting a literature review helps the project manager build knowledge in the study area. This project focuses on pressure ulcers in older adults in the geriatric department. The clinical question that guides this literature review is; in older people in the senior department, does educating nurses about strategies to prevent pressure ulcers reduce the incidences of the condition in a nursing home. The geriatric department is the project’s focus because statistics show that the prevalence of pressure ulcers is high among patients in this unit. Lindhardt et al. (2020) reported that 70% of pressure ulcers are experienced in people aged 65 years and above. This literature review will improve the project manager’s knowledge of existing studies regarding pressure ulcers and the theoretical framework that can guide the implementation of the project.

Literature Search Strategy 

A literature search was significant to this project. The search helped the project team identify peer-reviewed articles that could be used to develop the project’s background and support the proposed solution. The following is the literature search strategy employed. The first step was identifying the research question that could be used as the basis of the search. The PICOT question was used as the research question during the search. The PICOT question was; in older people in the geriatric department, does educate nurses about strategies to prevent pressure ulcers reduce the incidences of the condition in a nursing home. The second step was developing the keywords that would be typed when searching for the articles. Some of the keywords used include pressure ulcer prevention strategies, effects of patient education on pressure ulcer rate, education about pressure ulcers, and pressure ulcers incidences. A Boolean strategy was used to connect the keywords to improve the search. Articles included in the search are the ones published from 2018 to 2022. The last step was identifying the databases that the search would be conducted. Three databases were used to search, including Nursing Reference Center Plus, PubMed, and CINAHL Plus with Full Text.

Pressure Ulcers 

A pressure ulcer (PU) is an injury on the skin or underlying tissue caused by constant pressure on these body parts. PU is often common in bony prominences such as the sacrum, ischial tuberosities, heels, greater trochanters, and lateral malleoli. For people who use wheelchairs, PU often occurs over the spine and shoulder blades, tailbone, backs of legs and arms (Gourlan et al., 2020). PU occurs on shoulder blades, sides or back of the head, tailbone, hip, lower back, and skin behind the knees for those who stay in bed. The symptoms of the condition depend on its category. The symptoms of category one PU include itchiness and pain in the affected area, discolored patches that do not turn white when pressed and discolored part of the skin (Gaspar et al., 2021). The symptom of category two pressure ulcers is an open blister or wound. The wound will go deep into the skin layers if the disease reaches category three. Category four PU has very deep wounds that may reach bone or muscle. Palese et al. (2017) argued that the disease is caused mainly by lying in bed for prolonged periods, especially lying on one side of the body for a long time. Lying in bed for prolonged periods reduces blood flow to tissues and thus damaging the skin nearby.

Prevalence and Incidences of Pressure Ulcers 

A pressure ulcer is a worldwide healthcare problem occurring in almost half of the healthcare settings across the globe. According to Afzali Borojeny et al. (2020), PU remains one of the global’s primary health concerns. According to the authors, in every one million patients with pressure ulcers, about 65 000 them die from the condition. The condition is considered an adverse effect by the Agency for Healthcare Research and Quality (AHRQ). The agency reported that the US health department reports more than 2.5 million cases of PU in the country. The agency also reports that PU causes nearly 60 000 deaths in the US yearly. Up to half of the healthcare facilities in the US have reports of pressure ulcers. Senmar et al. (2017) report that 0% ton7% of PU occurs in-home care settings, 0.4% to 8% in acute care, and 2% to 24% occur in long-term care settings. The authors also confirm that PU is a major threat to the US healthcare system and global public health.

The first and second stages of PU are the most reported in healthcare facilities. Afzali Borojeny et al. (2020) noted that the incidence rates of first and second PU stages were 45% (95% CI: 34–56) and 45% (95% CI: 34–56). The incidences of the third stage were 4% (95% CI: 3–5), and the fourth stage was 4% (95% CI: 2–6). The authors also reported that inpatients in the orthopedic surgery ward reported the highest incidences of PU 18.5%) (95% CI: 11.5–25). Senmar et al. (2017) noted that pressure ulcers are more common in older people than in other populations. The study showed that 91% of patients in the geriatric care home they visited had pressure ulcers. These reports show that healthcare providers should focus on improving the health of older patients by ensuring that they do not develop PU in their care.

Risk Factors for Pressure Ulcers 

There are many risk factors for pressure ulcers. One of the risk factors is immobility. According to Lindhardt et al. (2020), immobile people most of the time risk developing PU in various parts of the skin. The authors noted that immobility might be caused by spinal cord injury, physical disability, poor health, and many other issues. The second risk factor is urinary incontinence. According to Lavallée et al. (2018), urinary incontinence is a common and embarrassing problem, especially in older adults. A person with this problem often experiences urine leaks when sneezing, coughing, or laughing. It also causes a strong urge to urinate and prevents one from getting to the washroom on time (Gourlan et al., 2020). The urinary incontinence makes the affected skin more vulnerable to extended exposure to stool and urine.

The third risk factor is lack of sensory perception. Diseases that can lead to a lack of sensory sensation include neurological disorders, brain injury, spinal cord injury, and other conditions (Gourlan et al., 2020). Inability to feel discomfort or pain can make one unaware of warning signs of sores in their skin and the need to change position. PU can develop in people who cannot feel discomfort or pain without knowing. The fourth risk factor is poor hydration and nutrition. According to Gaspar et al. (2021), people need proteins, calories, fluids, minerals, and vitamins in their daily diets to develop and maintain healthy skin. Healthy skin prevents skin tissues from breaking down. In other words, the authors note that people who are not well hydrated or nourished risk developing PU.

The fifth risk factor is medical conditions affecting blood flow in the body. People with help problems that affect how the blood flows in the body risk developing PU (Lavallée et al., 2018). Another risk factor is diabetes. Diabetes is known for increasing tissue damage and thus making it easy for patients with diabetes to develop PU. Age is also a risk factor. According to Gaspar et al. (2021), PU is more prone in people aged 65 years and above compared to other populations. Age is also linked to diseases that make people immobile, making it a risk factor for PU (Gourlan et al., 2020). Peripheral vascular disease is also a risk factor for PU. The peripheral vascular disease makes people susceptible to pressure ulcers by blocking blood circulation around the skin organ.

González‐Méndez et al. (2018) report that being in the intensive care unit. Patients in ICU are often bedridden and cannot move. These patients often put pressure on specific skin parts, making it vulnerable to PU. Bedfast also makes one risk of developing PU. Bedfast is the inability of a person to leave the bed due to comorbidity or physical inability. One can stay in bed because of old age or chronic disease. People of nonwhite race risk PU compared to their white counterparts. Gunningberg et al. (2017) reported that as nonwhite person ages, the risk of PU becomes high. Other risk factors include bed mobility self-performance, nonroutine assessment, male gender, transfer self-performance, deterioration in cognitive status, falls, skin infections, a hip fracture within 180 days, obesity, end-stage disease, edema, and history of resolved PU.

Complications of Pressure Ulcers 

People with pressure ulcers risk suffering many health problems. The first complication is cellulitis. Bazaliński et al. (2018) note that cellulitis is a skin infection that affects skin tissues. The infection causes swelling, inflammation, and warmth in the affected area. Individuals whose nerves are damaged hardly note the infection. The disease can develop from bedsores or PU, which is not treated. The second complication is joint and bone infections. Papp (2019) noted that an infection from PU can spread to the bones and joints. Bone infections (septic arthritis) can damage tissue and cartilage. Infections affecting the bone (osteomyelitis) can lead to reduced functions of the limbs and joints. If noted and treated, the long-term nonhealing wounds, also known as Marjolin’s ulcers, can lead to cancer development (Alfonso et al., 2019). In other words, PU can lead to the development of skin cancer if not treated on time. Another complication is sepsis. Sepsis occurs when the body extremely reacts to the infection in the body (Espejo et al., 2018). PU is an infection and can lead to sepsis if the body severely reacts to it. The last complication is mental health problems. PU can lead to mental health problems by making one feel too much pain. A patient will develop stress when they think of PU and how it will make the feel pain.

Prevention Strategies for Pressure Ulcers 

PU can be prevented in many ways. One of the ways is skincare. Nurses can care for patients’ skin by keeping it dry and clean, avoiding rubbing a patient’s skin vigorously, investigating and managing incontinence, a pH appropriate skin cleanser and dry, applying barrier cream, and using chlorhexidine wipes daily ONLY around open wounds, CVC sites, and open sternotomies (Ledger et al., 2020, Avşar & Karadağ, 2018, Samuriwo, 2019). The second strategy is the redistribution of pressure. Nurses should use devices for releasing pressure that are appropriate to the patient to redistribute pressure. Pressure can also be redistributed by repositioning patients safely and often (Shikama et al., 2018). The third strategy is positioning and repositioning patients. PU can also be prevented by repositioning equipment (Sprigle et al., 2019, Moore et al., 2020). Lastly, pressure redistributing equipment can be used to prevent PU.

Proposed Intervention  

The proposed intervention is educating nurses on PU prevention strategies. Various studies have supported this intervention. Kim et al. (2020) argued that PU training could improve nurses’ knowledge of caring for patients with PU. The authors noted that the results from the study showed that education programs might help nurses improve clinical judgment, visual discrimination ability, and knowledge, making them fit to handle patients and prevent PU in hospital settings. The authors noted that larger studies should be conducted to confirm their conclusions. Seo and Roh (2020) also supported nursing education as an intervention to prevent PU in healthcare settings. The authors found that nurses who are well-trained in caring for patients and preventing PU have vast knowledge on how to ensure that the problem does not occur in healthcare facilities. According to the authors, nurses engaged in the PU prevention education program had higher scores for PU prevention behaviors, knowledge, and attitude than before the program was implemented.

The authors concluded that PU prevention education, regardless of whether it is conducted in lecture-based learning or team-based learning, is vital in improving nurses’ behaviors, knowledge, and attitudes about PU prevention. The authors, however, recommended that further studies should be conducted to determine the effect of education on incidences of PU among patients and nurses’ actual performance. Ebi et al. (2019) also support the proposed intervention. The authors conducted their study using a descriptive multicenter cross-sectional study design applying a quantitative method. The authors linked incidences of PU in hospital settings to nurses’ lack of knowledge of the condition. They concluded their study by noting that increasing regular adequate training of nurses about PU and its prevention points can hugely reduce incidences of PU in healthcare facilities.

Another article that supported that intervention was done by Grešš Halász et al. (2021). The authors noted that nurses with a lack of knowledge about PU had a low attitude towards preventing the condition. There should be a positive correlation between sufficient knowledge and a positive attitude towards PU prevention. In other words, the authors found that nurse education about PU increased their attitude about preventing the condition. Awad and Hewi (2020) also found a positive correlation between nursing education on PU and low incidences of the condition in healthcare facilities. The authors noted that educating nurses is an important prevention measure of PU. Sardari et al. (2019) also support the intervention.

The authors found that nurses’ performance regarding PU prevention is low, and a training program for PU can improve their performance in preventing the condition. Tirgari et al. (2018) noted that PU prevention is a priority for many health organizations and a key measure of the quality of care. This measure can be achieved by improving nursing knowledge and attitudes towards PU prevention. Saleh et al. (2019) noted that many nurses had PU knowledge, but only a few implemented it. Therefore, they recommended that nurses be motivated to implement PU prevention knowledge they have to improve the patients’ quality of care. In summary, the proposed intervention is evidence-based because many high-quality evidence supports it.

Theoretical Framework

Two theories will be the basis for this project: nursing and non-nursing. The nursing theory used in the project is the nursing process theory. This theory was designed by Ida Jean Orlando from research done at the Yale University School of Nursing. The study integrated mental health concepts into the nursing science curriculum. The theory proposes that “patients have their meanings and interpretations of situations and therefore nurses must validate their inferences and analyses with patients before concluding (Orlando, 1961, p. 9).” The theory has three major concepts: nursing, health, and person. According to the theory, the nursing practice should focus on humans in need. The theory sees health as a sense of helplessness and makes nursing practice necessary. According to the theory, nursing is meant for people who need help (Orlando, 1061). Orlando defines nursing as an independent and unique practice to solve patients’ immediate situations. This theory’s concepts highly correspond to the purpose of the project. The patients are humans, and they need immediate nursing help because they have pressure ulcers.

The second theory will be Lewin’s change management theory. This theory has been used for decades to introduce and manage change. The theory argues that change can be implemented in three stages. The first stage is the “unfreeze” stage (Lewin, 1951). In this stage, the project manager is tasked with letting people know of the change. The project manager should explain why they should accept the new norm to the stakeholders. Regarding the project, the project manager will explain to the stakeholders why PU should be prevented. The second stage is “change.” In this stage, the project manager will initiate change and help the organization move from old ways to new ones. The project manager will implement the change (Lewin, 1951). The last step is “refreeze.” The change manager’s role in this phase is to establish the change as the new norm and make it a standard operating procedure. The project manager should monitor the stakeholders to ensure that they do not return to their old ways.


This literature review has improved the project manager’s knowledge of existing studies regarding pressure ulcers and the theoretical framework that can guide the implementation of the project. Pressure ulcers are a global problem. Their risk factors include immobility, urinary incontinence, lack of sensory perception, poor hydration and nutrition, medical conditions affecting blood flow in the body, and many more. Complications of PU include cellulitis, joint and bone infections, skin cancer, sepsis, and mental health problems. It can be prevented through skincare, redistribution of pressure, positioning and repositioning of patients, and use of redistributing equipment. Studies have shown that the proposed intervention is evidence-based and effective in preventing PU. The theories used in the project are the nursing process theory and Lewin’s change management theory.


Afzali Borojeny, L., Albatineh, A. N., Hasanpour Dehkordi, A., & Ghanei Gheshlagh, R. (2020). The incidence of pressure ulcers and its associations in different wards of the hospital: A systematic review and meta-analysis. International Journal Of Preventive Medicine, 11, 171. https://doi.org/10.4103/ijpvm.IJPVM_182_19

Agency for Healthcare Research and Quality. (n.d). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html

Alfonso, A. R., Kantar, R. S., Ramly, E. P., Daar, D. A., Rifkin, W. J., Levine, J. P., & Ceradini, D. J. (2019). Diabetes is associated with an increased risk of wound complications and readmission in patients with surgically managed pressure ulcers. Wound Repair and Regeneration, 27(3), 249-256. https://doi.org/10.1111/wrr.12694

Avşar, P., & Karadağ, A. (2018). Efficacy and cost‐effectiveness analysis of evidence‐based nursing interventions to maintain tissue integrity to prevent pressure ulcers and incontinence‐associated dermatitis. Worldviews on Evidence‐Based Nursing, 15(1), 54-61. https://doi.org/10.1111/wvn.12264

Awad, W. H. A., & Hewi, S. A. H. (2020). Effect of pressure ulcer preventive nursing interventions on knowledge, attitudes and practices of nurses among hospitalized geriatric patients in Alexandria, Egypt. J Nurs Health Sci, 9(2), 1-12. https://d1wqtxts1xzle7.cloudfront.net/62964079/A090206011220200415-81605

Bazaliński, D., Więch, P., Kaczmarska, D., Sałacińska, I., & Kózka, M. (2018). Use of controlled negative pressure in management of phlegmon caused by fulminant complication of pressure wound: A case report. Medicine, 97(28). https://dx.doi.org/10.1097%2FMD.0000000000011319

Chung, M. L., Widdel, M., Kirchhoff, J., Sellin, J., Jelali, M., Geiser, F., … & Conrad, R. (2022). Risk factors for pressure ulcers in adult patients: A meta‐analysis on sociodemographic factors and the Braden scale. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16260

Ebi, W. E., Hirko, G. F., & Mijena, D. A. (2019). Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: A cross-sectional study design. BMC Nursing, 18(1), 1-12. https://doi.org/10.1186/s12912-019-0346-y

Espejo, E., Andrés, M., Borrallo, R. M., Padilla, E., Garcia-Restoy, E., & Bella, F. (2018). Bacteremia associated with pressure ulcers: A prospective cohort study. European Journal of Clinical Microbiology & Infectious Diseases, 37(5), 969-975. https://doi.org/10.1007/s10096-018-3216-8

Gaspar, S., Botelho Guedes, F., Vitoriano Budri, A. M., Ferreira, C., & Gaspar de Matos, M. (2021). Hospital‐acquired pressure ulcers prevention: What is needed for patient safety? The perceptions of nurse stakeholders. Scandinavian Journal of Caring Sciences.

González‐Méndez, M. I., Lima‐Serrano, M., Martín‐Castaño, C., Alonso‐Araujo, I., & Lima‐Rodríguez, J. S. (2018). Incidence and risk factors associated with the development of pressure ulcers in an intensive care unit. Journal of Clinical Nursing, 27(5-6), 1028-1037. https://doi.org/10.1111/jocn.14091

Gourlan, M., Pellechia, A., Robineau, S., Foulon, B., Gault, D., Lefort, M., … & Gelis, A. (2020). “What pressure ulcers mean to me?” Representations of pressure ulcer in persons with spinal cord injury: A qualitative study. Journal of Tissue Viability, 29(4), 324-330. https://doi.org/10.1016/j.jtv.2020.07.002

Grešš Halász, B., Bérešová, A., Tkáčová, Ľ., Magurová, D., & Lizáková, Ľ. (2021). Nurses’ knowledge and attitudes towards prevention of pressure ulcers. International Journal of Environmental Research and Public Health, 18(4), 1705. https://doi.org/10.3390/ijerph18041705

Gunningberg, L., Sedin, I. M., Andersson, S., & Pingel, R. (2017). Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial. International Journal Of Nursing Studies, 72, 53–59. https://doi.org/10.1016/j.ijnurstu.2017.04.007

Hultin, L., Gunningberg, L., Coleman, S., & Karlsson, A. C. (2022). Pressure ulcer risk assessment—registered nurses´ experiences of using PURPOSE T: A focus group study. Journal of Clinical Nursing, 31(1-2), 231-239. https://doi.org/10.1111/jocn.15901

Kim, G., Park, M., & Kim, K. (2020). The effect of pressure injury training for nurses: a systematic review and meta-analysis. Advances in Skin & Wound Care, 33(3), 1-11. doi: 10.1097/01.ASW.0000653164.21235.27

Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2018). Barriers and facilitators to preventing pressure ulcers in nursing home residents: A qualitative analysis informed by the Theoretical Domains Framework. International Journal of Nursing Studies, 82, 79-89. https://doi.org/10.1016/j.ijnurstu.2017.12.015

Ledger, L., Worsley, P., Hope, J., & Schoonhoven, L. (2020). Patient involvement in pressure ulcer prevention and adherence to prevention strategies: An integrative review. International Journal of Nursing Studies, 101, 103449. https://doi.org/10.1016/j.ijnurstu.2019.103449

Lewin, K. (1951). Field theory in social science: selected theoretical papers (Edited by Dorwin Cartwright.).

Lindhardt, C. L., Beck, S. H., & Ryg, J. (2020). Nursing care for older patients with pressure ulcers: A qualitative study. Nursing Open, 7(4), 1020-1025. https://doi.org/10.1002/nop2.474

Moore, Z., Patton, D., Avsar, P., McEvoy, N. L., Curley, G., Budri, A., … & O’Connor, T. (2020). Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the COVID-19 emergency. Journal of Wound Care, 29(6), 312-320. https://doi.org/10.12968/jowc.2020.29.6.312

Orlando, I.J. (1961) The dynamic nurse-patientrelationship. New York: Putnam’s.

Palese, A., Trevisani, B., Guarnier, A., Barelli, P., Zambiasi, P., Allegrini, E., Bazoli, L., Casson, P., Marin, M., Padovan, M., Picogna, M., Taddia, P., Salmaso, D., Chiari, P., Marognolli, O., Federica, C., Saiani, L., & Ambrosi, E. (2017). Prevalence and incidence density of unavoidable pressure ulcers in elderly patients admitted to medical units. Journal of Tissue Viability, 26(2), 85–88. https://doi.org/10.1016/j.jtv.2017.03.003

Papp, A. A. (2019). Incisional negative pressure therapy reduces complications and costs in pressure ulcer reconstruction. International Wound Journal, 16(2), 394-400. https://doi.org/10.1111/iwj.13045

Saleh, M. Y., Papanikolaou, P., Nassar, O. S., Shahin, A., & Anthony, D. (2019). Nurses’ knowledge and practice of pressure ulcer prevention and treatment: An observational study. Journal of Tissue Viability, 28(4), 210-217. https://doi.org/10.1016/j.jtv.2019.10.005

Samuriwo, R. (2019). Enhancing end-of-life skin care to prevent pressure ulcers in primary care: Key considerations for nurses. Journal of Community Nursing, 33(3), 56-60. https://orca.cardiff.ac.uk/124078/

Sardari, M., Esmaeili, R., Ravesh, N. N., & Nasiri, M. (2019). The impact of pressure ulcer training program on nurses’ performance. Journal of Advanced Pharmacy Education &, 3. https://japer.in/storage/models/article/cwlywYTJEfUwrgtzsY0M4F3uIC69x5wRBwDRhONenm6NPIqj3eP8CR0JYsHB/the-impact-of-pressure-ulcer-training-program-on-nurses-performance-over-the-pressure-ulcer-preven.pdf

Senmar, M., Azimian, J., Rafiei, H., Habibollahpour, M., & Yousefi, F. (2017). The incidence of pressure ulcer in old patients undergoing open heart surgery and the relevant factors. Journal of Preventive Epidemiology, 2(2), e15-e15. https://jprevepi.com/Article/jpe-46

Seo, Y., & Roh, Y. S. (2020). Effects of pressure ulcer prevention training among nurses in long-term care hospitals. Nurse Education Today, 84, 104225.

Shikama, M., Nakagami, G., Noguchi, H., Mori, T., & Sanada, H. (2018). Development of personalized fitting device with 3-dimensional solution for prevention of NIV oronasal mask-related pressure ulcers. Respiratory Care, 63(8), 1024-1032. http://rc.rcjournal.com/content/63/8/1024.short

Sprigle, S., Sonenblum, S. E., & Feng, C. (2019). Pressure redistributing in-seat movement activities by persons with spinal cord injury over multiple epochs. PloS one, 14(2), e0210978. https://doi.org/10.1371/journal.pone.0210978

Tirgari, B., Mirshekari, L., & Forouzi, M. A. (2018). Pressure injury prevention: Knowledge and attitudes of Iranian intensive care nurses. Advances in Skin & Wound Care, 31(4), 1-8. https://journals.lww.com/aswcjournal/FullText/2018/04000/Pressure_Injury_Prevention__Knowledge_and.13.aspx

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