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i) Formulate a clinical question from a set of pre-determined topics
ii) Employing the PICO1 method, refine your clinical question and perform a search of a nursing/health science database, i.e. CINAHL or MEDLINE only (NOT Google Scholar, Joanna Briggs Institute or Cochrane databases). Briefly report your search structure and results.
iii) Identify one paper that best answers your PICO question and undertake a structured appraisal of the paper
iv) Report the process from devising your clinical question through to the findings of your appraisal of the chosen paper.

Background

With the growing population of older adults, wound care management is highlighted as a significant issue in the clinical setting (Demarre et al., 2015).   In the hospital setting, Pressure ulcer is identified as one of the chronic issues, especially, Lower extremity deep vein thrombosis which breaks down the skin and underlying issue when an area is placed under constant pressure older adults. As reported by Demarré et al. (2015), the estimated pressure injury prevalence in Australia in the hospital is from 9.5% to 17.6%. In 2015   in New South Wales 1, 195 individuals were with pressure injury was a diagnosis, highlighting one per 10 people in the population was affected (Qaseem et al., 2015). Out of all pressure injury, the incidents of deep vein thrombosis in Australia is high , approximately 160 per 100000 and 14,000 new cases are diagnosed every year (Edsberg et al., 2016).  The purpose of the paper is to evaluate the effectiveness of compressed stockings therapy in managing pressure ulcers among older adults. This paper will illustrate the search methodology of paper, a summary of the paper, critically appraise the paper and lastly,   the relevance of paper in clinical practice in the following paragraph. The Pico Question: What is the effectiveness of compressed stockings therapy in managing pressure ulcers among older adults?

Population

Older Adults with pressure ulcers 

Intervention

 Compressed Stockings 

Comparison

No intervention 

Outcome

 Improved outcome in pressure ulcer management 

In order to gain the answer of the PICO question, the most appropriate nature of the study is quantitative study since it provides the relevant and possible results which  will further assist to gain the  understanding of graduated compression stockings in management and prevention of pressure ulcer the clinical setting (Brannen, 2017). The research was conducted using various electronic databases such as CINAHL, Medline, PubMed for gaining the accurate result of a PICO question. The key term used for the research includes “ pressure ulcer”,  “ role of Graduated compression stockings“, “  Lower extremity deep vein thrombosis in the post-operative patient“. Boolean operators were used for connecting and defining the relationship between search terms. Two boolean operators were used AND and OR to obtain an accurate answer. AND was used to narrowing the search term which was present in the retrieved record whereas  OR  was used to broadening the search term by connecting two or more synonyms.  There was specific inclusion and exclusion criteria were chosen as a roadmap for evaluating the efficiency of the health hygiene tool compared to the regular protocol. The inclusion and exclusion criteria are the following:

Inclusion criteria

Exclusion criteria

· All relevant journals included were published within last 8 years

· All relevant journals  which  were  included in the  research were peer review journal

· All relevant articles which were included in the research were published in English language.

· All relevant papers undertaking the management of pressure ulcer were included in the study.

· All relevant paper that  can be  apprised check list of CASP tool were  included in the study

· All relevant paper that undertaken primary studies were included.

 

· All  relevant journal than  8 years were  excluded

· All non-reviewed articles were excluded

· All articles published in other than English article were excluded.

· All relevant paper   undertaking other than the management of pressure ulcer were excluded.

· All relevant paper that   cannot  be  apprised check list of CASP tool were  included in the study

· All relevant paper that was undertaken studies other than primary studies were excluded.

Search Methodology

Once search terms were given the databases were given a total of 119 pages were found in one search and 5423 journals were identified which further filtered for eliminating duplication (appendix 1). All the secondary studies were eliminated.  After elimination of all irrelevant articles, one article was identified with the help of a specific set of questions of  CASP tool for comprehensive study which would further provide the literature for clinical practice ( appendix 2).

The paper was chosen because the paper is peer-reviewed and researchers have undertaken randomized led trial as a primary study which is a level one of evidence.  Moreover,   the paper can assist to compare between two different interventions because of the nature of the study and the result shows minimum biases which is crucial for the accurate result.

The aim of the paper is to evaluate whether compressed stockings are effective in management of   Lower extremity deep vein thrombosis by comparing three GCS with different sizes and pressures and to analyze the efficacies of the GCS in relation to postoperative patient which further will help to address the PICO question (What is the effectiveness of compressed stockings therapy in managing pressure ulcers among older adults?). 

Ayhan et al. (2015), conducted a randomized control trial as a quantitative study to identify the efficiency of the graduated compression stockings in the management of postoperative DVT.    As discussed by McCusker and Gunaydin (2015), Quantitative study provides systematic empirical investigations of the observational phenomena via statistical mathematical or computation technique. Hence, the study design was appropriate for the study.

219 post-operative patients were randomized into three groups each with 73 participants. Group I was provided with knee-length graduated compression stockings of low-pressure, group II provided with thigh-length graduated compression stockings of low-pressure, and group III was provided with knee-length graduated compression stocking of moderate-pressure,.  Ayhan et al. (2015), conducted the study general surgery obstetrics,  urology units and gynecology of a training and research hospital in Ankara, Turkey. The selection criteria for the study are the following:

  •    18 years of age
  •    No history of preoperative anticoagulation
  •    undergoing abdominal–pelvic surgery
  •     having high risk factors of development of postoperative DVT

To conduct research adequately, 219 individuals are an inadequate sample size to compare the effectiveness of the different graduated compression stockings.

Initially, the DVT risk of the patients and sociodemographic data were collected and the result was collected based on the primary and secondary outcome. To evaluate the comfort level and efficacy of the graduated compression stocking in post-operative patients, the researcher analyzed every morning for each participant whether there was any problem of roll down, redness, edema or pressure ulcer in the toes during neurovascular assessment and if any problem observed when the data was recorded in the collection form. Moreover, the patients were enquired they had any problems with the GCS, these problems were recorded if patient stated any problem. The GSC comfort level measurement was collected based on the four points scale.  Since researchers undertook both verbal inquiry and the evaluation through the assessment tool, it is an appropriate way of collecting data without any potential bias (Barnham, 2015).

Summary of the Paper

The data analysis was sufficiently rigorous for the in-depth research for obtaining an accurate result from the study. Ayhan et al. (2015), used the Statistical Package of Social Sciences version 15.0 package program for data analysis which includes numerical variables which were expressed as percentage and numbers and quantitative variables are used as the mean median and mode.  The consistency of the calculated data was compared with the normal range with the help of one sample Kolmogorov–Smirnov test. The mean age between three groups was evaluated using one way ANOVA and to compare between other parameters and the health Kruskal–Wallis test. Lastly, to determine the correlation between the numerical variables the chi-square test was used.

In the study conducted by Ayhan et al. (2015),, the parameter of the evaluation was the level of patients comfort regarding the graduated compression stockings and the occurrence of deep vein thrombosis was examined.  The result suggested that 79.9 % of the post-operative patient who wore group III using compression stocking low-pressure, knee-length graduated compression stockings and 52.1 % of the patient in the group using low-pressure, graduated compression stockings of thigh-length were feeling uncomfortable.  The level of significance for both the group III and II was p < 0•001 whereas p-value <0. 05 are accepted as a level of statistical significance.  The patient of group I wearing low-pressure, knee-length graduated compression stocking stated that it was very comfortable. However, no thrombosis was found in any of the groups. In group II, by the 95% confidence intervals problem relative risk was found to be 2.9 times more whereas in group III risk was found to be 4. 4 times more compared to the group I.  

The validity of the study defined as the indication of how sound research is, especially in terms of research method and study design (McNabb, 2015). In the current context, the study conducted by Ayhan et al. (2015) is internally valid since the researchers have taken into consideration randomized control trial which is a level one of evidence to minimize the potential biases and the data collection of the research was adequate where statistical analysis was undertaken for analysis of the patient. However,   only patients with moderate risk of deep vein thrombosis and post-operative patient abdominal and pelvic surgery were taken into consideration. This characteristics further showed the selection bias of the researchers.  Besides, the larger sample size is required with different characteristics of the post-operative patients to evaluate whether graduated compression stocking is effective in management or prevention of pressure ulcer or not (Hartas, 2015).  The study is externally valid since the risk of the deep vein thrombosis in the study participants is similar for all the participants and length of hospital stays was not significantly different among groups. Since, the pressure injury such as deep vein thrombosis does not depend on the demographic, ethnicity and qualification of the participants, the graduated compression stocking, as intervention is effective for other post-operative patients.

Critical Appraisal

Considering the significance of the result, the level of significance for both the group III and II was p < 0•001 whereas p-value <0. 05 is accepted as a level of statistical significance which further suggested that result would be useful for management or prevention of pressure ulcer, especially for deep vein thrombosis using graduated compression stockings of low?pressure, knee?length.   The researchers hypothesized that graduated compression stockings are effective in the management of pressure injury or ulcer.  The prime reason behind it is that a considerate number of the older adults experienced health issues related to the pressure ulcer which further increased their hospital staying since complete healing of wounds requires time.    It can be used as one of the intervention, especially for the prevention of development.

The strength of the study is that researcher conducted randomized control trial which is a best suitable method of quantitative research to compare between different types of pharmacological as well as non-pharmacological interventions which further helped to determine the clinical significance of the study. Another strength of the study is that the study undertook both factual data collection as well as emotional data collection for evaluating the study. However, the study also contains limitation which further provided a scope of further detailed research.   The sample size was limited for examining the effectiveness of DVT protocol in management and prevention of the pressure injury.  Majority of the participants of the study were female and about half of female participants had undergone general surgical operations were high school graduates which further highlighted the selection biases. Selection bias of the study is also observed in selecting participants for the randomized control trial.  The result of the study suggested that although graduated compressed stockings are effective in the post-operative patient, application in patients increase the blood flow who has risk factors of developing a pressure ulcer, not for the patients who already developed a severe pressure ulcer.  The result may be generalized for patients undergoing major abdominal and pelvic surgery as well. Lastly, the research conducted in one clinical setting with specific protocol and regulation which further indicated that the result may vary for another clinical setting with different degree of pressure ulcer development and different characteristics of selected participants.   

Pressure ulcer development observed in the combination of physiological and external conditions which is a highly common phenomenon for the older adults surgeries in their lower extremities (Dissemond et al., 2016).  The biomedical burden of this tremendously high since it requires a prolonged course of interventions to fully heal their wounds.  Therefore, the prevention and treatment of pressure ulcers are highly relevant to wound care professionals.   There is a great risk for DVT development  for patient who are undergoing abdominal and pelvic surgery.  Ayhan et al. (2015) conducted a randomized controlled trial to evaluate whether graduated compression stocking is effective in reducing pressure ulcer and management pressure ulcer by comparing three groups of the stocking with various length, size and an association with the comfort level of the patient. The result suggested that the patient of the group I who had knee length low pressure of graduated compression stockings were highly satisfied which furthers suggested that it can be used as one of the effective intervention in the wound healing and management. The researchers showed that in case of the patient, who was using thigh length, it was difficult for the nurses to remove those compared to the others who were wearing knee length and low pressure and patient stated a high level of satisfaction wearing this.  The research also suggested that although the degree of blood flow increases in vein after using graduated compression stockings as an intervention for the prevention,  no significance of a difference between three types of the graduated compression stockings only it increases the patient satisfaction.  Therefore, accomplished study help to modify rules and regulations along with the clinical practice of the palliative care as well as surgical wards where patients undergo the surgery of lower extremities, abdominal and tumor.  The accomplished study also helps clinical researchers to study in details about the patient of the other hospital to design management. Moreover, research also highlighted that this intervention is effective for the patient who has risk factors of developing deep vein thrombosis indicating that it is effective for a post-operative patient who has the risk factor of developing ulcer not after development. Therefore, in clinical practice, the use of graduated compression stockings of knee?length, low?pressure, may be suggested for the older patient to prevent of postoperative deep vein thrombosis since post-operative patient have few problems while they use these graduated stockings with high satisfaction. The combined use of mechanical and physical methods along with patient education is effective for management of the pressure ulcer.

References:

Ayhan, H., Iyigun, E., Ince, S., Can, M. F., Hatipoglu, S., & Saglam, M. (2015). A randomised clinical trial comparing the patient comfort and efficacy of three different graduated compression stockings in the prevention of postoperative deep vein thrombosis. Journal of clinical nursing, 24(15-16), 2247-2257.  Retrieved from ; https://doi.org/10.1111/jocn.12866

Barnham, C. (2015). Quantitative and qualitative research: Perceptual foundations. International Journal of Market Research, 57(6), 837-854. Retrieved from ; https://journals.sagepub.com/doi/abs/10.2501/IJMR-2015-070

Brannen, J. (2017). Mixing methods: Qualitative and quantitative research. Routledge. Retrieved from: https://www.taylorfrancis.com/books/e/9781351917186

Demarré, L., Van Lancker, A., Van Hecke, A., Verhaeghe, S., Grypdonck, M., Lemey, J., ... & Beeckman, D. (2015). The cost of prevention and treatment of pressure ulcers: a systematic review. International journal of nursing studies, 52(11), 1754-1774. Retrieved from : https://doi.org/10.1016/j.ijnurstu.2015.06.006

Dissemond, J., Assenheimer, B., Bültemann, A., Gerber, V., Gretener, S., Kohler?von Siebenthal, E., ... & Münter, C. (2016). Compression therapy in patients with venous leg ulcers. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 14(11), 1072-1087.  https://doi.org/10.1111/ddg.13091

Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing, 43(6), 585. doi: 10.1097/WON.0000000000000281

Hammersley, M. (2017). Deconstructing the qualitative-quantitative divide 1. In Mixing methods: Qualitative and quantitative research (pp. 39-55). Routledge. retrieved from : https://books.google.co.in/books?hl=en&lr=&id=7LhSBgAAQBAJ&oi=fnd&pg=PR5&dq=qualitative+and+quantitative+approaches&ots=YtiN--DM9l&sig=nzNO2EPs0IwnK7kJu9o7sroQhkA#v=onepage&q=qualitative%20and%20quantitative%20approaches&f=false

Hartas, D. (Ed.). (2015). Educational research and inquiry: Qualitative and quantitative approaches. Bloomsbury Publishing. Retrieved from : https://books.google.co.in/books?hl=en&lr=&id=7LhSBgAAQBAJ&oi=fnd&pg=PR5&dq=qualitative+and+quantitative+approaches&ots=YtiN--DL7q&sig=cQz_H1CF3r_wa19Mt9US1iIgVnE#v=onepage&q=qualitative%20and%20quantitative%20approaches&f=false

McCusker, K., & Gunaydin, S. (2015). Research using qualitative, quantitative or mixed methods and choice based on the research. Perfusion, 30(7), 537-542. Retrieve from : doi=10.1.1.968.2338

McNabb, D. E. (2015). Research methods for political science: Quantitative and qualitative methods. Routledge. retrieved from: https://books.google.co.in/books?hl=en&lr=&id=6CFoDwAAQBAJ&oi=fnd&pg=PP1&dq=+Quantitative+and+qualitative+research:&ots=A-gECB-I08&sig=6lTbh4Tq4_VdZ2wNhbthQJPYkv4#v=onepage&q=Quantitative%20and%20qualitative%20research%3A&f=false

Milic, D. J., Zivic, S., Peric, D., Petrovic, J., & Bogdanovic, D. (2015). A Randomized Trial of Elastic Compression Systems With High and Very High Sub-Bandage Pressure Values in the Prevention of Recurrence of Venous Ulceration. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 3(1), 123. Retrieved from: https://www.jvsvenous.org/article/S2213-333X(14)00199-1/abstract

Qaseem, A., Mir, T. P., Starkey, M., & Denberg, T. D. (2015). Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 162(5), 359-369. Retrived from : https://annals.org/aim/article-abstract/2173505/risk-assessment-prevention-pressure-ulcers-clinical-practice-guideline-from-american

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