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Does two-hourly pressure area care affect sleep?

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10 March, 2014

This week’s Behind the Rituals is from Liz Charalambous, staff nurse at Nottingham University Hospital

We have had a discussion on our ward about how two-hourly pressure area care affects sleep. The tissue viability team has introduced a skin bundle, which prescribes care for patients depending on whether they are classed as red, amber or green.

The latest meta-analysis from the Cochrane Collaboration finds no difference in pressure ulcer prevention when a risk assessment tool is used compared with clinical judgement. However, the current scheme does not allow for clinical judgement to supersede the tool.

What do you think?

I am doing a research study into prevention of delirium, and part of the criteria for preventing delirium is sleep hygiene. This involves ensuring patients get enough sleep.

  • Should clinical judgement override policies in this situation?
  • Is there any evidence to support a decision to do this?

Readers' comments (22)

  • I certainly think it does and it's not just the patient being turned that loses sleep the whole ward or bay does as lights have to be turned on, equipment moved etc.

    The NHS spends £M's on renting these alternating pressure relieving mattresses yet we still perform the ritual of two-hourly turns needlessly.

    Most managers seem to think that nothing really happens at night and I think turns are a way to demonstrate that staff are actually working.

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  • One of my students this week told me that 2 hourly turns originates from the war and the time has just stayed the same, its not evidence based

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  • There is good and bad points to this issues. Where patients are more prone to pressure marking ,turning them 2hrly has reduced their risk factors of developing pressure ulcers. On the other hand sleep is also important to recovery. Each patient is different, mobility, skin integraty,nutrition intake, health condition are important factor. Hospitals are now being fined for hospital acquired pressure ulcers,it could be argued that the focus on pressure care can is impacting on patients sleep and dignity.Having worked on an acute elderly care unit l can see for and against pressure care,most patients requiring pressure care are often immobile or incontinent which puts them at high risk and are check two hourly but others at less risk are also turned just because they may appear they are not turning themselves at night. How can we expect them to comply with rehabilitation if they are tired and would we like to be woken during the night. Bariatric bed are designed to turn patients and do not disturb sleep, would it not be more economical into looking into replacing beds on ward with high risk patients.

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  • The two hourly turns originated in Crimea, because that was the time needed to complete the turns for everyone in the ward.
    On a more serious point, a person who is in REM sleep is unable to move, therefore they wouldn't be able to alter their position. This level of sleep is possibly the most important type of sleep, by disturbing anyone every two hours means they are unable to obtain this.

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  • Respiratory care is also part of this equation as moving people aids air entry into different parts of the lungs helping to prevent chest infections.

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  • it's alright if patients can say no but what about acting in their best interests under mental capacity act 2005? What IS the best thing if they are getting no REM sleep because of turns? Sleep aids skin healing anyway....

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  • It all boils down to benefit and risk. Patients should be turned at least once in the night, if unable to do so themselves. Also, take into account the type of incontinence aid used. Clinical judgement time.

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  • tinkerbell

    waking someone every 2 hours - although not intended is a bit like mental cruelty. I wouldn't like to be woken every 2 hours. Could I opt for 4 hourly at least?

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  • we always carried pa care according to need. if patients needed cleaning and turning every two hours so be it. if they were unable to move themselves or were unconscious it was considered very necessary, others were four hourly and others obviously not at all. we also tried to use the best aids available to avoid such frequent care but even with this there were still a few patients who needed this extra attention and care which we tried to carry out with as little disruption to them as possible. obviously if we could skip one episode of care we would but till needed to check they were clean and dry and in a comfortable position.

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  • quick search shows very little evidence to support 2 hrly turns, everything I read seems to avoid the issue of time, no mention of how often we should turn patients.
    http://www.ncbi.nlm.nih.gov/books/NBK48938/
    lots of evidence here and in depth info but still no time scales. Why do we bother with air mattresses then f we are still turning patients every 2 hours? I think we should let the nurses use their clinical judgement, if patient is incontinent then they may be wet and will need checking anyway

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  • With all the tick boxing these days, it seems we are going full circle and back to task orientation. Whatever happened to individualised patient care?

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  • I agree. there seems to be a return to task orientated nursing, but in a new guise with a penchant for tick boxes which seems to have taken priority over care!

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  • please can somebody explain what these green male signs are which have suddenly started peppering NT articles which if you hover the mouse over you get a little tab 'Click to Continue > by BlockTheAdApp'. If you click one does this block the ads. or does it open up adds all over the place which I have gone though all of my settings numerous times painstakingly trying to remove?

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  • depends on organisational culture. Some nurses say they are too afraid to change 2hrly to 4hrly in case patients gets a sore and they get the blame. Heavy burden of accountability makes nurses play too safe without looking 'peripherally' to weigh up all the consequences.

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  • has care become more dangerous because too much time is taken up by staff trying to stay safe?

    - ie through too much form filling and box ticking, etc. the whole process seems to be stiffing the art, creativity, initiative, professional autonomy, intuitive and rational decision-making and the capacity for nurses to apply their skills in providing individualised patient care - as well as a host of other reasons!

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  • In answering the question of the article I would have to say a definate yes, 2hrly turns does disturb sleep. As a Nursing Home Nurse we rigorously reposition our Clients 2hrly through the night. Our Clients who are confined to bed are repositioned 2hrly over the 24hrs. Some Clients are able to demonstrate their discontent at being woken slightly to ask their consent to alter their position, by hitting out, swearing, screaming, and disagreeing. They settle easily and go back to sleep, but they're sleeps disturbed frequently. I would not like anybody coming into my room and turning me over every 2hrs if I didn't need to be. These Clients get up the next morning and fall straight back to sleep in a chair, but is that surprising, they keep having broken nights. If the mattresses people are on are designed for pressure area care, does that not reduce the need to reposition 2hrly? and extend to 4?. Should we not be able to use our own judgement and evidence, when assessing who is most at risk and therefore would benefit from 2hrly, 4hrly turns?. We use so many assessment tools as it is, so we know who are the most vulnerable, and we assess skin integrity regularly. So wouldn't it be in the best interests of our Clients/Patients, to let them sleep for 4hrs if they have no active pressure sores, areas of reddening?. After all, we all need a good nights sleep for good health, healing and well-being.

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  • any disruptions to sleep affect it!

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  • what about obs. rounds at 5-6 am, and any other interventions during the night if it comes to that, including lights, torches shone in patients faces to see if they are asleep or still alive or nurses walking up and down the wards or clanking in the kitchens or chatting in corridors or at their station? or even other patients who can be noisy or even the snorers? hospital isn't exactly a peaceful or ideal place to recuperate!

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  • ... not to mention other work carried on during the night, early morning cleaners, people turning up to work on early shifts chatting outside, early morning deliveries,, noise from carparks, etc.

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  • I agree, noise can impede on an individuals sleep, but there are ways of minimising noise (and light), to aide a good nights sleep. Plus, once an individual enters REM sleep, noise and light don't usually affect them. My response to the question at hand, which is "Does 2hrly Pressure Area Care Affect Sleep" is, absolutely. Waking somebody intentionally, no matter how gently you try, to ask their consent to reposition them, is waking them, and you have to wake them to manage their pressure areas. They're usually disorientated and may even be unsure what they're consenting to, as they've just been woken. Wouldn't it be in the best interests of the individual for Nurses to use clinical judgment, assessment tools and knowledge of mattresses (and the person where appropriate), to help decide who definately requires 2hrly repositioning?.

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