Is Turning Every 1 Hour More Effective than Turning Every 2 Hours

to Prevent Pressure Ulcer Development?

Nur Hidayati

, Tintin Sukartini

and Padoli

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

State Health Polytechnic of Surabaya, Jl. Pucang Jajar Tengah 56 Surabaya, Indonesia

Keywords: Incidence, Neurological Ward, Pressure Ulcer, Stroke, Turning Interval.

Abstract: Pressure ulcers (PU) are common on stroke patients with immobility. The best turning interval to prevent

PUs development still unknown. The objective of this study was to compare the PUs incidence between

stroke patients turned every 1 h and those turned every 2 h. This study used quasi experiment - post test with

control group design, conducted between January – March 2018. Samples recruited within 1-3 days of

admission in neurological ward in two hospital. The experimental group (n=26) was turned every 1 hour

while the control group (n = 23) was done every 2 hours in the day (6 am – 6 pm) and every 3 hours in the

night (6 pm – 6 am); using 30

tilt; continued for the next 5 days. All partisipants (n = 49) were 23 men and

26 women, aging 42-81 y/o. 6/26 patients (23.1%) in the experimental group and 6/23 patients (26.1%) in

the control group developed PUs (p = 1.000; p > 0.05). All PUs were grade 1 (10.2%), grade 2 (12.2%), and

DTI (2%). There was no statistically difference in PUs development over 5 days of turning between stroke

patients those turned at 1 h or 2 h intervals.

1 BACKGROUND

Pressure ulcer incidence is found in stroke patients

with immobility (Amir et al., 2013). Pressure ulcer is

a localized injury in the skin and or the tissues

underneath covering the bone resulting from

pressure or the combination of pressure and shear or

friction (Wiens, 2010; Casey, 2013). Pressure ulcer

caused longer hospitalisation and extra nusing care

(Dealey, et al., 2012), also decreased patient’s health

– related quality of life (Thein et al., 2010).

Approximately, more than 2.5 milion patients

hospitalized develop pressure ulcer and 60,000

patients die of the complication of pressure ulcer

(HRET, 2017). Mortality rate due to pressure ulcer

count for 40% annually while patients die after one

year treated with pressure ulcer in hospital count for

60% (Compas 2010 in Tarihoran, et al., 2010). The

highest incidence of mortality resulting from

pressure ulcer occurs in patients aging ≥ 75 years old

and septicemia contribute to 39.7% mortality

(Bryant, 2012). Post stroke complication and

mortality increased in patients with pressure ulcer

(Lee et al., 2016).

In Indonesian public hospital, hospital acquired

pressure ulcer reaches 33% in 2007 (Amir, et al.,

2013). The incidence of pressure ulcer of patients

with stroke in ICU & neurological ward in one of

the government hospital in 2011 counted for 10/36

(28%) grade I and 6/36 (17%) grade 2 or higher.

More than 50% of those including patients and

families have been educated while 74% patients

have been repositioned in irregular basis by either

nurses or families (Amir, et al., 2013). Preliminary

study conducted in Stroke Ward of Dr. Ramelan

Military Hospital of Surabaya from April as of

September 2017 found 79 patients developing

pressure ulcer, 56 of whom are patients with stroke

(19 prehospital acquired and 37 hospital acquired).

Pressure ulcer may occur 3 days after skin is

exposed to pressure (Tarihoran, et al., 2010). Several

factor affecting the development of pressure ulcer

include tissue tolerance and pressure (duration and

intensity) (Nursalam, 2016). Factor of pressure is

influenced by decreased mobility, activity, and

sensory perception commoly occurring in patients

with stroke (Bryant, 2012).

Turning every 2 hours is one of the

recommended nursing interventions to prevent the

development of pressure ulcer (Linton, 2012; Miles,

et al., 2014; HRET, 2017) resulting from decreased

mobility and sensory perception in patients with

132

Hidayati, N., Sukartini, T. and Padoli, .

Is Turning Every 1 Hour More Effective than Turning Every 2 Hours to Prevent Pressure Ulcer Development?.

DOI: 10.5220/0008321601320137

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 132-137

ISBN: 978-989-758-336-0

stroke. However a number of study found that

turning every 2 hours is no longer efficacious to

prevent the development of pressure ulcer

(Ostadabbas et al., 2011; Bergstrom et al., 2013;

Manzano et al., 2014).

Tarihoran, et al. (2010) did turning on patient

with stroke using 30° triangle pillow for 2 hours

interval toward the strong side, 2 hours supination,

and 1 hour toward the weak side, but there was one

patient developing pressure ulcer at sacrum. Study

conducted by Ostadabbas et al. (2011) found that

patients on supine position must be turned within

less than 1 hour. In early 20 century, several books

recommended more frequent turning despite limited

research (Casey, 2013). Reddish body part and or

weak/paralised body part must not be in the same

position for > 30 minutes (Linton, 2012). Demol et

al. (2013) found that the size and severity of deep

tissue injury (DTI) can be reduced by shortened the

repositioning interval. Therefore researcher tries to

shorten turning interval for every 1 hour, 30° lateral

turning position with one pillow and 30° head

elevation in supine position. Shorter turning interval

can reduce duration pressure, 30° lateral position can

reduce pressure intensity while 15-30° head

elevation during supination prevent shear and

pressure against sacrum. This study aims to analyse

the difference of pressure ulcer incidence on patient

with stroke who were turned every 1 hour and 2

hours.

2 METHODS

2.1 Design

This study used quasy experiment - post test with

control group design. This study hypothesis that

there is different incident of pressure ulcer on

patients who were turned every 1 hour opposed to 2

hours.

2.2 Sample

Samples of this study were stroke patients treated in

Neurological Ward of Dr. Ramelan Military

Hospital of Surabaya and Flamboyan Ward of

General Hospital of Jombang for three months (1

January 1, 2018 – March, 31 2018) meeting

inclusion criteria. Sample size was 54 patients;

intervention group (n = 27) and control group (n =

27).

2.3 Inclusion and Exclusion Criteria

The main inclusion criteria of this study were stroke

patient adults who were; suffering from immobility,

Braden scale ≤ 18, absence of pressure ulcer,

absence of anasarca edema, stable hemodynamic

(systolic blood pressure ≥ 100 mmHg), recruited

within 1 – 3 days of admission in neurological ward.

Exclusion criteria were; restless, having diagnosed

or suspected spinal/ cervical injury/ brain death, on

critical condition, and presence of pressure ulcer at

admission/ before intervension started. Patients were

dropped out if passing away/discharge/moving to

other ward, patient’s condition suddently

deteriorated/ hypotension, and refused to continue

the procedure before intervention was complete (5

days).

2.4 Procedures

Two sample groups were turned by researcher

helped by an assistant. Control group was turned by

using 30° tilt (right side, back, left side, back)

supported by a pillow on the back every 1 hour in

the day (6 am – 6 pm) and every 3 hours (supination

and turned to the strong side) at night (6 pm – 6 am).

Control group was turned 30° tilt (right side, back,

left side, back) supported by a pillow on the back

every 2 hours in the day (6 am – 6 pm) and every 3

hours (supination and turned to the strong side) at

night (6pm – 6am).

Pressure ulcer risk assessment used Braden scale.

Result of systematic review – meta analysis showed

that Braden scale was more valid for general

population with 87.42% sensitivity and 90%

reliability (García-Fernández, et al., 2013). Similar

studies found that should it be seen from >14 score,

Braden scale would range from 82.4%-100% while

specificity < 15, it wolud range from 72.7%-81.8%.

By using cut of point 15, validity at Braden scale

prediction would be sensitivity 88.2%, specificity

72.7%, FP 27.3% and FN 11.8%, and area beneath

ROC curve was 0,880 (Kale et al., 2014).

Development of pressure ulcer was evaluated

every time the position was changed until 5 x 24

hours using EPUAP-NPUAP 2014 pressure ulcer

grade classification.

2.5 Analysis

Statistical tests utilized were; Chi-Square to figure

out the difference of pressure ulcer incidence

between stroke patients turned every 1 hour and 2

hours; Mann – Whitney to compare the difference of

Is Turning Every 1 Hour More Effective than Turning Every 2 Hours to Prevent Pressure Ulcer Development?

133

PU grade classificatin between two groups.

Statistical significance was set at the 5% level (α <

0.05).

2.6 Ethical Considerations

This study has gained approval of ethical eligibility

from ethic commission of health research Dr.

Ramelan Military Hospital of Surabaya number

01/EC/KERS/2018. All informed consents were

signed by the families.

3 RESULTS

Fithty nine patients selected for eligibility with

consecutive sampling, 10 patients were dropped out

due to; discharge (3), moving to the other ward (1),

and passing away (6) before intervention was

complete, leaving a final study sample of 49

patients, who were assigned to intervention group (n

= 26) and control group (n = 23).

Participant distribution ranges from 42 to 81

years old with average age of intervention group

(63.77 years old) and control group (67.26 years

old); infarcted stroke (65.3%) and hemorrhagic

stroke (34.7%); men (46.9%) and women (53.1%);

braden scale > 9 (87.8%) and ≤ 9 (12.2%); albumin

level < 3mg/dl (6.1%) and ≥ 3 mg/dl (93.9%) (Table

1).

3.1 Incidence of Pressure Ulcers

Pressure ulcer occurred in both group i.e., 6 patients

(intervention group), 6 patients (control group, and

37 patients no pressure ulcers development were

found (Table 2).

The incidence of pressure ulcer in intervention

group was 6/26 (23.1%) which included 2 patient

developing grade 1 PU on sacrum and tight; and 4

patients developing grade 2 PU on buttocks. The

incidence of pressure ulcer in control group was

6/23 (26.1%) which included 3 patients developing

grade 1 PU on buttocks and trochanter; 2 patient

developing grade 2 PU on buttock, tight, and

shoulder; 1 patient developing deep tissue injury PU

on the tight (Table 2 & 4).

Result of Chi - Square test shows no statistically

difference of pressure ulcer incidence between

intervention group and control group (p = 1.000 or p

>0.05) (Table 2). There was no statistically

difference of pressure ulcer grade classification

between stroke patients who were turned every 1 h

and those turned every 2 h (p>0.05) (Table 3).

This study found that 12/49 patients who

developed pressure ulcer, 7/12 (58.3%) had it in the

buttocks, 1/12 (8.3%) on sacrum, trochanter (2),

tight (3) and left upper arm (1) (Table 4).

Table 1: Respondent distribution based on the age,

types of stroke, age, albumin level, and Braden scale.

Caracteristic

Intervention

Control

Total

Age

≤ 75

> 75

76.9

23.1

82.6

17.4

79.6

20.4

Type of

Stroke

Infarction

Hemorrhagic

38.5

61.5

30.4

69.6

34.7

65.3

Gender

Male

Female

42.3

57.7

52.2

47.8

46.9

53.1

Albumin

< 3 mg/dL

≥ 3 mg/dL

11.5

88.5

100

6.1

93.9

Braden scale

≤ 9

> 9

11.5

88.5

13.0

12.2

87.8

Table 2: Incidence of pressure ulcer in intervention and

control group.

Pressure

ulcer

Intervention

Control

Total

No PU

76.9

23.1

73.9

26.1

75.5

24.5

Total

100

Chi-Square test, p = 1.000

Table 3: Grade of pressure ulcer in intervention and

control group.

Grade of

Intervention

Control

Total

No PU

Grade 1

Grade 2

Deep

tissue

injury

76.9

7.7

15.4

73.9

8.7

4.3

75.5

10.2

12.2

2.0

Total

100

Mann-Whitney test, p = 0.831

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

134

4 DISCUSSION

4.1 Age & Gender

Five patients (41.7%) developed pressure ulcer were

aged ≥71 years old; 3 patients (25%) were aged 60-

70 years old; and 4 patients (33.3%) < 60 years old

(Table 4). Previous study revealed that no significant

association between age and development of

pressure ulcer, but indicate risk. Patients aging ≥71

years old were 0.8 times greater to suffer from

pressure ulcer (Tarihoran et al., 2010). Pressure

ulcer was significantly increased poststroke

mortality in patients aged 60 years or older (Lee et

al., 2016). Pressure ulcer incidence in elderly can

increase risk for mortality and reduce quality of life

(Khor, et al., 2014).

According to the distribution of sex of PU

development, 12 patients developed PU (6 women; 6

men). It show equal incidence of pressure ulcer both

in men and women (50% : 50%). Pressure ulcer was

correlated with poststroke mortality and

complications in men and women (Lee et al., 2016).

Haast et al. (2012) suggested that women are a

higher risk for bad prognosis such as decreased

quality of life and increased risk for post stroke

depression compared to men.

4.2 Incidence of Pressure Ulcer

This study revealed no difference in pressure ulcer

development between stroke patients turned every 1

hour and those turned every 2 hours. The study

hypothesis was rejected. Previously, there was no

study which turned patients every 1 hour.

The previous studies compared the turning

interval every 2 hours with 3, 4, or 6 hours. A study

conducted by Bergstrom et al. (2013) statistically

revealed no difference in pressure ulcer incidence on

patients who were turned every 2, 3 and 4 hours. A

study conducted by Manzano et al. (2014) also

found no difference in pressure ulcer incidence

between patients who were turned every 2 hours and

4 hours. Result of systematic review cannot prove

the best interval between 2 h vs 3 h, or 4 h vs 6

hours (Gillespie, et al., 2014).

Demol, et al. (2013) conducted a study by

comparing 4 turning interval; every 2, 3, 4, and 6

hours over degree of DTI. The study revealed degree

and extent at deep tissue injury could be reduced by

shortening the turning interval.

Still et al. (2013) conducted an experiment at

turning team who did the turning every 2 hours

around the clock on patients with stable

hemodynamic condition. The study found that

turning every 2 hours by employing a turning team

could reduced pressure ulcer incidence from 15.1%

(before) to 5.24% (after).

No discrepency of pressure ulcer incidence on

both groups turned every 1 h and 2 h resulted from

turning which was not carried out in 24 hours. In the

day (6 am – 6 pm) turning was done every 1 h

(intervention group) and 2 h (control group) while at

night (6 pm – 6 am) turning was performed every 3

hours. Night turning was carried out every 3 hours

aimed to minimize disturbing sleeping time because

sleeping and rest is important for recovery process

(Latimer et al., 2015). A study conducted by Moore

et al. (2011) found that turning every 3 hours at

night with 30° lateral tilt reduced pressure ulcer

incidence by 67% than those turned every 6 hours

with 90

lateral rotation (Moore & Cowman, 2012).

According to a study by Ostadabbas, et al. (2011)

body can maximum tolerate supine position for 1

hour. Erythema can develop within 1-2 hours on

person with healthy skin and adequate circulation

(Linton, 2012). Ischemic stroke affecting motor

cortex leads to weakness/ paralysis on the muscle

innervated by the nerve; as a result, muscle

contraction weakens or loses. If the paralysed or

weak area is underneath and is under prolonged

pressure, it will potentially lead to develompment of

Table 4: Location and time of incidence of pressure

ulcer in intervention and control group.

Age

(y/o)

Albumin

(g/dL)

Grade

Location

Time

(day)

Intervention group (turning every 1 hour)

4.58

left and right

buttocks

3.53

sacrum

4.38

left and right

buttocks

4.42

1 & 2

left buttock (1)

& right

buttock (2)

3.82

right tight

3.81

left buttock

Control group (turning every 2 hours)

3.89

left tight, left

upper arm

3.85

left and right

buttocks, left

trochanter

Is Turning Every 1 Hour More Effective than Turning Every 2 Hours to Prevent Pressure Ulcer Development?

135

pressure ulcer (Pendit, 2017). Therefore, paralysed

area must not be at similar position for 30 minutes

(Linton, 2012).

An experimental study found that ischemia for at

least 90 minutes lead to organ and root fiber

damage. Prolonged ischemia may reduce adenosine

triphosphate (ATP) and compromise cellular

activities leading to necrosis and subsequent

pressure ulcer (Casey, 2013).

4.3 Location of Pressure Ulcer

This study found only 1 of 12 patients who

developed pressure ulcer at sacrum. Reduced

incidence of pressure ulcer on sacrum due to 30°

lateral position allows distribution of pressure in

wider areas (Nursalam, 2016), and can reduce

pressure against sacrum (Miles et al., 2013).

According to Yoshikawa, et.al. (2015) sacrum is in

intense contact with the surface of the bed during

supination. 30° and 40° lateral position can

minimize contact with the surface of the bed.

This study also found that 7/12 (58.3%) patients

developed pressure ulcer in the buttocks. Different

from theory proposed by Bryant (2012) and

Nursalam (2016) stating that the most frequently

affected areas include sacrum (28.3%), heel

(23.6%), dan buttocks (17.2%). Miles et al. (2013)

found that the most affected area include sacrum,

buttocks, and heel.

Previous studies show no significant association

between body mass index (BMI) and pressure ulcer

incidence, but indicate risk, for patients with BMI <

18 at risk for 0.8 time to develop pressure ulcer

(Tarihoran et al., 2010). People with lower BMI lead

to have extending bone more than those with higher

BMI. However, the prevalence of pressure ulcer is

higher in patients with lower BMI as well as in

patients with low or obesed weight (Kale et al.,

2014).

The latest study found significant association

between buttock shape and risk for pressure ulcer,

round and square buttocks have significant influence

over higher BMI and Waterlow Risk Assessment

scores (Dunk & Gardner, 2016). Other factors likely

to contribute to the development of pressure ulcer in

buttock area include buttock shape correlated with

higher BMI, moisture, and duration of supine

position (3 hours at night). Higher BMI than normal

with round and square buttock shape leads to

pressure against buttock during supination. In

addition, buttock still touches the bed despite 30°

lateral position (supported by 1 pillow on the back).

All patients in this study used diapers. Using diapers

leads to more moisture area. HRET (2017)

suggested not to use diapers when laying down on

the bed to prevent pressure ulcer. Review conducted

by Coleman, et al. (2013) found 3 most contributing

factors in the development of pressure ulcer which

include mobility/activity, perfusion, condition of

skin/pressure ulcer. Skin moisture, age, nutrition,

hematology are also the contributing factors, but are

not as frequent as the three factors mentioned.

4.4 Limitations

This study has some limitation. Both groups were

not turned with equal interval for 24 hours. At night

turning was done every 3 hours at 6pm – 6am to

prevent from disturbing the patients during sleep

(ethical consideration). Therefore, the incidence of

pressure ulcer was likely to occur due to length

turning interval at night. Small number of sample is

less strong for generalization. Patients using diapers

can be bias in whether pressure ulcer was caused by

pressure or moisture caused by diaper.

5 CONCLUSIONS

Turning every 1 hour is not better than 2 hours to

prevent the development of pressure ulcer. In

addition to turning, other factors deserve

consideration such as turning duration at night,

material of the mattress, moisture, body and room

temperature as well as diaper utilization. Turning

every 2 hours can still be done in clinical practice as

long as no latest study suggesting the better turning

interval. Further studies with more samples and

equal turning interval for 24 hours are needed.

REFERENCES

Amir, Y., Halfens, R.J., Lohrmann, C., Schols, J.G.M.A.,

2013. Pressure ulcer prevalence and quality of care in

stroke patients in an Indonesian hospital, Journal of

Wound Care, 22(5), pp. 254-260.

Bergstrom, N., Horn, S.D., Rapp, M.P., Stern, A., Barret,

R., Watkiss, M., 2013. Turning for Ulcer Reduction: A

Multisite Randomized Clinical Trial in Nursing

Homes, The Journal of American Geriatrics Society,

61(10), pp.1705–1713.

Bryant, R.A., Nix, D.P., 2012. Acute & Cronic Wounds -

Current Management Concepts, Elsevier. The United

States of America, 4th Edition.

Casey, G., 2013. Pressure ulcers reflect quality of nursing

care, Kai Tiaki Nursing New Zaeland, 19(10), pp.20–

25.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

136

Coleman, S., Gorekci, C., Nelson, E.A., Clos, S.J.,

Defloor, T., Halfens, R., Farrin, A., Brown, J.,

Schoonhoven, L., Nixon, J., 2013. Patient risk factors

for pressure ulcer development : Systematic review,

International Journal of Nursing Studies, 50, pp.974–

1003.

Dealey, C., Posnett, J., Walker, A., 2011. The cost of

pressure ulcers in the United Kingdom, Journal of

Wound Care, 21(6), pp.1–5.

Demol, J., Deun, D.V., Haex, B., Oosterwyck, H.V.,

Sloten, J.V., 2013. Modelling the effect of

repositioning on the evolution of skeletal muscle

damage in deep tissue injury, Biomech Model

Mechanobiol, 12, pp.267–279.

Dunk, A.M., Gardner, A., 2016. Body shape: a predictor

for pressure injury risk, Wound Practice and

Research, 24(2), pp.92–98.

García-Fernández, F.D., Pancorbo-Hidalgo, P.L., Agreda,

J.J.S., Torres, M.C.R., 2013. Risk assessment scales

for - pressure ulcers in intensive care units: A

systematic review with meta-analysis, European

Wound Management Association (EWMA) Journal,

13(2), pp.7–14.

Gillespie, B.M., Chaboyer, W.P., McInnes, E., Kent, B.,

Whitty, J.A., Thalib, 2014. Repositioning for pressure

ulcer prevention in adults (Review), The Cochrane

Collaboration, 4, pp.1-45.

Haast, R.A.M., Gustafson, D.R., Kiliaan, A.J., 2012. Sex

differences in stroke (review article), Journal of

Cerebral Blood Flow and Metabolism, 32(12),

pp.2100–2107.

Health Research and Educational Trust (HRET), 2017.

Preventing Hospital Acquired Pressure Ulcers/

Injuries (HAPU/I): Change Package, Health Research

and Educational Trust. Chicago.

Kale, E.D., Nurachmah, E. & Pujasari, H., 2014.

Penggunaan Skala Braden Terbukti Efektif Dalam

Memprediksi Kejadian Luka Tekan, Jurnal

Keperawatan Indonesia, 17(3), pp.95–100.

Khor, H.M., Tan, J., Saedon, N.I., Kamaruzzaman, S.B.,

Chin. A.V., Poi, P.J.H., Tin, M.P., 2014. Determinants

of mortality among older adults with pressure ulcers,

Archives of Gerontology and Geriatrics, 59(3),

pp.536–541.

Latimer, S., Chaboyer, W. & Gillespie, B.M., 2015. The

repositioning of hospitalized patients with reduced

mobility: a prospective study, Nursing Open, pp.85–

93.

Lee, S-Y., Chou, C-L., Hsu, S.P.C., Shih, C-C., Yeh, C-C.,

Hung, C-J., Chen, T-L., Liao, C-C., 2016. Outcomes

after Stroke in Patients with Previous Pressure Ulcer:

A Nationwide Matched Retrospective Cohort Study,

Journal of Stroke and Cerebrovascular Diseases,

25(1), pp.220–227.

Linton, A.D., 2012. Introduction to Medical - Surgical

Nursing, Elseiver. Canada, 5th Edition.

Manzano, F., Colmenero, M., Pérez-Pérez, A.M., Roldán,

D., Jiménez-Quintana, Md.M., Mañas, M.R., Sánchez-

Moya, M.A., Guerrero, C., Moral-Marfil, M.A.,

Sánchez-Cantalejo, E., Fernández-Mondéjar, E., 2014.

Comparison of two repositioning schedules for the

prevention of pressure ulcers in patients on mechanical

ventilation with alternating pressure air mattresses,

Intensive Care Medicine, 40, pp.1679–1687.

Miles, S.J., Nowicki, T., Fulbrook, P., 2013. Clinical

Update Repositioning to Prevent Pressure Injuries:

evidence for practice, Australian Nursing Midwifery

Journal, 21(6), pp.32-35.

Moore, Z., Cowman, S., Conroy, M., 2011. A randomised

controlled clinical trial of repositioning, using the 30°

tilt, for the prevention of pressure ulcers, Journal of

Clinical Nursing, 20, pp.2633–2644.

Moore, Z., Cowman, S., 2012. Using the 30 ° tilt to reduce

pressure ulcers, Nursing Times, 108(4), pp. 22-24.

Nursalam, 2016. Manajemen Keperawatan: Aplikasi

dalam Praktik Keperawatan Profesional, Salemba

Medika. Jakarta, 5th Edition.

Ostadabbas, S., Yousefi, R., Faezipour, M., Nourani, M.,

2011. Pressure Ulcer Prevention : An Efficient

Turning Schedule for Bed-Bound Patients, Life

Science System and Applications Workshop (LiSSA),

pp.159–162.

Pendit, B.U., Dany, F. (ed.), 2017. Patofisiologi Penyakit:

Pengantar Menuju Kedokteran Klinis/ Stephen J.

McPhee, William F. Ganong, EGC. Jakarta.

Still, M.D., Cross, L.C., Dunlap, M., Rencher, R., Larkins,

E.R., Carpenter, D.K., Buchman, T.G., Coopersmith,

2013. The Turn Team: A Novel Strategy for Reducing

Pressure Ulcers in the Surgical Intensive Care Unit,

Journal of the American College of Surgeons, 216(3),

pp.373–379.

Tarihoran, D.E.T.A.U., Sitorus, R., Sukmarini, L., 2010.

Penurunan kejadian luka tekan grade I (Non

Blanchable Erythema) Pada Klien Stroke Melalui

Posisi Miring 30 Derajat, Jurnal Keperawatan

Indonesia, 13(3), pp.181-186.

Thein, H.H., Gomes, T., Krahn, M.D., Wodchis, W.P.,

2010. Health status utilities and the impact of pressure

ulcers in long-term care residents in Ontario, Qual Life

Res, 19, pp.81–89.

Wiens, J., The Effect Of Using A Turn Clock To Cue

Patient Repositioning for pressure ulcer prevention in

an acute care setting, Thesis. Fort Hays State

University.

Yoshikawa, Y., Maeshige, N., Sugimoto, M., Uemura, M.,

Noguchi, M., Terashi, H., 2015. Positioning bedridden

patients to reduce interface pressures over the sacrum

and great trochanter, Journal of Wound Care, 24(7),

pp.320-325.

Is Turning Every 1 Hour More Effective than Turning Every 2 Hours to Prevent Pressure Ulcer Development?

137