ASSESSMENT OF NURSING PRACTICE, COMPETENCES AT CLINICAL TO PREVENT DECUBITUS ULCERS AT TERTIARY CARE HOSPITAL LAHORE PAKISTAN

Introduction: Globally higher-than-anticipated decubitus ulcer rates normally viewed as a quality of care indicator. Numerous nations at present has no national strategies for pressure ulcer hazard appraisal, anticipation, and treatment. Decubitus ulcer lead to torment and distress for patients and furthermore cause disease, defer healing, increment duration of patient's stay in hospital, and may prompt sickness and even expiry Methodology: quantitative observational descriptive study design was used to assess the nursing practice, competences at clinical to prevent decubitus ulcers at tertiary care hospital, data was collected through the standardized checklist regarding decubitus ulcer prevention. The check consists of 27 items. Results: The findings of this study revealed that there are poor practices of nurses regarding prevention of decubitus of critically ill patients. Conclusion: This study was conducted to assess level of nurses’ practice towards pressure ulcer prevention. Generally, the study showed that: Nurses’ overall practice regarding pressure ulcer prevention was poor. Education can bring a change in individual behavior so change in knowledge can influence the practices. So, nurses need to get continuing education and training about pressure ulcer prevention that will enhance their knowledge and practices. Further researches about pressure ulcer prevention are needed. ward as expected was majority 89 (59.3%) admitted in critical care units, only 23 (15.3 %) admitted in medical wards and 38 (25.3%) were admitted in surgical ward. The length of stay (days) in hospital of the participants was found as 22 (14.3%) were stayed in hospital for 1-10 days, 43 (28.3%) were stay for 11-20 days, majority 53 (35.2%) were stay 21-30 days and 32 (21.2%) stay for 31 or more than 31 days. Assessment regarding history of pressure ulcer and results revealed that majority 78 (52%) have not previous history of ulcer and 72 (48%) have previous history of ulcer. Observation regarding presence of pressure ulcers, and results revealed that 92 (61.3%) have pressure ulcer at the time of study and 58 (38.7%) have not ulcer at the time of study .

At whatever point an individual has a decubitus ulcer chance appraisal that shows they are at high danger of creating pressure ulcers, a subsequent skin evaluation ought to be completed. A clinical appraisal of the skin by a human service proficient, considering any agony revealed by the individual, may anticipate the improvement of a decubitus ulcer. The aftereffects of the skin appraisal can be utilized to offer appropriate protection intercessions to individuals who are at high danger of creating pressure ulcers. A skin evaluation should be rehashed at whatever point an individual is recognized as at high hazard because of a pressure ulcer chance appraisal, to assess any progressions to the skin and to guarantee patient and administration client wellbeing (Stansby, Avital, Jones, & Marsden, 2014).
Individuals who are in danger of creating pressure ulcers ought to get guidance about changing their position routinely, how changing position can help diminish the danger of building up a decubitus ulcer, and how as often as possible they should change position (as per their individual danger of building up a pressure ulcer) (Stephens & Bartley, 2018). Healthcare experts guarantee that they give individuals who are at high danger of creating pressure ulcers, custommade data on the most proficient method to forestall them.
Nourishing hardship and inadequate dietary admission are the key hazard factors for the improvement of decubitus ulcers and hindered wound recuperating. Impromptu weight reduction is a significant hazard factor for ailing health and decubitus ulcer advancement. Problematic nourishment meddles with the capacity of the invulnerable framework, collagen blend, and rigidity. No research center test can precisely characterize a person's healthful status. Satisfactory liquid admission is important to help the blood stream to injured tissues and to forestall extra breakdown of the skin (Saghaleini et al., 2018).
Problem statement: Now days if a patient built up a decubitus ulcer during his hospitalization it will demonstrate the low quality of nursing care. World stop pressure ulcer day indicated that almost 700,000 patients were influenced by pressure ulcers every year. Around 186,617 patients build up new decubitus ulcer in intense consideration settings every year (Dilie & Mengistu, 2015).
Consequently, there is proof that administration and anticipation of patient need a novel assortment of information and aptitudes from a capable multidisciplinary colleague particularly the medical caretaker, and explicit decubitus ulcer preventive rules ought to be produced for forestalling pressure ulcer. The real need to do the investigation is to survey the act of medical caretakers with respect to counteraction of patient from pressure ulcer.
Purpose of the study: The motivation behind the examination is to evaluate the nursing practice, capabilities at clinical to prevent decubitus ulcers at tertiary care hospital Lahore Pakistan.

Research questions:
• What is the practice, competences of nurses at clinical to prevent decubitus ulcers at tertiary care hospital? Hypothesis Alternative hypothesis: • Nurses practices may have effect to prevent decubitus ulcers at tertiary care hospital. Null hypotheses: • Nurses practices may have effect to prevent decubitus ulcers at tertiary care hospital. Conceptual definition Practices: "The application of rules and knowledge that leads to action" (Badran, 1995) Decubitus ulcer: Decubitus ulcers can be defined as when localized tissue gets deprived of circulation due to soft tissue compressed between external surfaces and bony prominence for prolong time (Black et al., 2007). Operational definition Practices: Standard guidelines follow/use by nurses to prevent decubitus ulcer working in medical and surgical department of tertiary care hospital Lahore. Decubitus ulcer: patient admitted in medical or surgical department are suffer from the deprivement of circulation due to tissue compression between external surfaces and bony prominence for long time at tertiary care hospital Lahore Pakistan.

Variables of Study:
• Practices Dependent variable; • Decubitus ulcer Limitation/ Scope of the study • Investigation discoveries will be restricted and can't be summed up generally that the little example and chose from one topographical zone in Pakistan. • The extent of the investigation will be likewise restricted not utilized benchmark group.

CHAPTER -II REVIEW OF LITERATURE
An examination led in 2018 to survey the nursing staff with respect to anticipation of decubitus ulcer and results uncovered that the overall, 64.4% nurses had right decubitus ulcer information and 74.4% had an uplifting demeanor toward forestalling pressure ulcers. In any case, 62.2% couldn't help contradicting ordinary rescreening of patients whom they esteemed not in danger of creating pressure ulcer, and 77.8% accepted decubitus ulcer counteraction ought to be the joint duty of the two medical caretakers and family members of the patients. Along these lines, most of the 90 nurses knew the variables answerable for decubitus ulcers and how to forestall them (Esan et al., 2018).
In Pakistan, Lahore area an examination led in tertiary consideration hospital with respect to evaluation of nursing staff works on in regards to decubitus and results uncovered that 82.6% have poor practices, 7.1% have reasonable practices and 10.3% have great acts of weight ulcer counteraction. Medical caretaker's professional training has a huge relationship with their practices and information toward pressure ulcer anticipation. Nurses in general information and practices toward pressure ulcer are poor. Working experience had a critical relationship with nurses practices and information at Lahore general hospital (Nasreen et al., 2017).
Another investigation directed in Pakistan, Peshawar area in 2016 with respect to the evaluation of medical caretaker's practices for the avoidance of decubitus ulcer and results uncovered that the acts of nurses in regards to the "consistently" explanations was 45.4% while of the "never" proclamation was 42.4%. The scope of most elevated and least reacted "consistently" proclamation was 57% and 18%. Study finding additionally shows that nursing staff however had sufficient information with respect to pressure ulcer avoidance yet the absence of legitimate strategies and rules, absence of proof based practice and absence of in-administration trainings prompted negative mentality and inappropriate practice among medical caretakers in Khyber Teaching Hospital in regards to pressure ulcers counteraction (Muhammad, Ahmad, Khan, Ali, & Muhammad).
In another examination author recommended that the factually noteworthy decrease in the predominance of Pressure ulcer to 7.53% (p < .001). The online instructional exercise improved staff information level with a measurably fundamentally higher mean post-test score (n = 80). Thirty-five bleeding edge staff shared their viewpoints of the decubitus ulcer Prevention Program with "it's very a blend of everything" and "there's a distinction between what's required and what's accessible" as the fundamental subjects (Martin et al., 2017).
In 2019, an examination directed for the appraisal of weight ulcer care execution of nurses was evaluated 3.99 out of 5. Execution level in "wound consideration: debridement"; "torment control"; "anticipation healthy skin"; "incontinence the executives"; "supporting surface"; and "sustenance in pressure ulcer avoidance and treatment" was underneath normal. Enthusiasm for pressure ulcer care (β = .28, p = <.001), the fundamental decubitus ulcer administrator in a ward being an injury, ostomy, self-control nurture (β = .22, p = .013), and an establishment with a nursing practice rule for pressure ulcer care (β = .16, p = .02) were recognized as noteworthy variables influencing a decent decubitus ulcer care execution (Kim, Yoo, Nho, & Ju, 2019).
Risk assessment undertaken on admission: Service suppliers (health care and care homes with nursing) guarantee that frameworks are set up for human services experts to be prepared in surveying pressure ulcer chance, and that they do and report a decubitus ulcer chance evaluation inside 6 hours of an individual being admitted to medical clinic or Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 a consideration home with nursing. Hospital services experts guarantee that they realize how to survey an individual's decubitus ulcer hazard, and that they complete and archive a decubitus ulcer chance evaluation inside 6 hours of an individual being admitted to emergency clinic or a consideration home with nursing (Gage, 2015).
Skin assessment: Service suppliers (essential consideration, community care, clinics and care homes with nursing) guarantee that social insurance experts are prepared to complete skin evaluations, and that they do a skin appraisal if an individual is recognized as high danger of creating pressure ulcers. Social insurance experts guarantee that they realize how to complete a skin evaluation, and that they do a skin appraisal if an individual in their consideration is recognized as high danger of creating pressure ulcers. Cleaning of the skin, least power and rubbing during cleaning, use of saturating operators, least introduction to dampness, utilization of boundary against dampness, skin assurance during moves are productive mediations for pressure ulcer avoidances (Stansby et al., 2014) Repositioning: Repositioning, where the individual moves into an alternate situation in a seat or bed, expects to diminish or stop pressure on the zone in danger. To improve quiet understanding, wellbeing and social consideration experts ought to inform individuals in danger regarding creating pressure ulcers (or their vocations, as suitable) about the significance of continuous repositioning, and that it might assist with forestalling pressure ulcers. The recurrence of repositioning prompted ought to be fitting for the distinct individual and their desires and needs. For security reasons, repositioning is prescribed no less than like clockwork for grown-ups in danger, and at regular intervals for grown-ups at high hazard. heels lifted to diminish pressure, limiting the period in which the leader of the bed tilted in excess of 30 degrees, trained how to reposition themselves when sitting on the seat and when sitting on the seat position changed each hour or moved to bed are fundamentals to forestall ulcer (Stephens & Bartley, 2018).
Using devices to prevent contact between bony prominences: Pressure redistribution equipment's work by decreasing or redistributing weight, grating or shear powers. equipment's incorporate high-particular sleeping cushions, pressure redistribution pads and hardware that offloads heel pressure. The sort of equipment's an individual need will rely upon their conditions, for instance, their portability, the consequences of the skin appraisal, their degree of hazard, the site that is in danger, the individual's weight and the individual's general wellbeing. Utilizing pressure redistribution equipment's as quickly as time permits can forestall pressure ulcers creating and help to treat them on the off chance that they do emerge, guaranteeing persistent wellbeing and improving the experience of individuals at high danger of weight ulcers. Persistent activated (where conceivable) Use of weight assuaging bedding and utilization of weight alleviating equipment's on seats (Ashour, 2019) Nutritional assessment: The National Institute for Health and Care Excellence expresses that satisfactory hazard evaluation of pressure ulcer advancement, including the job of unhealthiness, improves care. Satisfactory sustenance is indispensable for the anticipation of weight ulcers and lack of healthy sustenance can block recuperating when pressure ulcers have created. The danger of lack of healthy sustenance ought to be evaluated with a perceived device, for example, the Malnutrition Universal Screening Tool, and fitting treatment plans ought to be drawn up for patients distinguished as being in danger of failing health to improve their dietary state. Moreover, helped with eating and drinking and Recording of healthful appraisal of patients assumes a significant job (Taylor, 2017). Support staff given information on the prevention of pressure sores: Many decubitus ulcers are preventable. A great part of the deterrent consideration required happens in an individual's own home and should be conveyed routinely to guarantee persistent security. Social insurance experts should offer data to individuals at high danger of creating pressure ulcers (and their vocations, as fitting) about precaution care that may prevent pressure ulcers from creating. To improve tolerant experience, data about forestalling pressure ulcers ought to be suitable to the distinct individual and their professions. Data ought to incorporate the causes and indications of weight ulcers and how they influence wellbeing and personal satisfaction. It ought to likewise incorporate an exhibit of how to utilize gear that might be provided, and what individuals can do to help forestall pressure ulcers from creating (Shanley et al., 2019).

Objectives General objective:
• To assess the nurse's practices for counteraction of decubitus ulcer among patients in tertiary care hospital Lahore.

Specific objectives:
• To assess the nurse's practices regarding risk assessment for anticipation of decubitus ulcer among patients in tertiary care hospital Lahore. • To assess the nurse's practices regarding positioning for anticipation of decubitus ulcer among patients in tertiary care hospital Lahore. • To assess the nurse's practices regarding use of devices for anticipation of decubitus ulcer among patients in tertiary care hospital Lahore. • To assess the nurse's practices regarding skin assessment for anticipation of decubitus ulcer among patients in tertiary care hospital Lahore. • To assess the nurse's practices regarding nutrition for anticipation of decubitus ulcer among patients in tertiary care hospital Lahore.

Significance of the study
Patient: who conceded for the most part is profoundly helpless to pressure ulcer. In this manner, the use of widespread safety measures, protect the patient from pressure ulcer. it also promotes patient safety and decrease risk.
Nurse: subsequently, assessment level of nurses' practice about prevention of pressure ulcer is vital action to control and prevent pressure ulcer. In this way nurses will understand their weakness and tried to adopt standard guide line in results their knowledge and skills will be improved.

Organization:
The Finding of the examination may be useful for the association to build up the methodologies to control superfluous of pressure ulcer through instructional meeting, workshop, and class in result at last this will improve the workplace and nature of care. It will be appropriate for the administration to find a way to locate the powerless components. In results the quality of care will be improved.
Policy maker: This mindfulness will help the strategy creator to plan methodologies and set in motion to improve the workplace.

Future researcher:
The aftereffect of this investigation will provide guidance to the future analyst to use this examination as a writing and direction. Moreover, study will assist them with identifying the investigation hole. The discoveries of the examination can be utilized as optional information for future research researchers.

CHAPTER -III MATERIAL AND METHODS Study Design:
Observational descriptive design was use to assess the nursing practice, competences at clinical to prevent decubitus ulcers at tertiary care hospital Lahore Pakistan.

Study site:
The study was conducted in urban area located at Lahore, Pakistan. Study Setting: The study was conducted medical and surgical units of Jinnah hospital Lahore.

Study Duration:
The Study span was 4 months from February, 2020 to May, 2020.

Study Population:
The examination population was all charge nurses working in medical and surgical units of Jinnah hospital.

Inclusion Criteria:
• All charge nurses working in medical and surgical units of Jinnah hospital for a half year before the beginning of data collection. • Willing to participate Exclusion Criteria: • Nurses working in medical and surgical units, who were not involved in direct patient care e.g. Head nurses, Clinical Instructors and Nurse Managers and nurses who have worked for less than six months in the Burns Unit.

•
Not willing to participate Sampling Technique: Data was collected by convenient sampling technique from selected sample. Sample Size: Sample size was calculated by using "Selvin's formula".
The population for this study is 240. The sample size for this study will be 150.

Ethical Consideration;
Composed consent was taken from the Ethical board of University of Lahore. Authorization was taken from the Nursing director of Jinnah hospital to lead inquire about investigation. All members were educated about the motivation behind the examination. All data and gathered information were kept classified by head examiner printed version in lock. Classification of delicate duplicate will be kept up by a coding. The subject was educated that there are no drawbacks or hazard on the techniques of the investigation.

Data collection procedure:
After endorsement survey was given to the nurses to evaluate the information and watch the attendant's practices over a time of 01 months beginning from March, 2020. The chose units was visited on regular routine and nurses will approached during morning, night and night shifts.

Data Collection Instrument and Tools:
A well-adapted check was used to measure the practices in this study and it consists of two sections.
Section A: section A consists of demographic data such as gender, age, type of the wards, length of stay, history of hospitalization and history of pressure ulcers.
Section B: section "B" is a checklist including, Risk assessment undertaken on admission, skin assessment, nutritional assessment, positioning and use of devices. Check list will use to assess the practices of nurses working in burn units.

Data Analysis Method:
The data was analyzing the data by SPSS version 16. Statistical analysis of the study was descriptive. The study sample will be characterized by using a measure of central tendency (mean, median, and mode).

CHAPTER -IV RESULTS
This study is conducted at Jinnah hospital to assess the nurses' practice, competences at clinical to prevent decubitus ulcers. The result of this study distributed into two sections, first section is statistics of demographic factors of patients admitted in hospital acquiring care regarding decubitus ulcer prevention from nurses and second is frequency and statistics of checklist items regarding prevention of decubitus ulcer and assessment the nurse's practices accordingly.
Section A:   Figure 1 shows that the age of participants and results revealed that minimum 21 to highest 60, participant's age group 21-30 years frequency was 11 (7.3%), moderately 44 (29.3%) participants were belong to age group 31-40 years and 33 (22.1%) were fall in age group 41-50 years and majority 62 (42.3%) were 51-60-year-old.              Table 2 Section B, consist of check list regarding prevention of decubitus ulcers consisting 29 items. Table 4 shows the frequency percentage of 27 items of checklist regarding prevention of decubitus ulcers and results revealed that mostly above 60 % nurses have good practices and follow the standard guideline for prevention of decubitus ulcers of admitted patient in different ward such as surgical, medical and critical care unite. Further the observation revealed that the participant relates to different level of age group and the observation regarding first item of checklist results revealed that the 76 (50.1 %) were observed as Risk assessment undertaken on admission, 53 (35.4%) were not observed and only 21 (14.6%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item two is "Recording of risk assessment scores" and results revealed that the 66 (44.1%) were observed, 61 (40.9%) were observed and only 23 (15%) observed as not applicable. Item three is "Systematic inspection of skin" and results revealed that the 93 (62%) were observed, 61 (40.9%) were not observed and only 18 (12%) were observed as not applicable. The observation regarding fourth item of checklist and results revealed that the 92 (61%) were observed as recording of results of skin inspection, 48 (32.3%) were not observed and only 10 (6.7%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item five is "Cleaning of the skin" and results revealed that the 88 (58%) were observed, 42 (28.4%) were observed and only 20 (13.6%) observed as not applicable while give care to the patients. Item six is "Minimum force and friction during cleaning" and results revealed that the 81 (54%) were observed, 63 (42%) were not observed and only 6 (4%) were observed as not applicable regarding decubitus ulcer prevention. The observation regarding seventh item of checklist and results revealed that the 93 (62%) were observed as application of moisturizing agents, 44 (29.4%) were not observed and only 13 (8.7%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item eight is "Minimum exposure to moisture" and results revealed that the 92 (61%) were observed, 38 (25.3%) were observed and only 20 (13.6%) observed as not applicable while give care to the patients. Item nine is "Use of barrier against moisture" and results revealed that the 98 (65.3%) were observed, 35 (23.3%) were not observed and only 17 (11.3%) were observed as not applicable regarding decubitus ulcer prevention. The observation regarding item ten of checklist and results revealed that the 91 (60.3%) were observed as skin protection during transfers, 55 (26.7%) were not observed and only 4 (2.6%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item eleven is "Changing positions and turning" and results revealed that the 94 (62.3%) were observed, 41 (27.7%) were observed and only 15 (10%) observed as not applicable while give care to the patients. Item twelve is "Recording the nursing interventions and its results" and results revealed that the 87 (58%) were observed, 52 (34.7%) were not observed and only 11 (7.3%) were observed as not applicable regarding decubitus ulcer prevention. The observation regarding item thirteen of checklist and results revealed that the 105 (70%) were observed as repositioning, 26 (17.3%) were not observed and only 19 (12.3%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item fourteen is "Use of a chart for changing position and turning:" and results revealed that the 95 (63%) were observed, 48 (32.3%) were observed and only 7 (4.7%) observed as not applicable while give care to the patients. Item fifteen is "Using devices to prevent contact." and results revealed that the 100 (66%) were observed, 39 (26.7%) were not observed and only 11 (7.3%) were observed as not applicable regarding decubitus ulcer prevention. The observation regarding item sixteen of checklist and results revealed that the 116 (77.3%) were observed as heels lifted to decrease pressure, 29 (19.3%) were not observed and only 5 (3.3%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item seventeen is "Minimizing the period in which the head of the bed tilted more than 30 degrees" and results revealed that the 101 (67.3%) were observed, 35 (23.3%) were observed and only 14 (9.3%) observed as not applicable while give care to the patients. Item eighteen is "Patient mobilized (where possible) Use of pressure relieving mattress" and results revealed that the 87 (58%) were observed, 40 (26.7%) were not observed and only 23 (15.3%) were observed as not applicable regarding decubitus ulcer prevention. The observation regarding item nineteen of checklist and results revealed that the 96 (64%) were observed as taught how to reposition themselves when sitting on the chair, 44 (29.3%) were not observed and only 10 (6.7%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. The observation regarding item twenty of checklist and results revealed that the 106 (70.6%) were observed as when sitting on the chair position changed every hour or transferred to bed, 27 (18%) were not observed and only 17 (11.4%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Item twenty-one is "Use of pressure relieving devices on chairs" and results revealed that the 96 (64%) were observed, 39 (26.7%) were not observed and only 15 (10%) were observed as not applicable regarding decubitus ulcer prevention. Item twenty-two is "Nutritional assessment" and results revealed that the 102 (68%) were observed, 36 (24%) were not observed and only 12 (8%) were observed as not applicable regarding decubitus ulcer prevention. Item twenty-three is "Assisted with eating and drinking" and results revealed that the 77 (51.3%) were observed, 41 (27%) were not observed and only 32 (21%) were observed as not applicable regarding decubitus ulcer prevention. Item twenty-four is "Recording of nutritional assessment" and results revealed that the 86 (57.3%) were observed, 44 (29.3%) were not observed and only 20 (13.3%) were observed as not applicable regarding decubitus ulcer prevention. Item twenty-five is "Patients given information on the prevention of pressure sores" and results revealed that the 52 (34%) were observed, 74 (49.3%) were not observed and only 24 (16.7%) were observed as not applicable regarding decubitus ulcer prevention. The observation regarding item twenty-six of checklist and results revealed that the 75 (50%) were observed as relatives given information on the prevention of pressure sores, 53 (35.3%) were not observed and only 22 (14.6%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. The observation regarding item twenty-seven of checklist and results revealed that the 52 (34.6%) were observed as Support staff given information on the prevention of pressure sores, 74 (49.4%) were not observed and only 24 (16%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer.  Table 3 Table 4 shows that the statistics (mean, median, mode and standard deviation) of 27 items of checklist regarding practices regarding prevention of decubitus ulcer and results revealed that the highest mean value is 1.71 of item two which is "Recording of risk assessment scores" and other two items and comparatively lowest mean value is 1.45 for item four which is "Recording of results of skin inspection" and two items. The mean value for others item is between 1.45-1.71 respectively. Median and mode value of most of items is 1 and highest is 2. Standard deviation value .720 is highest and comparatively .576 is low.  Table 4 Figure 8 shows that the observation regarding first item of checklist results revealed that the 76 (50.1 %) were observed as Risk assessment undertaken on admission, 53 (35.4%) were not observed and only 21 assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 9 shows that the observation regarding item two is "Recording of risk assessment scores" and results revealed that the 66 (44.1%) were observed, 61 (40.9%) were observed and only 23 (15%) observed as not applicable. Figure 10 shows that the observation regarding item three is "Systematic inspection of skin" and results revealed that the 93 (62%) were observed, 61 (40.9%) were not observed and only 18 (12%) were observed as not applicable. Figure 11 shows that the observation regarding fourth item of checklist and results revealed that the 92 (61%) were observed as recording of results of skin inspection, 48 (32.3%) were not observed and only 10 (6.7%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 12 shows that the results of Item five which is "Cleaning of the skin" and results revealed that the 88 (58%) were observed, 42 (28.4%) were observed and only 20 (13.6%) observed as not applicable while give care to the patients. Figure 13 shows that the results of Item six which is "Minimum force and friction during cleaning" and results revealed that the 81 (54%) were observed, 63 (42%) were not observed and only 6 (4%) were observed as not applicable regarding decubitus ulcer prevention. Figure 14 shows that the observation regarding seventh item of checklist and results revealed that the 93 (62%) were observed as application of moisturizing agents, 44 (29.4%) were not observed and only 13 (8.7%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 131 Figure 15 shows that the observation regarding Item eight which is "Minimum exposure to moisture" and results revealed that the 92 (61%) were observed, 38 (25.3%) were observed and only 20 (13.6%) observed as not applicable while give care to the patients. Figure 16 shows that the results regarding item nine which is "Use of barrier against moisture" and results revealed that the 98 (65.3%) were observed, 35 (23.3%) were not observed and only 17 (11.3%) were observed as not applicable regarding decubitus ulcer prevention. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 132 Figure 17 shows that the observation regarding item ten of checklist and results revealed that the 91 (60.3%) were observed as skin protection during transfers, 55 (26.7%) were not observed and only 4 (2.6%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 18 shows that the assessment results regarding Item eleven which is "Changing positions and turning" and results revealed that the 94 (62.3%) were observed, 41 (27.7%) were observed and only 15 (10%) observed as not applicable while give care to the patients. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 19 shows that the results of Item twelve which is "Recording the nursing interventions and its results" and results revealed that the 87 (58%) were observed, 52 (34.7%) were not observed and only 11 (7.3%) were observed as not applicable regarding decubitus ulcer prevention. Figure 20 shows that the observation regarding item thirteen of checklist and results revealed that the 105 (70%) were observed as repositioning, 26 (17.3%) were not observed and only 19 (12.3%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 21 shows that the results of Item fourteen which is "Use of a chart for changing position and turning:" and results revealed that the 95 (63%) were observed, 48 (32.3%) were observed and only 7 (4.7%) observed as not applicable while give care to the patients. Figure 22 shows that the results of Item fifteen which is Item fifteen is "Using devices to prevent contact." and results revealed that the 100 (66%) were observed, 39 (26.7%) were not observed and only 11 (7.3%) were observed as not applicable regarding decubitus ulcer prevention. Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 23 shows that the observation regarding item sixteen of checklist and results revealed that the 116 (77.3%) were observed as heels lifted to decrease pressure, 29 (19.3%) were not observed and only 5 (3.3%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 24 shows that the results of Item seventeen which is "Minimizing the period in which the head of the bed tilted more than 30 degrees" and results revealed that the 101 (67.3%) were observed, 35 (23.3%) were observed and only 14 (9.3%) observed as not applicable while give care to the patients. Figure 25 shows that the results of item eighteen which is "Patient mobilized (where possible) Use of pressure relieving mattress" and results revealed that the 87 (58%) were observed, 40 (26.7%) were not observed and only 23 (15.3%) were observed as not applicable regarding decubitus ulcer prevention. Figure 26 shows that the the observation regarding item nineteen of checklist and results revealed that the 96 (64%) were observed as taught how to reposition themselves when sitting on the chair, 44 (29.3%) were not observed and only 10 (6.7%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer.

Figure 25
Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 27 shows that the observation regarding item twenty of checklist and results revealed that the 106 (70.6%) were observed as when sitting on the chair position changed every hour or transferred to bed, 27 (18%) were not observed and only 17 (11.4%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 28 shows that the results of item twenty-one which is "Use of pressure relieving devices on chairs" and results revealed that the 96 (64%) were observed, 39 (26.7%) were not observed and only 15 (10%) were observed as not applicable regarding decubitus ulcer prevention. 138 Figure 29 shows that the results of item twenty-two which is "Nutritional assessment" and results revealed that the 102 (68%) were observed, 36 (24%) were not observed and only 12 (8%) were observed as not applicable regarding decubitus ulcer prevention. Figure 30 shows that the results of item twenty-three which is "Assisted with eating and drinking" and results revealed that the 77 (51.3%) were observed, 41 (27%) were not observed and only 32 (21%) were observed as not applicable regarding decubitus ulcer prevention.

Figure 29
Journal of Health, Medicine and Nursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.74, 2020 Figure 31 shows that the results of item twenty-four which is "Recording of nutritional assessment" and results revealed that the 86 (57.3%) were observed, 44 (29.3%) were not observed and only 20 (13.3%) were observed as not applicable regarding decubitus ulcer prevention.

Figure 30
. Figure 32 shows that the results of item twenty-five which is "Patients given information on the prevention of pressure sores" and results revealed that the 52 (34%) were observed, 74 (49.3%) were not observed and only 24 (16.7%) were observed as not applicable regarding decubitus ulcer prevention. Figure 33 shows that the observation regarding item twenty-six of checklist and results revealed that the 75 (50%) were observed as relatives given information on the prevention of pressure sores, 53 (35.3%) were not observed and only 22 (14.6%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer. Figure 34 shows that the observation regarding item twenty-seven of checklist and results revealed that the 52 (34.6%) were observed as Support staff given information on the prevention of pressure sores, 74 (49.4%) were not observed and only 24 (16%) assess as not applicable while giving care to the patients regarding prevention of pressure ulcer.
The length of stay (days) in hospital of the participants was found as 22 (14.3%) were stayed in hospital for 1-10 days, 43 (28.3%) were stay for 11-20 days, majority 53 (35.2%) were stay 21-30 days and 32 (21.2%) stay for 31 or more than 31 days. Assessment regarding history of pressure ulcer and results revealed that majority 78 (52%) have not previous history of ulcer and 72 (48%) have previous history of ulcer. Observation regarding presence of pressure ulcers, and results revealed that 92 (61.3%) have pressure ulcer at the time of study and 58 (38.7%) have not ulcer at the time of study.
In this study results that nurses have poor practices 66 (44.1%) regarding risk factors of pressure ulcer development, patient's position every two hourly 105 (70%) but in contrast another study conducted in Bangladesh which result shows that nurse's practices about factors related to pressure ulcer, was at very low to low level (Islam, Sae-Sia, & Khupantavee, 2010). But the study of Uganda revealed that nurses knowledge about frequent patient positioning can protect patient from pressure ulcers was (98.2%), risk factors which can cause pressure ulcer in bedridden patients was 92.9% , prolong positioning 83.9% (Mwebaza et al., 2014).
This study finding shows that nurses practices are poor 52 (34%) and 52 (34.6%) in order to give pressure ulcer prevention education to patient's and caregivers but the study conducted in Aydr referral hospital result shows that nurses practices regarding education of patients and care givers were 90.1% which was much higher than us (Yitayih, Panerio, & Molla, 2019). From this current study one of what mostly nurses never do is documentation of all data related to Pressure ulcer development 86 (57.3%) for nutritional assessment record, "Recording the nursing interventions and its results" and results revealed that the 87 (58%) were observed and use devices to prevent ulcer is 96 (64%). But in contrast this study revealed the results regarding nurses practices of pressure ulcer prevention that ( 16.6%) use assessment scale, that is very low then Ethiopian nurses, nurses who using air mattress for patients who are at high risk for pressure ulcer development(23.3%), and only (22.5%) nurses document all data regarding to pressure ulcer assessment which is even lower then Ethiopian nurses practices (Nasreen et al., 2017).
Indicates practice Frequency and percentage as per questionnaire. Total 150 participants attended 27 test items. 60 % showed good practices towards prevention of pressure ulcer. A similar study conducted by Nurhusien Nuru find out as Nearly half (48.4 %) of the respondents had a good practice; whereas the remaining 51.6 % respondents had a poor practice of pressure ulcer prevention (Nuru et al., 2015). Above 50% participants always practice for test item no.5,15 on skin care, use comfort devices and more attention on a pressure point. As well as 108(56%) participants were performing skin assessment for pressure ulcer. 52 (34.6%) never gave advice to the caregiver about a use of creams for prevention of pressure ulcer.

Conclusion:
This study was conducted to assess level of nurses' practice towards pressure ulcer prevention. Generally, the study showed that: Nurses' overall practice regarding pressure ulcer prevention was poor. Education can bring a change in individual behavior so change in knowledge can influence the practices. So, nurses need to get continuing education and training about pressure ulcer prevention that will enhance their knowledge and practices. Further researches about pressure ulcer prevention are needed.
Recommendation: Training programs should be conducted about pressure ulcer prevention for nurses who are working in hospital. • Results of the study should be disseminated and shared with the administration including nurse administrator, hospital administration. • Practices of nurses regarding pressure ulcer prevention not only enough without utilization of standards protocols into practices while caring of patients.