2 Pressure Ulcers Common problem Reduce quality of life Indicator of quality of careAssessment requires a multidisciplinary approachPressure ulcers present a challenge to healthcare providers. In 2006 there were over 500,000 hospital stays in the U.S. for which the principal diagnosis was pressure ulcer and hospital stays were 3 times longer for individuals with pressure ulcers (Jankowski, 2010). Development and treatment of pressure ulcers is painful and causes distress for patients. (Sterner, Lindholm, Berg, Stak, & Fossum, 2011). Pressure ulcers are an indicator of quality of care and development of a pressure ulcer is listed as a “never event” by CMS. Assessment and treatment of pressure ulcers requires a multidisciplinary approach in order to consider all factors that precipitated the development of the ulcer and to develop the plan for treatment (Jaul, 2010).
3 Learning Outcomes Cognitive Affective Psychomotor Outlines the factors involved in development of a pressure ulcer.AffectiveDiscusses the importance of a holisticapproach to pressure ulcer assessment.PsychomotorDescribes the pressure ulcer using NPUAP guidelines.The learning outcomes for the QSEN simulation include Bloom’s (1956) three domains of learning. The cognitive domain involved development of knowledge and comprehension. The affective domain includes the way in which we deal with a phenomena such as feelings and motivations. The psychomotor domain includes development of skill and technique.
4 Scenario 75 year old male Fractured hip History of cognitive impairmentFrequently incontinentWeight lossDeveloped a pressure ulcer to coccyxThe patient is a 75 year old male who had fallen at home and fractured his hip. Since being hospitalized he has suffered from incontinence and poor appetite with weight loss. The nurse on duty notes the development of a pressure ulcer to the coccyx when inspecting the skin. The student will be expected to initiate an assessment of the pressure ulcer, identify factors related to development of the pressure ulcer, identify members of the multidisciplinary team that should be involved in the plan of care, accurately document the assessment, and discuss appropriate interventions with the nursing assistant staff and family member.
5 Equipment Needed Roles Family member Nurse Nursing assistant Dietician TimeScenario 20 minDebriefing 20 minEquipment NeededWound mannequinCentimeter wound measuring deviceSterile cotton swabsGlovesEducational materialEquipment for the scenario would include the mannequin with wound, disposable measuring device, sterile cotton swabs, gloves, and educational material for the patient and family. The students will role play with one member of the group as the nurse. Other members of the group will role play parts of a family member, nursing assistant, and the dietician. The scenario should take approximately 20 minutes and debriefing would be 20 minutes.
6 Measurement Assessment Procedure Length x Width x Depth Length- head to toeWidth- side to sideDepth- deepest part of wound using sterile cotton swabAssessment ProcedureWash hands and put on gloves.Describe location of the woundDescribe drainage type and amountDescribe skin surrounding the woundAssess for s/s infectionMeasure the woundDocumentThe student should describe wound location, exudate type and amount, describe skin surrounding the wound, measure the wound, and document.
7 Educate the patient and caregiver on treatment and prevention strategies Provide physical and emotional comfortQSEN CompetencyPatient Centered CareKnowledge- Empower patient and family through educationSkills- Assess for presence of painAttitude- Value nurses role in relief of painNurses must play an active role in educating patients and caregivers on treatment and prevention strategies for development of pressure ulcers. Family members can play an active role in assisting patients to reposition, encouraging nutritional support, and providing emotional support. Pressure ulcers can be painful and symptom control in relation to pain management should be provided (Jaul, 2010).
8 Teamwork & Collaboration NursingNursing AssistantMDDieticianSocial ServiceTherapyQSEN CompetencyTeamwork & CollaborationKnowledge-Describe how teamwork improves outcomesSkills-Assumes the role of team member in treatment of pressure ulcerAttitude-Values teamworkA multidisciplinary approach is needed in assessment and management of pressure ulcers (Jaul, 2010). Each discipline has a role and collaboration is necessary. Nurses measure, assess, and provide treatment to the wound. Nursing assistants turn and reposition, assist with nutritional needs, and treat incontinence. The dietician should be involved in assessing nutritional needs and correcting factors that compromise protein and calorie intake (National Pressure Ulcer Advisory Panel(NPUAP), 2007). Social services should be involved in helping patients and families make informed decisions. The social worker may be involved in helping find community support and resources (Jaul, 2010). The therapy department should be involved in improving patients mobility and choosing proper support surfaces. The student should demonstrate the value of teamwork in healing the pressure ulcer.
9 Evidence Based Practice NPUAP GuidelinesAMDA GuidelinesNational ClearinghouseQSEN CompetencyEvidence Based PracticeKnowledge-Describes guidelines for pressure ulcer assessmentSkills-Locate clinical practice guidelines for pressure ulcersAttitude-Values evidence based practiceCommon guidelines for prevention, assessment, and treatment of pressure ulcers include the National Pressure Ulcer Advisory Panel, the National Clearing house, and the American Medical Directors Association Guidelines for Pressure ulcer prevention. The student should use these tools as resources in evidence based practice.
10 QSEN Competency CMS Quality Improvement Knowledge-Recognizes the importance of prevention of pressure ulcers in quality careSkills-Uses quality measures to evaluate careAttitude-Values contributions to improve outcomes related to pressure ulcersCMS lists development of a full thickness pressure ulcer as a “never event” in hospitals and facilities will be denied reimbursement for facility acquired areas (Jankowski, 2010). In long term care settings, development of a pressure ulcer is tracked through the CMS quality measures and affects a facilities 5 star rating.
11 QSEN Competency Turning and repositioning q 2 hours Infection control Toileting programsMonitoring for incontinenceUse of support surfacesEducating nursing assist staffQSEN CompetencySafetyKnowledge- Describes a culture of safety in prevention of pressure ulcersSkills-Communicates observations related to plan of care being followedAttitude-Values monitoring of care activities provided by teamA culture of safety in prevention and treatment of pressure ulcers should include proper hand washing, knowledge of interventions such as turning and repositioning, toileting assistance, and education and monitoring of nursing assistant staff.
12 QSEN Competency Electronic health records for documentation Electronic database for plan of careOn-line slide showsInternet resources for patient educationQSEN CompetencyInformaticsKnowledge-Describe how information technology can improve outcomes related to pressure ulcersSkills-Use technologies to communicate care plan and uses internet resourcesAttitude-Value nurses role in implementation of technology for improvement of pressure ulcersThe student should be able to practice documentation and care planning in the electronic medical record. The student can also us internet resources for patient education. The American Nurses Association has an on-line training tool for nurses regarding assessing pressure ulcers that if free to all.
13 DebriefingExplains nursing interventions to prevent and treat pressure ulcers.Uses evidence based guidelines to measure and describe wound.Discusses roles of team members in wound treatment and prevention.Debriefing is an important component of clinical simulation. The debriefing portion should be as long or longer that the scenario. Key items the students should discuss are interventions to prevent or reduce pressure ulcers, evidence based guidelines, and the importance of a team approach. The debriefing topics should relate to the learning objectives.
14 ReferencesBloom B. S. (1956). Taxonomy of educational objectives, handbook book I: The cognitive domain. New York: David McKay Co. National Pressure Ulcer Advisory Panel. (2009) Treatment of pressure ulcers: Quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel. Jankowski, I,M.(2010). Matching patient safety goals to the nursing specialty. Using wound, ostomy, continence nursing services. The Journal of Nursing Administration, 40(1), Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly. Drugs and Aging, 27(4), Sterner, E., Lindholm, C., Berg, E., Stark, A., & Fossum, B. (2011). Category I pressure ulcers how reliable is clinical assessment? Orthopaedic Nursing, 30(3),