1. QSEN Simulation Pressure Ulcer Assessment
Stacey Johnson BSN, RN
Bethel College
MNUR 613

2. Pressure Ulcers Common problem Reduce quality of life
Indicator of quality of care
Assessment requires a multidisciplinary approach
Pressure 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.
Affective
Discusses the importance of a holistic
approach to pressure ulcer assessment.
Psychomotor
Describes 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 impairment
Frequently incontinent
Weight loss
Developed a pressure ulcer to coccyx
The 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
Time
Scenario 20 min
Debriefing 20 min
Equipment Needed
Wound mannequin
Centimeter wound measuring device
Sterile cotton swabs
Gloves
Educational material
Equipment 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 toe
Width- side to side
Depth- deepest part of wound using sterile cotton swab
Assessment Procedure
Wash hands and put on gloves.
Describe location of the wound
Describe drainage type and amount
Describe skin surrounding the wound
Assess for s/s infection
Measure the wound
Document
The 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 comfort
QSEN Competency
Patient Centered Care
Knowledge- Empower patient and family through education
Skills- Assess for presence of pain
Attitude- Value nurses role in relief of pain
Nurses 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
Nursing
Nursing Assistant MD
Dietician
Social Service
Therapy
QSEN Competency
Teamwork & Collaboration
Knowledge-Describe how teamwork improves outcomes
Skills-Assumes the role of team member in treatment of pressure ulcer
Attitude-Values teamwork
A 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 Guidelines
AMDA Guidelines
National Clearinghouse
QSEN Competency
Evidence Based Practice
Knowledge-Describes guidelines for pressure ulcer assessment
Skills-Locate clinical practice guidelines for pressure ulcers
Attitude-Values evidence based practice
Common 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 care
Skills-Uses quality measures to evaluate care
Attitude-Values contributions to improve outcomes related to pressure ulcers
CMS 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 programs
Monitoring for incontinence
Use of support surfaces
Educating nursing assist staff
QSEN Competency
Safety
Knowledge- Describes a culture of safety in prevention of pressure ulcers
Skills-Communicates observations related to plan of care being followed
Attitude-Values monitoring of care activities provided by team
A 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 care
On-line slide shows
Internet resources for patient education
QSEN Competency
Informatics
Knowledge-Describe how information technology can improve outcomes related to pressure ulcers
Skills-Use technologies to communicate care plan and uses internet resources
Attitude-Value nurses role in implementation of technology for improvement of pressure ulcers
The 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. Debriefing
Explains 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. References
Bloom 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),