Promoting Clinical Excellence

Pressure sore is a common clinical problem, which has an impact on patient forcibility, morbidity, and rehabilitation. The supply of blood to the skin cut off for more than two to three hours, turn the skin color to red, this initiates the occurrence of pressure sore in patients (Boyko, Lonaker, & Yang, 2016). A patient who is on the bed due to typical, sever, or long-term disease condition suffers mainly from pressure sore characteristics. Pressure sore can take days, months, and even years to heal. Pressure ulcers occur over predictable pressure points where the protuberances compress the tissues when the patient is in prolonged contact with hard surfaces (Boyko, Lonaker, & Yang, 2016). Many patients in ICU, surgical wards, mental health units, or aged care facilities suffer from pressure ulcer problem. The treatment for the ulcers should be properly planned with the mission to reverse the factors responsible for ulcer development.

The health care crew must undergo a careful assessment of the situation and should remove the causative factors such as shear, fiction, or pressure. The body, limb movement should follow to improve the venous and lymphatic drainage (Bhattacharya, S. Mishra, R., 2015). It is the responsibility of the registered nurse to maintain the pressure ulcer symptoms. the nurse's primary responsibility is to maintain skin integrity, reducing complications, and reducing friction through the usage of pressure ulcer devices (Ebi, W. E., Hirko, G. F., & Mijena, D. A., 2019). Many health care settings adopt the QI assessment approach that will help in capturing Braden scale, pressure ulcer risk assessment score, general skin assessment, as well as patient activity (Jacobson, Thompson, Halvorsom, Zeitler, 2016). These scores help in measuring the type, severity, and incidence of ulcers on patients.

Pressure ulcers represent one of the major concerns for the healthcare professional who is responsible for the wellbeing of patients. A pressure ulcer is one of the recognized ill-health conditions and is a mostly avoidable indicator of health quality (McBride, & Richardson, 2016). However, its care, treatment does not receive standardized guidelines, protocols, SOPs, and method for treatment universally (Zuo & Meng, 2015). But pressure ulcer prevention is a critically important element which needs to consider and need additional attention for its treatment. As if kept untreated, the ulcer can also result in complex and other serious infectious complications like bacteremia, and sepsis (Krupp & Monfre, 2015). Some of the hospitals adopt a “care bundle” approach with the goal of promoting corporation among healthcare professionals to translate clinical guidelines into clinical practice (Zuo & Meng, 2015). The care bundle is a step-based approach and comprises of risk assessment, skin assessment, support surfaces assessment, nutrition assessment, and repositioning initiative.

Risk assessment outlines the extrinsic and intrinsic factors such as shear stress, friction, maceration, and pressure. With the evaluation and adoption of effective prevention method, one can reduce the skin injury vulnerability. Under risk assessment, other factors also consider such as mobility, body temperature, immunity, hematology, and body moisture (Norton, et al, 2018). Under skin assessment, the patient skin was monitored, inspected, and evaluated. The reason for skin assessment is because, the ulcers only occur over bony prominences lie heels, ischial tuberosities, occiput, and sacrum (Xin, Lei, Xin, 2014). Surface assessment involve the frequent turning, patient shifting, and usage of physical accessories like pillows, cushions, and wedges that provide support, and help in bridging of bony prominences with bed surfaces. Undernutrition assessment, the patient must be provided with a good diet and nutrias diet. A good amount of Albumin and prealbumin should be administered routinely (Zuo & Meng, 2015). As their regular administration would help in early and easy relief of damaged tissues. Repositioning is one of the important components for reducing pressure. Continuous bedside pressure mapping can be used as a preventive strategic tool for improving patient positioning. the patient body turned laterally not more than 30ᵒ and the head of the bed elevated not more than 30ᵒ as that will prevent the pressure on Coccyx (Zuo & Meng, 2015).

Kwong hung, & woo (2016) states that the practice guidelines of the European pressure ulcer advisory panel and national pressure ulcer advisory panel incorporates a risk assessment approach by the Braden scale. The scale comprises of flow chart that will guide the health care staff on how to make decisions in performing preventive care. According to scale, the health care provider also responsible to review ad heck for the redness and lesions on the skin. 

In-home care setting as well, one can improve the condition of ulcers, with SKIN acronym (Ellis, 2017). Under SKIN, S is for surface, K is for keep moving, I mean incontinence, and N is for nutrition. The health care professionals must note the early signs of tissue damage (blanching, redness, pain, localized warmth) which should need to regularly check and monitored. This will reduce the severity of the condition. Keep moving help in mobilizing the person through effective repositioning, so as it may reduce the shear force on one site. Incontinence characterizes by the effective continence management and prevention of dermatitis associated with inconsistency. Nutrition must be provided to individuals as per the guidelines of the National Pressure Ulcer Advisory Panel (NPUAP). These demonstrate that the suffering patient must have enough amount of protein, fluid, and micronutrients which help the patient to maintain and repair tissue. The article (Boyko, Longaker, Yang, 2018) suggest that pressure ulcer prevention can be directed by alleviating risk factors for the individual patient. The pressure on the body can be minimized by incorporating appropriate paddle, mattresses, foam pads, or cushions.

Through these tools along with routine positioning could reduce the pressure on the body and help in relieving pain and ulcer development. According to the National Safety and Quality Service Standard, the health service provider must provide patients with guidelines for ulcer injury prevention (Government of South Australia). The clinicians must undergo a comprehensive skin inspection, with a summary of recommendations for prevention ulcers and treatment. Many kinds of literature provide a list of risk factors, which are associated with pressure ulcer development. Meta-analysis provides insight into various detrimental factors associated with the prevention of ulcers. The systematic risk assessment is too accomplished through the Braden scale or Norton scale (Hopkins Medicine). This will further help in identifying and managing critical care towards patients. Further, ulcer assessment is done which helps in determining the ulcer treatment plan.

The ulcer assessment is followed by monitoring healing, under this approach, the pressure score status tool and pressure ulcer scale are used for healing (Jaul, Rosenzweig, & Menczei, 2018). These are the excellent tool which helps in monitoring pressure ulcer heading. The pressure ulcer heals to progressively more shallow depth and does not replace the lost muscle or subcutaneous fat (John Hopkins Medicines). Treatment associated with ulcer prevention involves the adoption of multiple methods responsible to alleviate the condition. Support surface, repositioning, nutrition support, wound protection, creation of clean wound environment, tissue healing, adjunctive therapy, and surgical repair treatment (Qaseem, Humphrey, Forciea, Starkey, & Denberg, 2015).

The health care professional uses hydrocolloid dressing than gauze dressing for covering the wound from external contamination. Platelet-derived growth factor improves the damage caused by ulcers as compared to other placebo or other medications. Other than this, some of the medical professionals adopt adjunctive therapies like laser therapy, electromagnetic therapy, wound therapy, negative pressure therapy, and ultrasound therapy. The elderly patient suffering from ulcer development may treat with light therapy for reducing ulcer size as compared to control. This is because light therapy does not have any chances for the development of substantial adverse events and skin irritation (Qaseem, Humphrey, Forciea, Starkey, & Denberg, 2015).

PDSA

PDSA cycle 1

PLAN – First important thing is to manage the pressure ulcer in patients admitted to hospitals, old age care, and rehabilitation center. Staff education and awareness need to incorporate an effective treatment plan. The staff, healthcare profession, and other medical professionals must know about pressure ulcer prevention, sound knowledge of tissue viability method, ulcer preventive guidelines, and policies.

DO – The record for patients admitted in critical units, long-term ward, or any other unit who are suffering from ulcer problems should be done. Then, health care professionals need to divide them based on ulcer severity, ulcer type, patient age, and reason for admission. According to this, the health care provider must provide relevant treatment options, nutrition diet needed, and other medication.

STUDY – on a regular basis, the health care provider must demonstrate the condition and record the feedback for the same. They must evaluate the condition through different tools and assess their recovery rate. 

ACT – The feedback and the assessment criteria should be crosschecked. In addition, if this works properly, the organization should implement them for future health care needs.

PDSA cycle 2

PLAN – the pressure ulcer can also be prevented if there is strong and proper communication between the health care profession and patient. The overall health gain can only be accomplished if there is no gap in communication between the patient and the nurse.

DO – For proper communication, the patient and nurse professional must be given training regarding the patient's requirement, patients needs, how to fulfill needs, patient-nurse relationship, patient-centric approach, nurse-working criteria, and how should both work. This session will make the smooth functioning of the health care profession and setting the overall good health of the patient.

STUDY – regular patient and nurse feedback should be done, as this will raise a win-win situation for both parties. It will also address how the patient recovers from an ulcer, and also how the nurse has made its effort.

ACT - Depending on the patient's condition, and treatment option adopted, the ulcer problem can be solved through various methods. These methods should be encountered effectively for long-term relief.

PDSA Cycle 3

PLAN – the practitioner must adopt the strategies for the treatment option with respect to the cases encountered. For this, different treatment options should be administered such as physical support, medication, therapy, and surgery.

DO – Healthcare practitioner must adopt mattresses, cushions, healing pillow. Under medication, they can adopt various medicines topical or atypical as per the patient’s condition. Therapy and surgery should be considered as the last step for the prevention of pressure ulcers and management.

STUDY – the type of treatment used should be checked regularly. The degree of recovery through the use of a particular treatment option should also be noted and checked.

ACT – The risk, skin, and treatment assessment should be evaluated for the long-term approach.

Quality Improvement Program

A pressure ulcer is a condition that deteriorates the body of an individual if untreated can lead to tissue, bone, and skin damage. The underlying cause of the symptom is long term lying or sitting position with less or negligible movement. The pressure ulcer can occur on any location where kin compressed between a bony prominence and hard surfaces such as bed, chair, or any device. To improve the patient's condition, there is a high need for adoption of quality improvement programs. In the hospital, nursing care, home care setting, and health center, there must be a separate team that should be responsible for the especially for ulcer care. The reason for this is because the maximum number of people suffers from pressure ulcer problem. The team should adopt the qualitative approach with strong critical care nursing leadership. The approach must be divided into four main pillars: a) establishing critical care network specialized group, b) baseline standard and guidelines for pressure prevention establishment, c) evaluate and monitor pressure ulcer prevalence, and d) management of electronic health record system (EHR). The critical care network specialized group comprises specialized nursing, doctors, and healthcare profession.

They will be responsible for program mission, preventive awareness, and leadership initiative. The baseline standard guidelines comprise of all the preventive measure (physical accessories, therapy, medications, and surgery) which suits the patient’s condition. It also comprises detailed assessment tools require for managing patient care including risk assessment, skin assessment, ulcer assessment, and ulcer measurement tool. Evaluation and monitoring of ulcer prevention were done, which include regular monitoring of the patient's condition and ulcer deterioration, regular feedback, and regular quality check. Lastly is the management of EHR, it includes the implementation of those guidelines that are responsible for providing effective treatment options on pressure ulcer prevention. The EHR will be basic for the future treatment of pressure ulcers and will act as a baseline for further health management care. With the adoption of these qualitative improvements, the pressure ulcer conditions can be treated.

Reference for Promoting Clinical Excellence

Boyko, T. V., Logaker, M. T., George, P. Y. (2016). Review of the current management of pressure ulcers. Advances in Wound Care, 7, 57-68.

Bhattacharya, S., & Mishra, R. K. (2015). Pressure ulcers: current understanding and newer modalities of treatment. Indian Journal of Plastic Surgery, 48, 4-16.

Ebi, W. E., Hirko, G. F., & Mijena, D., (2019). Nurses’s knowledge to pressure ulcer prevention in public hospitals in Wollega: a cross sectional study design. BMC Nursing, 18, 1-12.

Ellis, M. (2017). Pressure ulcer prevention in care home settings.  Nursing older people, 29, 29-35.

Government of South Australia. Reitrived from https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/infection+and+injury+management/pressure+injuries/

Hopkins Medicine. Retrieved from https://www.hopkinsmedicine.org/geriatric_medicine_gerontology/_downloads/readings/section8.pdf

Jacobson, T. M., Thompson, S. L., Halvoron, A. M., Zeitler, K. (2017). Enhancing documentation of pressure ulcer prevention interventions. A quality improvement strategy to reduce pressure ulcers. Journal of Nursing Care Quality, 31,  207-214.

Jaul, E., Barron, J., Rosenzweig, J., &Menczei, J. (2018). An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatrics, 18, 1-11.

Krupp A. E., Monfre, J. (2015). Pressure ulcers in the ICU patient: an update on prevention and treatment. Current Infectious Disease Reports, 17, 1-11.

McBride, J. & Richardson, A. (2016). A critical care network pressure ulcer prevention quality improvement project. Critical Care Nurse, 1-10

Norton, L, Parslow, N, Johnston, D., Ho, Chester, Aflavi, A., Mark, M, Dromolis, D., Moffat, S. (2018). Retrieved from https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/172-bpr-prevention-and-management-of-pressure-injuries-2/file

Pressure Ulcers (n.d.). Retrieved from https://www.mayoclinic.org/diseases-conditions/bed-sores/diagnosis-treatment/drc-20355899

Qseem, A., Humphrey, L, Forciea, M., Starkey, M., and Denberg, T. (2015). Treatment of pressure ulcers: A clinicl practice guideline from the American college of Physicians. ACP Journals, 1-10.

Xin, G., Lei, W., & Xin, S. (2014). The incidence and risk factors of pressure ulcers in the intensive care unit patients. Chinese Journal of Nursing, 49, 840-843.

Zuo, X. L., & Meng, F. J. (2015). A care bundles for pressure ulcer treatment in intensive care units. International Journal of Nursing Science, 2, 340-347.

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