Download - GATES LEBANESE GERMAN UNIVERSITY
GATES – LEBANESE GERMAN
UNIVERSITY
PROJECT IN HEALTHCARE AND QUALITY MANAGEMENT
Management of Pressure Ulcers in Intensive Care Unit
Prepared by:
Fadia Chabchoul
Fattoum Awad
Alya Solh
Submit in partial fulfillement of the requirements of the Healthcare and
Quality Management Diploma Program
1/8/2015
Advisor: Dr. Marale Atechian
ii
ACKNOWLEDGMENT
Graduation reminds me of everyone who has touched my life. The gift of their
Presence and acknowledgment is truly appreciated
We would like to thank
Dar Al Amal University Hospital
Dr. Marale Atechian
GATES and LGU
My family and friends
For treasured memories and loving support throughout my education and graduation.
Fadia Chabchoul
Fattoum Awad
Alya Solh
iii
ABSTRACT
Pressure ulcers (PU) are a potential complication for intensive care patients and their prevention
is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in
ICU in Dar AL Amal University hospital including the path physiology, risk factors, risk
assessment, prevention, treatment and outcomes and to develop the performance level of staff.
Knowing that the rate of PU in ICU in 2014 increased to (7.9%) from all complete bed rests
patients compared with 2013 (5.59%).
This topic will determine the factors related to increase occurrence of PU in ICU and to manage
it, because of its importance issue in nursing care. 42 Registered nurses are sampled. Data
collected from a questionnaire and competency test. Our study shows that the Nurses had limited
knowledge about critical parameters of pressure ulcers especially the new employees in addition
the increase in the admission of critical and complicated cases, these 2 factors increase the rate of
Occurrence of PU in 2014.
It is an important to focus on pressure ulcer as a serious issue because it affects negatively on the
patient health and the hospital and to apply certain and immediate interventions as continuous
training and education of the employees' in order to manage bed sore and prevent its
development.
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TABLE OF CONTENTS
ACKNOWLEDGMENT ...................................................................................... II
ABSTRACT ....................................................................................................... III
LIST OF FIGURES ............................................................................................. V
LIST OF GRAPHS .............................................................................................. V
LIST OF TABLES ............................................................................................. VI
LIST OF ABBREVIATIONS ........................................................................... VII
INTRODUCTION ................................................................................................1
PROBLEM STATEMENT ...................................................................................2
OBJECTIVES .......................................................................................................3
LITERATURE REVIEW .....................................................................................4
HYPOTHESIS ......................................................................................................8
PROJECT DESIGN AND METHODOLOGY ....................................................9
DATA ANALYSIS AND RESULTS ................................................................ 11
CONCLUSION .................................................................................................. 14
RECOMMENDATIONS AND FUTURE WORK ........................................... 15
REFERENCES ................................................................................................... 16
APPENDICES ................................................................................................... 17
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LIST OF FIGURES
Figure 1: Stages of pressure ulcer ................................................................................................... 4
Figure 2 Nursing interventions to prevent PU ................................................................................ 5
Figure 3: Fishbone analyse major causes of pressure ulcer occurrence in ICU ........................... 10
LIST OF GRAPHS
Graph 1: Distribution of patients gender 10
Graph 2: Distribution of pressure ulcer related to age 10
Graph 3: Percentage of PU related to admitted diagnosis 10
Graph 4: Risk factors related to PU 10
Graph 5: Percentage related to PU degree 11
Graph 8: Availability of equipment’s 12
Graph 9: Causes that prevent nurse from PU 12
Graph 10: Staff nurse education about bed sore 12
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LIST OF TABLES
Table 1: line list for pressure ulcer in ICU department.
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LIST OF ABBREVIATIONS
PU : Pressure Ulcer
ICU: Intensive Care Units
HN: Head Nurse
CBR: Complete Bed Rest
RN: Register Nurse
e.g.: Example
K.cal: Kilo calories
SBAHC: Sultan Bin Abdulaziz Humanitarian City
KPI: Key of Performance Indicator
INTRODUCTION
Pressure ulcer (PU) or bedsore is significant health care problem especially for geriatric
population (1). Over one million of hospitalized patients are subjected to the affliction of bed
sores every year. Data from United States indicates that about 11% of all hospital admissions
mostly in intensive care departments have PU (2). In Saudi, the rate of PU in ICU was 27% in
2012, the SBAHC (Sultan Bin Abdulaziz Humanitarian City) launched its wound care service to
prevent and manage PU; it uses guidelines from National Pressure Ulcer Advisory Panel
(NPUAP) and puts its efforts to eradicate pressure ulcer by approving a team for identifying,
preventing and managing PU (3).
PU is areas of tissue necrosis that tends to develop when soft tissue is compressed between a
bony prominence and an external surface for a prolonged period of time. Pressure ulcers are
associated with adverse patient outcome; contribute to patient pain, depression, loss of function
and independence, increase incidence of infection and sepsis, additional surgical interventions,
significant economic costs and prolonged hospital stays. Therefore, the most effective treatment
for pressure ulcers is to prevent their development.
The development of pressure ulcers remains a problem and a major issue in nursing care. The
development of PU is very complex phenomenon. Contributing factors are related to both
patients' conditions and extrinsic factors.
Pressure ulcer remains the chief complications of prolonged hospitalization, specifically in
situations of poor nutrition; it increases moisture on skin (e.g. incontinence) and prolonged
pressure. Pressure ulcer increases the cost of hospitalization, morbidity, mortality and plays a
significant role in the spread of infection, leading to dictum of preventive therapy being not only
beneficial to the patient but also to the health care system.
In clinical area, the presence or absence of PU has been generally regarded as performance
measure of quality nursing care and over all patient health; an average 60.000 people die yearly
world wide due to pressure ulcers related causes (5). Pressure ulcers have plagued critically ill
and debilitated patients since the dawn of recorded medicine.
Studies have shown a clear association between development of pressure ulcers and increased
mortality (6). Since we focused in our hospital to achieve nine goals of patient safety, the
evaluation of this topic was followed from 2005 as a Key of Performance Indicator (KPI). We
noticed that not only the underlying physiologic causes as CBR may predispose to develop PU
but also the knowledge deficit of health care personnel. Eventually, it is a must to deal with these
causes as a serious issue in hospital and improvement actions should be taken to manage PU.
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PROBLEM STATEMENT
Patients in Intensive Care Units (ICU)) are at high risk of developing pressure ulcers. PU is
considered to be chronically contaminated wounds and this may lead to sepsis occurrence.
In 2014, PU incidence declaration in ICU at Dar at Al Amal University Hospital was increased
compared with 2013. So there was an alarm to take a certain corrective and preventive measures
toward this issue in order to identify factors related to this rasing, to put certain interventions to
manage it and to assess the personal knowledge level.
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OBJECTIVES
The objective of this thesis:
1. To analyse the data and to identify the underlying causes and unrelieved factors behind
the development of PU and to make management for it.
2. To identify the adequacy of personnel, materials and supplies.
3. To assess the performance level of the employees in ICU and to increase their levels.
4. To improve the quality of care by resolving gaps in order to attempt Zero target and to
increase staff consciousness regarding harm caused by PU.
5. To support clinical practice by providing consistent research-based information related
PU, initiating better practice, better patient outcome
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LITERATURE REVIEW
Definition of pressure ulcers PU is localized areas of tissue necrosis that tend to develop when soft Tissue is compressed
between a bony prominence and an external surface for a prolonged period of time.
PU occurs when the pressure on the skin reduces the blood flow to the area. PU most commonly
occurs over body areas or prominences in the body such as shoulders, hips, or heels. PU can be
difficult to treat in extreme cases. (7)
Staging of pressure ulcers Stage I
A redden area on the skin that when pressed does not turn white.
Stage II
It is a partial thickness loss of dermis presenting as a shallow open ulcer with a red wound.
Stage III
There is damage to the tissue below the skin. Subcutaneous fat may be visible but bone, tendon
or muscle is not exposed.
Stage IV
PU becomes so deep that there is damage to the muscle and bone, and sometimes to the tendons
and joints.
Stage V
There is full thickness tissue loss with exposed bone, tendon or muscle.
Figure 1: Stages of pressure ulcer
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Deep tissue injury
Purple localized area of discoloured intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure. (8)
Figure 2 : common sites for PU prevalence
Risk Factors of PU - Immobility is one of the most important host factors that contribute to pressure ulcer
development. Immobility may be permanent or transient.
- Urinary incontinence is frequently cited as a predisposing factor for pressure ulcers.
- Mal nutrition: The role of nutritional status in the development of pressure ulcers is
uncertain.
- Neurological diseases such as dementia, delirium, spinal cord injury, and neuropathy are
important contributors to pressure ulcer development. This may in large part be related to
immobility, plasticity, and contractures that are common in these conditions. Sensory loss
is also common, suggesting that patients may not perceive pain or discomfort arising
from prolonged pressure.
- Other factors identified in some studies are: older age, white race, and male gender.
Specific diagnoses that have been associated with ulcer development include the presence
of dry skin, recent lower extremity fractures, diabetes, and cardiovascular disease. (9)
Valuation of Pressure Ulcers (9) The patient must be evaluated through the scales for identify the patients who have risk to
develop pressure ulcer in intensive care units. The Braden and Norton scales are the most used.
Pathogenesis Development of a pressure ulcer is a complex process that requires the application of external
forces to the skin. However, external forces alone are not sufficient to cause an ulcer; their
interaction with host-specific factors culminates in tissue damage.
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Prevention - Skin moisturising and hygiene to all complete bed rest patients.
- Regular turning schedule of 2 hours is recommended.
- Patient should be placed at a 30 degree angle to avoid direct pressure over the greater
trochanter.
- Pillows or foam wedges may need to be placed between the ankles and knees.
- Implement measures to reduce the risk of developing pressure ulcers.
- using heel protection devices
- Use air mattress for CBR patients.
- Use skin protection cream for patients with frequent faecal incontinence.
- Offer individuals with nutritional and PU risks a minimum 30-35kcal/day per kg body
weight per day.
- After urinating or having bowel movements, clean the area and dry it well.
Nursing intervention to prevent PU Nurses play an important role in preventing PU in CBR patients by doing the following steps by
using "PROMPT".
P: Pressure Points
Nurses should regularly check areas of the body that may be under pressure.
R: Report it.
Report promptly to your health professionals any painful areas.
O: Oral intake
It is important to eat a balanced diet and drink plenty of fluids.
M: Moisture
Keep the skin clean and dry.
P: Position
Poor position can contribute to development of pressure ulcers. Avoid pressing down on heels to
move up the bed.
T: Take pressure off
Change position every 2 hours.
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Complications:
- Pressure ulcers may be associated with both medical (cellulites, bone and joint infections
and sepsis) and psychosocial complications. The medical complications can be life
threatening and are more common with stage 3 and 4 ulcers.
- Psychosocial consequences are not often considered. However, patients with pressure
ulcers may suffer pain and feel stigmatized by the development of chronic skin ulcer.
This could result in depression, social isolation, and decrements in overall health-related
quality of life.
- The worst complication of PU is the infection, bacteria multiply, the healing is disrupted
and damage tissues. The symptoms typical are inflammation, pain, hot and blush.
Treatment:
Most stage 1 and stage 2 sores will heal within weeks with conservative measures. But stage 3
and 4 may require surgery.
- Wound should be evaluated for stage, size, necrotic tissue, exudates, and presence of
granulation.
- Pressure reduction
- positioning
- Adequate pain relief
- Infection management. (Local antibiotic)
- Dressings - Debridement and surgery
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HYPOTHESIS
We hypothesized that PU rate was increased in intensive care units in 2014 because of:
- Most patients admitted to ICU have more risk factors to develop pressure ulcers, as
complete bed rest patients, urinary incontinence and age. These factors may be the major
causes to develop PU.
- PU may be caused by mal practice of ICU employees or lack of performance of RN’s
especially in skin assessment.
- PU may be increased in intensive care units due to limit available of preventive tools as
ICU bed standards.
- PU increases the morbidity and mortality rate and affect negatively on the quality of the
hospital.
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PROJECT DESIGN AND METHODOLOGY
Methodology:
Part A:
- A retrospective descriptive, data collection was approved by hospital administration to make - -
statistical analysis about percentage of PU occurrence in intensive care departments in Dar al
Amal hospital in 2014. (Data included in Appendix A).
- Characteristic of Data Collection: data were abstracted from the hospital’s existing
computerized documentation systems of sheet of PU indicator, included the following study
variables: pressure ulcer, Norton scale, age, length of ICU stay, risk factors. Demographic data
and patient characteristics included sex and admitting diagnosis, PU stages, and sites of PU.
- Criteria of inclusion: patients who had risks for developing PU (complete bed rests patients,
diseases that affect blood flow, CVA cases, respiratory cases and patients of long period
hospitalizations).
- Criteria of exclusion: Patients who had PU at time of admissions to ICU, diabetic patients.
The prevalence of PU indicator in ICU was calculated according to the following formula:
Prevalence = 100 * total PU in ICU / (Number of CBR patients)
Description of the sample:
Number of CBR patients= 515 by reviewing the medical files, Norton scale and statistical
data of ICU department
o In-ICU PU = 41 had bed sore
Tools:
– Computerized data: PU Indicator of 2013 -2014
– Cause and Effect analysis (fishbone) to analyze major causes of PU occurrence.
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Figure 3: Fishbone analyse major causes of pressure ulcer occurrence in ICU
Part B:
- A prospective study, through analysis of knowledge assessment questionnaire, conducted
among 42 ICU Nurses (included in Appendix B).
Criteria of inclusion: All ICU nurses.
Criteria for exclusion: All nurses in nursing floors except ICU.
Data Analysis
Excel, version 2003 for windows, was used for data analysis. Descriptive statistics included
frequency distribution for study variables and demographic data.
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DATA ANALYSIS AND RESULTS
Part A: Results of data collected as indicator by ICU department
From PU indicator data of 2014 collected by ICU department we have conclude the following
points:
o PU prevalence= 7.96%. We suggest this increasing by 1.4% in 2014 may be due to,
knowing that this rate was 5.59% in 2013 while in 2014 it becomes 7.96%:
- increase admission of critical cases
- most of who developed PU had more than 2 risk factors on admission
- increase ICU bed number in 2014 more admission of critical patients
- New RN’s not well trained in PU care especially in skin assessment
o Graph 1: Females were more affected by bed sores due to their complicated cases at
admission.
o Graph 2: 19% of PU patients were less than 50 years due to Polytrauma & post
operative cases.
o Graph 3: Major diagnosis of aged patients was related to neurological & respiratory
problems.
Distribution of PU
related to Age4%
15%
81%
<25 years
25-50 years
>50 years
Graph 1 Graph2 Graph 3
02
o Graph 4: The highest prevalence of PU: grade 1(48.7%), grade 2 (39%), grade 3(12%)
and grade 4 (2.3%).
o Graph 5: Most of ICU patients who developed PU in 2014 had the following risk
factors:
- Age > 60 years (92%),
- CBR (87%),
- Mmalnutrition (78%)
- Dehydration (60%)
- Most patients had more than 1 risk factor to develop PU.
Graph 4 Graph 5
o Graph 6: The most common site that developed PU in ICU was sacrum (56%) and then
heels (24.4%).
o Graph 7: 65.8% from patients who developed PU had long period of hospitalization
(more than 20 days), and 29.2% had period between 10-20 days, and 5% had less than 10
days of hospitalization. We conclude that PU was increased as hospitalization period
increased.
Graph 6 Graph 7
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Part B: Statistical analyses of questionnaire that analysis the knowledge of nurses
According to employees’ opinions:
o Graph 8: 98% of nurses agreed the availability of equipment used for pressure ulcer in
ICU department (mattress, dressing types, creams, ointments). In fact, hospital insure all
nursing care unit all preventive measures to prevent PU occurrence since the
establishment of hospital.
o Graph 9: shows causes that prevent nurse from PU care, in which the lack of experience
(55%) was the highest percentage, then the negligence (28%) and insufficient time
(15%). From these data effort should be done to increase knowledge of the employees,
and to manage negligence by motivating the employees.
o 55% of nurses answered that PU occurrence due to lack of experience. Otherwise 30% of
nurses are interested in evidence base practice to increase their knowledge.
Graph 8 Graph 9
Education of patient family upon discharge
Graph10: reflects the poor involvement of nurses in giving
proper instructions to home. 55% from nurses educate
patients and family about PU upon discharge while 45%
from nurses don’t involve them. Education of patient
family is one of the most important steps for treatment at
home and how to deal with bed sore. It’s important to
involve patients and family in treatment plan. Graph 10
04
CONCLUSION
It is known that pressure ulcer prevalence is higher in intensive care patients than in other health
care settings and this supports the hypothesis that pressure ulcer is higher in intensive care
patients. The most common sites in intensive care patients are the sacrum and the heel.
It is crucial to select appropriate and applicable preventive measures (nursing care and materials
or devices); furthermore, the factors that are significantly related to pressure ulcer, such as old
age and bowel incontinence should be considered for the prevention of further pressure ulcer
development.
Also the mal practice of new employees due to lack of knowledge about management of PU will
affect negatively on patients status it lead to increase rate of morbidity and mortality and this
effect on the quality hospital. Not only PU cost the patient, cause pain, loss of self esteem and
altered body image but also PU cost the hospitals by increase length of stay, increase use of
resources and increased use of nursing time.
The incidence of PU is likely to increase if hospitals and employees put their effort to manage it.
The best method of addressing PU in the intensive care setting is thorough institution of
preventive measures that target patients at greatest risk. The preventive measures should remain
the primary goal, early recognition and treatment of PU is imperative. Raising awareness of
preventive and treatment strategies among nurses and other health care professionals is
recommended. Also the managers have an opportunity to motivate employees by providing a
climate that encourages growth and productivity.
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RECOMMENDATIONS AND FUTURE WORK
We recommend the following solutions in order to decrease PU rate, increase employee’s
knowledge and maintain high standards of care:
Specify “PU – team” to round twice a week on :
the most vulnerable patients
bedside education provided on skin assessment
staging definitions and prevention techniques to avoid PU
Improve communication between staff and PU team (pre-shift huddles)
All ICU employees should take precautions and do risk assessment to prevent bedsore
development
Taking preventive measures and corrective actions to reduce PU
Enhancing continuous education and training schedules for employees for better
performance
Efficacy of intervention for preventing the development of pressure ulcers, and
facilitating wound healing
Validity of tools used to assess patients at risk and pressure ulcer healing (oscillating
support surface for positioning)
Initiating of a multidisciplinary committee to set a plan of action to decrease PU
incidence.
Continuous follow up progress technologies as a technique called platelets rich fibrin
(PRF) that is generated from plasma of the patients that applied to PU site to promote
healing.
For future work we will focus on management of PU care upon and after discharge. We will
make study about availability of preventive equipments at home and we will involve family in
playing role in management of PU at home. In fact, family can be a good partner and support
patients and to improve quality of life of patient.
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References
1. Cowart V.Pressure ulcers preventable, say many clinicians.JAMA 1987, 589-93.
2. Perdue RW, Wilson JL. Decubitus ulcers. J Am Board Fam Pract 1989; 2:43-8
3. Joane Aspiras Jovero,BSEd, BSN,RN, Hussam Al-Nusair , MSc Critical care ANP,RN.
4. Data collected from ICU departments including KPIs and statistics. (Dar Al Amal University
Hospital).
5. Pressure ulcers in the intensive care units: the forgotten enemy Evans JM, Andrews KL,
Chutka DS, et al: Pressure Ulcers prevention and management. Mayo Clin Pro 1995:70: 789-
799.
6. Berlowitz DR, Wilking SV. The short-term outcome of pressure sores. J Am Geriatr Soc
1990; 38:748-52.
7. C.Richard. Gibbs. MD, Differential Diagnosis of dermatology, chapter 7, 2005, p: 104.
8. Scienkiewiz size, E. Whitney & T. Wads won, Nutrition, concept & contra version, chapter 6
and 10. 2005, pp: 186-192
9. P. Angelton &H.Chalmers, Nursing Model and Nursing Practice, chapter 4 second editions,
2003, p: 120.
10. Data collected from ICU department as KPI,indicators,protocols,competency test, medical
files, register. Statistics 2013-2014
07
Appendices
Appendix A: Line list for pressure ulcer in ICU: Table (1)
Dep
.
To
tal P
ati
en
t
To
tal b
ed
so
re
Risk Factors Degree Site ICU
hospitalization
Bed Sore
Progression
CB
R
Deh
yd
rati
on
Maln
utr
itio
n
Ag
e >
60y
1st
2n
d
3rd
4th
Elb
ow
s
Bu
tto
cks
Sac
ral
Heels
Oth
ers
<10d
ays
10-2
0d
ays
>20d
ays
Heale
d
Un
heale
d
Wo
rsen
ICU 515 41 36 25 32 38 20 16 5 1 2 4 23 10 2 2 12 27 12 18 11
08
Appendix B: Knowledge assessment questionnaire
GATES – LEBANESE GERMAN
UNIVERSITY
Addressed to: ICU nurses
Aim: to assess the knowledge; attitudes and practices of pressure ulcer care of nurses at Dar Al
Amal University Hospital.
Prepared by: Fadia Chabchoul, Fattoum Awad and Alya Solh
This study is made just for scientific aim, its confidentiality is respected and the link to specific
individuals will not be disclosed to any other research personnel.
Thanks for help
09
eneral dataG
1. Age:
20-29
30-39
40 and above
2. Sex:
Male
Female
3. Status:
Single
Married
4. Educational level:
Master degree
BS
LT
TS
5. What is your job description?
HN
RN
N
6. What are the experience years in this hospital?
Less than 1 year
From 1-5 years
From 5-10 years
More than 10 years
7. What is your duty shift? Daily
Night
Both
Specific Data:
1. In your opinion do you have enough data and experience about management of pressure
ulcers? Yes
No
2. in your opinion, what are the main factors related to Pressure ulcer occurrence in your
department? You can Chose 3 answers as maximum. Factors related to patient: complicated cases
Mal nutrition
Bad positioning
Unavailability of specific equipments for bedsore care and prevention as mattress….
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Negligence of employees
Lack of knowledge of employee toward PU
Number of employees is not sufficient for ICU department
3. In your opinion, do you agree that the equipments used in ICU are sufficient for preventing
PU? Yes
No
4. In your opinion, do you offer good care to all patients suffer from bed sores? Yes
No
5. In your opinion, what are the causes that prevent nurse from caring of bed sore? Negligence
Lack of experience
No sufficient time for caring PU
6. Have you share with training about PU (Management and Care)? Yes
No
7. Have you make researches (up to date) on PU? Yes
No
8. Do you agree that the low number of employees is from factors that related to PU occurrence? Yes
No
9. What is number of nurses in every shift in your department? What is number of beds?
Nurses' number……………beds number…………….
10. Is there a specific policy to put actions that prevent PU occurrence? Yes
No
11. Is there a follow up plan by your head nurse toward prevention and management of PU? Yes
No
12. Does the employees punish if bed sore occurrence is due to negligence? Yes
No
13. If PU occurs, are there specific forms to evaluate bedsores? Yes
No
If yes, list the available forms:
---------------------------------------------------------------------------------------
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14. Was competency test (pressure ulcer) done for you? Yes
No
15. Do you collect data and make statistics about PU occurrence in your department? Yes
No
16. Do you consider that PU cases occur in 2014 in your department is a result of? Community acquired
Hospital acquired
Unit acquired
17. Do you support the patients by suitable education about caring and preventing PU upon
discharge from hospital? Yes
No
18. Is there a specific team for PU in your hospital? Yes
No
19. Mention suggestions you have to manage PU in your department?
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
....................................................................................
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Appendix C: Pressure Ulcer- Risk Assessment
In order to determine which patients might be at increased risk of developing pressure, several
scales are used and the most frequently one is the Norton Scale. This scale was created in
England in 1962.
Physical
condition
Mental
condition
Activity
Mobility
Incontinence
4 4 Good
3 Fair
2 Poor
0 Very Bad
4 Alert
3 Apathetic
2 Confused
0 Stuporous
4 Ambulant
3 Walks with help
2 Chairbound
0 Bedfast
4 Full
3 Slightly
impaired
2 Very limited
0 Immobile
4 None
3 Occasional
2 Usually urinary
0 Urinary
&Faecal
Low Risk Greater than 18
Medium Risk Between 18 and 14
High Risk Between 14 and 10
Very High Risk Less than 10