压疮预防指南临床应用的效果分析

目的 评价<成人压疮预测和预防实践指南>对指导和规范护士预防压疮的效果.方法 对2008年5月至2010年4月在住院期间有压疮发生危险的成人患者11808例进行观察分析.2008年5月至2009年4月共2081例为对照组,按照<医疗护理常规>第4版中的预防压疮常规实施护理;2009年5月至2010年4月共9727例为观察组,按照2009年出版的<成人压疮预测和预防实践指南>实施护理.观察两组院内获得性压疮发生例数及压疮分期.结果 两组院内获得性压疮例数和Ⅲ期压疮发生数有显著差异.结论 <成人压疮预测和预防实践指南>的应用可有效降低压疮发生率和压疮严重度,规范护士预防压疮的护理行为.     

Evidence-based protocol: prevention of pressure ulcers

Those who provide direct care to older individuals who are functionally impaired and immobilized must be constantly vigilant for the potential development of pressure ulcers. Use of the evidence-based guideline "Prevention of Pressure Ulcers" (Folkedahl et al., 2002) can provide a template for identification of patients at risk and implementation of interventions to prevent their occurrence.     

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Aims and objectives: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). Background: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. Design: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. Methods: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient‘s skin condition and stage of pressure ulcer. Results: Out of the 253 patients, 72 (28·4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41·7%), stage II (45·8%), stage III (10·4%) and stage IV (2·1%). In ICU B, the incidence was 31·6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut‐off score of 4. The area under the receiver‐operating characteristic curve was 0·888 (confidence interval: 0·84–0·93). Conclusion: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.     

The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers

Aims and objective. The objective of this study was to identify prognostic factors associated with the development of pressure ulcer lesions (grade 2–4) in nursing home patients with non‐blanchable erythema. Background. No studies could be found that identify risk factors for further development of pressure ulcer in patients with non‐blanchable erythema. For some patients with non‐blanchable erythema, standard preventive measures do not suffice to prevent pressure ulcers from deterioration. Identifying these patients beforehand can considerably contribute to the efficiency of pressure ulcer prevention. Design. Secondary data analyses of a previously conducted randomised controlled trial were performed. Methods. Eighty‐four wards of 16 Belgian nursing homes participated in the study. In total, 235 nursing home residents with a grade 1 pressure ulcer (non‐blanchable erythema) were included. All the residents received standard preventive care. Potential prognostic factors were collected using a standardised form. The incidence of pressure ulcers was recorded according to the European pressure ulcer classification system. Results. The cumulative pressure ulcer incidence was 18·7% (44/235). Hypotension (relative risk = 3·42, 95% CI = 1·56–7·49), a history of a cerebral vascular accident (relative risk = 1·94, 95% CI = 1·10–3·70) and contractures (relative risk = 2·02, 95% CI 1·03–3·95) were identified as independent predictive factors for developing pressure ulcers. Remarkably, being urinary incontinent decreased the risk of developing a pressure ulcer by 76%. Conclusions. In nursing home residents with non‐blanchable erythema, hypotension, contractures, and a history of cerebral vascular accident were independent risk factors for the development of pressure ulcer lesions. Relevance to clinical practice. Patients with non‐blanchable erythema who have hypotension, contractures or a history of cerebral vascular accident are in need of more intensive preventive measures. Identifying these patients can contribute considerably to a more efficient pressure ulcer prevention policy, resulting in a lower pressure ulcer lesion incidence and in lower costs.     

Guidelines for the prevention and treatment of pressure ulcers

An 'all-in-one' guideline on pressure ulcer prevention and management in primary and secondary care was published last year by the National Institute for Health and Clinical Excellence (NICE 2005a). The guideline is published in two parts. The first part is The Management of Pressure Ulcers in Primary and Secondary Care (Royal College of Nursing (RCN) and NICE 2005). The second part concerns pressure ulcer risk assessment and prevention, including the use of pressure-relieving devices (NICE 2003). A quick reference guide (NICE 2005b) summarises the recommendations made in both parts and is the focus of this article.     

Variation in pressure ulcer prevalence and prevention in nursing homes: A multicenter study

AimTo estimate the prevalence of pressure ulcers in nursing homes and its variability, the frequency of use of preventive measures and treatment.BackgroundPressure ulcer is a frequent pathology across healthcare settings. Most pressure ulcers are preventable and are considered an important quality of care indicator.MethodsAssessments were done on a single day of November 2015 in nursing homes in Geneva, Switzerland. Of the 51 institutions (3824 patients) eligible, 33 homes agreed to participate, representing 2671 patients (69.8%).One referent nurse per nursing home received training on pressure ulcer detection. To estimate the residual variability in prevalence and in number of prevention measures, adjusted multilevel logistic regressions were used.ResultsPatients were on average 85.6 years old, with a median length of stay of 2.1 years. The overall prevalence was 5.7% but varied considerably, from 0% to 19.6%.The variability across nursing homes decreased slightly when taking into account patient-level and institution-level characteristics.In the adjusted models, pressure ulcers prevalence was significantly associated with Braden risk; number of preventive measures was significantly associated with nursing home size, and Braden risk, and marginally associated with length of stay.ConclusionsOverall prevalence of pressure ulcers was relatively low. While several prevention measures for patients at risk were taken, the correct use of all of them was rare.The variability in prevalence and in number of preventive measures across nursing homes was very high. Programmes focusing on the correct use of all recommended prevention measures could help reducing pressure ulcers prevalence.     

Pressure ulcer prevalence in intensive care patients: a cross-sectional study

Background  Pressure ulcers 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 intensive care patients, patients' characteristics and preventive measures related to pressure ulcer prevalence in intensive care patients and to determine the most common body sites of pressure ulcers.
Method  The research design was a cross-sectional study. The sample consisted of 1760 patients (298 in 2002, 408 in 2003, 453 in 2004, 368 in 2005 and 233 participants in 2006) from surgical, medical and interdisciplinary intensive care.
Results  The results revealed a mean prevalence rate of ±30% from 2002 to 2005 while it considerably decreased down to 16.2% in 2006. Half of the pressure ulcers were of grade 1. Furthermore, a significant relation was found between the presence of pressure ulcers and age ( P  ≤ 0.022), Braden score ( P  ≤ 0.01) and bowel incontinence ( P  ≤ 0.01).
Conclusion  It is crucial to select appropriate and applicable preventive material/devices and nursing care measures. Moreover, factors related to the presence of pressure ulcers should be taken into consideration in order to prevent development of further pressure ulcers.     

Guidance on pressure ulcer risk assessment and prevention

Pressure ulcers remain a problem throughout Europe, with prevalence figures ranging from 8.3 per cent to 22.9 per cent (Clark and deFlour, 2002). In 2001 the National Institute for Clinical Excellence issued a clinical guideline on pressure ulcer risk assessment and prevention (NICE, 2001). However, this guidelines has recently been reissued with additional information on pressure-relieving devices (NICE, 2003a; NICE, 2003b).     

Pressure ulcer prevention and management: the current evidence for care

Pressure ulcers, a common occurrence across healthcare settings, are a costly phenomenon. Since the publication of the AHCPR Guidelines on Pressure Ulcer Prevention and Treatment in the 1990s, additional attention has been focused on pressure ulcer prevention and management. This article discusses current evidence regarding known causes of pressure ulcers, pressure ucler prevention, pressure ulcer classification and assessment, and interventions to effectively manage pressure ulcers.     

The Effectiveness of Skin Care Protocols for Pressure Ulcers

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.     

Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial

Aims and objectives. To evaluate whether postponing preventive measures until non‐blanchable erythema appears will actually lead to an increase in incidence of pressure ulcers (grades 2–4) when compared with the standard risk assessment method. Background. To distinguish patients at risk for pressure ulcers from those not at risk, risk assessment scales are recommended. These scales have limited predictive validity. The prevention of further deterioration of non‐blanchable erythema (grade 1 pressure ulcer) instead of the standard way of assigning prevention could be a possible new approach. Design. Randomized‐controlled trial. Methods. Patients admitted to surgical, internal or geriatric wards (n = 1617) were included. They were randomly assigned to an experimental and a control group. In the experimental group (n = 826), prevention was started when non‐blanchable erythema appeared, in the control group (n = 791) when the Braden score was <17 or when non‐blanchable erythema appeared. In both groups, patients received identical prevention, either by using a polyethylene–urethane mattress in combination with turning every four hours or by using an alternating pressure air mattress. Pressure points were observed daily and classified according to the four grades of the European Pressure Ulcer Advisory Panel. The Braden scale was scored every three days. Results. In the experimental group, 16% of patients received preventive measures, in the control group 32%. The pressure ulcer incidence (grades 2–4) was not significantly different between the experimental (6·8%) and control group (6·7%). Conclusion. Significantly fewer patients need preventive measures when prevention is postponed until non‐blanchable erythema appears and those patients did not develop more pressure ulcers than patients who received prevention based on the standard risk assessment method. Relevance to clinical practice. Using the appearance of non‐blanchable erythema to allocate preventive measures leads to a considerable reduction of patients in need of prevention without resulting in an increase in pressure ulcers.     

Pressure ulcer prevention in intensive care patients: guidelines and practice

Background  Pressure ulcers are a potential problem in intensive care patients, and their prevention is a major issue in nursing care. This study aims to assess the allocation of preventive measures for patients at risk for pressure ulcers in intensive care and the evidence of applied pressure ulcer preventive measures in intensive care settings in respect to the European Pressure Ulcer Advisory Panel (EPUAP) and Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer prevention.
Design  The design of this study was a cross-sectional study (point prevalence).
Setting  The study setting was intensive care units. The sample consisted of 169 patients – 60 patients from surgical wards, 59 from interdisciplinary wards and 50 from medical intensive care wards.
Results  The study results revealed that pressure reducing devices like mattresses (alternating pressure air, low air loss and foam) are applied for 58 (36.5%) patients, and all of these patients are at risk for pressure ulcer development. Most patients receive more than one nursing intervention, especially patients at risk. Nursing interventions applied are skin inspection, massage with moisture cream, nutrition and mobility (81.8%, 80.5%, 68.6% and 56.6%) respectively. Moreover, all applied pressure ulcer preventive measures in this study are in line with the guidelines of the EPUAP and AHCPR except massage which is applied to 8.8% of all patients.
Conclusions  The use of pressure reducing devices and nursing interventions in intensive care patients are in line with international pressure ulcer guidelines. Only massage, which is also being used, should be avoided according to the recommendation of national and international guidelines.     

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting

Aims and objectives. To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. Background. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. Design. A prospective cohort study. Method. A total of 197 subjects in a 106‐bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. Results. Out of 197 subjects, 18 patients (9·1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0·736 and for the Braden scale was 0·648. The modified Braden cut‐off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = ?1·544, OR=0·214, p = 0·016), body build for height (Beta = ?0·755, OR = 0·470, p = 0·030) and skin type (Beta = ?1·527, OR = 0·217, p = 0·002) were significantly predictive of pressure ulcer development. Conclusion. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. Relevance to clinical practice. The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.     

The first national pressure ulcer prevalence survey in county council and municipality settings in Sweden

Aim To report data from the first national pressure ulcer prevalence survey in Sweden on prevalence, pressure ulcer categories, locations and preventive interventions for persons at risk for developing pressure ulcers. Methods A cross‐sectional research design was used in a total sample of 35 058 persons in hospitals and nursing homes. The methodology used was that recommended by the European Pressure Ulcer Advisory Panel. Results The prevalence of pressure ulcers was 16.6% in hospitals and 14.5% in nursing homes. Many persons at risk for developing pressure ulcers did not receive a pressure‐reducing mattress (23.3–27.9%) or planned repositioning in bed (50.2–57.5%). Conclusions Despite great effort on the national level to encourage the prevention of pressure ulcers, the prevalence is high. Public reporting and benchmarking are now available, evidence‐based guidelines have been disseminated and national goals have been set. Strategies for implementing practices outlined in the guidelines, meeting goals and changing attitudes must be further developed.     

Comparison of two skin examination methods for grade 1 pressure ulcers

Aims and objectives. The purpose of this study was to find out whether the application of a transparent device for diagnosing grade 1 pressure ulcers influences grade 1 pressure ulcer prevalence rates and the total number of observed grade 1 pressure ulcers. Background. It is assumed that the accuracy of visual grade 1 pressure ulcer diagnosis is enhanced if a transparent device is used. Design. Quasi‐experimental. Method. Within a pressure ulcer prevalence study participating institutions were divided into groups at random. Data collecting nurses of the intervention group (n = 4667) applied a transparent disc. Data collecting nurses of the control group (n = 5095) conducted skin inspection using the ‘finger‐method’. Group comparisons were conducted. Relations between skin assessment methods and grade 1 pressure ulcer prevalence was analysed by logistic regressions. Results. Both groups were comparable regarding demographic characteristics. Grade 1 pressure ulcer prevalence in the intervention group was 3·9% and 7·1% in the control group (p<0·001). The total number of observed grade 1 pressure ulcers was 282 (intervention group) and 555 (control group). The chance to identify at least one grade 1 pressure ulcer increased when the ‘finger method’ was used (p<0·001). Conclusions. The use of a transparent disc influences the grade 1 pressure ulcer prevalence rates and the total number of observed grade 1 pressure ulcers. Relevance to clinical practice. Accurate identification of grade 1 pressure ulcers is important, because the development of those skin alterations indicate an urgent need for preventive measures. As the diagnosis of grade 1 pressure ulcers seems to be affected by the observation method, it is unknown which method is the more accurate. A study of diagnostic accuracy is needed to answer this question. It is recommended to report pressure ulcer prevalence rates including and excluding grade 1.     

Hospital pressure ulcer prevalence rates and number of raters

Aim. The purpose of this study was to evaluate the influence of different numbers of nurse raters conducting skin inspection (one or two) on observed pressure ulcer prevalence rates. Background. Pressure ulcer prevalence and incidence rates are important outcome measures for the quality of care. To ensure reliability and comparability of such rates standardisation of study methods is recommended. It is assumed that data accuracy can be improved if skin inspection is conducted by a team of two raters. Design. A secondary data analysis of pressure ulcer prevalence data was conducted. Method. Groups of hospital patients which were examined by one (n = 2420) or two raters (n = 15,009) were compared regarding demographic characteristics, pressure ulcer risk and pressure ulcer prevalence. Logistic regressions were conducted to examine the association between the number of raters (one or two) and the outcome pressure ulcer (yes/no). Results. Groups of one and two raters were comparable regarding demographic characteristics. There was no statistically significant difference regarding pressure ulcer prevalence between both groups (p = 0·222). There was no relation between the number of raters and the probability of identifying a pressure ulcer patient (p = 0·060). Conclusions. Pressure ulcer prevalence rates in the analysed studies were not affected by the number of raters. There seems to be no relation between the numbers of nurses conducting skin inspection and observed prevalence rates. Relevance to clinical practice. Conducting pressure ulcer prevalence studies require a lot of effort and personal costs. Provided that one nurse alone or a team of two nurses rate the existence of pressure ulcers equally it is no longer obligatory to have two raters. This would save resources. However, when patients are restricted in their mobility two nurses are recommended to provide assistance in patient turning.     

Pressure ulcer prevention in critical care: state of the art

Prevention of pressure ulcers in the critically ill patient is a major responsibility of the critical care nurse. The authors review the causes of pressure ulcer development and the methods of identifying the patient at increased risk. Pressure relief strategies for use in critical care are presented, and currently available pressure reduction and relief devices are discussed. Because few research studies address pressure ulcer prevention in the critical care setting, future research in this area is needed to develop a reliable predictive tool for use with the critically ill patient. Level of risk needs to be linked with intervention to assist the nurse in managing the pressure relief options available in today's market. In the meantime, prevention of pressure ulcers in critical care patients requires vigilance and the best use of available knowledge in the field.