Reducing Pressure Ulcer Prevalence, Nursing Success and Priority - Research Paper Example

? REDUCING PRESSURE ULCER PREVALENCE Reducing Pressure Ulcer Prevalence: Nursing Success and Priority Theresa Nussbaumer The of Saint Francis Word Count: 5,000 (20 pages) TABLE OF CONTENTS ABSTRACT………………………………………………………………………..3 I. INTRODUCTION………………………………………………………………4 II. LITERATURE REVIEW / CONCEPTUAL FRAMEWORK…………….5 III. METHODOLOGY AND DESIGN…………………………………………..7 a. Essential Step………………………………………………………………8 b. The Foundation……………………………………………………………11 IV. RESULTS……………………………………………………………………13 a. A Need to Implement……………………………………………………13 b. Evaluation……………………………….……………………………….13 IV. DISCUSSION / CLINICAL RELEVANCE……………………………….14 a. Clinical Relevance………………………………………………………14 b. Recommendations Derived from the Study………………………...…15 1. Education is Critical…………………………………………………15 2. Communication is Integral………………………………………….16 3. Leadership Must Be Present At All Levels…………………………16 4. Priority………………………………………………………………..17 c. Further Discussion & Comments……………………………………….17 V. CONCLUSION………………………………………………………………19 a. Overall Conclusions………………………………………………………19 b. Recommendations for Continued Treatment…………………………...20 VI. REFERENCES……………………………………………………………….22 ABSTRACT Purpose: To identify keys used for a successful pressure prevention program and if nursing priority impacts pressure ulcer prevalence rates. Methods and Design: An integrated review of the nursing literature within the United States health care system. Results: Evidence-based guidelines are the foundation for all successful prevention programs. Leadership, communication and education are three subcultures that influence facility success with prevention. Discussion / Clinical Relevance: Organizations nationwide declare the regulatory requirements for quality care and terms for accreditation and reimbursement based on patient condition. Is a zero prevalence achievable? This question remains. Conclusion: The ability to decrease PU prevalence rates is a complex process that is achievable when priority is placed in prevention through increased awareness to the causes and standardized prevention measures are utilized for prevention. I. INTRODUCTION Quality of care remains a concern across the health care settings as pressure ulcers (PU) continue to afflict over 2.5 million people each year with an $11 billon price tag for the United States (Institute for Healthcare Improvement, 2007). Skin integrity maintenance is a longstanding outcome measure for quality nursing care. PU development, a severe impairment to skin integrity, is therefore a negative reflection of the nursing profession (The American Nurses Association, 2007). A seven-year period of PU prevalence stagnation near 15% and facility-acquired prevalence at 7.5% through 2005 heightened awareness and increased the importance placed on PU prevention measures (VanGuilder, MacFarland, & Meyer, 2008). The National Pressure Ulcer Advisory Panel defines prevalence as “a cross-sectional ‘snapshot’ to count and measure the proportion of a group that has pressure ulcers at a given time; expressed in a percentage of all patients participating in the study.” (Cuddigan, Berlowitz, & Ayello, 2001). Prevalence rates are used to benchmark individual facility pressure ulcer reduction success to facilities across the nation of equal size. A facility-acquired pressure is defined as “any pressure ulcer identified and not documented within 24 hours of admission” (Hiser et al., 2006). Agencies involved in accreditation and payment for services have increased the responsibility for facility-acquire PU development. According to Duncan (2007) the Joint Commission has placed PU reduction as a National Patient Safety Goal with a new measure of “zero” set as the overall goal for facility-acquired pressure ulcers, and the Centers for Medicare and Medicaid Services (CMS) are denying payment for facility-acquired PUs effective October 1, 2008 by placing PUs in the “never-ever” event category. Multiple guidelines exist today to provide clinicians a starting point to begin their successful PU prevention journey towards “zero” facility-acquired prevalence. The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) combined forces to assist health care professionals in use of standardized best practice guidelines for PU prevention by creating International Pressure Ulcer Prevention and Treatment Guidelines (IPUPTG) in 2009. The IPUPTG defines a pressure ulcer as “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. ” The 2009 national prevalence study results reveal a glimmer of hope as prevalence rates have decreased to 12.3% and facility-acquired rates to 5%. The variance found among the participating facilities from a low of 4% in eastern regions to 8.2% among pacific regions indicating inconsistencies in prevention success (VanGilder, Amlung, Harrison, & Meyer, 2009). PU development remains a major obstacle in the delivery of quality nursing care. What are the keys to a successful PU prevention program? Does nursing priority of pressure prevention affect these rates? II. LITERATURE REVIEW / CONCEPTUAL FRAMEWORK In this review, the literature is critically examined to identify studies that developed successful programs to decrease PU prevalence. The Health Belief Model provides the theoretical framework for this study. According to this model, health behaviors are determined by personal perceptions about a health problem and the strategies available to decrease its occurrence. Four major components influence adherence to preventive health actions: Perceived barriers of the recommended health action, perceived benefit of the recommended health action, perceived susceptibility of the health problem, and perceived severity of the health problem. Modifying variables and cues to action are utilized to influence the four major constructs of perception to change behaviors toward prevention strategies. The purpose of this review is to identify keys to successful PU prevention programs, and if nursing’s priority of prevention impacts PU prevalence rates. A literature search conducted during August 2010 using Medical Literature Analysis and Retrieval System Online (MEDLINE) and the Cumulative Index to Nursing and Allied Health Literature Plus (CINAHL Plus) databases for the following terms: pressure ulcer, reducing pressure ulcer prevalence, and decreasing pressure ulcer prevalence. Preliminary review of these articles determined the need to utilize the database heading phrases program evaluation and program development due to their frequent appearance in the literature and desire to capture all scientific evidence currently available. Inclusion criteria included peer-reviewed, English-language publications conducted within the United States from 2005 to 2010, identified 44 articles in MEDLINE and 33 in CINAHL. These articles were reviewed for relevance by title and abstract to identify studies where process implementation resulted in decreased PU prevalence. Case studies, quality improvement, and descriptive studies investigating effective processes resulting in a decrease in PU prevalence, setting in any level of care including acute hospital, long-term care, and home health were included. Articles reflecting personal opinions, editorials, and studies that did not identify PU prevalence were excluded. The 24 studies applicable for this review were conducted within acute care (N = 15) and long-term care (N = 6) settings with a small percentage extending across healthcare settings and into the home health arena (N = 3) with a majority conducted within eastern states (N = 17). III. METHODOLOGY AND DESIGN I identified three essential steps for a PU prevention program and a broad range of properties influencing its success in reducing PU prevalence rates organized into four subcultures defined as: 1. The Essential Steps a. Foundation: The defined purpose for the program with clearly stated outcome measures to determine success. PU prevention policies, protocols, documentation requirements, and monitoring forms. b. Implementation: Process through which the developed protocols and prevention measures are placed into action. Defined roles of responsibility and need for teamwork c. Evaluation: The data collection and monitoring processes required to assess PU prevention program effectiveness. 2. The influencing subcultures: a. Education: The knowledge and skills obtained or developed by a learning process to accurately identify PU risk factors, document findings, implement measures to off set the increased risk, monitor for condition changes, and need for further intervention to prevent PU formation. Guidelines and myth busters a continual process b. Communication: Exchange of pertinent and accurate information for prevention and care required for patients identified at risk through verbal and written forms. Open and accurate relaying of information and effectiveness of the prevention measures currently in place. c. Leadership: Leaders acknowledge the negative impact in quality of care associated with PU formation and seek to align policy, protocol and staff competency in decreasing PU prevalence from the chief officers to the direct care providers. d. Priority: The importance placed on PU prevention and goal to reduce PU prevalence throughout the organization. Nursing plays a lead role in defining and hierarchal placement among daily tasks a. Essential Step Throughout the healthcare settings protocols based on evidence-based guidelines as the skeleton for PU prevention. The process to implement and evaluate its use is the foundation to measure a successful program. Identification of common barriers and corrective actions utilized is central to the programs success. The common barriers reported throughout the literature are identified during the evaluation process and occur most often during the implementation process. The common barriers include: Protocols and policies utilizing evidence-based guidelines are unanimously chosen as the foundation for successful PU prevention programs with NPUAP and AHRQ the most common guidelines referenced. Six elements with defined time frames and standardized measures direct and monitor PU prevention effectiveness are: Conducting a PU admission assessment that includes a thorough skin assessment utilizing the Braden risk tool to assess risk for PU development and a skin assessment based on the NPUAP 2007 updated guidelines to identify existing PU formation; Daily risk reassessment; Daily skin inspection; minimize pressure, optimize nutrition and hydration; and managing moisture (). The ability to effectively implement the protocols into routine care ultimately determines the success Knowledge of PU causes and populations at risk, and correct use of the protocol are crucial to ensure the protocol is implemented. The importance nursing places in PU prevention is reflective through the accuracy and timeliness in implementing the prevention measures as inaccurate and inconsistent identification of patients at risk are the most common barriers found (Bales, Cantiana, Chicano, Courteny, Crumbley, Frain, Garrett, Gibbons, Hiser, Lyman, McElhinny, McInerney, Padula, Rosen, and Young). Misconceptions and myths commonly stated by staff are additional barriers (Padula, Hiser, Catania, and Gibbons). A variety of disease processes are reported to increase a person’s risk for breakdown even with prevention measures implemented according to Braden risk (Bales, Courtney, Gibbons, Lyman, and Padula). Accessibility of supplies and equipment, and knowledge in correct use is found to impact the timeliness and appropriateness of prevention measures implemented (Catania, Dibsie, Crumbley). Simplified and standardized prevention measures are critical to implementing and monitoring the effectiveness of prevention measures as underuse of the defined protocol and implementation of inappropriate measures are common barriers (Bales, Catania, Chicano, Courtney, Crumbley, Garret, Gibbons, Hiser, Rosen, Thomas). Defined roles of responsibility and accountability among staff members empowers staff to initiate intervention and heightens the awareness to populations at risk () Matching prevention measures with the Braden subscales utilized in the risk assessment provides direction and simplicity to the implementation process (Anderson, Bales, Catania, Chicano, Crumbley, Frain, Garrett, Gibbons, Hiser, Lyman). Success to any intervention depends on the degree to which both organization and staff have Evaluating effectiveness through monitoring PU prevalence rates and adherence to the implementation of Prevalence rates and adherence to protocol identified importance Prompt intervention is critical to the success of a prevention program. Eliminating barriers of access and availability of supplies provides the consistency in treatment and empowers staff to carry out the process the required interventions. Defining responsibility and accountability and access to the appropriate supplies to implement to members throughout the process is essential to correct and prompt implementation of PU prevention measures. keeping PU prevalence rates near guidelines are The precedence of PU prevention throughout the facility ultimately determines the success. Nursing service as the primary provider of patient care must be engaged and direct the PU prevention process. Ownership of the process by nursing leaders and defined responsibility to PU prevalence rates throughout the nursing force to the direct care of the patient are defined and placed as a priority of the care process ensures each participant within the process is responsible for PU prevention. Defined roles and responsibility to the outcomes find increased awareness to at risk populations and empowered to implement prevention measures. Open communication through posting of monthly outcomes and participation in quarterly prevalence keeps leaders and staff focused on the goal and sense of pride as the PU prevalence rates decline. The priority placed on PU prevention by nursing is critical to the overall success. Identifying the keys he driving force for success is identified in the priority and support nursing leaders and staff place in PU prevention. Priority nursing places in PU prevention is found to greatly influence the overall success in decreasing prevalence rates. The studies show that nursing leaders acceptance of accountability of the the facility rates and defining the responsibility of the unit managers as accountable for the unit success in specific unit rates the responsibility for implementation and time frames for assessment and risk identification increase the overall awareness. The increased awareness is based on changes and increased focus on education responsible for the development stage and defining the roles of PU prevention is found throughout the literature to greatly affect the success Decreasing PU prevalence rates Two common goals stated throughout the literature are delivering high quality and decreasing cost of care. A majority of the studies identify high PU prevalence within their facility, the cost of care due to the increased length of stay and required treatments related to PU formation. These goals are reinforced by the changes in payment and accreditation and obtaining Magnet status. Although a goal is set, the commitment and priority set on PU prevention ultimately reflects the success. from leadership and direct care providers must be on board for the program to be successful. b. The Foundation A protocol utilizing evidence-based guidelines is identified throughout the literature as the foundation for successful prevention programs. NPUAP and AHRQ are the two most often referenced guidelines for protocol development. Assessing risk for PU development is the initial step, requiring utilization of a risk tool in combination with a skin inspection for any PU identified on admission. The Braden Scale is unanimously chosen as the risk tool used. Six elements are incorporated to identify risk that includes: mobility, sensory perception, moisture, nutrition, friction and shear. The timeliness and accuracy of this initial step guides the subsequent care and PU prevention during the time admitted to the care setting. Inconsistency in scoring, inaccurate scoring, underuse, and awareness of risk are identified as common barriers (Bales et al., 2009; Catania et al., 2007; Chicano & Drolshagen, 2009: Courtney et al., 2006; Crumbley & Crane, 2010; Dobbs, Frain, Garrett; Gibbons; Lyman 2009; McElhiney & Hooper 2008; Milne et al., 2009; Padula et al., 2008; Rosen et al., 2006; Werkman et al., 2008). Although the Braden risk is the tool utilized to assess risk, disease processes are found to increase risk for PU formation. Padula et al. (2008) finds patients with PVD, DM, and low albumin levels at high risk for breakdown. McInerney (2007) finds patients with renal disease and ventilators at higher risk and Gibbons finds those with CHF, respiratory failure, renal failure and sepsis have a higher risk for PU development. Crumbley & Crane (2010) find patients with neurological, sensory, and mobility impairment at higher risk. Education in use, communication of the risk score, and enforcement of completion of risk documentation by leadership are essential for successful PU prevention to be implemented. Accuracy of skin breakdown using the NPUAP six stage system provide facilities with identified on admission and throughout the care course differentiate a hospital acquired PU and a PU that was present on admission. This differentiation is crucial to the facility for payment of treatment and accountability of formation. A thorough skin assessment with documentation completed within 24 hours of admission is found essential as inaccurate staging and incomplete skin assessments are identified as contributing to high PU prevalence (Bales et al, 2008; Chicano & Drolshagen, 2009). Courtney et al, Crumbley & Crane, 2010; Frain; Garett; Lyman, Milne; Rosen; Werkman). The identification of skin condition and risk score in combination dictate the prevention measures to be implemented. Staff must be knowledgeable and responsible for the implementation of required interventions. Accurate use of the Braden and NPUAP staging criteria are critical points if not accurately completed and repeated daily throughout the course of treatment can lead to facility acquired PU prevalence rates. the tools on which to build a successful prevention program. Catiana, Hiser, Crumbley, find the existence of a protocol does not ensure it will be followed and identify the need to monitor adherence and effectiveness of the protocol implemented. IV. RESULTS a. A Need to Implement A protocol is only helpful if it is implemented into action. Inappropriate interventions, lack of accessibility, knowledge of protocol existence, and underuse are common barriers identified. Utilization of standardized and simplified interventions corresponding to the identified risk elements are found most effective (Anderson; Chicano & Drolshagen ;Crumbley & Crane; Frain, Garrett; Hiser; Lyman; Thomas, Werkman, Young) Dibsie (2008) find the ability for staff to implement prevention measures increases ownership and empowerment. Catiana developed PUPPIU; Courteny and Young utilized SOS, Gibbons SKIN, Rosen focused on TAP (turn and reposition). Use of defined roles and responsibility in the prevention process provide clear direction and accountability for facility-acquired PUs. Staff must have access to the supplies and sterilization techniques because so often lack of knowledge in interventions are common, which are barriers and decrease the adherence to the identified risk. b. Evaluation The auditing process provides staff and leadership knowledge of their effectiveness and a forum for communicating additional needs and through chart audits and PI process. A monitoring system is the final piece to the foundation of a prevention program prevention program. Monitoring adherence to the established protocols is essential to identify gaps and problems that must be rectified for outcome measures to reflect the effectiveness of the protocol. III. DISCUSSION / CLINICAL RELEVANCE a. Clinical Relevance Reducing PU prevalence rates is a complex process. Facilities across the healthcare settings have defined PU prevention through evidence-based guidelines, identified the role of leadership and communication as processes that reinforce and enhance the knowledge provided through in-depth education programs lead by expert clinicians, and designed tools to monitor and track PU prevalence. Yet, questions remain unanswered to the effect of co-morbidity factors and the ability to prevent PU formation. The focus of prevention has been in the spotlight for nursing care over the past 10 years and continues today yet the education of our undergraduate nurses continues to be limited to 3 hours of lecture that discusses the PU prevention bundle including Q2 hour turn and reposition, manage moisture, relieve pressure, mobilize if able, and nutritional needs. The lecture also includes PU staging limited to the four-stage system exclusive of suspected deep tissue injury and unmanageable ulcerations included with the 2007 update. Etiology and pressure points are discussed yet use of the Braden risk tool is not included within the lecture provided nursing students. discussed. It was mentioned that the CWOCN staff did provide the lecture but the content was too focused in treatment and these students are in their first semester …… lecture hours on skin, risk for PU development, most frequent location of PU occurrence, risk assessment (Braden) and prevention measures the overall importance is process improvement Education, communication, and leadership are qualities identified among advanced practice nurses. Do no harm decrease cost, positive outcomes and quality care through prevention of pressure ulcer formation. Need to enhance patient and family education Standardized education materials identifying high risk diagnoses, pressure points most affected, prevention measures to request from primary care providers. Standardization of key prevention supplies with easy to read algorithms and off reports to include Braden risk and if breakdown location and current stage/condition/prevention measures b. Recommendations Derived from the Study 1. Education is Critical Knowledge in high-risk populations and the six factors utilized within the Braden Risk and proper identification of PU is essential. Staff Education for staff is crucial to the success of a prevention program. Effective education programs include causes of pressure ulcers, the six stages of pressure ulcer formation, risk factors commonly found associated with PU development, use of the Braden Risk tool, assessment frequency, and prevention measures to be implemented. Mentoring and reinforcement of newly learned education is a must. Mandated education for treating pressure wounds is key. When education is mandated by leadership, nurses are more likely to adhere to the prevention protocols and education program standards. It has been found that misconceptions in causes and prevention measures were prevalent among staff. Lack of knowledge in accurate staging of tissue injury and Braden scale scoring produced inconsistencies among staff in implementing prevention measures. It was found that staff believed that PU are considered unavoidable among certain patient populations. Staff education focusing on the causes, risk factors, and prevention measures are commonly used to increase staff knowledge eliminates the identified barriers and increases the likelihood of consistency in documenting accurate risk scores and implementing appropriate prevention measures and implementing risk-averse strategies. Instruction in use of the assessment tools and documentation forms utilizing case studies focusing on patient health are priceless. 2. Communication is Integral. Education in use of the risk tool and communication of risk to coworkers and ancillary staff is essential to monitoring and continuation of the prevention measures implemented. The priority placed on PU prevention drives the process toward success. As nursing is the process owner for skin integrity, the priority placed in prevention is reflective of the relationship between facility leadership and direct care providers. The commitment is not only identified in the boardroom but must filter down to the bedside. Staff buy-in to the overall goal and the importance attached to their participation in the process and the consequences of non-compliance continually reinforced through data collection and posting. An up-down and down-up chain of communication provides the structure and open communication required for change to take place. 3. Leadership Must Be Present At All Levels Engaged leaders are critical to the success of a prevention program. Engaged leaders accept accountability for PU prevalence rates within the facility. Providing staff the skills and knowledge to PU prevention through mandatory classes to review the causes, risk factors, and standardized interventions utilized to reduce the risk and development of PU are used for initial education to the process. There are standards in place requiring all new employees to attend an education class with a competency check; others utilize skills labs and product fairs to reinforce knowledge in prevention products and correct use. With a review completed every year with skills labs and product fairs to reinforce the knowledge, this would be useful, especially in finding use of resource manuals and quick reference pocket guides to identify risk and prevention protocols reduce. Role-plays and case study discussions increase knowledge and consistency in Braden scoring and implementation of prevention measures. Utilization of unit champions as a resource and guide for staff lead to increased awareness and empowerment through the ability to intervene. Staff must be knowledgeable in the cause for pressure ulcer formation, risk factors, pressure points, and stages of tissue damage associated with PU development. 4. Priority Knowledge of the protocols and documentation requirement must be clear and simple to complete. Education programs focus on risk factors for PU occurrence, the current prevention protocol: based on the Braden score, implementation of prevention measures Barriers identified include: lack of skills to identify patients at risk for PU development; misconceptions in cause for pressure ulceration; misconception that PU are unavoidable; misunderstanding of the Braden risk tool; inconsistency in PU staging; and inconsistency in risk assessment scoring. In order to overcome barriers, there must be: mandatory education classes presented in new orientation of staff; a skills lab competency test and graded display of products and proper use; continuing education; increase knowledge in skin function; a survey of risk factors for PU formation; and correct use of a risk assessment tool. Also, other elements that may be involved include: standardized protocols/prevention measures based on these identified risk factors; PU staging based in NPUAP guidelines with pocket guides; unit resource books; and newsletters to post updates and reminders for reinforcement of knowledge learned. c. Further Discussion & Comments All of the studies identify evidence-based guidelines as the foundation of a successful prevention program whether care is provided in an acute care, long-term care, or within the home health care setting. The studies show that although evidence-based guidelines are the foundation for a successful program, it is the processes used to implement and monitor adherence of evidence-based programs that determine the overall program success. The program must be simple to implement and monitor with real time feedback provided to show staff and the organizational leaders the effectiveness through reduced prevalence of facility acquired PU. The increased consistency with standardized protocols, easy access to supplies empowers staff and instills a sense of pride in the quality of work. Along with the health belief model actions and change toward prevention occurs with but in and awareness of the improvements identified in quality of life for the patients served. A near-zero prevalence may be a goal as a zero prevalence is impossible to maintain as the skin like any organ id subject to failure and under even with the best of interventions can result in PU formation. Facilities must clearly documents these circumstances as the studies show different authors find a higher occurrence of PU formation among a variety of chronic disease processes requires a strong foundation. A simple process with clearly stated goals provide direction to the stakeholders in why PU prevention must be a priority for nursing. The accurate and early identification of risk is found to be the critical point for PU prevention. PU prevalence is a facility wide problem that takes a commitment from all members to become successful. Utilizing evidence-based guidelines to provide protocols and algorithms require active communication and knowledge of skin care to implement appropriate interventions and prevent ulcerations. PU prevalence when made a priority by nursing can greatly be reduced as nursing are the primary care providers in accurately determining a patients individual risk and directing and PU prevention programs are developed in response to meeting regulatory and reimbursement regulations for provision of quality patient care and decreasing the cost of care related to the development of pressure ulcers. Success begins with a motivating factor for change and improvement to occur. All studies focus on improving quality of care and decreasing care cost with PU prevention as a means to achieve this goal. V. CONCLUSION a. Overall Conclusions The ability to identify and provide the importance placed in PU prevention begins with leadership through the identification of PU reduction as a main facility goal, education to the policies and procedures for prevention, leadership support, and priority placed are key components of this. The findings identify the continual need for education and knowledge of key risk factors associated with PU development that can be changed through activation of prevention measures and the factors that cannot be changed (chronic disease processes of the patient) and therefore rely on the additional vigilance of the nursing staff to treat these disease processes as a high risk indicator and closely monitor for signs of breakdown. Staff must understand that skin like any organ may fail even with adherence to prevention protocols and through accurate an consistent documentation that care is adherent to best practice guidelines provides the foundation for additional research to the specific disease processes and may prove a bases for changes in current CMS and JC guidelines to accept that skin failure like DM and HF has associated co-morbidities that increase risk and may not respond to preventative measures. Hand-off reporting is crucial to continue the current care and monitor as the patient moves across the health care settings. Without leadership support, communication among care providers, inaccurate assessment PUs will continue to plague our society. Patients will continue to suffer the pain and disfigurement. b. Recommendations for Continued Treatment Pain associated with dressing time is typical and not uncommon. The nurse should arrange for the caregiver to give the Tylenol before the dressing change. Something stronger should be given if that doesn’t help. With regards to the wound, wound care can vary depending on the type of wound it is. With a dry wound, one probably wants to use a moist dressing. With a draining or wet wound, one wants to use a dry dressing. Also, it is important that if there is exudate, that some emollient be put around the wound to protect it from the drainage. Exudate should be removed from the wound area. “Excess loose slough and exudate is removed prior to assessment and/or dressing change” (“Best Practice Statement,” 2009, p. 21). Since the patient has a heel wound, it would be helpful to put Curlex on the dressing to keep it in place. However, one should not tape the dressing directly on the skin. There should always be hand washing before and after the dressing is removed or put on. The nurse should wash her hands about as long as singing “Happy Birthday,” and when she is done, she may stop hand washing. The nurse, once the dressing is changed, should follow certain protocol. The old dressing should be double-bagged and summarily disposed. Also, the nurse should wear gloves when first taking the dressing off. She should then change gloves when putting a new dressing on the wound. With regard to the difference between home care and being cared for in the hospital, there is differentiated care. One of the premier aspects of home care is teaching the primary caregiver about how to change the dressing. The nurse must help the caregiver to do the dressing. She must feel confident and satisfied that the caregiver can change the dressing suitably and correctly. The dressing should be changed every other day or every other day if it is a dry wound. If the wound is a wet wound, the wound should be changed once or more because of the possibility of excessive drainage. When changing the dressing, the caregiver and the nurse should observe several things. The length, width, and depth of the wound should be assessed. In addition, if there is any pocketing in the wound, this should be duly noted by the caregiver and the nurse. When talking about the wound, the wound should be addressed as a clock. For example, let’s say there is pocketing on the right side of the wound. This would be described as three o’clock. The nurse should notice what the wound looks like. Is the wound black? Does the tissue look necrotic? Is the tissue healthy? Does the tissue look red and healthy? The caregiver might look into buying ointment for debridement. Chemical debridements are available. The caregiver should be careful not to get the debridement on the healthy tissue. Things that the hospital nurse should look out for vary. She should worry about preventing pressure, turning the patient. Is pain involved? The hospital nurse should also be concerned about the patient’s nutrition. Is the patient eating on a regular basis or is the patient avoiding meals? These questions need to be answered. It is hoped that with appropriate care, pressure ulcers will be a phenomena of the past. However, as long as people are languishing in obsolescence due to being bedridden, many people do not have the luxury of being able to have someone turn them in order to prevent such problems. However, with an educated work force in nursing, it is possible to make the problem of pressure ulcers a thing of the past. Let us hope that through education and a commitment to improving health care that this will fade as a trend. REFERENCES Agency for Health Care Policy and Research. Pressure ulcer in adults: prediction and prevention. Clinical Practice Guideline, Number 3. Rockville, MD: Public Health Service, U.S. Department of Health and Human Services; 1992. Retrieved from . Anderson, J. J., Mokracek, M., & Lindy, C. N. (2009). A nursing quality program driven by evidence-based practice. The Nursing Clinics of North America, 44(1), 83-91. doi:10.1016/j.cnur.2008.10.012 American Nurses Association (2007). American nurses association nursing sensitive measures: national database of nursing quality indicators (NDNQI). Retrieved from: . Bales, I., & Padwojski, A. (2009). Reaching for the moon: achieving zero pressure ulcer prevalence. Journal of Wound Care, 18(4), 137-144. 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Partnering for prevention: A pressure ulcer prevention collaborative project. Home Healthcare Nurse, 26(1), 17-22. Young, J., Ernsting, M., Kehoe, A., & Holmes, K. (2010). Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention. Journal of Wound, Ostomy, & Continence Nursing, 37(5), 495-503. VanGilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009). Results of the 2008-2009 international pressure ulcer prevalence survey and a 3-year, acute care, unit specific analysis. Ostomy Wound Management, 55(11), 39-45. VanGuilder, C., MacFarland, G., & Meyer, S. (2008). Results of nine international pressure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound Management, 54(2), 40-54. Read More