Clinical Nursing Practice 1: Strategies for Preventing Pressure Sores

This report, a contribution to Desklib by a student, focuses on clinical nursing practice, specifically addressing the prevention of pressure sores. The report begins with an introduction to the Australian Commission on Safety and Quality in Health Care and its guidelines on pressure injury management. It presents a PICO question: "In non-ambulatory patients, does the use of the Braden scale compared to the Waterlow score reduce the risk of pressure sores?" The report details the search strategy used to find relevant literature, including the databases, keywords, and Boolean operators employed. It includes an analysis of five selected articles, discussing their methodologies, findings, and relevance to the PICO question. The articles explore risk assessment scales, the importance of early intervention, and the need for preventive measures, such as repositioning and appropriate support surfaces. The report highlights the significance of evidence-based practice in nursing and emphasizes the role of nurses in identifying patients at risk and implementing preventive strategies. It also mentions the EPUAP and NPUAP guidelines for pressure ulcer prevention. The report provides an overview of the methodology used, the rationale for choosing the articles, and the key findings related to the assessment and prevention of pressure ulcers.

Running head: Clinical nursing practice
Clinical nursing practice
Name of the Student
Name of the University
Author Note

1
Clinical nursing practice
Introduction
The Australian Commission on Safety and Quality in Health Care is a Government body
set up by the Coalition to advise and facilitate regional developments in protection and health
care quality across Australia, with the assistance of the Federal of the State and Territory. The
goal of the Australian Health Care Commission is to provide an accurate, funded and organized
health system that leads to ensuring secure and high-quality health care and improved outcomes
for patients and consumers and improved public health outcomes (Safetyandquality.gov.au,
2020).
The Australian Commission on Safety and Quality in Health Care (ACSQHC) has
reported pressure injuries as the fifth most expensive frequently occurring preventable disease.
Many pressure injuries may be avoided and the long recovery period has repercussions for
quality of life involving infection response, discomfort, and sleep and mood changes. They often
impact refurbishment, longevity and long-term life consistency. Pressure injury management is
the duty of all healthcare employees, independent of their place or role. Staff, patients and/or
carers have a major role in preventing of pressure injuries. This Policy Guideline defines
common practice in compliance with ACSQHC, National Safety and Quality Health Service
Standards (NSQHSS), Standard 8–Preventing and Managing Pressure Injuries, 2012
(health.nsw.gov.au, 2020).
Pressure injury prevention and management policy of Australia, thus, aims to reduce the
occurrence of pressure-related accidents on patients in NSW Health by effective risk evaluation,
compliance control and timely care. Establish a comprehensive, systemic approach to the
prevention and treatment of pressure injuries through NSW Safety. Fund public care for the

2
Clinical nursing practice
avoidance and control of pressure injury in accordance with national protection in quality health
services standard (NSQHSS); Increase understanding of the value of stressful injury reduction
and treatment techniques for staff, patients and the public (health.nsw.gov.au, 2020).
Although, pressure ulcers or pressures sores are a global concern, the incidence of these
injuries has been found at an increasing rate among the elder population. In comparison to the
potential to live longer and a decent quality of life, many elderly people in treatment suffer from
various diseases, fragility and disability, culminating in hospitalization and transition to nursing
home residences. Older people show a reduced physiological capacity and sometimes contract
chronic illnesses, often culminating in frailty, illness and geriatric syndromes. Immobilization,
remaining in bed for extended periods of time, leads to the production and emergence of pressure
ulcers (Jaul et al., 2018). Pressure ulcers are typical end-of-life complications for patients in
residential care facilities. These may be particularly uncomfortable, and the pain is sometimes
unrelenting. Monitoring residents for the possibility of ulcer pressure as a preventive technique
includes the usage of a predictive monitoring method and a clinical judgment (Sharp et al.,
2019).
Preventing the development of pressure ulcers is targeted at alleviating risk factors for the
particular patient and focuses mainly on reducing periods of persistent pressure, either by
inserting sufficient padding at pressure points or by regular patient repositioning. Any people use
prosthetics or needing a wheelchair for movement will be adequately fitted to insure appropriate
fit and sufficient padding is provided. Pressure mapping techniques have been developed to
calculate the amount of pressure applied to various areas of the sitting or reclining body (Boyko,
Longaker & Yang, 2018). Every individual who has been found to be at risk for having a
pressure ulcer or who currently has a pressure ulcer requires a repositioning strategy. The

3
Clinical nursing practice
program has to be customized specifically to address each patient's unique needs. The frequency
of repositioning has to take into account several considerations, including the patient support
structure, the overall medical situation, and the goal of care (Boyko, Longaker & Yang, 2018).
This paper will, therefore, focus on this aspect of the policy on the strategies of
preventing pressure sores among patients with the help of a PICO question and will discuss on
the literatures found on this research topic to generate a succinct idea about the same.
PICO question:
The PICO process (or framework) is utilized in evidence-based practice (and especially
evidence-based medicine) to frame and address clinical or health care relevant queries. The
PICO method is often used to establish methods for the search for information, for example in
systematic studies (Eldawlatly et al., 2018). Within the evidence-based scientific practice, it is
widely recognized that resolving the research question is the crucial and integral aspect of the
quality of science. Population, intervention, comparison and outcomes (PICO) is a specialized
system for the preparation, interpretation and examination of studies by most scholars
(Eldawlatly et al., 2018). PICO stands for
P – Patient, Problem or Population.
I – Intervention.
C – Comparison.
O – Outcome(s).
Thus, using these elements, the PICO question framed is “In non -ambulatory patients (P) does
the use of Braden scale (I) compared to waterlow score (C) reduce the risk of pressure sore?
(O)”

4
Clinical nursing practice
Search strategy:
In order to conduct this literature review, several online databases like PubMed, CINAHL
and Google Scholar were searched with basic keywords like “pressure ulcer”, “Pressure sores”,
“Pressure ulcer risk assessment”, “risk assessment tools for pressure ulcers”, “risk assessment in
pressure ulcers”, “prevention of pressure ulcer”, “Braden scale”, “Waterlow scale” etc were
used. Since, it is broad topic, after inserting the keywords, there were many articles available,
among which the majority were irrelevant. Therefore, a combination of the specific keywords
were used to search related papers along with the Boolean operators like AND, OR, NOT in
between the keyword to make the search more specific and to the point. A total of 24 papers
from all such sources were considered to be important and then reviewed by skimming through
the abstract, which offered accurate details on the paper. The abstracts gave adequate
information on the contents of the paper that helped to check the quality and validity of the
paper. The selected papers were further screened by gaining insight of the author’s and
researcher’s qualification presenting those articles. However, a majority of the article were found
to be written by qualified scholar and therefore, have been included in the study. Reports without
a clear description have been omitted from the review. The timeline chosen for the study review
was in and after 2011 in order to obtain the most recent results in this field. The chosen papers
were focused on good facts that had reported scientific conclusions that, as a result, a total of 5
publications were chosen for the analysis as they met the inclusion criterion.
Rationale of choosing those 5 articles:
All these articles discuses on a common issue pressure ulcer which is a prevalent issue
decreasing quality of life and complicating the patient’s health condition. Pressure ulcers are
typically formed rapidly and hinder the diagnosis and recovery of the patient who is admitted,

5
Clinical nursing practice
thus worsening quality of life, contributing to suffering, and increased mortality. The need to
prevent PUs is inevitable considering the severity of the issue for the individual, the family, and
the organization (Borghardt et al., 2015). EPUAP, "The European Pressure Ulcer Advisory
Panel" was formed in December 1996 in London for leading and supporting all European
countries to both prevent as well as treat pressure ulcers, and NPUAP, “The National Pressure
Ulcer Advisory Panel”, which is a non-profit and independent organization created in 1987 for
conducting research, preventing, treating and managing pressure ulcers, finds the highest and
most efficient form of prevention of ulcer pressure to reduce the incidence of ulcer pressure. The
recommendations for the prevention of ulcers have been categorized into five primary areas: risk
evaluation, skin evaluation, nutrition, repositioning and surface help (Sáteková, Žiaková &
Zeleníková, 2017). The first method of their treatment was to determine the likelihood of
forming pressure ulcers. Nurses have a vital part to play in identifying and understanding
patients at risk and introducing appropriate preventive steps. Risk evaluation methods have been
created to identify people at risk of acquiring pressure ulcers. Early and regular stratification of
the probability of PU acquisition is necessary in order to take appropriate preventive measures on
the correct execution of the therapeutic program. It requires strategies for reducing predisposing
factors and to improve the overall wellbeing of patients. For certain situations, though, the
treatment approach also relies on the availability of health care practitioners and expensive
inputs. The requirement for research evaluating tools, procedures and materials used to deter
PUs, which can be applied to a variety of health care contexts. In this respect, the usage of
indirect approaches, such as PU risk evaluation measures, is noteworthy since, whether they
provide accurate psychometric indexes, they would be affordable, realistic and efficient (de
Araújo, de Araújo & Caetano, 2011).

6
Clinical nursing practice
CASP
de Araújo, T. M., de Araújo, M. F. M., & Caetano, J. A. (2011). Comparison of risk assessment
scales for pressure ulcers in critically ill patients. Acta Paulista de Enfermagem, 24(5), 695-700.
The authors of this article are highly qualified. de Araújo, M. F. M is a nursing MSc.
Professor at the Nursing Graduation Course at Universidade Federal do Maranhão, Brazil and
student of the Nursing Post-graduation Program (PhD). Caetano, J. A. is a Nursing PhD.
Professor at the Nursing Post-graduation program, Brazil.
The purpose of the analysis is to evaluate the three measures Braden, Waterlow and
Norton used for the risk evaluation of pressure ulcers in patients who are chronically ill. It is a
longitudinal and exploratory study involving 42 patients treated over 15 days or at least 10
consecutive days in three Intensive Care Units in Fortaleza, Brazil, from March to July 2009.
Around the same period, the patients were examined by three nurses, each of whom was
responsible for applying just one of the scales. This is an exploratory and longitudinal study
carried out to compare the three scales using a qualitative approach. The study aimed at
comparing the three scales Braden, Waterlow and Norton scales used for risk assessment of
pressure ulcers for patients who are chronically ill. Thus, the study has involved all the patients
who were above 18 years old, not showing a Pressure Ulcer at the time of admission staying at
the ICU for at least 48 hours prior to data collection. There were a total of 31 ICU beds of which
8 beds were assigned for pediatric patients. Thus, a total of 23 beds were involved in the study to
compare the scores of each assessment tools.
There were 83 inpatients during the four months of study. For these, 11 have been
admitted with PU; 2 are under the age for 18 years; 10 are deceased and 18 have been excluded
for 10 follow-up days before being available. Four instruments were used in data collection: the

7
Clinical nursing practice
first was a social, demographic and health data questionnaire; the remaining three applied to the
adapted and translated versions of Norton, Braden and Waterlow risk assessment. The study was
ethically approved by the Institutional Ethics Committee and conducted in accordance with the
protocol number 86145/08. Patients who were unable to give their consent or unconscious,
approval was taken from their parents or family. Data was inserted twice and stored in the Excel
database of the software. The SPSS 13.0 system was used to assess the percentage and absolute
frequency according to the key trend metrics. The Kolmogorov-Sminorv test was used to assess
the homogeneity of the data and the 95% conviction level was set. For the 15 tests, the non-
parametric test Friedman was used to measure all the values in each scale category as well as in
each thescale in order to determine statistical differences among patients who experienced injury
and who did not injure over the span of time. The Conover test was often supplemented by
several comparisons over the time period. The Waterlow scale reported better ratings in the
evaluation of pressure ulcer risk in comparison to the Norton and Braden scales. Early and
frequent stratification of the probability of developing a PU is important in order to take effective
protective measures on correct therapeutic plan execution. This requires strategies to decrease
predisposing variables and to improve the overall safety of patients. The requirement for research
evaluating tools, procedures and materials used to deter PU, which can be tailored to a variety of
health care contexts, is thus required on urgent basis.
Moore, Z. E., & Patton, D. (2019). Risk assessment tools for the prevention of pressure
ulcers. Cochrane Database of Systematic Reviews, (1).
The authors are from school of Nursing & Midwifery, Royal College of Surgeons in
Ireland, 123 St. Stephen's Green, Dublin, Ireland, D2.

8
Clinical nursing practice
The research aimed to determine how the usage of systematic and structured pressure
ulcer risk management methods in any healthcare setting decreases the risk of pressure ulcers.
This systematic review was conducted searching Cochrane Wounds Specialised Register; the
Cochrane Central Register of Controlled Trials (CENTRAL); Ovid Embase; Ovid MEDLINE
(including In‐Process & Other Non‐Indexed Citations); and EBSCO CINAHL Plus. The authors
have also searched clinical trials registries to access unpublished and ongoing studies and
scanned references of studies that were relevant and included them which are meta analyses,
systematic reviews and health technology reports for identifying and including additional studies.
The study is a systematic review aimed to access researches conducted in this area and
provides an overview of findings relating to the measurement of pressure ulcer risk in clinical
practice.
Two participants engaged in the selection of the studies, the retrieval of the data and the
execution of the chance of bias evaluation, and the evaluation of the rating was carried out to
determine the reliability of the evidences. The authors also noted that the insufficient evidence or
low reliability of the results collected from the included study is not adequately reliable to
suggest that the usage of standardized and systemic pressure ulcer risk reduction approaches
decreases the occurrence of pressure ulcers.
The usage of pressure ulcer risk management tools or interventions is part of the
screening process used to classify individuals at risk of having a pressure ulcer. Many
professional guidelines for the management of pressure ulcers advise the use of a risk assessment
tool, but it is not obvious if the use of a risk assessment system creates a difference to patient
outcomes. The authors have, therefore, performed a study to include a overview of the findings
relevant to the risk evaluation of ulcer pressure in clinical practice.

9
Clinical nursing practice
Šáteková, L., Žiaková, K., & Zeleníková, R. (2017). Predictive validity of the Braden Scale, Norton
Scale, and Waterlow Scale in the Czech Republic. International journal of nursing practice, 23(1),
e12499. Doi: 10.1111/ijn.12499
Šáteková, L., and Zeleníková, R. Belongs from Department of Nursing and Midwifery,
Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic. Žiaková, K., belongs from
Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in
Bratislava, Bratislava, Slovakia.
The goal of this analysis was to determine the predictive utility of the Braden, Norton and
Waterlow scales in two long-term care departments in the Czech Republic. This is a prospective
comparative instrument testing study in which a randomized sample of 123 patients was chosen.
All participants who enrolled in the study were initially assigned to long-term care facilities in
the hospital. By the outset of the experiment, both groups of participants were handled equally.
All participants with and without pressure ulcers were handled similarly in the sample.
Throughout this analysis, the Norton Scale, followed by the Braden Scale and the Waterlow
Scale, were the major statistical values of validity. Throughout the Czech clinical setting, the
investigators indicated that the above 3 risk management indicators for ulcer pressure would
continue to be assessed. Statistical research was carried out using the Stata version 13 statistical
kit. The decision tree algorithms Quick, Unbiased, and Strong statistic trees and classifications
and regressive trees have been used to establish the cut-off points for each dimension. SPSS
Solution Tree v. 3.1 has been used for calculations. The predictive validity of the pressure ulcer
risk assessment scales was measured based on responsiveness, specific features, positive and
negative values and on the ROC region. In 2009, the NPUAP and EPUAP released a guide paper
on clinical procedure entitled "Pressure Ulcer Prevention." In this report, eighteen prevention
steps have been chosen proposed in this paper. The following interventions were accompanied

10
Clinical nursing practice
by major discrepancies between two classes of patients (with or without pressure ulcers): risk
evaluation of developing pressure ulcers (P= 023), patient repositioning (P= 0.029),
repositioning during day (p= 0.019), repositioning in night (P= 0.031) and devices for heel safety
(P= 0.002, etc.).
The research was limited by the small sample size and the presence of patients in one part
of the Czech republic from just 2 long-term care facilities. Consequently, the results in the Czech
Republic should no longer be generalised to the whole patient community. All clinically
important outcomes were considered.
Borghardt, A. T., Prado, T. N. D., Araújo, T. M. D., Rogenski, N. M. B., & Bringuente, M. E. D. O.
(2015). Evaluation of the pressure ulcers risk scales with critically ill patients: a prospective cohort
study. Revista latino-americana de enfermagem, 23(1), 28-35. Doi: 10.1590/0104-1169.0144.2521
The authors are MSc, RN, and professors of Hospital Universitário Cassiano Antônio
Moraes, Universidade Federal do Espirito Santo, Vitória, ES, Brazil.
The aim of the study is to test the efficacy of the Braden and Waterlow risk evaluation
scales among patients who are seriously ill. This prospective cohort study was performed with 55
patients registered in the Cassiano Antonio Moraes University Hospital (HUCAM) between
March and June 2013 in intensive care facilities (Intermediate Surgical Intensive Care Unit and
Intensive Care Centre). The results also showed the preponderance of surgical patients with
gastrointestinal problems, with many days of ICU hospitalization and an average period of
almost four days for the outbreak of pressure ulcers, thus reconfirming the importance of
treatment and daily patient follow-up from admission to, more importantly, routine patient
evaluation. The variables examined relevant to socio-demographic details were: gender, age, skin
colour, medical settings (ICU Intensive Care Unit or IU Intermediate Unit); marital status;

11
Clinical nursing practice
schooling; work status General health details were: duration of hospitalization; method of
hospitalization; specific condition; involvement or nonexistence of diabetes mellitus, smoking or
congestive heart failure (CHF); use or lack of artificial breathing, norepinephrine or sedation
were also taken into consideration. Factors linked to ulcers, i.e. groups (I, II, III, IV, SDTI and
Unclassified), amount of ulcers and positions were identified.
In this study period 87 patients were admitted to the facility, of which 4 were omitted
because they already had ulcers during data collection procedures, 6 because they did not
undergo clinical testing and 22 because they did not have the total of three successive
assessments. Therefore, 55 patients were in the sample, 17 of these developed pressure ulcers,
which corresponded to 30,9 percent. The follow up of subjects in this study was long enough.
Pressure ulcers were found to be at 30.9 percent with high sensitivity and low specificity (21
percent and 47 percent) respectively in the Braden and Waterlow scales in the three assessments.
In the first, second and third evaluations 12, 12 and 11 were calculated for the Braden scales,
while in the Waterlow scales 16, 15 and 14 were configured.
Braden scale was found to be a successful screening instrument, and a greater predictive
ability. However, the results cannot be applied to the local population. The use of a single
research site does not allow findings to be generalized. It is recommended that more, well-
designed experiments of such tools should be carried out utilizing wider populations and certain
categories of patients, thereby leading to the right assessment of risk for PUs and to carry
out better prevention.