Some Pressure Ulcers Are Unavoidable

Wallis, Laura

Pressure ulcers can't always be prevented. That's the official word from the National
Pressure Ulcer Advisory Panel (NPUAP), which met at a conference in February at the
Johns Hopkins Medical Center in Baltimore, Maryland. The multidisciplinary voting
panel, comprising 24 experts in pressure ulcer prevention and treatment, unanimously
agreed that some patient situations make pressure ulcers unavoidable. Examples include
patients who refuse to cooperate with repositioning and those with hemodynamic
instability that precludes turning or repositioning. In addition, the panel agreed, a
condition called "skin failure" can occur.

The term pressure ulcer (also known as bedsore or decubitus ulcer) is defined as a
localized injury to the skin or underlying tissue (or both), usually over a bony
prominence, as a result of pressure or pressure in combination with shear. Several
contributing factors are associated with the development of these ulcers—not all of which
are under the control of caregivers, according to the NPUAP.

The voting panelists agreed on a revised definition of "unavoidable skin ulcers," as

follows:

Unavoidable means that the individual developed a pressure ulcer even though the
provider had evaluated the individual's clinical condition and pressure ulcer risk factors;
defined and implemented interventions that are consistent with individual needs, goals,
and recognized standards of practice; monitored and evaluated the impact of the
interventions; and revised the approaches as appropriate.

Expert consensus on this issue is significant for nurses because they're typically the first
professionals to examine any skin lesion and are primarily responsible for preventive
care. The development of pressure ulcers is commonly seen as a direct reflection of the
quality of nursing care. Indeed, the occurrence of pressure ulcers in long-term care
facilities and nursing homes has often been viewed as evidence of neglect and has
increasingly been the subject of litigation.

Bibliography:
AJN, American Journal of Nursing: September 2010 - Volume 110 - Issue 9 - p 16

© 2010 Lippincott Williams & Wilkins, Inc.

summary
Pressure ulcers can't always be prevented. The multidisciplinary voting panel,
comprising 24 experts in pressure ulcer prevention and treatment, unanimously agreed
that some patient situations make pressure ulcers unavoidable. The term pressure ulcer
(also known as bedsore or decubitus ulcer) is defined as a localized injury to the skin or
underlying tissue (or both), usually over a bony prominence, as a result of pressure or
pressure in combination with shear. The development of pressure ulcers is commonly
seen as a direct reflection of the quality of nursing care.
Vital Signs
Rose, Louise PhD, RN; Clarke, Sean P. PhD, RN, FAAN

Vital sign monitoring is a fundamental component of nursing care. We're taught in

nursing school that a patient's pulse, respirations, blood pressure, and body temperature
are essential in identifying clinical deterioration and that these parameters must be
measured consistently and recorded accurately.

These ought to be the most reliable data in a patient's chart—but they're not. Abundant
research indicates that vital signs aren't consistently assessed, recorded, or interpreted.
These lapses interfere with appropriate and timely interventions for deteriorating patients.
All too often physiologic abnormalities that develop up to 24 hours prior to death are
either undocumented or unrecognized, as evidenced by a well-publicized case in which a
patient died from hemorrhagic shock after major abdominal surgery, either because blood
pressure wasn't monitored or changes in vital signs weren't interpreted properly.

Vital sign monitoring is a repetitive, time-consuming task. The average nurse measures
and documents thousands of normal vital signs during the course of her or his career.
Have nurses come to see this task as tedious and unprofitable, despite its potential to
identify significant adverse consequences? Or are nurses neglecting vital sign monitoring
because they're trying to balance their workloads with the need for greater
documentation?

In some settings, nonnursing personnel are responsible for this task, in others, automated
devices do it. Whether or not they're actually taking the measurements, nurses are always
responsible for overseeing vital sign monitoring and interpreting the data. They must be
alert to trends and abnormal values.

Our profession has yet to adequately study and address nurses' failure to reliably
measure, record, and interpret vital signs. Possible reasons for this include excessive
workloads, failure to recognize the importance of vital signs (particularly respiratory
monitoring), and unclear delineation of accountability for decision making. Nursing
practice leaders and researchers—preferably working collaboratively—must learn more
about why so many nurses fail to monitor these parameters effectively and propose
evidence-based solutions.

Education programs that teach nurses to recognize and manage acute patient
deterioration may help—to the extent that they strongly emphasize the need for extra
vigilance in vital sign monitoring. But a lack of knowledge isn't the main problem. Our
years of observing clinical practice and studying the literature lead us to believe the
problem is in the application of these monitoring skills. Nurses are under heavy time
constraints and overloaded with information about many assessment parameters. Perhaps
we need to reduce and focus the physical assessment and examination skills taught to
undergraduate students. We should also devote attention to individually targeting and
tailoring the measurement of vital signs and better equipping nurses to interpret the
information vital signs provide, which can be achieved through continuing professional
education.

Nurses bring a wide skill and knowledge base to the service of the public, but there's no
excuse for neglecting the most fundamental tools at our disposal. The longer we wait to
acknowledge, discuss, and research this situation, the greater the risk of a serious
reengineering of our work, which could shift the responsibility of vital sign assessment
away from nurses—a move that's unlikely to benefit patients or our profession.

Bibliography:

AJN, American Journal of Nursing:

May 2010 - Volume 110 - Issue 5 - p 11

© 2010 Lippincott Williams & Wilkins, Inc.

Summary

Vital sign monitoring is a fundamental component of nursing care. Abundant

research indicates that vital signs aren't consistently assessed, recorded, or interpreted.
Vital sign monitoring is a repetitive, time-consuming task. The average nurse measures
and documents thousands of normal vital signs during the course of her or his career.
Whether or not they're actually taking the measurements, nurses are always responsible
for overseeing vital sign monitoring and interpreting the data. Our profession has yet to
adequately study and address nurses' failure to reliably measure, record, and interpret
vital signs. Nursing practice leaders and researchers—preferably working collaboratively
—must learn more about why so many nurses fail to monitor these parameters effectively
and propose evidence-based solutions. Nurses are under heavy time constraints and
overloaded with information about many assessment parameters