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Risk Assessment for Pressure Ulcers

Risk Assessment for Pressure Ulcers

Pressure ulcers (PUs), also known as bedsores, occur when a skin area is subjected to considerable pressure over a short or long time. Blood supply to the affected part of the skin is cut such that the affected part fails to receive oxygen and nutrients. Consequently, this part of the skin breaks down resulting to the formation of an ulcer (Cooper, 2013). Pressure ulcers present a major problem in hospitals with statistics indicating that as much as 50% of hospitalized patients develop pressure ulcers (Cooper, 2013). Fortunately, a majority of PU cases are preventable. Suggested methods of preventing PUs include regular exercising, healthy eating, drinking plenty of water, changing sitting or sleeping position after every two hours and keeping the skin clean and dry (). However, despite these methods of preventing PUs, their high incidence and prevalence rates require the implementation of evidence-based practice (EBP). John Hopkins Nursing Evidence-Based Practice Process model will be used.

Change Model Overview

John Hopkins Nursing Evidence-Based Practice Process, also known as the PET (practice question, evidence, translation) process is a widely used model for implementing evidence-based practices (EBPs). The PET model is comprised of three key phases, which include the practice question, evidence, and translation. Each of the three phases has a number of steps aimed at ensuring that healthcare providers address the problem comprehensively, implement EBP (the desired change), evaluate the outcomes of the change and communicate the findings with relevant stakeholders (Poe & White, 2010). The PET model outlines systematic process of implementing EBP. Following the process ensures that nurses implement EBPs that they are sure will bring the desired change, which in turn helps in avoiding wastage of resources.



Practice Question

Step 1: Recruit Interprofessional Team

An interprofessional team is highly recommended because members from different disciplines help in clarifying the EBP question. In addition, members from different disciplines bring in diverse insights and perspectives during the process of appraising the evidence (). The team of five will include two nurses working in the intensive care unit, a nurse from the general ward, a clinician, and a physician.

Step 2: Develop and Refine the EBP Question

The PICO question is, in critically ill patients, does risk assessment for PUs during admission to the Intensive Care Unit (ICU), compared to no risk assessment, reduce the risk of developing PUs during the admission period? The PICO elements are as follows: the population comprises of critically ill patients, the intervention is risk assessment during admission, the comparison is no risk assessment during admission, and the desired outcome is the reduction in the risk of developing PUs.

Step 3: Define the Scope of the EBP

Pressure ulcers present a major healthcare problem worldwide. Studies show that the incidence rates of PUs in ICU ranges between 10% and 40% (Cooper, 2013). According to Shahin, Dassen and Halfens (2008), the incidence rates as high as 124% have been recorded in Germany and Denmark. If the problem can be this serious in developed countries such as Germany, it is without doubt that the problem is a major concern in developing countries such as African countries. The prevalence of PUs ranges between 4% and 49% (Shahin, Dassen & Halfens, 2008). PUs significantly reduce the quality of care. PUs are not only painful but more so provide entry points for disease causing microorganisms. The time required to treat PUs increase the length of stay of patients. PUs also increases mortality rates because they complicate the health condition of patients. In addition, PUs increases the cost of medication. Cooper (2013) estimates that the annual cost of PUs ranges between $5,000 and $50,000. It is evident that PUs presents a major healthcare problem. Addressing this problem will improve healthcare quality, patient safety and significantly reduce healthcare costs that patients and governments incur

Steps 4 and 5: Determine Responsibility of Team Members

The formation of an interdisciplinary team will help in providing a comprehensive view of the problem and critical appraisal of evidence. In addition, team members will bring in their perspectives, which may vary with discipline. Each of the team members will gather evidence from respective discipline and present the evidence for critical appraisal. Team members will then collaborate in appraising the evidence, assessing the strength of the evidence and determining whether the evidence warrants practice change. The five members will also work together in implementing the EBP as a pilot and hospital-wide project. The three nurses will then collect and analyze data. I, the team leader and one of the nurses from the ICU department, will compile the report and communicate findings with internal and external stakeholders.


Steps 6and 7: Conduct Internal/External Search for Evidence and Appraisal of Evidence

The team found three level I evidence articles. The three articles are experimental studies. The team also found one level V evidence article, a review of literature.

Steps8and9: Summarize the Evidence

Risk assessment has been established as an effective method of preventing the development of PUs in hospitalized patients (Chou et al., 2013; Feuchtinger, Halfens & Dassen, 2007; Saleh, Anthony & Parboteeah, 2008; Schluer, Scols & Halfens, 2014). In their study, Sculer, Scols and Halfens (2014) concluded that risk assessment for PUs is critical in preventing their development among hospitalized patients. Feuchtinger, Halfens and Dassen (2007) compared three PU risk assessment instruments, which include 4-factor model, modified Norton Scale and Braden Scale. They concluded that the use of standardized risk assessment instruments is important although for critically ill patients, it would be better to classify all patients as at high risk of developing PUs due to immobility. Saleh, Anthony and Parboteeah (2008) found that the combination of PU risk assessment during admission and clinical judgment in the course of admission greatly helps in reducing PUs.

Step 10: Develop Recommendations for Change Based on Evidence

Research evidence shows that risk assessment during admission is an EBP for preventing PUs among critically ill patients. Based on this evidence, it is recommended that nurses should conduct systematic skin inspection, judgment, and consequent risk assessment of the development of Pus. Other risk factors to consider include body installations and the level of immobility. A pilot test on risk assessment is therefore recommended to be undertaken to assess whether this EBP will help in reducing PUs among critically ill patients.


Steps 11, 12, and 13, 14: Action Plan

The implementation process will take six months. The first two months will be used for pilot testing whereby the team will conduct training on nurses in one of the HDU wards. Nurses will be trained how to conduct risk assessment and classify patients based on risk of development of PUs. Training will take two weeks after which nurses will conduct risk assessment for every patient before admission. The two nurses in the team will oversee proper implementation of risk assessment. Implementation will take one month. During this time, the number of patients admitted in the ward will be recorded, the outcomes of the assessment (number of patients classified as very high, high, moderate and low risk) and the number of PU cases. Data analysis will take place after the implementation. The project will then be implemented in all the hospital wards. Training of nurses will take one week. The five team members will conduct the training on PU risk assessment after which they will oversee the implementation (risk assessment of every patient during admission). Data will be collected on a continuous basis for three months and three weeks. Data analysis will then take place immediately after full implementation. Incidence rates of PU before and after implementation will be compared to assess whether there will be a significant reduction in the incidence rate of PUs. Finally, a report will be compiled to report the results.

Steps 16and 16: Evaluating Outcomes and Reporting Outcomes

It is expected that there will be a significant reduction in the incidence rate of PUs. The incident rate will be determined as the number of PUs development in every 1000 patients admitted for more than 2 days. Correlational analysis will be performed to determine whether there is significant reduction in PU cases whereby PU cases before implementation (obtained from hospital records) will be compared with PU cases after implementation. The results will be presented to the management.

Steps 17: Identify Next Steps

Once the team has achieved its target outcomes, it shall replicate the EBP into other wards. The team shall first present the findings from the pilot study to the hospital management to convince the management on the need to implement the EBP on a larger scale. Then, the team shall provide education to all nurses, physicians, and clinicians on how to conduct risk assessment for PUs, classifying patients as low risk, moderate risk, high risk, and very high risk. The team shall also teach healthcare providers on how to take care of each class of patients to prevent the occurrence of PUs. Finally, the team shall develop guidelines that will act as reference materials for healthcare providers. To ensure that the EBP becomes permanent, the team shall develop a nursing procedure that nurses must follow, which includes patient risk assessment for PUs during admission.

Step 18: Disseminate Findings

The team will communicate the findings internally through presentations. The team will also present the findings internally and externally in the form of a report outlining the process it took and the findings. The team will publish the report on prominent healthcare magazines so that external stakeholders can easily access the findings. External stakeholders can also access our report via the internet because the team will publish it on the internet.


The use of the John Hopkins Nursing Evidence-Based Practice Process model will help in defining the problem, gathering, and appraising evidence, implementing EBP and communicating results with internal and external stakeholders. The use of the model will greatly help in reducing the prevalence and incidence of PUs, through the implementation of EBP, risk assessment for PU development during patient admission.



Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A. J., Reitel, K. & Buckley, D. I. (2013). Pressure Ulcer Risk Assessment and Prevention: A Systematic Comparative Effectiveness Review. Annals of Internal Medicine, 159(1), 28-38.

Cooper, K. L. (2013). Evidence-Based prevention of PUs in the Intensive Care Unit. Critical Care Nurse, 33(6), 57-67.

Feuchtinger, J., Halfens, R. & Dassen, T. (2007). Pressure Ulcer Risk Assessment Immediately After Cardiac Surgery- Does it make a Difference? A Comparison of Three Pressure Ulcer Risk Assessment Instruments within a Cardiac Surgery Population. Nursing in Critical Care, 12(1), 42-49.

Poe, S. S. & White, K. M. (2010). John Hopkins Nursing Evidence-based Practice: Implementation and Translation. Sigma Theta Tau International.

Saleh, M., Anthony, D. & Parboteeah, S. (2008). The Impact of Pressure Ulcer Risk Assessment on Patient Outcomes among Hospitalized Patients. Journal of Clinical Nursing, 18, 1923-1929. Doi: 10.1111/j.1365-2702.2008.02717.x

Schluer, A., Scols, J. M. & Halfens, R. J. (2014). Risk and Associated Factors of Pressure Ulcers in Hospitalized Children over 1 Year of Age. Journal for Specialists in Pediatric Nursing, 1, 80-89.

Shahin, E. S., Dassen, T. & Halfens, R. J. (2008). PU Prevalence and Incidence in Intensive Care Patients: a Literature Review. Nursing in Critical Care, 13(2), 71-79.


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