Karen Zulkowski

Comprehensive programs for preventing pressure ulcers: a review of the literature

PURPOSE: To enhance the learner’s competence in pressure ulcer (PrU) prevention through a literature review of comprehensive programs. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Analyze the findings of the PrU prevention program studies found in the literature review. 2. Apply research findings to clinical practice. OBJECTIVE: The objective of this study was to examine the evidence supporting the combined use of interventions to prevent pressure ulcers (PrUs) in acute care and long-term-care facilities. DESIGN: A systematic review of the literature describing multifaceted PrU prevention programs was performed. Articles were included if they described an intervention implemented in acute care settings or long-term-care facilities, incorporated more than 1 intervention component, involved a multidisciplinary team, and included information about outcomes related to the intervention. MAIN RESULTS: Twenty-four studies were identified. Recurring components used in the development and implementation of PrU prevention programs included preparations prior to the start of a program, PrU prevention best practices, staff education, clinical monitoring and feedback, skin care champions, and cues to action. Ten studies reported PrU prevalence rates; 9 of them reported decreased prevalence rates at the end of their programs. Of the 6 studies reporting PrU incidence rates, 5 reported a decrease in incidence rates. Four studies measured care processes: 1 study reported an overall improvement; 2 studies reported improvement on some, but not all, measures; and 1 study reported no change. CONCLUSIONS: There is a growing literature describing multipronged, multidisciplinary interventions to prevent PrUs in acute care settings and long-term-care facilities. Outcomes reported in these studies suggest that such programs can be successful in reducing PrU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results.

Certification and education: do they affect pressure ulcer knowledge in nursing?

OBJECTIVE: To determine whether wound care certification and education affect nursing knowledge. This study examined pressure ulcer knowledge among registered nurses who were (1) certified in wound care, (2) certified in specialty areas other than wound care, or (3) not certified in any specialty area. DESIGN: A convenience sample of 460 nurses, located in both urban and rural areas, provided demographic information and completed a standardized pressure ulcer knowledge test using (Pieper Pressure Ulcer Knowledge Tool). RESULTS: The mean standardized test score for the total sample was 78%, with nurses certified in wound care scoring 89%, nurses certified in specialties other than wound care scoring 78%, and nurses receiving no certification scoring 76.5%. CONCLUSION: Wound care certification and education significantly affect nursing knowledge.

Chronic Wound Colonization, Infection, and Biofilms

The recognition of bacterial biofilm in chronic wounds is from 2008. The “Best Practice” treatment of chronic wounds seems to have developed a way of coping with biofilm without recognizing its presence with means like debridement and excessive fluid removal. The recognition of bacterial biofilm in chronic wounds may give us the opportunity to explain many of the characteristics of the chronic wound. It may explain why chronic wounds do not heal despite adequate treatment of underlying condition and give hope for future effective ways of treatment.

Diagnosing and treating moisture-associated skin damage.

PURPOSE: To enhance the learner’s competence in identifying and treating moisture-associated skin damage. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Differentiate moisture-associated skin damage and related pathophysiology from other skin conditions. 2. Use incidence data related to urinary and fecal incontinence to help guide case-finding activities and provide patient education for this health problem. 3. Apply knowledge of moisture-related skin changes and their treatment to patient care scenarios. ABSTRACT Certain types of moisture can cause debilitating damage to the skin. Terms such as perineal dermatitis, diaper rash, incontinence-associated dermatitis, or moisture-associated skin damage describe some of the conditions caused by moisture from wound drainage, fecal and/or urinary incontinence, and perspiration. It is important for clinicians to correctly diagnose and to locally treat the cause of skin damage, as well as promote appropriate cleaning techniques, to keep patients’ skin healthy.

Perineal dermatitis versus pressure ulcer: distinguishing characteristics.

PURPOSETo provide wound care practitioners with information comparing characteristics of perineal dermatitis and pressure ulcers.TARGET AUDIENCEThis continuing education activity is intended for physicians and nurses with an interest in wound care.OBJECTIVESAfter reading this article and taking this

Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm.

PURPOSE: To provide information about a secondary analysis of pressure ulcer data regarding incidence, avoidability, and level of harm. TARGET AUDIENCE: This continuing activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Summarize the data provided in the Office of Inspector General (OIG) study regarding incidence of pressure ulcers (PrUs) found in hospitals and skilled nursing facilities (SNFs). 2. Identify the classification systems used that designate levels of harm to patients and the avoidability of PrUs. OBJECTIVE: To investigate in greater detail the government data on pressure ulcer (PrU) incidence, avoidability, and level of harm. DESIGN: The authors performed a secondary analysis of PrU data published in 2 studies by the Office of Inspector General (OIG) on adverse events in hospitals and skilled nursing facilities (SNFs). SETTING: Acute care hospitals and Medicare-certified SNFs across the United States. PATIENTS: The hospital sample included 780 Medicare beneficiaries randomly selected from 999,645 discharges during October 2008. The SNF population included 653 Medicare beneficiaries randomly selected from 100,771 patients whose stay began within 1 day of hospital discharge, who had a length of stay of 35 days or less, and whose stay ended in August 2011. MAIN OUTCOME MEASURES: Pressure ulcer incidence with stage, location, avoidability, and level of harm using the Modified National Coordinating Council for Medication Errors Reporting and Prevention Index. MAIN RESULTS: The PrU incidence in hospitals was 2.9%, and the incidence in SNFs was 3.4%. Most PrUs were Stages I and II, with 78.3% in hospitals and 54.5% in SNFs. The avoidability of PrUs was similar in both locations, with 39.1% unavoidable in hospitals and 40.9% unavoidable in SNFs. All hospital-acquired PrUs and 90.9% of SNF-acquired PrUs were designated level E on the National Coordinating Council for Medication Errors Reporting and Prevention Index, indicating a temporary harm event. CONCLUSIONS: The OIG studies captured few Stage III PrUs and no Stage IV PrUs, and they underestimate the level of harm generated from PrUs in hospitals and SNFs. The studies offer a structured algorithm for avoidability determination, but lack measures of reliability and validity. Nonetheless, the high rate of unavoidable ulcers leads to questions on the reliability of PrUs as a quality indicator. There are several weaknesses in OIG methodology with regard to PrUs; however, its structured algorithm can be viewed as a starting point for future studies of PrU avoidability.

The Pieper-Zulkowski pressure ulcer knowledge test.

OBJECTIVE: To describe the development and initial testing of the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT). DESIGN: Cross-sectional, instrument testing. SETTING: Hospital association pressure ulcer educational program conference. METHODS: Pressure ulcer research and guidelines from the last 5 years were examined for test item content. The initial PZ-PUKT had 115 items; response options were “true,” “false,” and “don’t know.” Registered nurses (N = 108) were randomly divided into 2 groups to take either the 60 prevention/risk and staging items or the 55 wound description items. Analyses of these responses resulted in 72 items, which were administered in total to a second cohort of 98 nurses for reliability. RESULTS: Cronbach’s &agr; was .80 for the 72-item PZ-PUKT. Cronbach’s &agr; values for the subscales were as follows: staging, .67; wound description, .64; and prevention/risk, .56. The mean correct scores were as follows: total, 80%; prevention, 77%; staging, 86%; and wound description, 77%. Nurses with wound care certification scored significantly higher on the PZ-PUKT than did nurses with other clinical certifications or with nurses who lacked certification. CONCLUSIONS: The PZ-PUKT has updated content about pressure ulcer prevention/risk, staging, and wound description. Reliability values are highest for the total test. Further use of the instrument in diverse settings will add to reliability testing and may provide direction for determination of a passing cutoff score.

Practice implications for peristomal skin assessment and care from the 2014 world council of enterostomal therapists international ostomy guideline.

All persons with an ostomy are at risk for development of peristomal skin problems. This is true regardless of the persons nation of residence, type of stoma, or supplies available for stoma care. There are measures that can be taken to lessen the potential for peristomal skin problems. These measures include preoperative stoma site marking, preoperative education, appropriate pouch/barrier fitting, and pouch maintenance. The 2014 World Council of Enterostomal Therapists International Ostomy Guideline includes recommendations that can be implemented to prevent situations that may lead to peristomal skin complications.

Utilization and scope of practice of Nurse Practitioners and physician assistants in Montana.

Purpose To explore the licensing, certification, governance and education requirements of nurse practitioners (NPs) and physician assistants (PAs) in the state of Montana. Services provided and privileges retained in employment were also analyzed. Data Sources This was a descriptive study using a survey of rural hospital administrators (N=34). Conclusions Survey results show that 92.5% of PAs in Montana meet their supervision requirement by a telephone contact provision outlined by the state board of medicine. In contrast, 54.2% of NPs, who are autonomous by legal definition, have a telephone supervision requirement imposed on them by their employers. Implications for Practice These findings have implications for the current and prospective professionals and the businesses for which they work. Nurse practitioners and their professional organizations need to consider the implications these findings have on the professional image and marketability of all NPs.

Skin bacteria: implications for wound care.

Skin is the bodys physical barrier to the outside world. Its primary role is to protect the body from organisms or toxic substances, while maintaining fluid and electrolyte balance. Because skin interfaces with the outside world, it develops an ecosystem that may be colonized with bacteria, viruses, fungi, and mites.