Hello Stephanie

I don't know if the presentation below has any relevance:

Johnson S., QSEN Simulation:  Pressure Ulcer Assessment 

 http://sjohnsonrn.weebly.com/uploads/1/2/0/7/12072039/qsen_simulation_powerpoint.pptx.

 . . or this paper:

Hudson P, Lewis L, Stokes S and Yarbrough S. Quality and Safety Education for Nurses (QSEN) Electronic Resource Matrix 

http://www.ic4n.org/wp-content/uploads/2014/04/QSEN-Matrix-Final.pdf

Very best wishes with your research paper,

Mary

Thank you, Mary. I will look at these sources. I appreciate your help!

GENERAL CARE — The general approach to management of a patient with a pressure ulcer should include the following;

●Reduce or eliminate underlying contributing factors by providing pressure redistribution with proper positioning and support surfaces.

●Provide appropriate local wound care, which may include debridement for patients with necrotic tissue, based on the ulcer's characteristics.

●Consider adjunctive therapies, such as negative pressure wound therapy.

●Monitor and document the patient's progress.

●Provide appropriate psychosocial support.

The extent and magnitude of psychosocial complications have not been well defined, and psychosocial support is often not considered. However, patients with pressure ulcers suffer pain and a loss of control over their lives. Wound care disrupts normal activities of daily life, and patients often feel stigmatized. This results in lifestyle changes leading to social isolation, depression, and decrements in overall health-related quality of life .

Control pain — Adequate pain relief should be provided as pressure ulcers can be quite painful . Local factors that may be contributing to pain such as ischemia, infection, or breakdown of the surrounding skin should be addressed.

Initial and on-going pain assessment should be documented using a pain scale. Assessment is aimed at identifying the type and extent of pain present so that appropriate therapy may be provided. Pain may be classified as intermittent, which occurs at the time of wound debridement, or cyclic, which occurs at the time of a dressing change, or as persistent pain occurring all the time and related to the pressure ulcer.  

Oral non-opioid pain medications can be used for mild pain. Opioid analgesics may be needed for moderate to severe pain. 

Topical local anesthetics (eg, lidocaine), which have shown some benefit in small randomized trials [16-18], can provide numbness for a short period of time and can be useful for a specific procedure, but should not be used as the only method of pain relief. Ibuprofen-releasing foam dressings can be used, if available . However, many patients with deep ulcers will require systemic therapy for pressure ulcer pain.

Wound cleansing and dressing techniques may need to be reconsidered if they are causing severe pain. In particular, adequate pain control should be provided prior to dressing changes and debridement. Extensive debridement should be performed in the operating room as patients may require conscious sedation or general anesthesia for these invasive procedures.

Treat infection — All pressure ulcers are colonized with bacteria, but only clinically evident infections should be addressed with culture and antibiotic treatment . Patients with deep ulcers should be evaluated for the presence of osteomyelitis. Treatment of infectious complications of pressure ulcers is discussed separately.

Optimize nutrition — Patients with pressure ulcers are in a chronic catabolic state. Optimizing both protein and total caloric intake is important, particularly for patients with stage 3 and 4 ulcers .

●Nutritional intake should be assessed by a nutritionist. This assessment may include protein and caloric intake, hydration status, serum albumin and/or prealbumin, and total lymphocyte count . Nutritional deficiencies should be corrected.

 ●If oral intake is not adequate to ensure sufficient calories, protein, vitamins, and minerals, nutritional supplementation with enteral or parenteral nutrition (according to the capabilities of the care facility) is recommended to correct deficiencies although clinical trial evidence supporting this approach is limited . A retrospective cohort study of 882 patients with pressure ulcers at 95 long-term care facilities demonstrated that total caloric intake of at least 30 kcal/kg promoted healing and decreased the size of stage 3 and 4 pressure ulcers . Increased dietary protein intake also promotes the healing of pressure ulcers .. The protein target is usually 1.5 g/kg/day, although some authors advocate higher protein intake . 

●Data do not support nutritional supplementation for patients who do not have nutritional deficiencies . Vitamin C and zinc supplementation are commonly employed to promote healing, but their efficacy has not been conclusively demonstrated ,. A number of randomized trials identified in systematic reviews have evaluated the role of nutritional supplements, but methodological flaws and study size have precluded confirmation of clinically significant results .. A later, larger trial randomly assigned 200 malnourished adult patients with pressure ulcers to a high calorie, protein-rich nutritional formula supplemented with arginine, zinc, and antioxidants, or to a control receiving a nutritional formula without supplements for eight weeks. This study found a greater reduction in pressure ulcer area for the supplemented compared with control formula (mean reduction, 61 versus 45 percent). No difference was noted, though, in the secondary outcome of complete healing of the pressure ulcer. Because previous studies of the individual nutrients failed to show benefit, the authors postulated a synergistic effect among the nutrients.

●Anabolic steroids are sometimes recommended in patients with weight loss and protein depletion. A clinical trial of 212 spinal cord injury patients with chronic pressure ulcers demonstrated no benefit from oxandrolone therapy.. 

Redistribute pressure — Proper positioning and support to minimize tissue pressure should be provided for all patients, including those with pressure ulcers. The development of any new ulcers should prompt review of the method and intensity of preventive measures. The use of these measures to prevent the development of pressure ulcers is reviewed separately. (See "Prevention of pressure ulcers".)

To date, there are no randomized trials available to identify whether repositioning makes a difference in the healing rates of pressure ulcers or what should be the optimal repositioning regimen. Nevertheless, in the absence of data, as a practice with good face value, patients should be positioned to minimize or avoid all pressure on the wound. Pressure-relieving support surfaces are also helpful in reducing tissue pressure. These support devices, as defined by the National Pressure Ulcer Advisory Panel Support Surface Standards Initiative, are described separately.

The effectiveness of support surfaces in promoting healing of pressure ulcers has been studied in a number of randomized clinical trials with inconsistent results 

●A randomized trial of 158 hospitalized patients found no difference in pressure ulcer healing between 85 patients on non powered support devices and 83 on powered support devices .

●In a study of 65 hospitalized patients with pressure ulcers, 31 patients were given an air-fluidized bed and repositioned every four hours, while 34 patients received conventional therapy with an air mattress covered by a foam pad and repositioning every two hours ]. The latter group also used elbow or heel pads as needed. Pressure ulcers showed a median decrease in total surface area on the air-fluidized beds, while increasing in size with conventional therapy (-1.2 versus +0.5 cm2). The difference was even greater in patients with large ulcers at baseline.

●In another report of 84 nursing home residents with pressure ulcers, subjects treated with a low-air-loss bed were 2.5 times more likely to heal compared with those using a foam mattress.

Given limited data, it is uncertain if powered mattresses are superior to nonpowered mattresses. The costs associated with powered beds become particularly significant when considering that treatment for at least two months is typically required . However, specialized support surfaces appear to be of benefit and should be used rather than a standard mattress.

It should again be emphasized that support surfaces alone do not address the underlying issues that lead to pressure ulcers.