Elsevier

Clinical Effectiveness in Nursing

Volume 6, Issues 3–4, September–December 2002, Pages 111-120
Clinical Effectiveness in Nursing

A study of the prevention and management of pressure sores

https://doi.org/10.1016/S1361-9004(02)00071-7Get rights and content

Abstract

Objectives: (1) To determine if there was an association between pressure sore risk assessment, severity of sore and planning of patient care and (2) to identify the methods used to prevent and treat pressure sores.

Design: The study was a two-phase non-experimental design.

Methods: All patients had pressure sore risk assessed on admission and discharge. They were scored according to the Waterlow system or the Stirling Pressure Sore Severity Scale. Nominal data were analysed by χ2 and grouped data by Kruskal–Wallis ANOVAR.

Setting: 500 bedded acute care hospital trust in Scotland.

Sample: 30 Registered Nurses and 327 patient records.

Results: Significant relationships were detected:

  • 1.

    Between the Waterlow score and pressure relief (χ2=32.92, df=2, p<0.001) between the Waterlow score and patient education (χ2=6.04, df=2, p<0.05).

  • 2.

    Between care plan type and pressure relief (χ2=38.3, df=2, p<0.01) mobilisation (χ2=12.1, df=2, p<0.016) and patient education (χ2=40.8, df=2, p<0.01).

Therewas no significant relationship between Waterlow score and mobilisation (χ2=3.2, df=4, p=0.530) or between Waterlow score and severity of sore (df=4, p=0.7265).

Conclusion: The initial Waterlow score was not predictive although the Stirling Pressure Sore Severity Scale was indicative of skin status. This study indicates that a number of issues need to be addressed. Of particular concern is that even when risk factors were identified for a patient, they were rarely taken into account when planning care. Furthermore, according to nurses’ own accounts and by patient record analysis, the Waterlow Risk Assessment Scale appears to be unreliable when used in clinical practice.

Introduction

Recent pressure sore guidelines (NMPDU 2002; RCN 2000) make it clear that when an individual is identified to be at risk of developing a pressure sore(s), it is the duty of the health care professional to ensure preventative measures are implemented. However, the uncertainty regarding pressure sore risk assessment scales, as evidenced by the absence of any firm guidelines on their use, has resulted in the recommendation that pressure sore risk assessment scales be used in conjunction with clinical judgement (NMPDU 2002; AHCPR 1992; EPUAP 1998; RCN 2000), a statement open to interpretation.

Some researchers have found clinical judgement alone to be a reliable method of identifying those at risk of pressure sores (Preevost 1992; Salvadena et al. 1992; Hergenroeder et al. 1992; Young 1996) while others (Norton et al. 1962; Waterlow 1995) consider that professional judgement is subjective and that the use of a formal risk assessment tool provides an objective measure of risk status (Norton et al. 1962). Nevertheless, few studies have investigated how risk assessment scales are used in practice or whether management of care is based on the risk factors identified at assessment.

Jones (1986) demonstrated that nurses, when using a logically structured database such as a pressure sore risk assessment scale, gave more specific, detailed and individualised prescriptions for care than those using an intuitive approach. However, results indicated that nursing care was highly routinised and that the intuitive approach resulted in patients receiving a blanket approach to care (Jones 1986). Furthermore, Salvadena et al. (1992) found that even when patients were identified to be at risk of pressure sores, preventative strategies were rarely implemented.

The Waterlow Risk Assessment Scale, the most widely used risk assessment scale in the UK (Waterlow 1991; Wardman 1991; Cook et al. 1999), incorporates 11 main assessment criteria (build/weight for height, continence, visual skin type, mobility, sex/age, appetite, tissue malnutrition, neurological deficit, major surgery/trauma and medication). The criteria sex and age have been combined, essentially leaving only 10 criteria. Each criterion has a number of sub-scales rated on a scale of 0–8 according to degree of risk. A zero rating is allocated to any sub-scale which indicates ‘no risk’. A patient’s risk score is calculated by adding the relevant number from each sub-scale. The degree of risk is then classified into one of three risk categories based on the total score obtained: 10–14 (‘at risk’); 15–19 (‘high risk’); 20+ (‘very high risk’) (Waterlow 1985).

The utility of a risk assessment scale is evaluated in terms of its sensitivity and specificity (National Pressure Ulcer Advisory Panel 1989; Bergstrom 1992). The reported sensitivity and specificity of the Waterlow Risk Assessment Scale has varied across studies (Chan et al. 1997; Pang & Wong 1998). This is not surprising when one considers the extraneous variables likely to affect the reliability and validity of the scale. However, it is unclear as to the mathematical model used by Waterlow to develop the score as the study from which the scale was developed has never been published. The sensitivity and specificity of the Waterlow scale has been shown to vary across different patient groups (Anthony & Barnes 1998; Anthony et al. 2000). Similarly, the variables within the Waterlow scale that have been found to be significant also vary across different patient groups (Anthony & Barnes 1998; Anthony et al. 2000; Boyle & Green 2001) leading to claims that many variables within the scale are confounding, weighted inappropriately (Anthony et al. 2000) or poorly discriminating (Boyle & Green 2001). Moreover Boyle & Green (2001) found the mean Waterlow score of patients developing a sore to be 21, which according to the Waterlow classification indicates ‘very high risk’. Nevertheless, many health care providers have used patients’ Waterlow risk scores to guide the allocation of pressure reducing equipment (Waterlow 1991; Malone 1992).

Pressure sore risk assessment scales are generally used in conjunction with pressure sore classification scales. The most detailed classification scale currently in use is the Stirling Pressure Sore Severity Scale which categorises pressure sores in four main stages. A fifth stage (stage 0), is applicable when no pressure sore exists. Each stage of the Stirling scale is categorised using several digits and it is recommended that at least the first two digits are recorded along with the location of the sore, its surface dimensions, severity of pain, degree of exudate and factors influencing wound healing (Reid & Morrison 1994).

It has been suggested that a care plan where all information relating to pressure sores is held together might be beneficial (Waterlow 1991). However, no research has been conducted to identify whether such a care plan improves care, or encourages a more logical and systematic approach to care. In today’s health care culture, where the use of bank and agency staff appear to be on the increase, it is unreasonable to assume that patient care will be evaluated by the same nursing team throughout a patient’s stay in hospital. Therefore it is imperative that the record systems used, promote continuity of care and encourage the adoption of a systematic and logical approach.

The purpose of this study was to determine if there was an association between pressure sore risk assessment, severity of sore and planning of patient care; and to identify whether the use of a pressure sore care plan was advantageous.

Section snippets

Ethics approval

Consent for the study was obtained from the hospital trust Ethics Committee including access to patient records. Written consent was obtained from all registered nurses (RNs) who participated in the study. Individual hospital consultants and nurse managers provided access. Once ethical approval was given a four-week pilot study was conducted before commencement of the main study.

Sample

A purposive sample of medical records (n=327) from patients who had been admitted to and discharged from the hospital

The sample

Of the patient records reviewed, most belonged to female patients (67%; n=218) and patients who were at least 65 years of age (n=219). More than half (58%; n=189) belonged to patients hospitalised for at least seven days. The majority of respondents from the nurse sample were grade E (n=15) or grade D (n=12). Almost half (n=14) had been qualified for at least 5 years.

Waterlow risk score and severity of sore

Skin status was not documented in any way in 85 (57.4%) medical patient records and 14 (7.8%) surgical patient records. These (n

Summary

The respondents participating in this study were employed across a wide range of medical and surgical departments across the Trust. Almost half had been qualified for more than five years. In their capacity as ward-based nurses employed on day duty or on a rotational shift basis, all were responsible for the prevention and management of pressure sores. In addition, a purposive sample (n=327) of patient records which represented admissions to, and discharges from, medical and surgical units

Discussion

Norton (1989) and Waterlow (1996) believe that the occurrence of pressure sores might be prevented if the obtained risk score prompts preventative measures and that in such circumstances, the Waterlow risk assessment scale may appear to have poorer sensitivity/specificity (Waterlow 1996). The ethical issues associated with this theory prevent it from being tested as patients identified to be at risk could never be denied care which would reduce this risk.

The results of this study showed that

Conclusion

As shown in this study, patient care plans are inadequate and provide little evidence that patient problems are being identified and appropriately planned for. These results, which support those of many earlier studies, suggest that the systems currently in place to record and evaluate patient care are at present, inadequate. In this study, use of the care plan relating specifically to prevention and management of pressure sores did not improve the situation to any great extent. Therefore it is

Study limitations

The main limitations of this study were that no observation of actual practice was conducted and the view taken that what was not documented was not done. In addition, the sample was obtained from a single hospital site using data collection instruments developed for the study. These limitations were minimised by using two different data collection methods and by establishing face and content validity of the data collection instruments via expert review and pre-testing.

Acknowledgements

We would like to thank Mr Philip Belcher, Glasgow Royal Infirmary, North Glasgow University Hospitals, and Dr Grace Lindsay, Glasgow University, Nursing and Midwifery School, for their advice and assistance. The study was supported by an educational grant from The Hospitals Savings Association, and the hospital in which the study took place.

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