Standardizing the classification of skin tears: validity and reliability testing of the International Skin Tear Advisory Panel Classification System in 44 countries.

BACKGROUND: Skin tears are acute wounds that are frequently misdiagnosed and under-reported. A standardized and globally adopted skin tear classification system with supporting evidence for diagnostic validity and reliability is required to allow assessment and reporting in a consistent way. OBJECTIVES: To measure the validity and reliability of the International Skin Tear Advisory Panel (ISTAP) Classification System internationally. METHODS: A multicountry study was set up to validate the content of the ISTAP Classification System through expert consultation in a two-round Delphi procedure involving 17 experts from 11 countries. An online survey including 24 skin tear photographs was conducted in a convenience sample of 1601 healthcare professionals from 44 countries to measure diagnostic accuracy, agreement, inter-rater reliability and intrarater reliability of the instrument. RESULTS: A definition for the concept of a 'skin flap' in the area of skin tears was developed and added to the initial ISTAP Classification System consisting of three skin tear types. The overall agreement with the reference standard was 0·79 [95% confidence interval (CI) 0·79-0·80] and sensitivity ranged from 0·74 (95% CI 0·73-0·75) to 0·88 (95% CI 0·87-0·88). The inter-rater reliability was 0·57 (95% CI 0·57-0·57). The Cohen's Kappa measuring intrarater reliability was 0·74 (95% CI 0·73-0·75). CONCLUSIONS: The ISTAP Classification System is supported by evidence for validity and reliability. The ISTAP Classification System should be used for systematic assessment and reporting of skin tears in clinical practice and research globally. What's already known about this topic? Skin tears are common acute wounds that are misdiagnosed and under-reported too often. A skin tear classification system is needed to standardize documentation and description for clinical practice, audit and research. What does this study add? The International Skin Tear Advisory Panel Classification System was psychometrically tested in 1601 healthcare professionals from 44 countries. Diagnostic accuracy was high when differentiating between type 1, 2 and 3 skin tears using a set of validated photographs.

Evaluation of pressure ulcer prevalence rates for hospice patients post-implementation of pressure ulcer protocols.

Hospice patients may be particularly at risk for pressure ulcer development due to several factors. Identifying populations at risk for pressure ulcer development, such as hospice patients, and providing prevention and risk protocols for these populations can substantially reduce the prevalence and incidence of pressure ulcers. However, are hospice patients prone for skin breakdown despite prevention and treatment efforts? This study examines the prevalence of pressure ulcers in hospice patients following the implementation of pressure ulcer prevention and treatment protocols. Levine's theory of conservation of structural integrity formed the theoretical framework for this descriptive study. A midwestern hospital-based hospice agency was the site for this study. All patients 18 years of age and older were included in the study. Pressure ulcer prevalence audits were done at four, eight, 12, and 18 months after protocols were outlined by the hospice staff. Results of the audits revealed prevalence rates of 14.8 percent, 8.5 percent, 13.6 percent, and 23.8 percent, at each of the aforementioned audits. 10 of 15 patients who were pressure ulcer positive were males; the sacral location was most common (seven of 19 ulcers occurred sacrally) with the ischial location being the next common (six of 19 ulcers were ischially located). No ulcers occurred above the waist or in patients below 51 years of age. Recommendations from this study urge that particular prevention attention be given to protocols which address "sitting," due to the predominance of ulcers located in the sacral and ischial regions. In addition, the author concludes that perhaps, pressure ulcers may occur in this population despite the best of efforts to prevent them.

The prevalence and incidence of pressure ulcers in the hospice setting: analysis of two methodologies.

Hospice patients may be at greater risk of pressure ulcer development than most patients. This descriptive study explored the prevalence and incidence of pressure ulcers in the hospice setting, utilizing both a prospective and retrospective methodological approach. Levine's theory of the four principles of conservation formed the theoretical basis for the study, and the Braden Scale for Predicting Pressure Ulcer Risk was used for data collection. Prevalence of pressure ulcers was noted to be 13 percent in the study. Incidence of pressure ulcers was found to be zero percent using prospective methodology and 13 percent using retrospective methodology. Five of eight ulcers (62 percent) occurred within two weeks of patient death. Factors related to pressure ulcer development are presented, as well as a discussion of using research methodologies in the hospice setting. The article suggests the need for preventive protocols for skin care for patients who are at risk for pressure ulcer development.

Skin care strategies in a skilled nursing home.

1. Pressure ulcers continue to be a serious problem in nursing home settings. They are significant as a source of discomfort and disability among nursing home residents, as well as a source of financial concern for the institutional agencies responsible for resident care. 2. Prevention and intervention at the earliest stages of pressure ulcer development offer the most effective approaches to mediating the human and economic costs imposed by pressure ulcers. 3. Strategies that are effective in reducing both the development and severity of pressure ulcers can be successfully implemented in long-term care settings. Further studies are needed that will provide additional support for the strategies and protocols used in this study.

Skin problems: epidemiology of pressure ulcers in a skilled care facility.

The majority of nursing home residents have conditions that place them at risk for the development of pressure ulcers. Reported pressure ulcer prevalence rates range from 16% to 35%. Pressure ulcers are multifactorial in origin and necessitate ongoing vigilance by the entire health-care team. Associated risk factors include impairments of circulation, sensation, physical condition, nutrition, mobility, and activity. Stage I pressure ulcers frequently go unrecognized, yet their recognition is essential to prevent further damage. Comprehensive initial assessments of the skin and risk factors of pressure ulcer development at admission will allow for easier reassessment and comparison.

Variables associated with hypotension in postoperative total knee arthroplasty patients receiving epidural analgesia.

The purpose of the study was to identify variables that may place the total knee arthroplasty patient receiving epidural analgesia at risk for hypotension postoperatively. A review of medical records of this convenience sample of 99 subjects was conducted in this retrospective, descriptive, correlational study. Variables predictive of postoperative hypotension using stepwise multiple regression included low postoperative systolic BP on the nursing unit the day of surgery (R2 = .26, p less than .001), low diastolic BP in postanesthesia room (R2 = .31, p less than or equal to .01), low hemoglobin the third postoperative day (R2 = .37, p less than or equal to .01), use of diuretics preoperatively (R2 = .40, p less than or equal to .05), and total fluid intake first day postoperatively (R2 = .43, p less than or equal to .05). These variables accounted for 43% of the variability in the occurrence of hypotension. Identification of variables predictive of hypotension should provide direction for future care givers and researchers.

Clinical evaluation of an automated turning bed.

PURPOSE: The purposes of this study were to assess client comfort and sleep quality, client physiologic response (skin and respiratory status), the effect on the need for caregiver assistance, and cost when using an automated turning bed. DESIGN: Nonexperimental, evaluative study. SAMPLE: Twenty-four adult home or long-term care resident subjects who had a degenerative disease, spinal cord injury, stroke, cerebral palsy, or back surgery. METHODS: Each subject agreed to use the automated turning bed for four weeks. Researchers completed a demographic survey and skin assessment, and assessed each subject for pressure ulcer risk and for the need of assistance of a care giver for turning before and after the four weeks of using the turning bed. Subjects rated the turning bed in terms of comfort and sleep quality. FINDINGS: Subjects rated the turning bed as more comfortable than their own bed and expressed satisfaction at the pain relief attained when on the turning bed. While using the turning bed, there was a significant improvement in sleep quality. No skin breakdown or deterioration in respiratory status occurred. Fewer subjects required the assistance of a caregiver for turning when on the turning bed. CONCLUSION: This automated turning bed shows great promise in meeting a need for patients with limited mobility whether they are homebound or in a residential community. IMPLICATIONS FOR NURSING RESEARCH: Future studies that further investigate use of the turning bed for postoperative back patients while still in the acute care setting are indicated. Replicative studies with a larger sample size are also indicated.

The effectiveness of skin care protocols for pressure ulcers.

Pressure ulcers (PU) remain a serious healthcare problem in the United States. This study investigated the effectiveness of a prevention and early intervention program in reducing the prevalence of pressure ulcers (i.e., the number or the percentage of persons with pressure ulcers at a given time) in a rehabilitation hospital. The Braden Scale for Predicting Pressure Sore Risk was used to assess subjects' PU risk. Protocols were established for PU stages consistent with the National Pressure Ulcer Advisory Panel consensus statement on pressure ulcers. Staff were educated about PUs and the specific protocols for prevention and treatment. Concurrent quarterly prevalence audits on a total of 116 patients were conducted for 1 year. An audit also was done 16 months after protocols had been established. There was a 60% decrease in pressure ulcer prevalence from the 25% baseline to the 10% found at the audit following implementation of the protocols.

Pressure ulcer prevalence and incidence in a rehabilitation hospital.

Pressure ulcers remain a serious health problem, especially in terms of personal suffering and economics. The study described here, conducted in a rehabilitation setting, investigated the prevalence (number of persons with pressure ulcers at a given time) and the incidence (number of persons developing pressure ulcers over a given time) of pressure ulcers. Skin assessments and risk assessments of the subjects were completed using the Braden Scale for Predicting Pressure Sore Risk. Demographic data were obtained. The prevalence rate was 25%, although there was no incidence during the time of this study. Factors associated with the prevalence of pressure ulcers are discussed.

Venous ulcers: etiology and care of patients treated with human skin equivalent grafts.

Care for a patient with a venous ulcer is complex, necessitating collaboration of a multidisciplinary team to achieve the goal of providing comprehensive wound care and optimally managing complications, current conditions, and healing time. Patients often have venous ulcers for a long time, and they frequently have multiple diagnoses. Chronic ulcers that do not heal necessitate closure with a graft. Apligraf, (Novartis Pharmaceutical Corp, East Hanover, NJ), a human skin equivalent, is often used in nonhealing or difficult-to-heal ulcers. Knowledge of how to care for the grafted wound and protection of the grafted site is essential.

Decreasing the prevalence of pressure ulcers using agency standards.

Home care patients either have or are at high risk for pressure ulcers. This article describes the outcome of a study that examined the effects of pressure ulcer prevention and treatment standards on the prevalence rate of a home healthcare agency's client caseload. Implications for practice and further research also are discussed.

Impact of work stress on female nurse educators.

Factors predictive of work-related stress in 287 female nurse educators were studied in a randomly selected sample of 18 U.S. (NLN) accredited schools of nursing. The Maslach Burnout Inventory-Form Ed, the Hardiness of Personality Inventory, the Blair Exercise Activity Index, a demographic tool and an administrator-completed questionnaire were used. Moderate levels of stress were found to exist, with five individual variables (hardiness, age, education, years in nursing education and exercise) and five organizational variables (student contact hours for part-time faculty, task complexity, economic environment of school, number of full-time faculty and percentage of tenured faculty) combining to best predict the occurrence of work-related stress.

Relationship between body weight, body position, support surface, and tissue interface pressure at the sacrum.

This descriptive, comparative study examined the relationship between three body positions, body weight, and tissue interface pressure measurement on three support surfaces among residents who were 65 years of age or older. The support surfaces included the Sof. Care bed cushion, Biogard foam mattress, and hospital mattress. Subjects included 12 ideal body-weight and six less-than-ideal body-weight individuals from a long-term care facility in a Mid-western state. Results indicated no significant difference in sacral tissue interface difference between ideal body weight and less-than-ideal body weight subjects. However, the sacral measurements were significantly greater in the supine position than those taken in the Fowler's and semi-Fowler's positions. A significant interaction was found between position and support surface with subjects in Fowler and semi-Fowler positions on the Sof. Care Surface exhibiting the lowest mean tissue interface pressure at the sacrum.

Pressure ulcer prevalence and incidence and a modification of the Braden Scale for a rehabilitation unit.

PURPOSE: We examined pressure ulcer incidence and prevalence, the cutoff score for risk for skin breakdown, and the contribution of each of the subscale risk factors of the Braden pressure ulcer risk-assessment tool in an inpatient rehabilitation unit. SUBJECTS AND SETTING: One hundred seventy adult men hospitalized on a rehabilitation unit during 1 calendar year were included in the research. Subject ages ranged from 35 to 99 years (M = 69). INSTRUMENTS: Pressure ulcer risk was assessed using the Braden Scale. METHODS: A retrospective chart review of a continuous series of 170 adult male patients hospitalized during a 1-year period on a 50-bed rehabilitation unit was conducted. Data were documented on a standardized researcher-designed form. RESULTS: A total of 46 pressure ulcers occurred, with the sacrum the most common location (46%), followed closely by the heel-ankle area (44%, n = 20). Most pressure ulcers (57%) were stage II, 24% were stage I, 15% stage III, and 4% stage IV. When using a cutoff score of 16, the Braden Scale demonstrated limited usefulness in predicting pressure ulcer development on our inpatient rehabilitation unit. Further calculations were completed, and a cutoff score of 18 or higher was found to provide better predictive value. With use of multiple logistic regression analysis, three of the six risk factors from the Braden Scale were found to significantly contribute to risk for pressure ulcer development in this sample: moisture, nutrition, and friction and shear. Therefore a modified Braden Scale was developed, with a possible range of scores from 3 to 11; the cutoff score was 8, sensitivity was 52%, and specificity 66%. CONCLUSIONS: The mean prevalence rate of 12% was comparable, and the incidence rate of 6% for this unit was lower, compared with other skilled care and rehabilitation settings reported in the literature. The proactive, interdisciplinary approach to skin integrity on this unit likely contributed to the lower incidence rate. Risk factors most predictive of pressure ulcer development in this sample were moisture, nutrition, and friction and shear. Predicting risk for skin breakdown with use of a consistent risk-assessment tool is essential for all rehabilitation patients. Assessing risk with the Braden Scale merits further research.