Neonatal Intensive Care Nursing Pressure Injury Prevention Practices: A Descriptive Survey.

PURPOSE: The purpose of this study was to explore neonatal nursing practices for neonatal pressure injury (PI) risk assessment, pressure redistribution surface use, and moisture management. DESIGN: A descriptive survey. SUBJECT/SETTINGS: A sample of 252 neonatal nurses mainly from the United States responded to a survey distributed electronically through the National Association of Neonatal Nurses, the Academy of Neonatal Nurses, and on the Wound Source Web site. METHODS: Nurses responded to questions that explored what neonatal nurses used to assess PI risk, types of pressure redistribution surfaces used for neonates, and what moisture management strategies were used to prevent PIs. Descriptive statistics were used to describe nurses' practices. RESULTS: When assessing risk, 78% (n = 197/252) reported using a risk assessment scale: the 2 most common scales were the Neonatal Skin Risk Assessment Scale and the Braden Q Scale. Sixty-nine percent (n = 174/252) reported using a rolled blanket or small soft object as pressure redistribution surfaces. In addition, 15% (n = 39) reported the use of different types of positioners such as a fluidized positioner as pressure redistribution surfaces; however, these are marketed as a positioning devices. It appears that these interventions were considered redistribution surfaces by the nurses. For moisture management, petrolatum-based products (6.7%; n = 17/252) and ostomy powders (6%; n = 16/252) were most frequently used. CONCLUSIONS: Practices for PI prevention are different for neonatal patients due to their gestational age, size, and level of illness. Findings from this study create a beginning knowledge of and an opportunity for further research to determine how these practices affect outcomes such as PI incidence and prevalence.

Student Nurses' Perceptions of Mercy: A Qualitative Study.

Mercy is a valued nursing attribute. It often identifies faith-based educational institutions, clinics, and hospitals and has been a quality valued and taught by the Catholic Sisters of Mercy through nursing's history. This qualitative study explored the meaning of mercy as expressed by undergraduate nursing students attending a faith-based nursing school. This article presents the findings of a question posed to students: What does mercy mean to me? Nursing practice and education implications are also presented.

Factors Associated With Pediatric Hospital-Acquired Pressure Injuries.

PURPOSE: The purpose of this study was to identify associations among pediatric patient characteristics (age and gender), hospital characteristics, inpatient unit characteristics (unit type, pressure injury prevention practices, and nurse staffing measures), and hospital-acquired pressure injuries (HAPIs) in a group of pediatric patients and in those determined to be at risk for pressure injury. DESIGN: A descriptive, correlational analysis of data from a large dataset. SUBJECTS AND SETTING: The sample comprised 39,984 children aged 1 day to 18 years of age from 678 pediatric units in 271 participating hospitals across the United States. METHODS: Data related to pressure injuries and prevention among pediatric patients from the National Database of Nursing Quality Indicators (NDNQI) were analyzed. All data were collected during the year 2012. Descriptive statistics were used to summarize the study sample. Hierarchical logistic regression analysis was used to analyze patient age and gender, unit type, pressure injury risk, prevention and staffing measures, and hospital characteristics associated with HAPI. RESULTS: The likelihood of a HAPI was more than 9 times higher among patients who were determined to be at risk for pressure injuries (odds ratio [OR]: 9.42, 95% confidence interval [CI]: 7.28-12.17, P < .001) compared to patients deemed not at risk. Hospital-acquired pressure injury was more likely to occur on pediatric critical care units (OR: 2.59, 95% CI: 1.28-5.26, P = .009) and rehabilitation units (OR: 4.05, 95% CI: 1.21-13.55, P = .02). Patients from hospitals that only provided care for children (OR: 2.6, 95% CI: 1.42-4.78, P = .002) were also more likely to be associated with HAPI compared to hospitals that provided care for adults and children. Among the 11,203 pediatric patients deemed at risk for pressure injuries, 95.8% received one or more prevention interventions. There were no prevention interventions associated with a lower occurrence of HAPI. CONCLUSIONS: Study findings support pressure injury risk assessment among pediatric patients and elucidates important information regarding pediatric unit and hospital characteristics associated with HAPI.

Pressure Ulcer Risk and Prevention Practices in Pediatric Patients: A Secondary Analysis of Data from the National Database of Nursing Quality Indicators®.

Little is known about pressure ulcer prevention practice among pediatric patients. To describe the frequency of pressure ulcer risk assessment in pediatric patients and pressure ulcer prevention intervention use overall and by hospital unit type, a descriptive secondary analysis was performed of data submitted to the National Database for Nursing Quality Indicators® (NDNQI®) for at least 3 of the 4 quarters in 2012. Relevant data on pressure ulcer risk from 271 hospitals across the United States extracted from the NDNQI database included patient skin and pressure ulcer risk assessment on admission, time since the last pressure ulcer risk assessment, method used to assess pressure ulcer risk, and risk status. Extracted data on pressure ulcer prevention included skin assessment, pressure-redistribution surface use, routine repositioning, nutritional support, and moisture management. These data were organized by unit type and merged with data on hospital characteristics for the analysis. The sample included 39 984 patients ages 1 day to 18 years on 678 pediatric acute care units (general pediatrics, pediatric critical care units, neonatal intensive care units, pediatric step-down units, and pediatric rehabilitation units). Descriptive statistics were used to analyze study data. Most of the pediatric patients (33 644; 89.2%) were assessed for pressure ulcer risk within 24 hours of admission. The Braden Q Scale was frequently used to assess risk on general pediatrics units (75.4%), pediatric step-down units (85.5%), pediatric critical care units (81.3%), and pediatric rehabilitation units (56.1%). In the neonatal intensive care units, another scale or method was used more often (55% to 60%) to assess pressure ulcer risk. Of the 11 203 pediatric patients (39%) determined to be at risk for pressure ulcers, the majority (10 741, 95.8%) received some kind of pressure ulcer prevention intervention during the 24 hours preceding the NDNQI pressure ulcer survey. The frequency of prevention intervention use among those at risk ranged from 99.2% for skin assessment to 70.7% for redistribution surface use. Most pediatric patients are being assessed for pressure ulcer risk, but the implementation of interventions to prevent pressure ulcers among children needs to be improved. Future qualitative research should be conducted to determine how and when clinical judgment is used to assess pressure ulcer risk and the type of pressure-redistribution surfaces used among younger pediatric patients.

Pressure Injury Prevalence and the Rate of Hospital-Acquired Pressure Injury Among Pediatric Patients in Acute Care.

PURPOSE: The purpose of this study was to describe the prevalence and rate of hospital-acquired pressure injuries (HAPIs) in pediatric patients. DESIGN: Descriptive, secondary analysis of 2012 data on pressure injuries among pediatric patients from the National Database for Nursing Quality Indicators (NDNQI). SUBJECTS AND SETTING: The sample included 39,984 patients 1 day to 18 years old from 678 pediatric acute care units (general pediatrics, pediatric critical care, neonatal intensive care, pediatric step-down, and pediatric rehabilitation units) in 271 US hospitals that submitted pressure injury data to the NDNQI for at least 3 quarters during 2012. RESULTS: The pressure injury prevalence was 1.4% and the prevalence of HAPI was 1.1%. The rate of HAPI among males was 1.06%, and the rate among females was 1.14%. HAPI rates were highest among children ages 9 to 18 years (1.6%) and 5 to 8 years (1.4%) and lowest among patients 1 to 30 days of age (0.72%). By unit type, HAPIs were highest among patients in pediatric critical care units (3.7%) and pediatric rehabilitation units (4.6%) and lowest in general pediatrics units (0.57%). Most of the HAPIs were Stage 1 and Stage 2 (65.6%); 14.3% were deep tissue pressure injuries and 10.1% were unstageable pressure injuries. CONCLUSION: Acutely ill children develop pressure injuries, including HAPI. Study findings provide data on HAPI from a large sample of hospitalized children and by pediatric unit type for comparison purposes.

The epidemiology of falls in hospitalized children.

This study was conducted to validate the CHAMPS pediatric fall risk assessment tool for hospitalized children. At the time of this study, there was a lack of published evidence for a valid pediatric fall risk assessment tool for hospitalized children. Adult instruments were the only valid tools for fall risk assessment, and they were being used in populations where the validity had not been established. A prospective cohort study was conducted to analyze the sensitivity and specificity of the CHAMPS pediatric fall risk assessment tool. Analysis was conducted to further establish validity. The CHAMPS instrument had a sensitivity of 0.75 and a specificity of 0.79, with a relative risk of 3.5, excess risk of 200%, and an odds ratio of 10.8. This instrument can be categorized as moderate to strong in prediction of pediatric falls, while specificity was found to be slightly stronger than sensitivity.

Improving venous thromboembolism prevention processes and outcomes at a community hospital.

BACKGROUND: Venous thromboembolism (VTE) is a cause of significant morbidity and mortality in hospitalized patients in the United States. Quality improvement (QI) strategies to increase the rates of prophylaxis in patients at-risk for VTE have been shown to be successful. The development of a formal, active strategy addressing the prevention of VTE, as a written, institutionwide VTE prophylaxis policy, presents a challenge for hospitals METHODS: In 2007 a multidisciplinary VTE committee was initiated to develop and implement a hospitalwide QI program to standardize VTE risk assessment and prophylaxis prescribing practices at Saint Francis Hospital (Tulsa, Oklahoma). The QI program included clinician education, VTE order set and electronic trigger implementation, and changes in mechanical prophylaxis usage. RESULTS: The VTE prophylaxis order set was successfully piloted and implemented hospitalwide within three months of the project's initiation. Standardization of VTE prophylaxis practices across surgical and medical specialties was the key aim of this QI program. As a result, patient-related outcomes were also improved. The number of hospital-acquired VTE events decreased from 123 (0.39%) in 2008 to 99 (0.32%) in 2009 and 87 (0.27%) in 2010, and a reduction in the VTE rate between 2008 and 2010 of 31.6%. There was a significant decrease between 2008 and 2010 in the number of hospital-acquired VTE events (p = .035). CONCLUSIONS: Keys to the success of this QI program included leveraging multidisciplinary VTE committee members, physician champions, multiple approaches to communication and education, and providing evidence to support the changes. Sharing the hospital's QI process may provide a model for other hospitals challenged with developing and sustaining positive outcomes in patients at risk for VTE.

The role of the wound, ostomy, and continence nurse with children.

This article describes the WOC nurse's role related to practice settings. The role of the WOC with children has been understudied, and there are multiple areas for development in the role that include entrepreneurial, outcomes, education, and evidence-based practice. These opportunities will enable a move from a traditional WOC role to a research-based foundation.

Pressure ulcer development in infants: state of the science.

The science of pressure ulcer development in infants is underdeveloped. Although recent conceptual frameworks have been applied to younger populations, this article focuses on the unique attributes of full-term and preterm newborns that have an impact on pressure ulcer development. A proposed schema identifies the theoretical elements associated with pressure ulcer development in infants.

Hereditary non-polyposis colon cancer: change the name to protect the innocent.

Hereditary non-polyposis colon cancer is a common form of colorectal cancer, accounting for 5%-10% of all colorectal cancers. This cancer is inherited in an autosomal dominant fashion, occurring as early as age 25, with an average age of 45 at diagnosis. Nurses are an integral part of educating patients and families with a history of colon and uterine cancer.

Current trends in the development of sedation/ analgesia scales for the pediatric critical care patient.

Evaluation of pain and sedation in the PICU patient population is challenging. This article provides an overview of sedation and analgesia assessment tools developed for the critical pediatric patient who is mechanically ventilated and pharmacologically paralyzed. Studies reviewed include adult critical care, pediatric, and neonatal patients. No single tool has emerged that can adequately address pain management in the mechanically ventilated pharmacologically paralyzed pediatric patient. Nurses, as an integral part of the health care of critical pediatric patients, should endeavor to develop evidence-based methods for the evaluation of simple yet accurate scales to monitor sedation and pain in the pharmacologically paralyzed pediatric patient.

Falls in hospitalized children.

PURPOSE: To identify risk factors in hospitalized children using two validated adult fall risk scales. METHODS: For each fall patient identified, a non-fall patient was matched for chronological age and year of hospitalization. The retrospective chart review coded the presence or absence of risk factors and completed both the Morse Fall Scale and Hendrich II Fall Risk Model. FINDINGS: Overall, a significant difference was detected between pediatric fallers and non-fallers on the Morse Fall Scale. The Morse Fall Scale's sensitivity, specificity and false positive rate suggested that the scale does little better than chance at detecting true fallers and may inaccurately identify non-fallers as high risk. CONCLUSIONS: Episodes of disorientation and fall history were the best predictors of pediatric falls for this sample.

Pain management for newborn circumcision.

PURPOSE: To describe current newborn circumcision pain interventions and to identify which forms of analgesia were most effective. METHOD: Each male newborn was assessed for pain during the circumcision procedure and at 15-minute intervals after the procedure using the FLACC pain scale. The type and combination of analgesia was also recorded on the pain assessment record. RESULTS: Pain scores were highest for newborns receiving no analgesia during circumcision. Newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores. The sucrose alone did not provide sufficient analgesia; however, it did reduce the FLACC score somewhat when used in conjunction with other analgesics/anesthesia. CONCLUSIONS: Information obtained from this project facilitated a change in policy wherein newborn circumcision is performed only with the use of analgesia and not concentrated oral sucrose alone.

Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale.

BACKGROUND: While there are valid and reliable pressure ulcer risk assessment tools available for adult patients, none exist for infants and children. To remedy this, the Braden Scale was adapted for use in pediatrics, calling it the Braden Q Scale. OBJECTIVE: The purpose of this study was to: (a) establish the predictive validity of the Braden Q Scale in an acutely ill pediatric population; (b) determine the critical cutoff point for classifying patient risk; and (c) determine the best time to assess patient risk. METHODS: A multisite prospective cohort descriptive study with a convenience sample of 322 patients on bedrest for at least 24 hours without pre-existing pressure ulcers or congenital heart disease were enrolled from three pediatric intensive care units (PICU). The Braden Q score and skin assessment were independently rated and data collectors were blind to the other measures. Patients were observed up to 3 times per week for 2 weeks and then once a week until PICU discharge for a median of 2 observations reflecting 887 skin assessments. RESULTS: Eighty-six patients (27%) developed 199 pressure ulcers; 139 (70%) were Stage I pressure ulcers, 54 (27%) were Stage II pressure ulcers, and 6 (3%) were Stage III pressure ulcers. Most pressure ulcers (57%) were present at the first observation. Using Stage II+ pressure ulcer data obtained during the first observation, a Receiver Operator Characteristic (ROC) curve for each possible score of the Braden Q Scale was constructed. The area under the curve (AUC) was 0.83. At a cutoff score of 16, the sensitivity was 0.88 and the specificity was 0.58. The Braden Q Scale was then modified to eliminate 4 subscales with an AUC <0.7. With 3 subscales (mobility, sensory perception, tissue perfusion/oxygenation) the AUC of this Modified Braden Q Scale was maintained at 0.84. At a cutoff score of 7, the sensitivity was 0.92 and the specificity was 0.59. CONCLUSIONS: The performance of the Braden Q Scale in a pediatric population is similar to that consistently reported for the Braden Scale in adult patients. The Modified Braden Q Scale, with 3 subscales, provides a shorter yet comparable tool.