An exploration of nursing documentation of pressure ulcer care in an acute setting in Ireland

To explore the nature and quality of documented care planning for pressure ulcers in a large teaching hospital in the Republic of Ireland.

A mixed method design was used; this encompassed a descriptive survey that retrospectively evaluated nursing records (n=85) in two wards (orthopaedic and care of the older adult) and a focus group (n=13) that explored nurses' perspectives of the factors influencing concordance and the quality of nursing documentation. Only records of at-risk patients (Waterlow score of >10) were included.

It was identified that 47% (n=40) were assessed as at high or very high risk of developing a pressure ulcer. Fifty-two patients (61%) had a weekly risk assessment, but 25% (n=21) had only one follow-up assessment. Only 45% (n=38) of charts had some evidence of documented care planning, and of those 53% (n=20) had no evidence of implementation of the care plan and 66% (n=25) had no evidence of outcome evaluation. Only 48% (n=41) of this at-risk population was nutritionally assessed. Of patients admitted with and without a pressure ulcer, there was no record of regular positioning in 70% (n=59) and 60% (n=51) respectively.

Documentation on pressure ulcer care is not standardised and requires development.

None.