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Comment: Nurse judgment is vital when assessing ulcers

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As a nursing student I was allocated to a ward, where on your first day the sister told you in no uncertain terms that patients did not get pressure ulcers on her ward. Her belief was so strong that no one dared to tell her about grazes or blisters or discoloured skin for fear of the consequences

Pressure ulcers are viewed as a failure to provide effective care and nurses know that only a small number of ulcers cannot be prevented. If we accept that skin breakdown can be avoided then we need to ask why ulcers occur when we have a vast armoury of equipment and numerous risk-assessment tools available.

The reality is that the prevention of pressure ulcers requires more than ticking boxes in a risk-assessment tool and following an algorithm. Heidi Guy points out in her article about pressure ulcer assessment that any risk-assessment tool should be used as an aide-mémoire.

All patients are different and ultimately clinical judgement is required to assess risk accurately. We have all nursed patients whose risk assessment does not match what we can see with our own eyes. The skill is knowing how these assessments fit with expert clinical judgement.

This is evident in the research paper published in this issue that describes patients’ experiences of living with pressure ulceration and the pain and discomfort that they associate with it. The surprising feature of this research is that a lot of what we do to prevent skin breakdown – asking patients to
move or placing them on a special mattress – can actually cause them both pain and distress. The authors of this research therefore conclude that our understanding of the patient’s perspective is limited and that there is room for further research to help us understand how we can work with patients to maintain their skin integrity.

The challenge to nurses is to ensure that pressure ulcer assessment and prevention is recognised as a nursing task that requires a high level of skill and expertise, and this involves an honest analysis of incidents where skin breakdown occurs. The challenge for managers is providing sufficient numbers of skilled nurses on wards to ensure effective care.

Eileen Shepherd, DipN, RGN, editor, Chronic Wound Management

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