My Point of View...
Commentary by Larry Leeds, RN
The nursing profession has a long-standing rule of practice, the q2 (every two hours) observe, turn, assess, and attend. This rule continues to be a standard, though many interventions may be carried out in a two-hour period. I would have to say turning patients is crucial. Pressure sores can form very quickly and can take a long time to heal. Turning your patient every two hours relieves the pressure on bony prominence and redistributes the weight. This simple but time consuming intervention can be the difference in a solid first line of defense or a source of pain, infection and increased length of hospital stay. A recent study revealed, "Pressure sores, for instance, (National Institute of Nursing Research NINR) take a heavy toll both on their victims and on our nation’s health care system, affecting up to 15 percent of all hospitalized patients and up to 35 percent of nursing home residents in this country.(1)" With the advent of new Medicare regulations and since diagnosis related groups (DRG) have been initiated the changes in acuity have been affected. We now see more acutely ill patients, which increases initial risk.
This is not a new problem. Created in 1987, "the NPUAP (National Pressure Ulcer Advisory Panel homepage History and Mission) is composed of leading experts from different health care disciplines— all of whom share a commitment to the prevention and management of pressure ulcers. (2)" As healthcare professionals we must take this very seriously. Diligent turning of patients deserves appreciation adequate to the damage that indifference can cause. "The NPUAP provides multidisciplinary leadership for improved (NPUAP) patient outcomes in pressure ulcer prevention and management through Education, Public Policy, & Research. (2)" Nurses and unlicensed assistive personnel are very busy and turning schedules require participation of both disciplines. I also know that, as nurses we are often very busy and may let something like turning every two hours become a delegated task. Delegation is appropriate for many tasks and nurses will always need UAP’s to help with things. Turning every two hours however, should be a shared task and the nurse should use the two-hour interval to perform the q2 assessment. We must make time to complete turning every two hours as an indispensable intervention.
New tools in nursing are being developed all the time and the use of one such tool "The Braden Scale" is becoming very useful in determining risk and implementing care. "The Braden Scale (Prevention Plus Homepage) for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client’s level of risk for developing pressure ulcers. (3)" The use of such tools on admission and periodically in long-term care could be a major benefit in reducing incidence of pressure ulcers. One of the beneficial aspects of this system is the lack of knowledge needed for use. A nurse with twenty years experience or a new graduate can use this tool with the same accuracy. It is solely dependent upon existing conditions and the ability of the patient to assist in care. If the "Braden Score" is below 16 the patient automatically requires a skin care consult or plan of care.
The use of specialty mattresses and specific beds are another way in which we as nurses can use our judgement and exercise autonomy. We can assess and recommend additional interventions. We are the first line of defense for our patients at risk and must advocate for better mattresses or specialty beds when needed. "Turning (Prevention of Pressure Ulcers in Older Patients) and/or repositioning patients is a practice with high face validity, but there are no well-designed controlled trials that examine its effect in the absence of other interventions. Other practices include regular skin inspection and assessment, use of appropriate pressure-relief surfaces, improved mobility, adequate nutritional intake, and documentation of the skin examination. (4)" These are important aspects of intervention regarding skin care and pressure sore prevention. As nurses we are responsible for each of the above mentioned practices.
The purpose of this article is not in any way to place blame or find fault. I as a nurse truly believe that pressure ulcers are a growing concern. The point I am stressing is that turning is an important intervention. Skin care and turning should receive the attention it deserves as the problem continues to grow. We owe our patients the best care we can provide and turning q2 should hold a top priority.