Registered Nurses: A Hope in HAPU Care



A hospital acquired pressure ulcer, sometimes referred to as a bedsore, can be defined as an injury to the skin or underlying tissue of the patients caused by physical pressure, friction and moisture often compounded by limited mobility and sedentary positions in bed during their stay in hospital.

Depleted nutrient levels, insufficient fluids, decreased circulation, fragile skin, change in bowel and bladder functions, intubations, drains and hospital equipments are factors that promote hospital acquired pressure ulcers.

HAPUs can damage the skin, muscles and associated tissues, delay recovery, cause pain, infection and other complications.

An estimated 2.5 million patients are treated for pressure ulcers in acute care facilities in the United States every year and the cost of managing a single full-thickness pressure ulcer is as high as $70,000 (Lynch, 2010).

Nursing interventions can not only cure but also effectively prevent HAPUs. Hospital-acquired pressure ulcer surveillance and prevention can be cost saving for hospitals and support quality patient outcomes (Spetz, 2013).


Studies to evaluate the prevalence, severity, location, etiology, treatment and healing of medical device-related pressure ulcers in intensive care patients staying in the setting for a seven days period has shown that the endotracheal (ET) and nasogastric (NG) tubes are the cause of most device-related pressure ulcers (Coyer, 2013).

Studies on prevalence and incidence rates of pressure ulcers in Emergency Departments show that even a very short stay in the ED is sufficient to induce stage I PUs (Dugaret, 2012).

Studies have also shown that as many as five percent of male hospital patients develop pressure ulcers in the urinary meatus as a result of urethral catheterization (Rassin, 2013).

Research studies to determine the incidence of pressure ulcers among inpatients in hospitals have elucidated that inpatients with spinal cord injury, orthopaedic and head injury are more at a risk of developing pressure ulcers.

These studies have further shown that pressure ulcers are more likely to occur in the sacrum, heel, greater trochanter and lateral and medial malleoli (Onigbinde, 2012).

Nurse Care

Nurse interventions in the pressure ulcer prevention protocol include turning and repositioning of patients, effective toileting care, specialty bed and heel provision (Lynch, 2010).

Retrospective studies to evaluate the nurse interventions for medical device-related pressure ulcers in a neurosurgical unit have shown that repositioning patients every one to two hours, specialty beds and continuous wound assessment by a team comprising of expert nurses and nursing assistants can effectively prevent ulcers.

Studies have also indicated that Head to Toe examination by nurses, documentation of pressure ulcers by staging and provision of pressure relieving heel protector boots reduce HAPUs substantially (McGuinness, 2012).

The prevention and treatment of pressure ulcers has off late become the sole responsibility of the nursing staff.

A cross-sectional survey of nurses on the knowledge about medications and products to prevent and treat pressure ulcers taking into account the socio demographic data and division of responsibility for the care of patients with pressure ulcers or at risk of developing them has shown that nurses have greater responsibility for the care of pressure ulcers, make greater use of medical prescriptions, are more familiar with the site's clinical practice guidelines and show better adherence to protocol recommendations (Romero-Collado, 2013).

Studies to determine nurses' level of knowledge of pressure ulcer prevention and treatment interventions in clinical practice have indicated that although nurses have excellent expertise in pressure ulcer care, training on most recent pressure ulcer interventions can improve outcomes (Saleh, 2013).

Risk Assessment and Prevention

A recent interdisciplinary study comprising of a clinical wound specialist, assistant director of nursing, nurse managers, staff nurses and rehabilitation nursing technicians to develop a standardized approach to pressure ulcer risk assessment and prevention to reduce hospital-acquired pressure ulcers have identified numerous factors that promote HAPUs and affect patient clinical outcomes.

These include misidentification of pressure ulcers present on admission, incomplete daily RN skin assessments and improper staging of the ulcers.

Proper documentation of the various stages of the ulcer, a thorough knowledge and understanding of complete visual head-to-toe skin assessment, accurate assessments and comprehensive individualized pressure ulcer prevention protocols have been identified as factors that effectively prevent HAPUs.

Research on implementation and evaluation of strategies to reduce the incidence of pressure ulcers have brought forth a protocol that includes devising a comprehensive pressure ulcer patient database, intensive monitoring using root cause analysis, writing action plans using high-impact actions (HIAs), staff training and innovative thinking to address and reduce the incidence of pressure ulcers (Harrison, 2013).

Studies have also shown that risk assessment of all admitted patients followed by provision of specialized support surfaces to all deemed to be at risk can reduce the incidence of hospital-acquired pressure ulcers. Since, some pressure ulcers have their origin in deep tissues; it is better for the nurses to intervene before the appearance of Stage I or II ulcers (Comfort 2008).

Studies to determine if digital photographs obtained by staff nurses in the acute care setting could be used to determine staging and wound characteristics of a pressure ulcer as part of bedside assessment have shown that digital photograph in combination with clinical information can increase the accuracy of the assessment and documentation (Jesada, 2013).

The correct staging of a PU is imperative in nursing's documentation and subsequent choice of best practices for improved outcomes.

A computerized clinical decision support system for improving accuracy of pressure ulcer staging and documentation has been evaluated successfully for this purpose (Alvey, 2012). Various pressure ulcer risk assessment scales (PURAS) have been developed and utilized in nursing practice.

Randomized controlled trials (RCTs) to determine the clinical efficacy and safety of these risk assessment strategies invariably take into account the clinical judgment of the nurses to compare these risk assessment scales (Balzer, 2013).


Data from the National Medicare Patient Safety Monitoring System Study show that patients who develop HAPUs are more likely have longer lengths of hospital stay and more prone for readmissions within 30 days after discharge (Lyder, 2012).

Studies do confirm that nosocomial pressure ulcers can be significantly reduced in long-term care when well-established standard guidelines are followed.


•Alvey B, Hennen N, Heard H. Improving accuracy of pressure ulcer staging and documentation using a computerized clinical decision support system. J Wound Ostomy Continence Nurs. 2012 Nov-Dec; 39(6):607-12.

•Balzer K, Köpke S, Lühmann D, Haastert B, Kottner J, Meyer G. Designing trials for pressure ulcer risk assessment research: Methodological challenges. Int J Nurs Stud. 2013 Mar 26. pii: S0020-7489(13)00047-3.

•Comfort EH. Reducing pressure ulcer incidence through Braden Scale risk assessment and support surface use. Adv Skin Wound Care. 2008 Jul; 21(7):330-4.

•Coyer FM, Stotts NA, Blackman VS.A prospective window into medical device-related pressure ulcers in intensive care. Int Wound J. 2013 Feb 4.

•Dugaret E, Videau MN, Faure I, Gabinski C, Bourdel-Marchasson I, Salles N. Prevalence and incidence rates of pressure ulcers in an Emergency Department. Int Wound J. 2012 Oct 8.

•Harrison T, Kindred J, Marks-Maran D. Reducing avoidable harm caused by pressure ulcers.Br J Nurs. 2013 Mar 28-Apr 12; 22(6):s4-s14.

•Jesada EC, Warren JI, Goodman D, Iliuta RW, Thurkauf G, McLaughlin MK, Johnson JE, Strassner L. Staging and defining characteristics of pressure ulcers using photographs by staff nurses in acute care settings. Wound Ostomy Continence Nurs. 2013 Mar; 40(2):150-6.

•Lyder CH, Wang Y, Metersky M, Curry M, Kliman R, and Verzier NR, Hunt DR. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012 Sep; 60(9):1603-8.

•Lynch, Sandra MS, BSN, RN, CRRN; Vickery, Pamela BSN, RN, CWS. Steps to reducing hospital-acquired pressure ulcers. Nursing: November 2010 - Volume 40 - Issue 11 - p 61–62.

•McGuinness J, Persaud-Roberts S, Marra S, Ramos J, Toscano D, Policastro L, Epstein NE. How to reduce hospital-acquired pressure ulcers on a neuroscience unit with a skin and wound assessment team. Surg Neurol Int. 2012; 3:138.

•Onigbinde AT, Ogunsanya GI, Oniyangi SO. Pressure ulcer incidence among high-risk inpatients in Nigeria.Br J Nurs. 2012 Jun 28-Jul 11; 21(12):S4, S6, S8-10.

•Rassin M, Markovski I, Fishlov A, Naveh RU. An evaluation of preventing pressure ulcers in the urinary meatus. Dimens Crit Care Nurs. 2013 Mar-Apr; 32(2):95-8.

•Romero-Collado A, Homs-Romero E, Zabaleta-Del-Olmo E. Knowledge about medications and products to prevent and treat pressure ulcers: a cross-sectional survey of nurses and physicians in a Primary Health Care setting. J Clin Nurs. 2013 Mar 29. doi: 10.1111/jocn.12175.

•Saleh MY, Al-Hussami M, Anthony D. Pressure ulcer prevention and treatment knowledge of Jordanian nurses. J Tissue Viability. 2013 Feb; 22(1):1-11.

•Spetz J, Brown DS, Aydin C, Donaldson N. The Value of Reducing Hospital-Acquired Pressure Ulcer Prevalence: An Illustrative Analysis. J Nurs Adm. 2013 Apr; 43(4):235-241.

•Tippet AW. Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation. Ostomy Wound Manage. 2009 Nov 1; 55(11):52-8.


Articles in this issue:


  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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