title: An exploration of nursing documentation of pressure ulcer care in an acute setting in Ireland.
abstract: OBJECTIVE
  To explore the nature and quality of documented care planning for pressure ulcers in a large teaching hospital in the Republic of Ireland.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  Documentation on pressure ulcer care is not standardised and requires development.
  
  
  BACKGROUND
  None.
authors.affiliation: Beaumont Hospital, Dublin, Ireland. juliejordanobrien@beaumont.ie
authors.forename: J A Jordan
authors.initials: JA
authors.lastname: O Brien
authors.forename: S
authors.initials: S
authors.lastname: Cowman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D006784:Hospitals, Teaching / Q000379:methods; D006801:Humans; D007494:Ireland; D008875:Middle Aged; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000592:standards*; D003668:Pressure Ulcer / Q000451:nursing*; D017064:Process Assessment, Health Care; D055815:Young Adult