Identifying Minimum Datasets for Pressure Ulcer Assessment and Analysis of Nursing Records in Home Nursing

Kim, Hyun Young; Park, Hyeon Ae

Abstract

PURPOSE
The purpose of this study was to identify minimum datasets for ulcer assessment and to map the minimum datasets to paper-based nursing records for pressure ulcer care in homecare setting.
METHODS
To identify minimum datasets for pressure ulcer assessment, the authors reviewed four guidelines for pressure ulcer care. The content validity of the minimum datasets was assessed by three homecare nurse specialists. To map the minimum datasets to nursing records, the authors examined 107 pressure ulcer events derived from 45 pressure ulcer patients who received home nursing from two hospitals in Gyeonggi Province.
RESULTS
The minimum datasets for initial assessment were anatomical location, stage, size, tissue, exudate, condition of periwound skin, undermining, odor, and pain. 'Location' was recorded best, accounting for a complete recording rate of 98.1%. 'Exudate' and 'pain' showed the poorest record, accounting for 2.8% and 0%,respectively. The minimum datasets for progress assessment were wound size, tissue, and exudate, each accounted for 31.8%, 2.8%, and 4.7%, respectively.
CONCLUSION
This study concluded that data on pressure ulcer assessment was not sufficient homecare and it can be improved by adopting minimum datasets as identified in this study.