PDSA Model for Pressure Ulcers

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PDSAModel for Pressure Ulcers

PDSAModel for Pressure Ulcers

Optimalcare of clients in hospitals is a pre-requisite for good outcomes. Pressure ulcers when they occur pose a great challenge to thehealthcare providers in achieving better results. As an APN, I havenoted that pressure ulcers are taking long to heal. Furthermore,some get worse, and it is with the team to ensure that this does notcontinue. Using the outline of Plan-Do-Study-Act (PDSA), I am goingto come up with a way to curb the problem (Taylor,McNicholas, Nicolay, Darzi, Bell, &amp Reed 2013).


Plan. Pressure ulcers do not need to take a very long time to resolve. Similarly, they are not supposed to be allowed to worsen. Members ofthe health care team need to learn specific methods of prevention andcontrol. These include 2-hourly turning, using non-high densitymattresses, sheepskin use under the bedding for bedridden patients,microclimate management, and adequate nutrition. These are thechanges that I intend to institute. I will task registered nurses totake the lead in organizing the nursing team to achieve optimal care. The aim is to ensure that clients with pressure ulcers heal as fastas possible and no further damages. Those that are bedridden shouldalso be taken care of adequately to prevent the occurrence. The teamwill ensure that ulcers resolve and healing begin within seven days.

Do. The problems and observations that I have noted that the care teamneeds to improve are adherence to the two hourly turning, usingappropriate materials for dressing different types and stages ofulcers as well as the use of sheepskin and ripple mattress forbed-ridden clients. Over the last one month, I noted that twopatients with pressure ulcers worsened and resulted in sepsis. Furthermore, two also took longer than two weeks for the ulcers toheal.

Study. It is important to note from the observation that four clients hadundesired outcomes for their condition. We had earlier committedthat we would have no development of pressure ulcers in ourcustomers. This is an apparent loophole, and we need to actaccordingly.

Act. From the study, the changes that need to be implemented includeimplementation of strict turning charts with monitored adherence, useof softer mattresses and sheepskin, application of zinc oxide in bonyprominences for pressure area care, appropriate dressing materialsfor the different types and stages of ulcers. Nurses responsible fordressing should be trained in the proper performance of theprocedure. When these loopholes are sealed, the process isreassessed, and appropriate changes can be made


Taylor,M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., &amp Reed,J. E. (2013). Systematic review of the application of theplan–do–study–act method to improve quality in healthcare.&nbspBMJquality &amp safety,bmjqs-2013.