Dokumentasjon av sykepleie : hvordan dokumenterer helsepersonell i sykehjem forebygging og behandling av trykksår, og er det samsvar mellom kartleggingsresultater fra en gruppe pasienter inneliggende i sykehjem og deres sykepleiedokumentasjon?

Abstract

Background: In Norwegian nursing homes there is a lack of systematic risk assessments, anddocumented interventions of prevention of malnutrition and pressure ulcer (PU). Earlierstudies have shown that prevalence of PU in the nursing documentation was low, compare toa skin examination.Aim: the purpose of this study was to describe the nursing documentation of prevalence, riskfactors and prevention of PU and compare the nursing documentation with a patientexamination conducted in nursing home practice.Design and methods: The study had a descriptive design and was conducted in five nursinghomes in southern Norway. A retrospective review of 155 patients’ records, and a patientexamination with the European Pressure Ulcer Advisor Panel (EPUAP) -form, and theBraden-scale.Results: In this study the prevalence of PUs was 33 (22 %) on patient examination, and 38(26%) in patient records. A total of 17 (45%) of the documented PUs was not graded.According to the patient examination 59 (40%) of the patients had preventive measures whileonly 13 (8%) had preventive measures documented in their records when comparing of recordcontent and patient examination.Conclusion: There was no great difference in prevalence of PU, however there was a largenumber of PUs in patient records, not graded, of unknown reason. The patient documentationdid not show use of research based instruments or systematic assessment’s to determine if thepatient had or were in risk of developing PUs.Keywords: patient record, patient documentation, nursing documentation, nursing home,pressure ulcer