B.ed 2nd Year Books Pdf Free Download
Keith Tolzmann
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The Burning Bed is both a 1980 non-fiction book by Faith McNulty about battered housewife Francine Hughes, and a 1984 TV-movie adaptation written by Rose Leiman Goldemberg. The plot follows Hughes' trial for the murder of her husband, James Berlin "Mickey" Hughes, following her setting fire to the bed he was sleeping in at their Dansville, Michigan home on March 9, 1977, and thirteen years of physical domestic abuse at his hands.
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Pressure ulcers remain a major health problem affecting approximately 3 million adults.1 In 1993, pressure ulcers were noted in 280,000 hospital stays, and 11 years later the number of ulcers was 455,000.2 The Healthcare Cost and Utilization Project (HCUP) report found from 1993 to 2003 a 63 percent increase in pressure ulcers, but the total number of hospitalizations during this time period increased by only 11 percent. Pressure ulcers are costly, with an average charge per stay of $37,800.2 In the fourth annual HealthGrades Patient Safety in American Hospitals Study, which reviewed records from about 5,000 hospitals from 2003 to 2005, pressure ulcers had one of the highest occurrence rates, along with failure to rescue and postoperative respiratory failure.3 Given the aging population, increasingly fragmented care, and nursing shortage, the incidence of pressure ulcers will most likely continue to rise.
Although the prevention of pressure ulcers is a multidisciplinary responsibility, nurses play a major role. In 1992, the U.S. Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research) published clinical practice guidelines on preventing pressure ulcers.8 Much of the evidence on preventing pressure ulcers was based on Level 3 evidence, expert opinion, and panel consensus, yet it served as a foundation for providing care. Although the AHRQ document was published 15 years ago, it still serves as the foundation for providing preventive pressure ulcer care and a model for other pressure ulcer guidelines developed afterward. Nurses are encouraged to review these comprehensive guidelines. The document identifies specific processes (e.g., risk assessment, skin care, mechanical loading, patient and staff education, etc.) that, when implemented, could reduce pressure ulcer development, and the literature suggests that following these specific processes of pressure ulcer care will reduce the incidence of ulcers. Research also suggests that when the health care providers are functioning as a team, the incidence rates of pressure ulcers can decrease.9 Thus, pressure ulcers and their prevention should be considered a patient safety goal.
Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge.14, 15 Most often, pressure ulcers do not cause death; rather the pressure ulcer develops after a sequential decline in health status. Thus, the development of pressure ulcers can be a predictor of mortality. Studies further suggested that the development of skin breakdown postsurgery can lead elders to have major functional impairment post surgical procedure.
In recent years, several new prediction tools have been developed (FRAGMMENT Score and Schoonhoven Prediction Rule); however, these tools lack sufficient evidence to evaluate their predictive validity.38, 39 Thus, the use of a validated pressure ulcer risk assessment tool like the Braden Scale should be used, given the fair research-based evidence. The U.S. Centers for Medicare and Medicaid Services (CMS) recommends that nurses consider all risk factors independent of the scores obtained on any validated pressure ulcer prediction scales because all factors are not found on any one tool.40
A growing level of evidence suggests that pressure ulcer prevention can be effective in all health care settings. One study examined the efficacy of an intensive pressure ulcer prevention protocol to decrease the incidence of ulcers in a 77-bed long-term care facility.50 The pressure ulcer prevention protocol consisted of preventive interventions stratified on risk level, with implementation of support surfaces and turning/repositioning residents. The sample included 132 residents (69 prior to prevention intervention and 63 after prevention intervention). The 6-month incidence rate of pressure ulcers prior to the intensive prevention intervention was 23 percent. For the 6-months after intensive prevention intervention, the pressure ulcer incidence rate was 5 percent. This study demonstrated that significant reductions in the incidence of pressure ulcers are possible to achieve within a rather short period of time (6 months) when facility-specific intensive prevention interventions are used. A subsequent study by the same researchers was undertaken to evaluate the cost effectiveness of the pressure ulcer prevention protocol after a 3-year period. The implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in pressure ulcer incidence were lost over time. However, clinical results of ulcer treatment improved and treatment costs fell during the 3 years.51
The use of quality improvement models, where systematic processes of care have been implemented have also been shown to reduce overall pressure ulcer incidence. In one study involving 29 nursing homes in three States, representatives of the 29 nursing homes attended a series of workshops, shared best practices, and worked with one-on-one quality improvement mentors over 2 years.53 This study found that six of eight prevention process measures (based on AHRQ prevention guidelines) significantly improved, with percentage differences between baseline and followup ranging from 11.6 percent to 24.5 percent. Another study using similar methods involving 22 nursing homes found 8 out of 12 processes of care significantly improved.7 Moreover, the study found that pressure ulcer incidence rates decreased in the nursing homes. Nursing homes with the greatest improvement in quality indicator scores had significantly lower pressure ulcer incidence rates than the facilities with the least improvement in quality indicator scores (P = 0.03).
Many aspects of managing pressure ulcers are similar to prevention (mechanical loading, support surfaces, and nutrition). Clearly, the health care team has to address the underlying causes (intrinsic and extrinsic) or the pressure ulcer will not close. In 1994, AHRQ published clinical practice guidelines on treating pressure ulcers.75 Much of the evidence related to treating pressure ulcers was based on Level C evidence, requiring one or more of the following: one controlled trial, results of at least two case series/descriptive studies in humans, or expert opinion. Although the AHRQ document was published 13 years ago, it provides the foundation for treating pressure ulcers. The document identified specific indices (e.g., wound assessment, managing tissue load, ulcer care, managing bacterial colonization/infection, etc.). The following section supplements this document.
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