Huruvida planerade åtgärder vid risk för trycksår genomförs eller inte

Sammanfattning: Background: Previous studies have shown that pressure ulcers are common in hospitalized patients. These wounds give rise to suffering and lower quality of life in the affected patients. Objective: To identify the shortcomings in documentation and risk assessment. Method: The study was descriptive-explorative. A journal review was made on records documented during October, November and December 2017. Data was collected in an excel document and was described descriptively. Results: Of the 50 journals that were included, three (6%) pressure ulcers were on entry. Less than half of the records (46%) had notes that actions planned against pressure ulcers were begun or implemented. None of the 42 journals with measures documented had evaluation of set goals and actions. 37 (74%) had a risk assessment made with Norton. 42 records (84%) had preventions and eight (16%) had none at all. 32 (64%) had both preventions and a full Norton assessment. Three records (6%) lacked both preventions and Norton assessment. In four (6%) of the records, pressure ulcers encountered during the care period. One of these records had a Norton assessment. All of these had preventions planned. Conclusion: There is a lack of whether or not actions taken at risk of pressure ulcers are implemented. It is unclear whether or not initiated measures have been initiated. Most often, a complete risk assessment is also lacking as a basis for being able to insert relevant measures and see the importance of their implementation. There is an increased need of education regarding documentation of pressure ulcer. Keywords: pressure ulcer, risk, prevention & control, nursing records, documentation