Nursing assessment documentation and care of hip fracture patients’ skin

SummaryThe aims of the present study were to describe and compare documented nursing assessment and care of skin in hip fracture patients in two settings. A retrospective review was made of 170 inpatient records from one county hospital (hospital A) and two local hospitals (hospital B), all in one county council in Sweden.In more than half (60%) of the records at arrival and in 78% on discharge a skin assessment was evident. Notes about pressure ulcers were included in 15% of all patient records at arrival and 20% on discharge. The registered nurses in hospital B risk assessed significantly more patients with the Modified Norton Scale compared with hospital A. Patients who were assessed with the Modified Norton Scale received more interventions than patients not assessed. Further, patients with a low Modified Norton Scale score, received interventions to a higher extent and patients with high Modified Norton Scale score received interventions to a minor extent. The most frequent measured interventions were turning schedule, fluid and food intake. The comprehensiveness in the nursing notes was acceptable in only 9% of the patient records. This study highlights the need for continuous audit of patient records with feedback to registered nurses (RNs) in order to follow the quality indicators and national principle for pressure ulcer prevention.