Strategies to Reduce Pressure Ulcers in Hospital Patients

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REDUCING
THE
INCIDENCE
 OF
PRESSURE
ULCERS 
IN
HOSPITAL
PATIENTS
 
Student A
Student B
Student C
Student D
Student E
 
Overview
 
Hospital-acquired pressure ulcers (HAPUs)
 
develop from injury to the skin or underlying
tissue caused by compression of soft tissue (Alderden et al., 2011)
Risk factors 
for developing HAPUs (Alderden et al., 2011)
Increased length of stay
Immobility
Mechanical ventilation
Multiple comorbidities – especially Diabetes and Renal insufficiency
Trauma/surgical patients
Older age
Low body mass index/poor nutritional status
Hypotensive patients on vasopressors
Current clinical screening tools/assessments
Braden scale
 
– tool used to assess risk for HAPU development
4-stage classification system
In 2007, suspected deep tissue injury (SDTI) and "unstageable" were added to this classification system (Alderden et
al., 2011)
 
Significance
 
HAPU prevalence in approximately 
15% of acute patients
 (Roe & Williams, 2014)
Occurrence is on the rise – 
79.6% increase
 in pressure ulcer incidence in 2006, compared to 1993 (IHI,
2011)
Nearly 
60,000 deaths
 reported annually related to HAPU complications (Roe & Williams,
2014)
Negative effects on patients
Increased suffering and discomfort
Increased risk of infection
Increased financial burden
Related to longer hospital stays and possible surgery
Negative effects on health care
Increased hospital stays
Poor patient outcomes
Increased costs
2008 Medicare/Medicaid law does not allow hospital reimbursement for care, services or treatment of stage 3 or 4
HAPUs  (Alderden et al., 2011)
In 2011 – reports estimated 
11 billion dollars
 spent by U.S. on pressure ulcer treatment (Roe & Williams, 2014)
 
Quality and Safety Education for Nurses (QSEN) Competencies
 
The QSEN framework outlines six core competencies that aim to achieve quality and
safety in nursing practice
1.
Patient-centered care
2.
Teamwork and collaboration
3.
Evidence-based Practice
4.
Quality Improvement
5.
Informatics
 
 
QSEN Competencies related to Pressure Ulcer Reduction
 
Patient-Centered Care
 
Educate patients on the risk for pressure
ulcers
Encourage patients to maintain activity as
tolerated
Active or passive ROM, ambulating with assistance,
etc.
Individualize repositioning plan
The 2-hour rotation rule may be too often or too
infrequent depending on the patient's condition
Observe sides/positions patient favors to determine
area at greatest risk
Manage factors that impede HAPU
prevention
Pain
Poor nutritional intake
 
Providing compassionate
care to patients in which
they are the focus and
partners in their health
care
 
Evidence-Based Practice
 
Hospitals and their health care teams should stay
up-to-date on best evidence-based practices
Focus on prevention and early recognition of HAPUs
Educate nurses on proper use of the Braden Scale to
increase interrater reliability (Roe & Williams, 2014)
Teach and implement the 
six essential elements
 to
preventing pressure ulcers (IHI, 2011)
Perform pressure ulcer admission assessment
Reassess daily, or more often as needed
Inspect skin daily
Manage moisture on skin
Optimize nutrition and hydration
Minimize pressure
 
Integrating the best and
most current evidence with
clinical practice experience
and patient and family
values.
 
Quality Improvement (QI)
 
Measure the incidence of pressure ulcers and
compare to similar units/hospitals
Create time specific and measurable goals aimed at
decreasing the occurrence of pressure ulcers in
patients (IHI, 2011)
 
 
Continually striving to
improve health care
systems by monitoring and
analyzing data trends in
current practices
 
Example: Reduce the incidence of new pressure ulcers in patients in the Surgical Progressive Care
Unit by 50% over the next month
Implement system changes on a small scale first until data measures prove
significant improvement
Consider the perspective of the entire health care team when implementing QI
changes – including nurses, doctors, physical therapy, nursing students, etc.
The focus of changing processes of care should always remain on the patient and
their family
 
 
 
Review of Literature
 
Studies reveal that the inadequate use of preventative measures to avoid the
development of pressure ulcers is a major problem in the hospital setting
.
Preventive strategies were used in only 66% of the patients who acquired a pressure ulcer during their
hospitalization and in only 60% of the patients with existing pressure ulcers 
(
Wann-Hansson et al.,
2008).
QSEN competency literature highlights the importance of education in patient safety
awareness in order to have better outcomes for patients in the healthcare setting
(Chenot & Daniel, 2010).
Wann-Hansson et al. (2008) found that an increased focus needs to be placed on
nurse training in the identification of the patients at risk for developing pressure ulcers
in order for appropriate preventative measures to be implemented as soon as
possible.
This aligns with the importance QSEN places on the awareness of patient safety in order to improve
their quality of care
 
 
 
Review of Literature
 
Patients in an intensive care unit (ICU) are particularly prone to developing pressure
sores, caused by severe illness and being immobile for long periods (Boyle & Green,
2001).
A study on pressure ulcer incidence in ICUs found that nurses were motivated to take
precautions based on the visible damage due to pressure more so than by the
presence of specific risk factors (Boyle & Green, 2001).
Promotion of evidenced based practice through consistent education and training of
nurses is key to long term implementation of pressure ulcer prevention guidelines
(Beal & Smith, 2016).
The use of risk measurement tools contributed to a significant decrease in prevalence of hospital
acquired pressure ulcers from 7.8% in 2005 to 1.4% in 2014 (Beal & Smith, 2016).
Pressure ulcer prevention measures used in this study included: patient assessment including the
Braden score, management of excess skin moisture, optimization of patient nutrition, skin hydration,
and pressure minimization (Beal & Smith, 2016).
 
 
Case Study – Assess, Assess, Assess!
 
I remember learning about pressure ulcers during my first few weeks of
nursing school and wondering how often I would actually encounter
them. I realized just how common they were when I began my long-term
care clinical. So many people had them! I had seen several stage 4
pressure ulcers reaching down to the bone. I was shocked at how
prevalent they were at the facility. It was then that I truly realized the
harmful effects of not rotating your patients or performing simple skin
assessments every shift.
 
Case Study
 
Fast-forward to Adult II clinical this spring, when I was on a cardiac PCU
with a patient in her sixties. Throughout my nursing school experience,
the importance of properly assessing your patients had been drilled
into our brains over and over again. We were constantly practicing our
assessment skills in the hospital and learning how to address the
specific needs of a variety of patients. This patient of mine presented
with multiple risk factors for pressure ulcers, including an increased
length of stay, immobility, and diabetes. She was also incontinent and
did not speak English. Therefore, communication was difficult. Her sons
came to visit every day and were a tremendous help when it came to
feeding their mother, cleaning her, and changing her bedding. They
were incredibly attentive and understood the needs of their mother.
 
Case Study
 
I cared for this patient twice, both days a week apart. While caring for
my patient on the second day, I realized she needed her briefs
changed. She was an overweight woman so I asked one of my
classmates to assist me. This was a perfect opportunity to perform a
good skin assessment on my patient. We removed the briefs, cleaned
up the patient, and we then rolled her over so that I could assess her
and change her into some new briefs. To my surprise, I noticed the
beginning stages of a pressure ulcer. I was surprised because it was not
there a week prior when I had last seen the patient. I knew that the last
time I worked with her we were applying barrier cream to protect her
skin. I informed my nurse of the situation and we applied an AQUACEL
foam dressing.
 
Case Study
 
My nurse was unaware of the ulcer and I began to wonder if previous nurses
had been performing a full skin assessment on this patient. The nurse that I
was following that day left it up to the patient’s sons to clean the patient and
change her briefs. Maybe other nurses did the same, missing out on an
opportunity to assess the patient’s skin in areas that are not easily seen. The
patient’s sons were upset about the pressure ulcer, but I was glad that I caught
it when I did. I made sure to rotate the patient every couple of hours, using
pillows to relieve pressure. Also, although the patient was in bed most of the
time, she was sometimes able to stand and walk to the bathroom using both a
walker and the assistance of another person - usually one of her sons. I
encouraged them to get her sitting up in the chair as well. Without proper
assessments and attention to detail, pressure ulcers can be easily missed.
Since that day, I have been even more cautious than before and never forget
to take preventative measures to ensure that my patients are protected from
pressure ulcers.
undefined
 
NURSING IMPLICATIONS
 
On Practice, Education and Research
 
Practice
 
The most current nursing practice for this concern include risk assessments,
appropriate monitoring, and tailoring interventions based off of risk
Risk Assessments:
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Interventions:
Turn the patient on a regular schedule
Help the patient be as active as possible
Protect the patient’s heels
Use pressure-redistribution surfaces
Manage moisture, nutrition, friction, and shear
Advance to a higher level of risk if other major risk factors are present
 
 
Education
 
Proper education for the clinical staff on how to prevent pressure ulcers in the
hospitalized client includes things such as:
Proper nutrition
Skin care
Use of pressure reducing devices
Decreasing mechanical load (friction)
Increasing the clients mobility
Consistent and frequent repositioning
Education on management of existing pressure ulcers is also imperative to prevent
further staging. Some important pieces of management include:
Cleansing: cleaned with a nontoxic solution
Assessment/Staging: stages according to the National Pressure Ulcer Advisory Panel include deep tissue
injury, I, II, III, IV and unstageable
Debridement: removal of necrotic tissue
Proper wound dressings
Nutrition: includes monitoring glucose levels in diabetic patients
Pain Management
 
Research
 
Priorities for further study
:
 
There is significant literature on pressure ulcer prevention methods but fewer
studies have been conducted on the most effective way to implement evidenced
based practice in hospitals and how to maintain those practices.
Further research is needed on education and training programs for nurses on
prevention of hospital acquired pressure ulcers, especially training geared towards
graduate nurses and new hires.
There is a gap in literature on prevalence and reduction strategies of pressure
injuries occurring in the residential care setting, and how this contributes to
subsequent hospitalizations and increased health care costs
.
Depending on patient capability to participate in their own care, further research is
needed to determine if patient education provided by nurses on pressure ulcers is
a successful prevention strategy.
 
 
 
References
 
Alderden, J., Whitney, J. D., Taylor, S. M., & Zaratkiewicz, S. (2011). Risk Profile Characteristics Associated With Outcomes
of Hospital-Acquired Pressure Ulcers: A Retrospective Review. 
Critical Care Nurse
31
(4), 30-43. doi:10.4037/ccn2011806
Beal, M. E., & Smith, K. (2016). Inpatient Pressure Ulcer Prevalence in an Acute Care Hospital Using Evidence-Based
Practice. 
Worldviews On Evidence-Based Nursing
13
(2), 112-117. doi:10.1111/wvn.12145
Boyle, M., & Green, M. (2001). Pressure sores in intensive care: Defining their incidence and associated factors and
assessing the utility of two pressure sore risk assessment tools. 
Australian Critical Care
, 14(1), 24-30.
Chenot, T.M., & Daniel, L.G. (2010). Frameworks for patient safety in the nursing curriculum. 
Journal of Nursing Education,
49(10), 559-568. doi:10.3928/01484834-20100730-02
Institute for Healthcare Improvement. (2011). 
How-to guide: prevent pressure ulcers
. Retrieved
from www.ihi.org/resources/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx
Lyder, C. H., & Ayello, E. A. (n.d.). Pressure Ulcers: A Patient Safety Issue. Retrieved July 10, 2017, from
https://www.ncbi.nlm.nih.gov/books/NBK2650/
Roe, E., & Williams, D. L. (2014). Using Evidence-Based Practice to Prevent Hospital-Acquired Pressure Ulcers and
Promote Wound Healing. 
American Journal Of Nursing
114
(8), 61-65. doi:10.1097/01.NAJ.0000453050.31618.ec
Wann-Hansson, C., Hagell, P., & Willman, A. (2008). Risk factors and prevention among patients with hospital-acquired and
pre-existing pressure ulcers in an acute care hospital. 
Journal Of Clinical Nursing
17
(13), 1718-1727. doi:10.1111/j.1365-
2702.2008.02286.x
What is the Braden Scale? (2012, December 07). Retrieved July 10, 2017, from http://www.woundrounds.com/wound-care-
technologies/what-is-the-braden-scale/
 
 
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Hospital-acquired pressure ulcers (HAPUs) are a significant issue affecting patient outcomes and healthcare costs. Factors contributing to HAPUs include immobility, comorbidities, and older age. Implementing patient-centered care, evidence-based practices, and quality improvement strategies, as outlined in the QSEN framework, can help in reducing the incidence of pressure ulcers. Educating patients about risk factors, encouraging activity, and individualizing repositioning plans are crucial steps in prevention.


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  1. REDUCING THE INCIDENCE OF PRESSURE ULCERS IN HOSPITAL PATIENTS Student A Student B Student C Student D Student E

  2. Overview Hospital Hospital- -acquired pressure ulcers (HAPUs) acquired pressure ulcers (HAPUs) develop from injury to the skin or underlying tissue caused by compression of soft tissue (Alderden et al., 2011) Risk factors Risk factors for developing HAPUs (Alderden et al., 2011) Increased length of stay Immobility Mechanical ventilation Multiple comorbidities especially Diabetes and Renal insufficiency Trauma/surgical patients Older age Low body mass index/poor nutritional status Hypotensive patients on vasopressors Current clinical screening tools/assessments Braden scale Braden scale tool used to assess risk for HAPU development 4 4- -stage classification system stage classification system In 2007, suspected deep tissue injury (SDTI) and "unstageable" were added to this classification system (Alderden et al., 2011)

  3. Significance HAPU prevalence in approximately 15% of acute patients Occurrence is on the rise 79.6% increase 79.6% increase in pressure ulcer incidence in 2006, compared to 1993 (IHI, 2011) 15% of acute patients (Roe & Williams, 2014) Nearly 60,000 deaths 60,000 deaths reported annually related to HAPU complications (Roe & Williams, 2014) Negative effects on patients Negative effects on patients Increased suffering and discomfort Increased risk of infection Increased financial burden Related to longer hospital stays and possible surgery Negative effects on health care Negative effects on health care Increased hospital stays Poor patient outcomes Increased costs 2008 Medicare/Medicaid law does not allow hospital reimbursement for care, services or treatment of stage 3 or 4 HAPUs (Alderden et al., 2011) In 2011 reports estimated 11 billion dollars 11 billion dollars spent by U.S. on pressure ulcer treatment (Roe & Williams, 2014)

  4. Quality and Safety Education for Nurses (QSEN) Competencies The QSEN framework outlines six core competencies that aim to achieve quality and safety in nursing practice 1. Patient-centered care 2. Teamwork and collaboration 3. Evidence-based Practice 4. Quality Improvement 5. Informatics QSEN Competencies related to Pressure Ulcer Reduction QSEN Competencies related to Pressure Ulcer Reduction Patient- Centered Care Evidence- Based Practice Quality Improvement

  5. Patient-Centered Care Providing compassionate care to patients in which they are the focus and partners in their health care Educate patients on the risk for pressure ulcers Encourage patients to maintain activity as tolerated Active or passive ROM, ambulating with assistance, etc. Individualize repositioning plan The 2-hour rotation rule may be too often or too infrequent depending on the patient's condition Observe sides/positions patient favors to determine area at greatest risk Manage factors that impede HAPU prevention Pain Poor nutritional intake

  6. Evidence-Based Practice Integrating the best and most current evidence with clinical practice experience and patient and family values. Hospitals and their health care teams should stay up-to-date on best evidence-based practices Focus on prevention and early recognition of HAPUs Educate nurses on proper use of the Braden Scale to increase interrater reliability (Roe & Williams, 2014) Teach and implement the six essential elements preventing pressure ulcers (IHI, 2011) Perform pressure ulcer admission assessment Reassess daily, or more often as needed Inspect skin daily Manage moisture on skin Optimize nutrition and hydration Minimize pressure six essential elements to

  7. Quality Improvement (QI) Continually striving to improve health care systems by monitoring and analyzing data trends in current practices Measure the incidence of pressure ulcers and compare to similar units/hospitals Create time specific and measurable goals aimed at decreasing the occurrence of pressure ulcers in patients (IHI, 2011) Example: Reduce the incidence of new pressure ulcers in patients in the Surgical Progressive Care Unit by 50% over the next month Implement system changes on a small scale first until data measures prove significant improvement Consider the perspective of the entire health care team when implementing QI changes including nurses, doctors, physical therapy, nursing students, etc. The focus of changing processes of care should always remain on the patient and their family

  8. Review of Literature Studies reveal that the inadequate use of preventative measures to avoid the development of pressure ulcers is a major problem in the hospital setting. Preventive strategies were used in only 66% of the patients who acquired a pressure ulcer during their hospitalization and in only 60% of the patients with existing pressure ulcers (Wann-Hansson et al., 2008). QSEN competency literature highlights the importance of education in patient safety awareness in order to have better outcomes for patients in the healthcare setting (Chenot & Daniel, 2010). Wann-Hansson et al. (2008) found that an increased focus needs to be placed on nurse training in the identification of the patients at risk for developing pressure ulcers in order for appropriate preventative measures to be implemented as soon as possible. This aligns with the importance QSEN places on the awareness of patient safety in order to improve their quality of care

  9. Review of Literature Patients in an intensive care unit (ICU) are particularly prone to developing pressure sores, caused by severe illness and being immobile for long periods (Boyle & Green, 2001). A study on pressure ulcer incidence in ICUs found that nurses were motivated to take precautions based on the visible damage due to pressure more so than by the presence of specific risk factors (Boyle & Green, 2001). Promotion of evidenced based practice through consistent education and training of nurses is key to long term implementation of pressure ulcer prevention guidelines (Beal & Smith, 2016). The use of risk measurement tools contributed to a significant decrease in prevalence of hospital acquired pressure ulcers from 7.8% in 2005 to 1.4% in 2014 (Beal & Smith, 2016). Pressure ulcer prevention measures used in this study included: patient assessment including the Braden score, management of excess skin moisture, optimization of patient nutrition, skin hydration, and pressure minimization (Beal & Smith, 2016).

  10. Case Study Assess, Assess, Assess! I remember learning about pressure ulcers during my first few weeks of nursing school and wondering how often I would actually encounter them. I realized just how common they were when I began my long-term care clinical. So many people had them! I had seen several stage 4 pressure ulcers reaching down to the bone. I was shocked at how prevalent they were at the facility. It was then that I truly realized the harmful effects of not rotating your patients or performing simple skin assessments every shift.

  11. Case Study Fast-forward to Adult II clinical this spring, when I was on a cardiac PCU with a patient in her sixties. Throughout my nursing school experience, the importance of properly assessing your patients had been drilled into our brains over and over again. We were constantly practicing our assessment skills in the hospital and learning how to address the specific needs of a variety of patients. This patient of mine presented with multiple risk factors for pressure ulcers, including an increased length of stay, immobility, and diabetes. She was also incontinent and did not speak English. Therefore, communication was difficult. Her sons came to visit every day and were a tremendous help when it came to feeding their mother, cleaning her, and changing her bedding. They were incredibly attentive and understood the needs of their mother.

  12. Case Study I cared for this patient twice, both days a week apart. While caring for my patient on the second day, I realized she needed her briefs changed. She was an overweight woman so I asked one of my classmates to assist me. This was a perfect opportunity to perform a good skin assessment on my patient. We removed the briefs, cleaned up the patient, and we then rolled her over so that I could assess her and change her into some new briefs. To my surprise, I noticed the beginning stages of a pressure ulcer. I was surprised because it was not there a week prior when I had last seen the patient. I knew that the last time I worked with her we were applying barrier cream to protect her skin. I informed my nurse of the situation and we applied an AQUACEL foam dressing.

  13. Case Study My nurse was unaware of the ulcer and I began to wonder if previous nurses had been performing a full skin assessment on this patient. The nurse that I was following that day left it up to the patient s sons to clean the patient and change her briefs. Maybe other nurses did the same, missing out on an opportunity to assess the patient s skin in areas that are not easily seen. The patient s sons were upset about the pressure ulcer, but I was glad that I caught it when I did. I made sure to rotate the patient every couple of hours, using pillows to relieve pressure. Also, although the patient was in bed most of the time, she was sometimes able to stand and walk to the bathroom using both a walker and the assistance of another person - usually one of her sons. I encouraged them to get her sitting up in the chair as well. Without proper assessments and attention to detail, pressure ulcers can be easily missed. Since that day, I have been even more cautious than before and never forget to take preventative measures to ensure that my patients are protected from pressure ulcers.

  14. NURSING IMPLICATIONS On Practice, Education and Research

  15. Practice The most current nursing practice for this concern include risk assessments, appropriate monitoring, and tailoring interventions based off of risk Risk Assessments: Braden Scale- consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk. Norton Scale- includes 5 subcategories: physical: condition, mental condition, activity, mobility, and incontinence. The total score ranges from 5 (high risk) to 20 (low risk). Interventions: Turn the patient on a regular schedule Help the patient be as active as possible Protect the patient s heels Use pressure-redistribution surfaces Manage moisture, nutrition, friction, and shear Advance to a higher level of risk if other major risk factors are present

  16. Education Proper education for the clinical staff on how to prevent pressure ulcers in the hospitalized client includes things such as: Proper nutrition Skin care Use of pressure reducing devices Decreasing mechanical load (friction) Increasing the clients mobility Consistent and frequent repositioning Education on management of existing pressure ulcers is also imperative to prevent further staging. Some important pieces of management include: Cleansing: cleaned with a nontoxic solution Assessment/Staging: stages according to the National Pressure Ulcer Advisory Panel include deep tissue injury, I, II, III, IV and unstageable Debridement: removal of necrotic tissue Proper wound dressings Nutrition: includes monitoring glucose levels in diabetic patients Pain Management

  17. Research Priorities for further study: There is significant literature on pressure ulcer prevention methods but fewer studies have been conducted on the most effective way to implement evidenced based practice in hospitals and how to maintain those practices. Further research is needed on education and training programs for nurses on prevention of hospital acquired pressure ulcers, especially training geared towards graduate nurses and new hires. There is a gap in literature on prevalence and reduction strategies of pressure injuries occurring in the residential care setting, and how this contributes to subsequent hospitalizations and increased health care costs. Depending on patient capability to participate in their own care, further research is needed to determine if patient education provided by nurses on pressure ulcers is a successful prevention strategy.

  18. References Alderden, J., Whitney, J. D., Taylor, S. M., & Zaratkiewicz, S. (2011). Risk Profile Characteristics Associated With Outcomes of Hospital-Acquired Pressure Ulcers: A Retrospective Review. Critical Care Nurse, 31(4), 30-43. doi:10.4037/ccn2011806 Beal, M. E., & Smith, K. (2016). Inpatient Pressure Ulcer Prevalence in an Acute Care Hospital Using Evidence-Based Practice. Worldviews On Evidence-Based Nursing, 13(2), 112-117. doi:10.1111/wvn.12145 Boyle, M., & Green, M. (2001). Pressure sores in intensive care: Defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools. Australian Critical Care, 14(1), 24-30. Chenot, T.M., & Daniel, L.G. (2010). Frameworks for patient safety in the nursing curriculum. Journal of Nursing Education, 49(10), 559-568. doi:10.3928/01484834-20100730-02 Institute for Healthcare Improvement. (2011). How-to guide: prevent pressure ulcers. Retrieved from www.ihi.org/resources/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx Lyder, C. H., & Ayello, E. A. (n.d.). Pressure Ulcers: A Patient Safety Issue. Retrieved July 10, 2017, from https://www.ncbi.nlm.nih.gov/books/NBK2650/ Roe, E., & Williams, D. L. (2014). Using Evidence-Based Practice to Prevent Hospital-Acquired Pressure Ulcers and Promote Wound Healing. American Journal Of Nursing, 114(8), 61-65. doi:10.1097/01.NAJ.0000453050.31618.ec Wann-Hansson, C., Hagell, P., & Willman, A. (2008). Risk factors and prevention among patients with hospital-acquired and pre-existing pressure ulcers in an acute care hospital. Journal Of Clinical Nursing, 17(13), 1718-1727. doi:10.1111/j.1365- 2702.2008.02286.x What is the Braden Scale? (2012, December 07). Retrieved July 10, 2017, from http://www.woundrounds.com/wound-care- technologies/what-is-the-braden-scale/

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