1. Jackson, Kathryn RN, CNS, CRRN
  2. McCubbin, Lena MS, RN, CWOCN, CNS

Article Content


This inquiry explores the underutilization of evidence-based skin care standing orders and attempts to address target etiologies to achieve the expected outcome of immediate, consistent treatment by the bedside RN.



Over 1 million people develop pressure ulcers yearly with treatment costing the United States healthcare system approximately $2.2 to $3.6 billion (Ratliff & Bryant, 2003). Pressure ulcer prevalence is currently estimated at 3.5%-29.5% in hospitals on any given day (Hiser et al., 2006). Pressure ulcers cause pain and suffering and can increase length of stay (Brem & Lyder, 2004). Many pressure ulcers can be prevented and treated utilizing nursing measures.



Two clinical nurse specialists (CNS) developed a set of evidence-based nursing skin care standing orders to allow the registered nurse (RN) to treat nondisease-based skin problems resulting from pressure, friction, shear, and moisture. The expected outcome of a decrease in the amount of time from onset of the problem to treatment of the problem did not occur.



A survey containing 8 questions was given to a convenience sample of 20 RNs. The questions were designed to target the correct etiologies. The results revealed a perceived presence of expertise in the standing orders not seen in nursing practice. The survey results revealed multiple etiologies: (1) RNs are not aware of standing orders. (2) RNs do not know how or what to write for standing orders. (3) RNs do not have confidence in deciding on dressings, distinguishing between pressure ulcers and nonpressure ulcers and accurately staging pressure ulcers.



The expected outcome is to empower the bedside RN to diagnose and treat the skin care conditions listed on the standing orders. An additional outcome is to positively influence pressure ulcer rates by reducing delay in treatment time and promoting consistent prevention and treatment. Unexpected outcomes were designation of unit-based skin care champions, training for the champions, designation of the skin care standing orders into a nursing order set, and development of pressure ulcer bundle indicators.



Continuous mentoring must exist in terms of assisting in problem solving, analyzing the effectiveness of the orders, and examining the salience of the problem to be successful in achieving desired outcomes.


Implications for Practice:

Prevention and treatment of stage I and II pressure ulcers are included in the skin care standing orders. Failure to utilize these orders could easily impact pressure ulcer rates. The mean cost per hospital admission for a patient who develops a pressure ulcer is $37, 288 (Ratliff and Bryant, 2003). The benefit of having expert RNs at the bedside trained and empowered to intervene at the point of care is to prevent costly, negative outcomes for both the patient and the organization.