NURS FPX 6085 Assessment 6 Final Project Submission
NURS FPX 6085 Assessment 6 Final Project Submission
Abstract
The capstone project addresses the critical need for timely and accurate pressure injury risk documentation within 24 hours of admission for adult patients in inpatient medical-surgical units. The evaluation plan utilizes a mixed-methods design measuring quantitative compliance improvements and qualitative staff satisfaction indicators.
Introduction
The capstone project deals with the urgent and highly important practice related to the necessity to record the pressure injury risk within 24 hours of the admission of adult patients in the inpatient medical-surgical unit properly and correctly. The target population, adult patients of the medical-surgical unit, encompasses highly acute levels, mixed acuity levels, and multidisciplinary care, among other challenges, making it extremely difficult to be consistent with documentation standards.
The scenario is a clinical practice in which the nursing and clinical workforce is engaged in patient intake and assessment, so the standardization of processes is mandatory to implement the quality improvement initiatives. The plan of interventions introduces the systematic audit and feedback cycle with education of the entire staff, optimization of the electronic health records, and the usage of automated prompts and checklists, and the active leadership involvement in order to improve the rates of documentation (Li et al., 2021).
The intervention is vital since poor documentation of the risk of pressure injuries leads to preventable nosocomial pressure injuries, soaring health expenditures, including longer-than-usual hospital stays, and non-compliance with the standards of the Centers of Medicare and Medicaid Services (Roderman et al., 2024). The implementation plan covers a phased approach of 12 weeks with the inclusion of stakeholder involvement, in-depth training of staff, integration of the EHR system, and execution of monitoring in the form of weekly audits and feedback sessions twice a week.
The evaluation plan will include a strong mixed-methods approach to assess the quantitative results, including documentation compliance rates and hospital-acquired pressure injury incidence, as well as qualitative data, including staff satisfaction surveys and focus groups to evaluate the effectiveness, usability, and long-term sustainability of interventions.
Need Statement
The need that will be addressed by the project is the quality improvement and patient safety issue associated with making the documentation of the risk of a pressure injury in a time-sensitive manner of 24 hours after admission. It is important to address the need as pressure injuries are a significant preventable complication of patients hospitalized, with an increased time in the inpatient facility, higher morbidity, and elevated healthcare expenses.
NURS FPX 6085 Assessment 6
Notable evidence supporting the urgency consists of the findings provided by Rose et al. (2022) showing that nurses perform documentation on manual repositioning sufficiently only in 31.01% of cases, which attests to the need to improve current practices. Also, when not updated consistently, the traditional assessment tools cannot detect any changes in the patient clinically, which makes it impossible to provide the necessary interventions and increases the risk of pressure injuries (Tomas & Mandume, 2024). Documentation gaps undermine continuity of care, and it does not reap benefits in risk-stratifying vulnerable profiling of patient populations.
Population and Setting
The medical surgical unit is a high-patient-turnover environment with multidisciplinary care teams, and market demand-driven, fast-paced work that may potentially undermine documentation consistency. The environment is suitable to have a structured audit and feedback process as it suits the standard of activity and access to unit-based educators and quality improvement personnel to provide training and follow-up. The infrastructure in place in the environment makes it appropriate to scale up effective interventions hospital-wide.
Intervention Overview
The proposed intervention implements a structured audit and feedback process combined with staff education, electronic health record optimization, and leadership engagement to enhance pressure injury risk documentation compliance within 24 hours of admission (Picoito et al., 2025).
The multi-component approach is well-suited to the adult medical-surgery demographic due to its ability to cover the breadth of risk factors the patient population presents and the complexity of clinical demands that the patient population pronounces upon the nursing staff’s ability to provide comprehensive assessments.
The evidence-based intervention can be easily implemented in the medical-surgical unit since an available infrastructure, such as the unit-based educators, quality improvement specialists, or EHR systems, will ensure the successful integration of the proposed intervention in the unit.
The structured audit element fulfills this identified need directly, as the component monitors the documentation lapses systematically, whereas the feedback is used to create accountability and to ensure the continuous improvement of the quality of the work performed by the nursing staff. Moreover, automated EHR prompts and educational courses create a habit of performing risk assessments in a timely and accurate way and ultimately decrease the number of potential hospital-acquired pressure injuries that can be avoided and positively affect patient safety outcomes at large (Rose et al., 2022).
Potential Interprofessional Alternatives
The strategy is also applicable to the adult medical-surgical population and renders a full risk assessment based on a diverse clinical understanding. Nevertheless, the alternative can be less applicable in the high-tempo medical-surgical environment under time-pressured circumstances and on an inter-professional basis. Though handling the documentation requirement via shared supervision it can be less sustainable compared to the systematic audit-and-feedback intervention.
Outcome
The primary outcome is to achieve a measurable increase in pressure injury risk documentation compliance rates within 24 hours of admission for adult patients in the medical-surgical unit over the 12-week intervention period.
Knowledge Gaps and Areas of Uncertainty
Several knowledge gaps exist regarding structured audit and feedback implementation for pressure injury documentation. Limited data exists on long-term sustainability beyond initial implementation periods, particularly in high-turnover medical-surgical environments.
Time Frame
The intervention development phase requires approximately 4 weeks, including stakeholder meetings, developing audit tools and training materials, and EHR system integration for tracking documentation. The timeframe is realistic given the availability of unit-based educators and quality improvement staff to support planning activities.
NURS FPX 6085 Assessment 6
Literature Review
Current evidence from multiple sources strongly validates the identified need for improved pressure injury risk documentation and supports its appropriateness within the adult medical-surgical population and setting.
References
- https://doi.org/10.1186/s12909-024-06084-9
- https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html
- https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/guide.html
- https://doi.org/10.1016/j.cnur.2022.06.005