Date of Award

Spring 5-1-2021

Document Type


Degree Name

Doctor of Nursing Practice (DNP)




Susan Butz, DNP

First Committee Member

John Davis, DNP


Pressure Injuries, Hospital Acquired Pressure Injuries, Critical Care, Pressure Injury Prevention

Subject Categories

Medicine and Health Sciences


In a large mid-western hospital, Hospital Acquired Pressure Injury (HAPI) rates are elevated in critical care units. Education sessions, a visual reminder, and skin rounds may increase use and documentation of 5-layer silicone dressings to prevent pressure injuries. The Plan-do-study-act (PDSA) method for quality improvement and Jean Watson’s Theory of Human Caring were utilized as the theoretical framework for the project. The purpose of the project was to reduce the incidence of HAPI in Medical Intensive Care Unit (MICU) II. Project objectives included education on HAPI prevention and documentation, skin rounds, and the addition of a visual documentation cue on the nursing hand-off tool for 30 days.

Pre-implementation chart audits and concurrent chart audits were completed to assess documentation of preventative 5-layer silicone dressings. Pressure injuries were also tracked before, during, and after the project. Audit results indicate an increase in documentation with a visual prompt. Pressure injury rates indicate no change from pre-implementation rates. Complete documentation of preventative measures may result in cost savings by demonstrating injuries are unavoidable despite preventative measures.

Licensing Permission

Copyright, all rights reserved. Fair Use

Fagan_DNP_Poster.pdf (244 kB)

fagan_dnp_441.mp4 (25158 kB)
Video Presentation

Available for download on Wednesday, April 27, 2022