Date of Graduation

Fall 12-17-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Dr. Nicole Beamish


Pressure injuries (PI) affect approximately 1-3 million people in the United States annually, and amount to 3-11 billion dollars in yearly healthcare costs (Mondragon et al., 2021; Padula & Delarmente, 2019). In veterans who seek care, especially the elderly (>65 y/o), pressure injuries are particularly devastating because they increase hospital costs and lengthen stays (Stroupe et al., 2011). In light of these statistics, the aim of this project was to decrease PI rates in veteran patients through the implementation of evidence-based practice. This project was conducted on a medical/surgical telemetry unit with 18 beds at a Northern California hospital that serves veterans. The tools used to analyze the microsystem and guide this quality improvement project included a SWOT analysis, process map, Root cause analysis (RCA), and PICOT question. After collecting microsystem data, we recognized unclear PI prevention methods and an absence of repositioning documentation. This represented a gap in care that needed to be addressed, and to solve this we conducted a literature review that turned up the SSKIN PI prevention bundle. This bundle demonstrated promising results in reducing PI’s, but due to constraints, we were not able to implement the intervention. Consequently, the results of the study were based on SSKIN bundle research. Using this as a template we expect the SSKIN bundle to have a positive effect on the PI rates on the unit. This project provided great insight into staff knowledge about pressure injuries, and will serve as a framework for future improvement projects on the unit.