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Nursing Leadership and Change Agent


Just like other professions, the nursing field has gone through numerous changes that the nurses should follow to provide exemplary work to their clients. Although the primary aim of nurse to provide adequate medical care for the patients to improve their conditions within the shortest time possible has not changed, procedures and strategies in the medical institutions are changing to accommodate all nurses in the facility. Nursing leaders are charged with the responsibility to ensure that all nurses are motivated and committed to serving the patients diligently. Actually, leaders who do not engage other nurses in decision-making fail in the quest to meet the facility's objectives. At the same time, the failure of nurse leaders to motivate other staff members leads to reduced patient satisfaction. In the end, this affects the organizational performance since the nurses are not committed to their tasks. An ideal nursing leader should have the skills to enact changes with the changing work environment to improve service delivery and motivate employees at all time (Honkavuo & Lindstro, 2014). In essence, this paper analyzes the essential leadership qualities that would lead to improved working conditions for all nurse and other staff members.

Characteristics of a Nurse Leader

            One of the primary leadership skills of a nurse is communication strategies that encourage other members of staff to improve the interpersonal relationship. A good leader should always ensure that their messages reach the intended audience and provide clarifications when misunderstandings arise. On the same note, leaders should not disclose personal information about other workers because it adversely affects the morale of the employees. Quality nurse leaders should understand that the profession poses challenges that affect the workers’ mental health (Honkavuo & Lindstro, 2014).

According to Honkavuo & Lindstro (2014), nurses experience difficult situations, which lead to suffering. As a result, nurse leaders need the qualities to alleviate suffering from their workers in order to ensure that the service delivery is excellent. A good leader should ensure that the organization has a positive culture because this increases the level of concentration in the workers. At the same time, nurses should learn how to make independent decisions that best suit the prevailing circumstances. For instance, emergency cases cannot wait for the nurse leader to provide the best procedure to apply. Consequently, it is upon the leader to let nurses make ethical decisions without any repercussions.

            Anonson et al (2014) note that, “Nursing leadership is a critical factor in the effective functioning of nursing units, high-quality patient care, retention of nurses and organizational effectiveness" (p. 128). Notably, teamwork is crucial to service delivery in the nursing profession. However, ineffective leaders cannot create the necessary environment for nurses to work in groups to improve the decisions making competencies. The leader should encourage the staff to seek clarifications from their peers to choose the best procedures that uplift the lives of the patients within real time. Such conditions reduce employee turnover, which affects service delivery since the job market does not provide enough replacements for nurses who quit their jobs. The responsibility of the leaders is to ensure that employees are competitively rewarded to dissuade them from joining the competition. Fundamentally, for-profit health care institutions, nurse leaders should not allow their workers to engage in monotonous duties that lead to boredom because it increases the chances of stress in the workplace (Anonson et al, 2014). The field of nursing has one of the highest levels of work-related stress; as such, leaders should not create a situation whereby the junior nurses dislike their work because the situation affects both their physical and mental health.

            Efficient leaders should encourage the virtue of openness. It refers to the ability of the leaders to accept new ideas and incorporate them into their tasks. Leaders who have the trait are curious and more innovative as they search for better ways to perform their duties. In addition, it is the degree of imagination or independence where employees prefer different activities to a strict routine. In addition, conscientiousness, which refers to the leaders’ dependability and higher levels of the organization, is a good trait in nursing leaders. Employees with the trait exhibit self-discipline and act dutifully. In addition, they always aim to achieve their targets while favor planned activities rather than spontaneous actions (Anonson et al, 2014).

On the other hand, extraversion refers to the need to work with others in a bid to meet the organizational objectives. Such leaders seek clarifications from their colleagues while they show positive emotions, sociability, assertiveness, energy, and surgency (Anonson et al, 2014). Moreover, the agreeableness or the propensity to be cooperative and compassionate as opposed to being antagonistic and suspicious towards colleagues provides essential qualities that make leaders better people to work with. Such people show higher levels of trustworthiness and the desire to help others. Lastly, neuroticism or the ability to absorb negative emotions such as vulnerability, depression, anxiety, and anger quickly encourages nurses to seek assistance from the leader. In addition, it is the measure of impulse control and emotional stability. 

Identification of a Current Nurse Leader

            Identification of a good leader is ascertaining that the person has the above-mentioned traits because they are essential to service delivery. Although it is impossible to have a leader with all the basic traits, it is important to look for persons who are ready to learn the modern methods of managing people. Communication plays an integral role in a successful leader; thus, the individual should display excellent communication skills that would create a positive culture I the health facility. Nevertheless, the leader should have self-drive. He or she should not be a person who puts the blame on the staff when things go wrong. In principle, the tendency to blame others affects employees’ motivation because in most cases they fail to act for fear of reprisals. The leader should be ready to work in conjunction with other staff members irrespective of their positions in the institution. In practice, leaders should be ready to defend their staff as long as they act in ethical manner. The outcome of spontaneous decisions should not form the benchmark to evaluate an individual’s performance (Honkavuo & Lindstro, 2014). All nurses should receive equal treatment from the leader to make them feel appreciated by the leadership.

How Your Particular Nurse Leader has Lead or Could Lead Changes in Healthcare

            My leader has excellent communication skills, which he uses to pass any necessary information to the team. In essence, the leader ensures that all the nurses are aware of any looming changes way before they are implemented. The leader has brought numerous changes in the institution because traditionally we were not working in teams because nobody knew the benefits. Nevertheless, the leader encourages every person to work as a group because it helps to make important decisions within a short time. At the same time, interpersonal interactions at the facility have improved and thus conflicts remain in the minimum. I have realized that interpersonal relationships affected my performance since I could spend days in bitterness after a colleague accused me of something that I did not do. The leader organizes breaks where I spend time from the stresses of the wards to freshen up and go back to work as a fresh person. Furthermore, other nurses seem to enjoy the breaks as they engage in chats unrelated to their work.


            In conclusion, it is evident that the nursing profession has undergone tremendous changes where nurse leaders have to perform decisions that were traditionally made by the top leadership in any medical facility. In most nursing facilities, employees work as partners without any clear boundaries between seniors and juniors. Such situations require leaders with exemplary skills who can organize all workers to form a team that improves service delivery. Such leaders should have excellent communication skills that ensure that all the workers are aware of what happens in the offices. Additionally, the nurse should encourage employees to work as teams because this improves satisfaction and motivation. The leaders should appreciate the individual participation of all members of staff to develop decision-making skills in the nurses. In brief, nurse leaders have a crucial role to play to increase patient satisfaction in patients. Such occurrences increase patient loyalty because they trust the nurses to perform a good job and improve the quality of their lives.




Anonson, J., Walker, M.E., Arries, E., Maposa, S., Telford, P. & Berry, L. (2014). “Qualities of exemplary nurse leaders: perspectives of frontline nurses.” Journal of Nursing Management, 22: 127–136. 

Honkavuo, L. & Lindstro, M U. A. (2014). “Nurse leaders’ responsibilities in supporting nurses experiencing difficult situations in clinical nursing.” Journal of Nursing Management 22: 117–126.




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Reducing the Prevalence of Pressure Ulcers in the Elderly






Heel pressure ulcers have become common, perhaps due to the fact that limited research has been carried out on the manner in which they can be prevented or treated. Although they are caused by external pressure on the heel, the treatment varies depending with the stage of infliction. Patients who are at risk include the aged, those suffering from diabetes mellitus, and those with mobility problems, among others. The purpose of this paper is to explore methods of prevention and treatment, including the waffle boot; however, most have not been found to be effective. Repositioning the client remains among the most important factors that need to be considered in reducing and treating pressure ulcers.

Keywords include heel pressure ulcers, mobility, blood, and tissue.



Reducing the Prevalence of Pressure Ulcers in the Elderly


            Pressure ulcers occur when external tissues are exerted with excess pressure, which is not adequately relieved. The tissues that are exerted with pressure are mostly due to bony prominence. It is a common occurrence that pressure ulcers mostly inflicts the heel and the sacrum. The outcome of the pressure ulcers at the heel has some immense consequences, because it is expensive to treat and it is very painful, and mobility of the victim is severely limited. It is imperative to acknowledge that heel ulcers are among the most serious and common lower extremity ulcers and in many instances can result in below the knee amputation among patients suffering from diabetes mellitus (Veves, Giurini & LoGerfo, 2012).

            According to the National Pressure Ulcer Advisory (2007), approximately 19% of patients diagnosed with heel pressure ulcers are not diagnosed with diabetes mellitus, whereas approximately 32% are diagnosed with diabetes mellitus, and the number of people suffering from pressure ulcers continues to rise. The heel pressure ulcers mostly begin in the acute care setting, but the prevalence is higher in the long –term care. As one lives longer, the chances of being infected with heel pressure ulcers. The purpose of this literature review is to answer the question, does use of waffle boot and/or preventative dressings, compared to repositioning, affect the prevalence of pressure ulcers among the elderly adults.

Literature Review

The purpose of this paper is to identify current strategies utilized in the prevention and management of heel pressure ulcers in the elderly.  To that aim, a review of the literature was performed using both Ovid and the Cumulative Index to Nursing and Allied Health Literature (CINAHL).  The following terms were used in the literature search: elderly patients, heel pressure ulcers, prevention, management, treatment, and mobility.  The search was limited to the years 2000 to 2015, and only full-text-articles, or articles available in portable document format (pdf) were included.  The articles were then reviewed for appropriateness to the topic, and for specificity to the emergency department setting.  Eleven articles were identified and are included for discussion in this paper.  The articles have been arbitrarily sorted into categories for discussion in this paper and include factors related to development of pressure ulcers on the heel, prevention and treatment research, implications for nursing, and recommendations.

Factor Related to Development of Pressure Ulcers on the Heels

Anatomy and Physiology

            The calcaneus foot, which is the largest bone in human foot is relatively wide and thus the skin has a large surface area despite the fact it is pointed shape due to the bone prominence, and has little subcutaneous fat cautioning it.  As a result, the pressure from the prominence makes the heel very vulnerable. Graff, Bryant and Beinlich (2000), noted that blood is transported to the heel through the peroneal and the posterior arteries. The heel becomes susceptiblebecause it has a delicate subcutaneous tissue pad with a thickness of 18 mm, while the epidermis and the dermis have a thickness of 0.64 mm, hence making the heel to be at risk of ischemia.

            These mechanical forces result in the occlusion of the blood vessels and tissue ischemia, and that results in death of tissues due to hypoxia. Occlusion is mainly attributed to shear force and the tissue interface pressure.  In addition, there are chances that occlusion can occur when there is shear force and in the absence of interface pressure. The heel vasculature has varying blood pressure depending with the load. When weight is completely loaded on the heel, a higher blood pressure is required to get oxygenated blood to the heel, compared to when there is low pressure on the heel, when it is off loaded using padding and/or pillows. However, Mayrovitz et al. (2002) examined the effect of direct surface load and reduction of flow on incidence of pressure ulcers during the ankle-cuff compression. Despite the fact that flow reduction and baseline flows did not show any difference, hyperemia was more evident when the reduction in flow was as a result of direct heel loading. Therefore, the recovery process after offloading actually contributed to the tissue breakdown.  More so, another study carried out on animals and humans revealed an inverse relationship between the intensity and duration of pressure. Hence a conclusion is reached that when the pressure is high, less duration is need for damage and tissue ischemia to occur (Koziak, 2004).

            It is significant to acknowledge that the sole of the foot lacks skin lubrication; therefore, the skin is vulnerable to damage resulting from friction because it is left dry. As one gets older, the skin gets thinner, and the ability to absorb shock declines with age, and that makes the skin to be left with less potential to resist from destructive forces of load. As one ages, arteriosclerosis and age factors can result in impairment of circulation, and that can also occur to young people who suffer from hypertension or diabetes, or those who smoke. As blood pressure in the capillaries reduces, they, the capillaries, become vulnerable due to external pressure (Kannell & Shurtleff, 2000).

Perfusion Problems

Among those suffering from peripheral arterial occlusive ailment, they have higher chances of being diagnosed with heel pressure ulcers. This is because the blood supply to the area is at the end of arterial plexus from the peroneal and posterior tibia arteries. As the heel area carries the body weight, it is left vulnerable because of the decrease of supply of the arterial blood. Heel pressure ulcers occur frequently on the lateral or the medial surfaces, more so, it has chance of occurring on the posterior and plantar aspects. For those diagnosed with diabetes, it can result from involvement with the peroneal and tibial,rather than the dorsalis pedis, arteries (Creager,  Beckman & Loscalzo, 2013). 


According to the National Pressure Ulcer Advisory (2007), friction is “the resistance to motion in a parallel direction relative to the common boundary of 2 surfaces”.  Friction occurs as part of the skin shifts, while the other remains stationary, and when  that occurs, there is reduced blood supply to the skin, hence a tissue damage occurs. In the presence of friction, the external pressure required to cause tissue damage reduces. In patients, when they become restless, especially those suffering from dementia cannot move in bed due to friction.


According to the National Pressure Ulcer Advisory (p. 2), shear pressure refers to “force per unit exerted parallel to the plane of interest”. Shear strain refers to the deformation or distortion of tissues arising due to shear stress. Shear is mainly affected by three critical factors, that include the quantity of pressure exerted, coefficient of friction occurring because of making contact withsolid surfaces, and degree of the body contact with the support surface. Shear occurs mainly among those who elevate their heads while in bed, and those who sit while sliding down in the chair.


Those who are immobile have a higher chance of being diagnosed with heel pressure ulcers due to their immobility. Thus, 87% of those diagnosed with heel pressure ulcers are those who are not mobile (Beckrich & Aronovitch, 2000). Most of the immobile people, like the inpatients who suffer from fractures, spinal cord injuries, or stroke, have increased chances of suffering from injuries of the skin around the heel. For example, if one suffers a hip fracture, the innervation to the extremity can be impaired, and since one is advised not to move the injured/ fractured leg, the result is increased risk of tissue breakdown on the heel.

Comorbid Risk Factors

            Older adults have increased chances of being diagnosed with heel pressure ulcers. Others who are likely to suffer from the disease include those who are paralyzed, incontinent, debilitated, and those who are suffering from metastatic cancer. Others include patients who are in the intensive care unit (ICU), those on ventilator, and those with diabetes mellitus. All these have similar level of peripheral vascular compromise, which adversely affect blood circulation, which can contribute to neuropathy and deformities on the foot. A study by Krueger (2006) reported that 25% of those suffering from heel pressure ulcers are also diagnosed with peripheral arterial occlusive disease and diabetic neuropathy. Among the major symptoms for people who suffer from heel pressure ulcers and diabetes include ischemic and neuropathic etiologies associated with lower resting perfusion pressures along with higher pressure when loaded. A person with diabetes mellitus is four times like to suffer from heel pressure ulcers than one who does not suffer from diabetes mellitus.

            Neuropathy is defined as the pathological transformations in the peripheral nervous system that are not easily understood; however, it is prevalent among the old adults who suffer from diabetes mellitus. It is common in individuals who have been diagnosed with diabetes mellitus for a period of five to ten years. It impairs sensation and increases the vulnerability to development of pressure ulcers because one is not able to sense and react to pressure changes. He damage occurs in a series of three stages that include loss of sensation, losing the ankle jerk and intrinsic muscles reflex, and the resultant inability to produce oil and absence of sweating. This combination of factors results in the skin losing elasticity and becoming dry (Sussman & Bates-Jensen, 2007).

            Edema limits the ability of blood to flow to the heels. Limited blood flow compromises the transportation of nutrients, oxygen, and the removal of wastes from the body, resulting in excess fluids being retained in the body, thus increasing weight which can cause tissue pressure, and adversely affect the ability of the tissue to tolerate loading weight. This, in turn, can produce heel pressure ulcers that affect the skin integrity full thickness (Cuschieri, 2013).

            A person who has suffered cerebrovascular injury is likely to suffer from heel pressure ulcers due to inability to move legs or due to shear or friction. Those individuals who have been diagnosed with spinal cord injury (SCI) have chances of suffering from neuropathy due to the impairment of the sensory, motor, and autonomic systems. Skin injuries that are neurological can cause metabolic changes that can take up to five hears to stabilize. The changes may include increase in the level of collagen metabolism, abnormal synthesis of collagen, defective reactions by the skin, and declined skin elasticity. Paralysis may result to reducing of the muscle bulk and that may include that over the bony prominences, hence exposing the skin, and that may cause to be susceptible to injuries. Some patients propel themselves in the wheelchairs using their heels, and that increases their risks to heel pressure ulcers (Dennis, Bowen & Cho,2012).

            A study by Black et al. (2007) revealed that among the people who have the highest risk of suffering from heel pressure ulcers are those who have previously suffered from heel pressure ulcers, diabetes mellitus, low serum albumin, poor nutrition, and low Braden scale level. People whose blood circulation has been impaired, those who wear anti-embolus stockings, those with low fluid intake, inadequate sense of temperature or pain and those who smoke, also have high risk factors. More so, patients who undergo surgical procedures lasting for more than one hour are also at risk. Others who have increased chances of being diagnosed with heel pressure ulcers are the patients go through epidural anesthesia/analgesia. This is because this procedure  limits the mobility of the lower extremities, resulting in extended pressure on the heels, and hence losing their protective senses that are responsible for moving the leg as the legs react to increased pressure.

Deep Tissue Injury

            In some instances, heel pressure ulcers may end up developing into deep tissue injury (DTI). According to National Pressure Ulcer Advisory Panel (2007), DTI is a maroon or purple portion of the dermis that is mostly discolored or it may be blister filled containing blood, and it occurs when the delicate tissue, which is under the skin, is damaged as a result of pressure or shear.    Before the occurrence of the deep tissue injury, the injured part may become firm compared with other parts of the skin surrounding it and may be painful and boggy. For the people who are have a dark complexion, it may be complicated to identify the areas that are developing the deep tissue injury. Evolution of the DTI may occur to result to a thin blister covering a wound, them a thin eschar, and sometimes may result to additional layers being exposed. It is a common occurrence for DTI to develop into a stage IV ulcers.

            DTI can appear as a purple or deep red area, have some bruises, or a blister filled with blood. The fluid in the blister is an indication of stage II pressure ulcers, whereas when a blister is filled with blood is a reflection of stage III to IV pressure ulcers. The color of the blister is normally related to the tissue necrosis along with the consequent blood coagulation. Even if the skin undergoes extensive pressure, it cannot lose its viability and can continue to be intact for 14 days even though it is non-viable (Black, 2003).

Heel Pressure Ulcer Prevention and Treatment Research

Many scholars have researched the problem of heel pressure ulcerss in efforts to find a lasting solution. Bots and Apotheker (2004) have studies the manner in which heel pressure ulcers can be prevented. This was using self-adhesivehydro polymer foam for the purpose of dressing. This study revealed that this procedure was only effective in reducing the heel pressure ulcers by only 76.7%. That means the strategy was not quite effective. Another study was carried out on old patients on the impact of shear forces on their heel (Nakagami, et, al, 2006).

In the research, part of the sample was treated by hydrocolloid dressing for prevention of pressure ulcers, while the other was managed using a thin film dressing. The results of the study revealed not differences between the healing of two groups after statistical analysis were carried out; however, statistical differences were noted in regards to the shear forces between the two groups (Ayello & Sibbad, 2012). Further, the results revealed that even though the dressing reduced the shear force, it could not prevent tissue interface pressures, and thus, it was recommended that the dressing could not be employed to elevate the heel for patients who were immobile. The study concluded that the heels needed to be offloaded.

Problem Analysis

            It is imperative to evaluate the products that can employ on patients with morbidity problems arising due to heel pressure ulcers. A device that can reduce heel pressure will end up separating and protecting the ankles, while maintaining heel suspension, and thus prevent the foot drop. Redistributing the pressure will be critical in reducing the interface pressure to be lower than 32 mm Hg. It important to note that, besides the specialty beds and typical dressing, it is important to guarantee that the heel is protected.  A commercial design for elevating the heel is four times more effective than pillows. A 2005 research by Gilcreast, et al, evaluated three devices that were meant to reduce pressure on patients who were vulnerable to heel pressure ulcers. These devices included foot waffle, egg crate and bunny foot. Among those patients who were at risk of getting heel pressure ulcers, 12 of them developed the ailment. However the effectiveness of these devices to prevent heel pressure ulcers among the vulnerable individuals was not significant because the foot waffle, egg crate and bunny boot prevented the ulcers by only 6.6%, 4.6%, and 3.9% respectively.  More so, out of the 41 patients who took part in the research revealed that the heel protector boots and the duoderm are less effective than eggshell foam and foam splints. Among the patients who considered to form the control group, it was found that 22 patients, some whom were under diabetes mellitus medication were not diagnosed with heel pressure ulcers. This is because, as these patients continued with their medication for their respective diseases, they were receiving high level nursing care (Rich, et, al, 2009).

Based on the above research on heel pressure ulcers, it is apparent that the disease continues to haunt the victims because there is not effective medication that has been developed. Despite the disease being discovered long time ago, it appears that the medical researchers have done an insignificant work because it appears that most of the speculated medications and preventative measures are not effective.


            Most of the medications used for treatment of heel pressure ulcers are similar to the ones used for prevention of the ailment. Before the health care providers begin to carry out treatment, it is important for them to carry out some risk assessment on the person. Among those who require risk assessments include those with mobility problems or their mobility is impaired, have impaired sensation, are diagnosed with diabetes mellitus, have foot deformities, or their lower extremities have circulation problems. Thus, an extensive research should be done in order to ensure that the assessments are scaled up. It is unfortunate that most of the assessment scales lack the required parameters required for evaluation of the non-movement in the lower extremity as a result, there could be some instances where one can suffer a leg fracture, but lack to be assessed appropriately. More so, the classification of those at risk is not standardized. Nonetheless, most scholars agree that the old adults who have suffered leg or  hip fractures are among those who are at risk. Therefore, appropriate preventive measures should be put in place to guarantee full recovery until they have made full recovery.

It is important that full assessment is done on patients to evaluate their level of risk when they are being admitted. The patients are a higher risk should be monitored closely and frequently. It is required that those in the acute care should be assessed every 48 hours in order to evaluate any significant change in their condition.  For those in the long care, they should be assessed every week, but that can be changed depending on the conditions of the patient. While carrying put the assessment, nurses employ the heel pressure ulcers assessment tool, which has a score. The nurses use the score to tell the patient risk level. Upon carrying out the assessments, patients whose have damaged skins or red skin should be handled with care, and heel protector should be used to prevent further damage of the heel

            The focus for the treatment and prevention of the heel pressure ulcers is the connection between the heel vasculature and the external pressure. In order to prevent cases of heel ulcers arising, comprehensive strategies should be employed, especially among the vulnerable populations. These may include identifying the comorbidities that comprise of skin assessment, the dietary intake, early use of pressure distribution devices, and use of evidence based interventions, among other interventions. According to Black, et, al (2003), among those suffering from diabetes mellitus, it is important that their heel is assessed at least twice in a day. In addition, those who are mentally incapacitated and those in acute care need their heels assessed at least twice or thrice on daily basis.

Implications of the Practice

Among the treatment procedures being carried out on patients suffering from heel pressure ulcers, or the vulnerable aged adults, repositioning or turning the patient frequently is a recommended procedure aimed at preventing the occurrence of the ailment. Defloor, et al (2005) proved that a turning schemes on either viscoelastic foam mattresses or standard mattress proved to be effective after following a preset schedule.

In regards to the heel pressure, it is imperative that this is controlled by use of pressure relief device. Among the people who are at risk of heel pressure ulcers, it is important that such individuals use pressure-redistribution device. This device plays a critical role in ensuring that the heel tissue does not breakdown, and remains protected from the adverse effects of the pressure, shear forces and friction (Black, 2003). Patients with boot type devices are mostly those who have been diagnosed with diabetes mellitus, or those with neuropathy; those with limited or poor mobility, and those who are immobile while recovering. There are varieties of boot type devices for all the diverse clients intending to distribute their pressure, and thus play it safe for their heels. According to Black (2004), the best devices to reduce pressure on are the ones that protect and separate the ankles, whilst at the same time maintaining the heel suspension and preventing the foot drop. In the health care facilities, some specially designed mattresses are built in such a way that they can reduce the pressure on the heels.  Patients normally demand a static device that has the potential to distribute the pressure over a large area, which offers the patients some comfort. Some devices or foam mattresses can be deflated or inflated in order to reduce pressure. In the market, there are some beds constructed in such a way that they have heel area pressure distribution properties. Irrespective of the availability of these devices, there is no device that can replace repositioning. Repositioning of the bed is very important.

            Based on what researchers have found, it is obvious that all the devices are not 100% effective in reducing the tissue interface pressure to the minimum level. The devices normally some limited protection on the heel against bony prominences, shear, and friction. This is mostly when the patient is lying on the side. To some degree, the foam boats are effective because the exterior surface aides in reducing friction. If the foam boot is more rigid, there is a high potential of developing pressure areas in the heel plantar surface or the lateral ankles. The booty type devices can reduce internal and external rotation, but have limited potential but can only manage to reduce the rotation only if they are more rigid. The air boot have less weight and aid in lessening the internal and external rotation, but cannot prevent it. Feet sweat in air bags, thus these bags are required to have air holes to enhance circulation. Boots have surfaces that make them to slip around on the bed surface; however, these allow more positioning checks. Straps ensure the bots stay on, but the straps should not be very tight. Tight straps can cause unnecessary pressure on the dorsum of the feet or the lower leg. Therefore, the boots should be removed at some time, and allow time for the feet to be assessed. Nurses should also check the pressure redistributing device to evaluate whether it is worn correctly.


The integrity of the skin should always be maintained it is important to make certain that the skin is protected from bony prominences and the heel pressure ulcers.  This is achieved by using lubricants removing pressure, and using moisturizers. More so, it is important to maintain protective dressing code. It is important to acknowledge that the dressing does not relief the pressure. At stage I of heel pressure ulcers, the tissues only need to be relieved off the pressure for them to recover. In case of the presence of blisters, one should not break them but should elevate the heel along with the leg. In case the heel pressure ulcers is at the II to IV stage, characterized by eroding of the skin, it is appropriate to dress the heel after cleaning it. In case of any infections, one should not use occlusive dressing because that can hold bacteria and facilitate their spread.  It is critical to monitor the heel closely to evaluate the positive or negative changes. Negative changes indicate deterioration, and they may include fever, odor, pain, exposed bone, and erythema.

            In reference to the literature review, it is apparent that research for stage III and IV of heel pressure ulcers is not inclusively done, and remains controversial. The issue of removal of stable eschar is still being debated. Considering that heel vascularity below the eschar is absent, and there is only fat tissue or subcutaneous tissue, it is susceptible to being infected and had limited potential to fight the infection. It is recommended that in the presence of eschar, the heel should be wrapped with gauze and be relieved off the pressure. Close monitoring of the patient is important. The adults need special care because their immune system may be weak and some bodies’ processes may be hindered by age. While assessing the heel pressure ulcers patient, it is important to take notes about the clinical observations from the score cards and other parameters.  More so, the management of heel pressure ulcers requires nursing nutritional assessment. This nurse should address both the hydration status and the nutrition status. In case the patient is at a nutrition risk, the nurse should give the best recommendation suiting the situation.

The heel pressure ulceris the second most pronounced part of the body infected with pressure ulcers. The current trend in regards to prevalence is a bit alarming, thus posing a real danger to society. Thus, it is important that nursing scholars research on effective mechanisms to prevent and to treat the condition. Identifying the condition at its initial stages is among the most effective ways to ensure that it is effectively managed. Those at high risk need their heels to be assessed frequently. All the health care institutions should have a protocol on the management of the heel pressure ulcers, that must employ evidence based nursing practices.











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Family Nurse Practitioner


A family nurse practitioner is a registered advanced practice nurse with the skills and knowledge to manage and assess health issues in people of all ages, from birth to old age. They are responsible for implementing and facilitating health maintenance, disease prevention, restorative care intervention, and health promotion. In order to be qualified to offer the assigned roles as a family nurse practitioner, there are current issues and trends that one should be aware of. To start with, certification depends on one education as well as recognition of abilities, knowledge, competence, or skills developed throughout one’s specialization in family nurse practitioner practicing field (Mezey, McGivern& Sullivan-Marx, 2010).This means that a nurse will only be certified for what he has specialized in and what he proves to be competent in. For this, the NP should be aware of the health issues affecting families and how to address them.

Another major trend in credentialing is the Open Door 2000 Program by the American Nursing Credential Center that requires that nurses qualify for the two levels of credentialing namely Board Certified and Certified. This means that a family practitioner has to be first certified for completing the studies and qualifying with the required skills and competency in the field. This is followed with Board certification in which the family NP should prove to the board that he is qualified and fit to practice as a family NP. Certification is authorized by the Committee for Modular Certification and the Certification for Diploma and Associate Degree Nursing Practice committee. On the other hand, the board certification is by the Board Certification for Advanced Certification and the Baccalaureate Nursing Practice (Cowen &Moorhead, 2014).

The last issue of consideration is the fact that there are new credentials in the field. For instance a family NP who is a registered nurse with diploma or associates in his area of specialization is eligible for RN,C credential. This is different for a family NP with a higher RN,C or Bachelors since he qualifies for RN,BC (Catalano, 2015).  One should thus know the credential he is after in order to determine the education level to pursue. 




Catalano, J. T. (2015). Nursing now: Today’s issues, tomorrow’s trends. Philadelphia: F.A. Davis Company.

Cowen, P. S., & Moorhead, S. (2014). Current issues in nursing. London: Elsevier Health Sciences.

Mezey, M. D., McGivern, D. O. N., & Sullivan-Marx, E. (2010).Nurse practitioners: Evolution of advanced practice. New York, NY: Springer Pub.

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Nursing-LPN to BS Transition


Nursing LPN to BS Transition


            Education is critical for professional growth and it enables one to climb the corporate ladder. Upon securing employment, one is faced with challenges in regard to enrolling for other courses due to commitment to work and family. The tight work schedule along with conflict of interest affect the decision making process; however, technological changes have made is possible for the professionals willing to enroll for part time courses to do so with ease. This is because technological advancement has made it possible for young professionals to enroll for online courses that are flexible. In so doing, they increase their competency and are in a position to climb the professional ladder.  Nursing is among the most critical professionals in regards to promotion of human health and prevention of diseases . Thus, many Licensed Practical Nurses (LPN) or licensed vocational nurses (LVN) are enrolling for Bachelor of Nursing (BN), which is a requirement before enrolling taking the registered nurses examination in some economies. The transition from LPN to RN is not a simple task, but entails a process of professional socialization that makes up eligible for more tasking role in the nursing profession. The chance to bridge between the LPN and RN was traditionally a complex issue that was only available in few universities; however, presently, the transition is offered by numerous universities. This research paper evaluates the LPN to RN transitions, and the differences between the LPN and RN.

Three major role differences between an LPN and RN

            Professional socializing entails learning the norms, values and skills that are required by people of certain social position. Professional socializing is not a simple task. This is because it comes with responsibilities.  In nursing, professional socializing is an important ingredient in their professional competency. The differences between the LPN and RN are caused by the training and education under which the respective nurse goes through. The registered nurses go through extensive training and education more than the licensed practical nurses. The registered nurses have higher chances of earning a higher pay than the LPN due to their differences in training and education.  Having considered that the LPN and RN go through different training and education, it is imperative to consider the role differences between the RN and the LPN.

            According to Duncan and DePew (2011), in regards to the role of the RN and the LPN, the former plays a senior role than the latter. The RN major duties revolve around ensuring that the patient needs are addressed in a favorable environment. Since the registered nurse is the head of the nurses, he/ she takeswritten and verbal instructions from the physicians. The RN must do the initial assessment of the patient, and develop the care management plan on the respective patient. On the other hand, the LPN gets instructions from the RN and performs the follow up for the patient along with daily check up, and must report to the registered nurse. That means the RN has the responsibility of supervising the LPN.  

The licensed practical nurse gives the basic nursing and medical to the patients. This entails routine check-up, which may include checking the blood pressure and inserting catchers among others.  They may also play a critical role in ensuring that patients are comfortable by helping them to bathe, and discuss the patient health status with the patient, and report to the doctor or the registered nurse.  On the other hand, the registered nurse administers treatment and medication to the patient.  They have to carry out the diagnostic tests, analyze them and report to doctors. They advise the patient the required processes of management of the illness after treatment. They also supervise the other nursing aides such as the home care aides and the LPN.

Generally, the RN has more responsibilities than the LPN/ LVN, thus their performance is expected to be higher because they have more medical responsibilities. Even though they can delegate duties to the LPN, the duties should be within the scope of the license of the LVN/ LPN. Therefore, before the LPN performs any medical practice on a patient, it must be approved by the RN.

Strategies and suggestions to the LPN to RN Transition

            Taking into consideration that RN have a more comprehensive medical roles than the LPN/ LVN, the transition require education. The transition can take place in two ways; first, by enrolling for a degree in Bachelor of Science Nursing, and secondly through enrolling for an Associate Degree in Nursing.  There degree courses takes between 1 and 2 years. Upon completing either of them, the LPN/ LVN must take the National Council Licensure Examination (NCLEX-RN) to become registered nurses (Claywel, 2013).  This increases the employment alternatives and guarantees pay increase. Among the courses that one undertakes includes nursing science and nursing theory among many other courses.  Some institutions offer bridging courses that make the LPN to transit to RN. These programs entail using the already acquired skills, knowledge and expertise to enable the LPV acquire the RN license.


Both the registered nurses and the licensed practical nurses are valuable members in health care because they play a critical role in preventing and management of  illness; however, there are some differences in respect to hierarchy. The differences dictate that the RN is superior to LPN, thus the latter is supervised and should report to the former. The differences in respect to their education and training demands that the RN can perform some tasks that LPN cannot perform. Irrespective of the differences, the LPN can go through some education and training and transit to become a RN.




Duncan, G., & DePew, R. (2011). Transitioning from LPN/VN to RN: Moving ahead in your career. Australia: Delmar Cengage Learning.

Claywell, L. (2013). LPN to RN transitions. NY: Elsevier Health Sciences.

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Core Competencies: care provider advanced role and non-direct care provider



As noted by Troseth(2012), both direct care provider advanced role and non-direct care provider advanced role are common in core competencies in that they should employ evidence based practice, utilize informatics, and apply quality improvement measures. Further, the two need to have doctorate of master’s degrees in nursing even though each should specialize in his/her field of practice.

Nevertheless, the two are different in a number of ways. According to Task Force Members (2013), direct-care workers are the healthcare workers who provide long-term personal assistance and care to people with disabilities or with chronic illnesses or elderly. The main role of these healthcare workers is to help the clients perform their daily tasks such as bathing and dressing among others. They are very important in the lives of the people they serve as well as to families of those people. These nurses are required to evidence some core competencies that make them successful in their practice. These core competencies include scientific foundation competencies, leadership competencies, quality competencies, practice inquiry competencies, technology and information literacy competencies, policy competencies, and health delivery system competencies. Other groups of competencies are ethics competencies, independent practice competencies. The major titles for direct care provider in advanced role are clinical nurse specialist, nurse practitioner, nurse-midwife, and nurse anesthetist. The nurse is this category should have high level skills in assessment, treatment, and diagnosis of potential health issues, prevention of diseases and injury, provision of comfort, and maintenance of wellness. One should hold a doctoral or master’s education level with clinical ad supervision experiences.

On the other hand, while nurses preparing for non-direct roles require masters and doctorate level of education just as is the case for those in direct roles, they further need to receive focused clinical experiences and education in the areas of specialization. They not only need opportunities to practice in the specialty areas but also have ample time to conduct adequate research in the respective fields (Troseth, 2012).




Task Force Members.(2013). Population-focused nurse practitioner competencies.Retrieved from

Troseth, M. (2012).Nursing informatics: Roles, competencies, skills, organizations and legislative aspects.Retrieved from,_Competencies,_Skills.pdf.