Capstone Project Milestone #1:
PICO and Evidence Appraisal Worksheets
PICO WORKSHEET
Your Name:
Date:
Your Instructor’s Name:
Purpose: To identify a problem or concern that nursing can change and develop a PICO question to guide the change project.
Directions: Use the form below to complete the PICO assignment in Milestone #1. This includes filling in the table with information about your research question and your PICO elements.
Step 1: Select the key PICO terms for searching the evidence. Clearly define your PICO question. List each element P (problem, population, or problem), I (intervention), C (Comparison with other treatment/current practice), and O (Desired outcome). Is the potential solution something for which you (as nurse or student) can find a solution through evidence research? Look in your book for guidelines to developing your PICO question.
Step 2: Identify the problem. What have you noticed in your work or school environment that isn’t achieving the desired patient or learning outcomes? What needs to change in nursing, what can you change with the support of evidence in the literature? Describe the problem or practice issue that you want to research. What is your practice area; clinical, education, or administration? (This is NOT where you will list your PICO question)
Step 3: How was the practice issues identified? How did you come to know this was a problem in your clinical practice? Review the listed concerns and check all that apply.
Step 4: What evidence must be gathered? Everyone should have a literature search. However, what other sources of reliable information will be helpful for your particular question?
Step 5: What terms will you use in order to make sure that your search is wide enough to obtain required information but narrow enough to keep it focused? What databases will you search? How will you narrow your search if needed?
PICO Worksheet
What is the PICO question? In critically ill patients, does risk assessment during admission to the Intensive Care Unit (ICU), compared to no skin assessment, reduce the risk of developing pressure ulcers during the admission period?

Define each element of the question below:
P- (Patient, population, or problem): critically ill patients
I- (Intervention): risk assessment during admission
C- (Comparison with other treatment/current practice): no skin assessment during admission
O- (Desired outcome): reduction in the risk of developing pressure ulcers
What is the practice issue/problem?
The practice issue is failure to identify patients at high risk of pressure ulcers. Identification of patients at high risk of pressure ulcers is extremely important in coming up with ways of preventing their occurrence such as referral to wound care specialists (in case the patient has an existing pressure ulcer or wound), nutritionists and the use of necessary facilities such as heel lift device.
What is the practice area?
__v_ Clinical
___ Education
___ Administration
___ Other
How was the practice issue identified? (check all that apply)
_v__ Safety/risk management concerns
_v__ Unsatisfactory patient outcomes
___ Wide variations in practice
_v__ Significant financial concerns
___ Difference between hospital and community practice
_v__ Clinical practice issue is a concern
___ Procedure or process is a time waster
___ Clinical practice issue has no scientific base
___ Other:
What evidence must be gathered? (check all that apply)
__v_ Literature search
__v_ Guidelines
_v__ Expert Opinion
___ Patient Preferences _v__ Clinical Expertise
___ Financial Analysis
_v__ Standards (Regulatory, professional, community)
___ Other
Search terms: predictors of pressure ulcers in critically ill patients; skin assessment for pressure ulcers

Databases to search: Medscape; EBSCohost; MedlinePlus
Search Strategies: I will obtain as many articles (research and non-research) as possible from these two databases. I will then scan the articles to identify only those that deal with my PICO question.
EVIDENCE APPRAISAL WORKSHEET
Your Name:
Date:
Your Instructor’s Name:
Purpose: To find evidence to support an intervention that will change the outcomes.
Directions: Type your search question below. Find AT LEAST FOUR sources to support the need for change and the potential intervention you have selected to solve the problem. At least three of your sources must be peer-reviewed articles. The fourth source could be another peer-reviewed article or a reliable, credible source. Look in your text for ideas of other sources that can be used. Using the table below, insert and describe your four chosen resources.
Step 1: APA Reference for the article. You will need to list the reference for the source in APA format. Be careful when using built-in APA formats and library citations. They may not be in APA format. Refer to Chapter 7 of your APA manual.
Step 2: Type of Source. If your source is a research article, you will need to ensure that it is a peer review article. You need at least three peer-reviewed articles for your project. If your article is a non–research source, then you will need to list what type of source it is; systematic review, clinical practice guidelines, organizational experience, or individual expert opinion/case study/literature review. You may only use ONE non-research source.
Step 3: Strength of Research. Refer to page 238-240 for research evidence and page 242-244 for non-research evidence. While you do not need to assign a level for each study, you will assign a quality of evidence (high, good, or low/major flaw) and should discuss the study using some of the elements that are discussed in the appraisal forms. For example, Research evidence: was the sample size adequate? Was there a controlled group? Was it a randomized study? Were results clearly stated? Was the conclusion based on the results? Were study limitations discussed? Not all of these elements need to be discussed, but you should discuss this information to determine if the strength of the evidence is HIGH, GOOD, or LOW/MAJOR FLAW.
Step 4: Brief Description of the Research. In this section, you will summarize the source in your own words. How does this information apply to your project? What are the results of the source? What are their recommendations?

Evidence Appraisal Worksheet
PICO Question:

APA Reference for Article
Give the APA-formatted reference for the article. Type of Source
*Research: Peer-reviewed article
*Non-research systematic review, clinical practice guidelines, organizational experience, or expert opinion/case study/literature review Strength of Research
Discuss the strength of the sources.
Report if evidence is High, Good, or Low/Major Flaw. Use the tools on page 238-244 of your text and discuss the reasons why you have assigned a particular level of quality. Brief Description of Research
Address the questions.
*How does the information in the article apply to the project problem or proposed intervention?
*Summarize in your own words.
* Include results of the study and how these results are applicable to your project.
* What is the recommendation of the source for clinical practice?
1 Saleh, M., Anthony, D. & Parboteeah, S. (2008). The Impact of Pressure Ulcer Risk Assessment on Patient Outcomes among Hospitalized Patients. Journal of Clinical Nursing, 18, 1923-1929. Doi: 10.1111/j.1365-2702.2008.02717.x Research This is a good because the pretest-posttest study was not done using one ward, but a group of 9 wards. Therefore, the results of the study can easily be generalized. However, randomization was not possible with this study, which means that the researchers were not able to control possible effects. Nevertheless, the researchers tried to randomize the study as much as possible. They created three groups and then randomly allocated the nine wards into the three groups as follows:
1. Required to perform risk assessment
2. Not required to conduct risk assessment
3. Required to perform clinical judgment This article sought to investigate whether conducting risk assessment for pressure ulcers improved patient outcomes through the reduction of the risk of developing pressure ulcers. The researchers compared the role of risk assessment and clinical judgment in the prevention of pressure ulcers. The study found that there was no statistical difference between risk assessment and clinical judgment in preventing pressure ulcers. These results show that risk assessment helps in reducing the prevalence of pressure ulcers for hospitalized patients. Therefore, the results serve to support my intervention, risk assessment during admission, as an evidence-based practice towards preventing pressure ulcers in critically ill patients. This source recommends the combination of risk assessment and clinical judgment to improve patient outcomes.
2 Schluer, A., Scols, J. M. & Halfens, R. J. (2014). Risk and Associated Factors of Pressure Ulcers in Hospitalized Children over 1 Year of Age. Journal for Specialists in Pediatric Nursing, 1, 80-89. Research This is a good source because the study was fairly spread over 14 pediatric hospitals. In addition, the study used a internationally recognized and widely used data collection instrument (Dutch National Prevalence Measurement of Care Problems), which was validated. However, this instrument was validated for older patients but not for use for pediatric patients. The study used an adequate sample of 268 participants of which 204 were used for analysis. However, the study participants were not randomly selected although the researcher had established inclusion criteria for selecting only the required participants. This study investigates on the importance of assessing the risk of pressure ulcers for pediatric patients as a strategy for preventing the development of pressure ulcers. The study concluded that there are two primary risk factors for pressure ulcers development in children: anatomical locations and use of external devices. The researchers recommended that since younger patients may not be able to distinguish pressure ulcers compared to older patients, they should be carefully assessed for pressure ulcers. The use of external devises on the skin increases the risk of pressure ulcer development. As such, strategies should be used to prevent their development where external devices are used. This source adds to the knowledge of pressure ulcers risk assessment and hence contributes greatly to my intervention.
3 Feuchtinger, J., Halfens, R. & Dassen, T. (2007). Pressure Ulcer Risk Assessment Immediately After Cardiac Surgery- Does it make a Difference? A Comparison of Three Pressure Ulcer Risk Assessment Instruments within a Cardiac Surgery Population. Nursing in Critical Care, 12(1), 42-49. Research This is a good source. Due to the nature of the study, the researchers used a convenience sample of 53 ICU patients whose length of stay after surgery was over 24 hours. The researchers drew conclusions based on critical analysis of research findings. This research article shows the importance of performing pressure risk assessment before surgery, which was found to show patients at high risk of developing pressure ulcers. This study explains the use of three risk assessment instruments, which include 4-factor model, modified Norton Scale and Braden Scale. Therefore, this study contributes to my intervention by outlining instruments that can be used to perform pressure ulcers risk assessment. The study concludes that it may not be necessary to use a standardized risk assessment instruments for patients in the cardiac surgery ICU. Due to reduced mobility, use of restrains, friction occurrence and nutrition, such patients should be considered at high risk of pressure ulcers for five days after operation.
4 Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A. J., Reitel, K. & Buckley, D. I. (2013). Pressure Ulcer Risk Assessment and Prevention: A Systematic Comparative Effectiveness Review. Annals of Internal Medicine, 159(1), 28-38. Non research (review of literature) This is a good source that reviews 82research articles on pressure ulcer risk assessment. The authors extracted and synthesized data from the reviewed articles that they used to draw conclusions. However, only three publications directly dealing with the effectiveness of risk assessment in reducing pressure ulcer incidence were reviewed. In the course of review, the researchers outline various methods of preventing the development of pressure ulcers. Of importance is that they discuss the role of risk assessment in preventing pressure ulcers especially focusing on risk assessment instruments. This information will acts as the basis for my intervention especially in the recommendation of the use of risk assessment instruments in identifying patients at high risk of developing pressure ulcers.

Capstone Project Milestone #1:
PICO and Evidence Appraisal Worksheets
PICO WORKSHEET
Your Name:
Date:
Your Instructor’s Name:
Purpose: To identify a problem or concern that nursing can change and develop a PICO question to guide the change project.
Directions: Use the form below to complete the PICO assignment in Milestone #1. This includes filling in the table with information about your research question and your PICO elements.
Step 1: Select the key PICO terms for searching the evidence. Clearly define your PICO question. List each element P (problem, population, or problem), I (intervention), C (Comparison with other treatment/current practice), and O (Desired outcome). Is the potential solution something for which you (as nurse or student) can find a solution through evidence research? Look in your book for guidelines to developing your PICO question.
Step 2: Identify the problem. What have you noticed in your work or school environment that isn’t achieving the desired patient or learning outcomes? What needs to change in nursing, what can you change with the support of evidence in the literature? Describe the problem or practice issue that you want to research. What is your practice area; clinical, education, or administration? (This is NOT where you will list your PICO question)
Step 3: How was the practice issues identified? How did you come to know this was a problem in your clinical practice? Review the listed concerns and check all that apply.
Step 4: What evidence must be gathered? Everyone should have a literature search. However, what other sources of reliable information will be helpful for your particular question?
Step 5: What terms will you use in order to make sure that your search is wide enough to obtain required information but narrow enough to keep it focused? What databases will you search? How will you narrow your search if needed?
PICO Worksheet
What is the PICO question? In critically ill patients, does risk assessment during admission to the Intensive Care Unit (ICU), compared to no skin assessment, reduce the risk of developing pressure ulcers during the admission period?

Define each element of the question below:
P- (Patient, population, or problem): critically ill patients
I- (Intervention): risk assessment during admission
C- (Comparison with other treatment/current practice): no skin assessment during admission
O- (Desired outcome): reduction in the risk of developing pressure ulcers
What is the practice issue/problem?
The practice issue is failure to identify patients at high risk of pressure ulcers. Identification of patients at high risk of pressure ulcers is extremely important in coming up with ways of preventing their occurrence such as referral to wound care specialists (in case the patient has an existing pressure ulcer or wound), nutritionists and the use of necessary facilities such as heel lift device.
What is the practice area?
__v_ Clinical
___ Education
___ Administration
___ Other
How was the practice issue identified? (check all that apply)
_v__ Safety/risk management concerns
_v__ Unsatisfactory patient outcomes
___ Wide variations in practice
_v__ Significant financial concerns
___ Difference between hospital and community practice
_v__ Clinical practice issue is a concern
___ Procedure or process is a time waster
___ Clinical practice issue has no scientific base
___ Other:
What evidence must be gathered? (check all that apply)
__v_ Literature search
__v_ Guidelines
_v__ Expert Opinion
___ Patient Preferences _v__ Clinical Expertise
___ Financial Analysis
_v__ Standards (Regulatory, professional, community)
___ Other
Search terms: predictors of pressure ulcers in critically ill patients; skin assessment for pressure ulcers

Databases to search: Medscape; EBSCohost; MedlinePlus
Search Strategies: I will obtain as many articles (research and non-research) as possible from these two databases. I will then scan the articles to identify only those that deal with my PICO question.
EVIDENCE APPRAISAL WORKSHEET
Your Name:
Date:
Your Instructor’s Name:
Purpose: To find evidence to support an intervention that will change the outcomes.
Directions: Type your search question below. Find AT LEAST FOUR sources to support the need for change and the potential intervention you have selected to solve the problem. At least three of your sources must be peer-reviewed articles. The fourth source could be another peer-reviewed article or a reliable, credible source. Look in your text for ideas of other sources that can be used. Using the table below, insert and describe your four chosen resources.
Step 1: APA Reference for the article. You will need to list the reference for the source in APA format. Be careful when using built-in APA formats and library citations. They may not be in APA format. Refer to Chapter 7 of your APA manual.
Step 2: Type of Source. If your source is a research article, you will need to ensure that it is a peer review article. You need at least three peer-reviewed articles for your project. If your article is a non–research source, then you will need to list what type of source it is; systematic review, clinical practice guidelines, organizational experience, or individual expert opinion/case study/literature review. You may only use ONE non-research source.
Step 3: Strength of Research. Refer to page 238-240 for research evidence and page 242-244 for non-research evidence. While you do not need to assign a level for each study, you will assign a quality of evidence (high, good, or low/major flaw) and should discuss the study using some of the elements that are discussed in the appraisal forms. For example, Research evidence: was the sample size adequate? Was there a controlled group? Was it a randomized study? Were results clearly stated? Was the conclusion based on the results? Were study limitations discussed? Not all of these elements need to be discussed, but you should discuss this information to determine if the strength of the evidence is HIGH, GOOD, or LOW/MAJOR FLAW.
Step 4: Brief Description of the Research. In this section, you will summarize the source in your own words. How does this information apply to your project? What are the results of the source? What are their recommendations?

Evidence Appraisal Worksheet
PICO Question:

APA Reference for Article
Give the APA-formatted reference for the article. Type of Source
*Research: Peer-reviewed article
*Non-research systematic review, clinical practice guidelines, organizational experience, or expert opinion/case study/literature review Strength of Research
Discuss the strength of the sources.
Report if evidence is High, Good, or Low/Major Flaw. Use the tools on page 238-244 of your text and discuss the reasons why you have assigned a particular level of quality. Brief Description of Research
Address the questions.
*How does the information in the article apply to the project problem or proposed intervention?
*Summarize in your own words.
* Include results of the study and how these results are applicable to your project.
* What is the recommendation of the source for clinical practice?
1 Saleh, M., Anthony, D. & Parboteeah, S. (2008). The Impact of Pressure Ulcer Risk Assessment on Patient Outcomes among Hospitalized Patients. Journal of Clinical Nursing, 18, 1923-1929. Doi: 10.1111/j.1365-2702.2008.02717.x Research This is a good because the pretest-posttest study was not done using one ward, but a group of 9 wards. Therefore, the results of the study can easily be generalized. However, randomization was not possible with this study, which means that the researchers were not able to control possible effects. Nevertheless, the researchers tried to randomize the study as much as possible. They created three groups and then randomly allocated the nine wards into the three groups as follows:
1. Required to perform risk assessment
2. Not required to conduct risk assessment
3. Required to perform clinical judgment This article sought to investigate whether conducting risk assessment for pressure ulcers improved patient outcomes through the reduction of the risk of developing pressure ulcers. The researchers compared the role of risk assessment and clinical judgment in the prevention of pressure ulcers. The study found that there was no statistical difference between risk assessment and clinical judgment in preventing pressure ulcers. These results show that risk assessment helps in reducing the prevalence of pressure ulcers for hospitalized patients. Therefore, the results serve to support my intervention, risk assessment during admission, as an evidence-based practice towards preventing pressure ulcers in critically ill patients. This source recommends the combination of risk assessment and clinical judgment to improve patient outcomes.
2 Schluer, A., Scols, J. M. & Halfens, R. J. (2014). Risk and Associated Factors of Pressure Ulcers in Hospitalized Children over 1 Year of Age. Journal for Specialists in Pediatric Nursing, 1, 80-89. Research This is a good source because the study was fairly spread over 14 pediatric hospitals. In addition, the study used a internationally recognized and widely used data collection instrument (Dutch National Prevalence Measurement of Care Problems), which was validated. However, this instrument was validated for older patients but not for use for pediatric patients. The study used an adequate sample of 268 participants of which 204 were used for analysis. However, the study participants were not randomly selected although the researcher had established inclusion criteria for selecting only the required participants. This study investigates on the importance of assessing the risk of pressure ulcers for pediatric patients as a strategy for preventing the development of pressure ulcers. The study concluded that there are two primary risk factors for pressure ulcers development in children: anatomical locations and use of external devices. The researchers recommended that since younger patients may not be able to distinguish pressure ulcers compared to older patients, they should be carefully assessed for pressure ulcers. The use of external devises on the skin increases the risk of pressure ulcer development. As such, strategies should be used to prevent their development where external devices are used. This source adds to the knowledge of pressure ulcers risk assessment and hence contributes greatly to my intervention.
3 Feuchtinger, J., Halfens, R. & Dassen, T. (2007). Pressure Ulcer Risk Assessment Immediately After Cardiac Surgery- Does it make a Difference? A Comparison of Three Pressure Ulcer Risk Assessment Instruments within a Cardiac Surgery Population. Nursing in Critical Care, 12(1), 42-49. Research This is a good source. Due to the nature of the study, the researchers used a convenience sample of 53 ICU patients whose length of stay after surgery was over 24 hours. The researchers drew conclusions based on critical analysis of research findings. This research article shows the importance of performing pressure risk assessment before surgery, which was found to show patients at high risk of developing pressure ulcers. This study explains the use of three risk assessment instruments, which include 4-factor model, modified Norton Scale and Braden Scale. Therefore, this study contributes to my intervention by outlining instruments that can be used to perform pressure ulcers risk assessment. The study concludes that it may not be necessary to use a standardized risk assessment instruments for patients in the cardiac surgery ICU. Due to reduced mobility, use of restrains, friction occurrence and nutrition, such patients should be considered at high risk of pressure ulcers for five days after operation.
4 Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A. J., Reitel, K. & Buckley, D. I. (2013). Pressure Ulcer Risk Assessment and Prevention: A Systematic Comparative Effectiveness Review. Annals of Internal Medicine, 159(1), 28-38. Non research (review of literature) This is a good source that reviews 82research articles on pressure ulcer risk assessment. The authors extracted and synthesized data from the reviewed articles that they used to draw conclusions. However, only three publications directly dealing with the effectiveness of risk assessment in reducing pressure ulcer incidence were reviewed. In the course of review, the researchers outline various methods of preventing the development of pressure ulcers. Of importance is that they discuss the role of risk assessment in preventing pressure ulcers especially focusing on risk assessment instruments. This information will acts as the basis for my intervention especially in the recommendation of the use of risk assessment instruments in identifying patients at high risk of developing pressure ulcers.