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Papers by Mary Rapp

Aims: The Braden Scale for Predicting Pressure Sore Risk© has been tested for reliability and val... more Aims: The Braden Scale for Predicting Pressure Sore Risk© has been tested for reliability and validity, but validity of subscale scores has received less scrutiny even though subscales guide care decisions in nursing facilities. The aim is to establish the construct validity of the nutrition subscale. Methods: The relationship of weekly nutrition subscale scores (999) and mean observed daily dietary intake of meals (% eaten), % supplements consumed, and servings of protein/day was analyzed. Results: There is a significant relationship between the mean meal intake and levels of nutrition subscale scores, (F = 93.3, p < .0001). Duncan’s multiple range test demonstrates a significant difference among the 4 levels of the nutrition subscale score. The mean total number of protein servings for nutrition subscale score 1 is significantly different from the means for subscale scores 2 – 4, (F = 13.99, p < .0001). The total number of protein servings and nutrition subscale score are po...

Journal of Wound, Ostomy & Continence Nursing, 2015

PURPOSE: The Braden Scale for Predicting Pressure Sore Risk is used to assess risk, and the Cente... more PURPOSE: The Braden Scale for Predicting Pressure Sore Risk is used to assess risk, and the Centers for Medicare & Medicaid guidelines suggest the use of a tissue tolerance procedure that detects time-to-erythema (TTE) to further refi ne tissue tolerance, a component of the Braden Scale. The aim of this study was to compare the Braden Scale and TTE as risk classifi cation methods and their utility in identifying care planning interventions. DESIGN: Descriptive study using retrospective chart review. SUBJECTS AND SETTING: Participants were a convenience sample of 89 adults 65 years or older residing in a long-term care facility in the Midwestern United States. The sample was drawn from a facilitygenerated list of 90 residents who had both Braden Scale and tissue tolerance testing performed within 24 hours of admission from any setting, readmission after a hospital stay, or performed as part of a routine annual reassessment. METHODS: Results of staff performance on the Braden Scale and TTE were compared as risk classifi cation methods and based on their utility for identifying care planning interventions. Data were collected during 1 session when TTE and the Braden Scale were completed. Agreement between the 5 risk categories from the Braden Scale and 5 TTE risk categories was analyzed via the kappa statistic and Kendall tau-c statistic. Spearman or Pearson correlation coeffi cients were calculated as appropriate for ordinal and continuous risk, intervention, and severity measures. RESULTS: The mean Braden Scale score was 17.5 ± 3 (mean ± SD); the mean TTE-Bed was 2.35 ± 0.57 hours and the mean TTE-Chair was 2.18 ± 0.52. Using a Braden Scale score of 18 or less as a cut point for identifying clinically relevant risk for pressure ulcer development, 55 participants were deemed at risk, 62 had mobility subscale scores less than 4, 76 had activity subscale scores less than 4, and 73 were incontinent. The weighted kappa statistic demonstrated weak agreement between

Nursing Administration Quarterly, 2010

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-... more Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-today direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.

Journal of the American Medical Directors Association, 2004

1. J Am Med Dir Assoc. 2004 May-Jun;5(3):219-20; author reply, 220-1. Nurse practitioner/physicia... more 1. J Am Med Dir Assoc. 2004 May-Jun;5(3):219-20; author reply, 220-1. Nurse practitioner/physician collaborative models of care. Bonner A, Rapp MP, Burl JB. Comment on: J Am Med Dir Assoc. 2004 Jan-Feb;5(1):16-23. PMID ...

Journal of the American Medical Directors Association, 2003

Advance practice nurses (APNs) have emerged as valuable members of the nursing facility interdisc... more Advance practice nurses (APNs) have emerged as valuable members of the nursing facility interdisciplinary team. They function in a variety of roles, including clinical care, administration, nursing consultation, and education. Positive outcomes in key indicators of care and reduction in costs to the healthcare systems have been attributed to their practice. Barriers to implementation of the role include regulatory issues, facility resistance, and difficulty adapting to the environment. Facilitation of the role is enhanced by collegial relationships and role negotiation. There is strength in the APN-physician collaborative model. The APN is likely to concentrate on prevention, restoration, maintenance, and palliative care, allowing the physician to concentrate on complex medical problems. There is a need for APN practices to identify APN-sensitive outcomes, collect and analyze data, and disseminate findings.

Journal of the American Medical Directors Association, 2011

Geriatric Nursing, 2009

Biological Research For Nursing, 2009

Background: No accepted standard exists to evaluate nonsleep-related activity in nursing facility... more Background: No accepted standard exists to evaluate nonsleep-related activity in nursing facility residents where monitors are variously placed at the ankle, waist, wrist, thigh, or embedded in sheeting and set to record activity frequency. Objectives: To determine optimal placement of activity monitors by site—at the ankle, waist, or wrist for nursing facility residents. Methods: Nursing facility residents (N = 16) wore accelerometers at three sites: the nondominant ankle, waist, and wrist, while recording activity in three modes: frequency, duration, and intensity. Results: The natural log activity mean for each mode by site and time revealed no significant differences between the three sites for activity intensity, F(2, 62.78) = .15, p = .86; activity duration, F(2, 69.84) = .50, p = .61; and activity frequency, F(2, 70.04) = 1.25, p = .29. There were no significant site—time interactions. The natural log activity by site and mode indicated no significant differences by site for ...

Advances in Skin & Wound Care, 2009

OBJECTIVES: The purpose of the study was to determine whether characterizing skin temperature reg... more OBJECTIVES: The purpose of the study was to determine whether characterizing skin temperature regulation as a functional property of the skin as it relates to tissue tolerance improves the clinician's understanding of pressure ulcer risk prediction. DESIGN: A 2-group time-series design was used to observe skin temperature regularity (entropy) and self-similarity (spectral exponent). METHODS: Twenty nursing facility residents wore skin temperature monitors continuously for 5 days. One bathing episode was observed because bathing is a commonly occurring care procedure. PRIMARY OUTCOME MEASURE: Difference in skin temperature multiscale entropy and spectral exponent by risk category and pressure ulcer outcome. RESULTS: Multiscale entropy (MSE) for skin temperature was lowest in those who developed pressure ulcers, F 1,18 = 35.14, P G .001. Skin temperature mean MSE, F 1,17 = 5.55, P = .031 and the skin temperature spectral exponent, F 1,17 = 6.19, P = .023 differentiated the risk groups. The change in skin temperature entropy during bathing was significant, t (16) = 2.55, P = .021. CONCLUSIONS: Skin temperature MSE and the spectral exponent were significantly different between low-risk and higher risk residents and residents who did and did not develop pressure ulcers. The study supports measurement of skin temperature regulation as a component of tissue tolerance to pressure.

Advances in Skin & Wound Care, 2013

In this study, the construct validity of the moisture subscale of the Braden Scale for Predicting... more In this study, the construct validity of the moisture subscale of the Braden Scale for Predicting Pressure Sore Risk is partially supported by the significant inverse relationships between moisture subscale scores, the number of wet observations and soiled observations, brief changes, and differences among the moisture subscale score groups.

Ontario health technology assessment series, 2014

Pressure at the interface between bony prominences and support surfaces, sufficient to occlude or... more Pressure at the interface between bony prominences and support surfaces, sufficient to occlude or reduce blood flow, is thought to cause pressure ulcers (PrUs). Pressure ulcers are prevented by providing support surfaces that redistribute pressure and by turning residents to reduce length of exposure. We aim to determine optimal frequency of repositioning in long-term care (LTC) facilities of residents at risk for PrUs who are cared for on high-density foam mattresses. We recruited residents from 20 United States and 7 Canadian LTC facilities. Participants were randomly allocated to 1 of 3 turning schedules (2-, 3-, or 4-hour intervals). The study continued for 3 weeks with weekly risk and skin assessment completed by assessors blinded to group allocation. The primary outcome measure was PrU on the coccyx or sacrum, greater trochanter, or heels. Participants were mostly female (731/942, 77.6%) and white (758/942, 80.5%), and had a mean age of 85.1 (standard deviation [SD] ± 7.66) ye...