Prevention of Pressure Ulcers in the ICU Patient

Decubitus ulcers have plagued the nursing profession for many years as a major health care problem in term of patients’ pain, disfigurement, prolonged hospitalization and financial cost. Decubitus ulcers, commonly referred to as pressure ulcers, are the most preventable complication of intensive care units (ICU). Nurses, caring for patients in ICU, can exert a positive influence in prevention of pressure ulcer development by taking aggressive measures such as alleviating pressure, implementing meticulous skin care, and providing nutritional support.
A pressure ulcer is defined as “any lesion caused by unrelieved pressure that result in damage to underlying tissue; pressure ulcers are considered both inevitable and preventable” (Pokorny, Koldjeski, & Swanson, 2003, p. 535). Development of pressure ulcers confer significant morbidity and mortality to the critically ill patient and dramatically increase the cost of a medical bill. Research done at Mount Sinai School of Medicine in New York showed that the “cost of complications directly related to hospital acquired pressure ulcer average $225, 615 per patient” (Chronakos & Nierman, 2003, p. 365). Intensive care unit patients, especially the trauma patients, are among the highest risk groups. Chronakos and Nierman (2003) reported that “The incidence of decubitus ulcers average 10% to 15% in acutely hospitalized patients and increases to 30% to 60% in critically ill patients” (p. 365). Every patient in ICU is potentially at risk for developing pressure ulcers due to immobility, decreased sensory perception, low albumin levels, altered nutrition status and medications. Furthermore, many ICU patients have medical devices such as splints, cervical collars, casts and endotracheal tubes which have the potential to cause skin breakdown. Even though the issue of whether or not pressure ulcers are preventable in an ICU setting remains controversial, evidence-based practice suggests that with a systemic approach, the development of ulcers can be substantially decreased. It is the responsibility of each and every nurse to understand the extent and the cause of this problem so actions can be taken to avoid the complication or to treat it in initial stages when treatment is most effective.
Majority of ICU patients are limited in overall physical mobility, resulting in decreased ability to change their position in bed and thus increasing risk of prolonged and intense pressure. This is especially true for patients who are placed in a drug-induced coma because they are unable to communicate or change their position independently. Another frequently encountered problem in a critical care setting is the use of medications such as anesthetics and sedatives which alter sensory perception. All of these patients are enabled to consciously be aware of the damage being accumulated from pressure buildup; therefore, daily examinations of pelvic, sacral, elbow, scapula and heel areas should be an essential responsibly of a nurse. When soft tissue is compressed between external surface and a bony prominence for an extended period of time, the external pressure exceeds capillary pressure. As a result, blood flow becomes restricted; tissue becomes anoxic and release toxic metabolites causing cell death and formation of a pressure ulcer. Some of the signs that would demonstrate that there is skin breakdown are discoloration, warmth, edema and induration. However, methods that prevent patients from getting pressure ulcers is frequent examination and reposition which are based on research done by Chronakos and Nierman (2003), “cornerstones of care” (p. 365). Moreover, as stated by Chronakos and Nierman (2003), intermittent relief of pressure effectively minimizes tissue damage and can reduce the incidence of decubitus ulcers by seventy five percent (p. 368). For repositioning to be effective, the Pressure Ulcer Prevention Protocol states that patients should be repositioned at least every two hours to help alleviate pressure (Wurster, 2007, p. 269). Furthermore, nurses must be conscious to avoid shear and friction associated with positioning and transferring. Keast, Parslow, Houghton, Norton and Fraser (2007), stated that “shear is the mechanical force that moves the bony structures in direction opposite to the overlaying skin” (p. 455). Therefore, particular attention should be directed in not placing patients directly on femoral trochanter and keeping bony prominences from direct contact with underlying surfaces by using pillows or foam wedges. For example, when the patient’s head is elevated, skin remains fixed against the bed linen but gravity pulls the skeleton towards the foot of the bed, which can cause distortion of capillaries, thrombosis and ischemia. Thus, to avoid injury, the head of the bed should not be elevated greater then thirty degrees. ICU patients present a challenge to this protocol due to the risk of aspiration and ventilator-associated pneumonia. These concerns should be balanced when caring for a seriously ill patient who is at risk for developing both pressure ulcers and aspiration pneumonia. Friction is another important aspect that needs to be considered when addressing pressure ulcers prevention. Friction or rubbing is defined as the force of two surfaces moving across one another, often resulting in abrasion. National Pressure Ulcer Advisory Panel recommends using bed linens to lift patients when turning or transferring to avoid dragging a patient who is physically weak (Chronakos & Nierman, 2003, p. 368). Additional beneficial tools used to reduce pressure are pressure-reducing mattresses, which help distribute weight evenly, specialized cushioning devices, and padding. However, studies done to identify types of mattresses to use for patients did not provide definite results. Though ultimately, it was concluded that “a patient who is judged to be at high risk for decubitus ulcers should not be placed on an ordinary hospital bed” (Chronakos & Nierman, 2003, p. 368).
Proper skin care for patients confined in bed for long periods is vital and must be done correctly. According to Chronakos and Nierman (2003), a moist environment increases the risk of pressure ulcer development fivefold (p. 369). Numerous factors such as fecal incontinence, leaking wounds, fever and perspiration due to higher ambient temperatures in the ICU may increase skin moisture and predispose patients to skin breakdown. In addition, moist skin is at increased risk for irritation, rashes and infections such as Candida. Wurster (2007) states that “skin care must be implemented by using a mild cleansing agent followed by thoroughly rinsing the skin with water” (p. 268). The use of warm water is recommended; dry the skin via patting and avoid using alcohol-based moisturizing agents to minimize drying and irritation. Keast et al. (2007) point out that fecal incontinence is a greater risk for skin breakdown than urinary incontinence because of the chemical irritation that results from the enzymes, which are caustic to the skin (p. 454). Therefore, to decrease the risk of developing an ulcer, the incontinence brief should be changed as soon as it becomes soiled. Frequent change of moist, soiled linen to promote evaporation and faster drying maintains dry, intact skin. Special attention should be given to trauma patients who require the use of cervical collars. Power, Daniels, McGuire and Hilbish (2006) report that “up to 55% of patients in a cervical collar for five days or greater develop skin breakdown” (p. 198). Research supports evidence showing that strict adherence to the standards of care, which include cleaning and assessing skin under the collar every twelve hours and changing the pads in the collar every twenty four hours, decrease the incidence of skin breakdown significantly. Care of wound drainage should be another factor to consider. Keast et al. (2007) recommends using appropriate dressings along with protective creams, ointments, films, and solid barrier sheets, such as hydrocolloids, to protect peri-wound skin from wound drainage (p. 454). When dressings have reached their maximum capacity for absorption they need to be replaced in order to prevent maceration of surrounding tissue. Pouching is also an option to control excessive exudates; if location of the wound permits.
Many ICU patients experience altered metabolism function, resulting in a poor nutritional state. Patients with major trauma, burns, and sepsis are particularly at increased risk for inadequate nutritional intake. An altered metabolism can lead to the loss of subcutaneous tissue, resulting in overexposed bony prominences and poor skin condition. Correction of nutritional deficiencies is very important for maintaining skin integrity. Albumin, the most abundant plasma protein, is responsible for the regulation of blood volume by maintaining osmotic pressure, and keeping the blood fluid from leaking out into the surrounding tissues. Thus, low serum albumin level can lead to interstitial edema which impedes the passage of nutrients from blood to the tissues. Studies have shown a significant correlation between levels of albumin and development of pressure ulcers. Chronakos and Nierman (2003) report that up to 75% of patients with albumin levels below 35g/L developed ulcers versus only 16% of patients with higher albumin levels (p. 367). Therefore, ICU patients must be assessed for nutritional deficiencies and proactive interventions should be implemented before malnutrition becomes severe. Wurster (2007), suggests that because nutrition is such an important element in wound prevention “adequate nutritional intake must be managed either by enteral or parenteral administration” (p. 269).
Pressure ulcers are considered a potentially preventable condition and many guidelines have been standardized and published to facilitate healthcare personnel in administering care. Yet current pressure ulcer prevalence and incidence rates in critical care settings remain unacceptably high and account for many unnecessary deaths. In the twenty first century, a world of advanced technology and medical expertise, pressure ulcers remain a major health care setback. It is believed that if nurses provide excellent quality and quantity of care, the patient outcome will be of a greater satisfaction. Therefore, it is a duty of every nurse to be educated and aware of the signs of tissue breakdown and factors that put patients at risk. Evidence-based practice suggests that with the systemic approach in the prevention of pressure ulcers, nurses can improve patients’ outcome significantly. Therefore, understanding predisposing factors and the principles of pressure ulcer prevention such as alleviating pressure, implementing meticulous skin care, and providing adequate nutritional support in conjunction with the ability to select appropriate devices and equipment are the key factors to a successful prevention and treatment plan.
References
Chronakos, J., & Nierman, D. (2003). Managing pressure ulcers in critically ill patients. Journal of Respiratory Disease, 24(8), 363-371. Retrieved February 5, 2008, from ProQuest database.
Keast, D., Parslow, N., Houghton, P., Norton, L., & Fraser, C. (2007). Best practice recommendations for the prevention and treatment of pressure ulcers. Advances in skin and wound care 20(8), 447-462. Retrieved February 1, 2008, from Ovid database.
Pokorny, M., Koldjeski, D., & Swanson, M. (2003). Skin care intervention for patients having cardiac surgery. American Journal of Critical Care, 12(6), 535-543. Retrieved January 29, 2008, from ProQuest database.
Power, J., Daniels, D., McGuire,C., & Hilbish, C. (2006). The incidence of skin breakdown associated with the use of cervical collars. Journal of Trauma Nursing 13(4), 198-201. Retrieved February 5, 2008, from ProQuest database.
Wurster, J. (2007). What role can nurse leaders play in reducing the incidence of pressure ulcers? Nursing Economics, 25(5), 267-269. Retrieved February 2, 2008, from ProQuest database.
nursing 211- disadvantages
Intervention 1: use of special pressure alleviating mattress beds.
Disadvantage 1: improper use of beds.
One of the interventions for prevention of pressure ulcers is the use of the special pressure alleviating mattress beds. There are numerous types of specialty mattresses such as float foam, water filled, air filled and gel filled (Carroll, 2003, p. 43). These beds provide pressure relief if used properly. Some of the disadvantages include time and knowledge for the medical staff to set it up properly, lack of moisture dissipation, staff injuries trying to move it and the cost of the system. For the bed to be effective it should be properly selected for the individual patient. However, according to Carroll, the type of bed therapy selected is often inappropriate due to the lack of knowledge among nurses and physicians (2003, p.46).
Disadvantage 2: high cost of the beds.
In addition, the cost of treating pressure ulcers with this technology can be very high. The national institute for clinical excellence reported that the individual cost of pressure reliving devices ranges from 1,000 to 30,000 us dollars (Theaker, Kuper, & Soni, 2005, p. 395). Therefore, to ensure quality patient care while reducing the cost of health care and improving patient outcomes, it is the role and responsibility of the nurses to make sure that the proper use of the specialty beds is implemented routinely and consistently.
Intervention 2: meticulous skin care.
Disadvantage 1: lack of knowledge of institution’s policies and protocols for pressure ulcer prevention among nurses.
With today’s critical nursing shortage, providing quality skin care to the patients can be a challenge due to factors such as time consumption and lack of knowledge of institution’s policy and pressure ulcers protocols. According to Zulkowski and Ayello (2007), studies done to assess competence of nurses caring for the patients with pressure ulcers reveal a low level of care knowledge (p.34). Prevention and mattress ordering guidelines were identified as deficient areas. Zulkowski and Ayello state that a recent survey of 694 RNs considered their wound education to be insufficient (2007, p.35). Without knowledge, can patients’ outcomes or practices in wound care prevention be changed? Of course, not. Since high prevalence rates of pressure ulcers have been linked to poor or inappropriate knowledge and education, educational program for the nurses and pressure ulcers protocols of the institutions should be readily available to all the nurses. Research suggests that when a nursing staff is educated about wound care and pressure ulcer prevention a positive change can ensue. (Beitz, Fey, & O’Brien, 2003, p.295).
Disadvantage 2: nursing shortage
Wurster (2006) states that with today’s nurse-patient ratio it is difficult to provide quality skin care due to time consumption (p.4). There are at least 135 different wound care products from cleansers to growth factors and to ensure not to cause patients more detriment, nurses need to know how to properly use it. Furthermore, it is equally important that RNs working in teams with nursing assistants ensure that the implementation of proper treatment is carried out routinely and consistently. With patient acuity and limited staffing due to overwhelming workload this can be a challenge. Therefore, developing a shared vision plan within the specific unit can promote common interests and goals which, ultimately, can lead to inspiration, motivation and accountability.
References
Beitz, J., Fey, J. & O’Brien, D. (October, 2003). Perceived need for education vs actual knowledge of pressure ulcer care in a hospital nursing staff. MEDSURG Nursing 7(5), 293-301. retrieved April 29, 2008, from ProQuest database.
Carroll, P. (November, 2004). Pressure ulcer management: cost-effective prevention and care .American Journal of Critical Care 16(3), 32-43. retrieved march 23, 2008, from Academic Search Premier database.
Theaker, C., Kuper, M., & Soni, N. (2005). Pressure ulcer prevention in intensive care- a randomized control trial of two pressure-relieving devices. Anaesthesia, 60, 395-399. Retrieved march 23, 2008, from ProQuest database.
Wurster, J. (October, 2007). What role can nurse leaders play in reducing the incidence of pressure sores? Nursing Economics 25(5), 267-269. Retrieved March 21, 2008, from CINAHL database.
Zulkowski, K. & Ayello, E. (August, 2007). Certification and education: do they affect pressure ulcer knowledge in nursing? Advances in Wound and Skin Care 20(1), 34-38. Retrieved April 18, 2008, from ProQuest database.