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Introduction and background. Pressure ulcer (PU) is a localized damaged area of a patient's skin that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time (Reddy, Gill, & Rochon, 2006). They are wounds initiated by pressure on the skin that blocks circulation causing the skin and underlying tissues to die (Cannon, B. & Cannon, J., 2004). Pressure ulcer development is one of the most serious problems in intensive care units with prevalence rates ranged between 4% and 49% internationally (Shahin, Dassen, & Halfens, 2008) and is associated with many serious complications (Marrie et al., 2003). The existence of pressure ulcers causes an increase in the incidence of infections, sepsis and additional surgical procedures, together resulting in increased hospital costs, prolonged lengths of hospital stays, excessive pain and unnecessary suffering in affected patients (Jiricka et al., 1995).
Critically ill patients are at high risk of pressure ulcer development due to multiplicity of factors related to either their illness, or the hospital environment (Brindle, 2010). It was found that the risk of developing PU is to be 50% at 20 days in the ICU (Reilly, Karakousis, Schrag, & Stawicki, 2007). Therefore, preventing and managing PU using the best practice are to be the primary goals in intensive care unit (ICU) (JACHO, 2008). Several PU prevention and management strategies have been developed such as the introduction of skin assessment tools, frequent patients' positioning and using appropriate pressure surfaces (Mimura, Ohura, Takahashi, Kajiwara, & Ohura, 2009). This paper will discuss issues surround evidence support the standard nursing strategies on PU prevention and management in intensive care unit (ICU). It will explore the validity and efficiency of the common risk assessment tools, and will evaluate the effectiveness of patients repositioning and pressure relief surfaces on preventing and managing PUs.
Pressure Ulcer risk factors and validity of the assessment tools
The increased efficiency and quality requirements in modern healthcare require the identification of patients at high risk for PU, and application of best PU prevention and treatment strategies. Several factors increase the risks of PU development within critically ill patients that are considered the main cause of prolonged friction and shears forces, and are usually associated with peripheral neuropathy, spinal cord injury, stroke, cardiovascular instability, and coma from any cause (including medically-induced sedation and/or paralysis) (Reilly et al., 2007). Moreover, many cross sectional studies have identified that body weight, prolonged immobilization, malposition, urinary and bowel incontinence are the strongest relative risk factors for pressure ulcer development (Lardenoye, ThieÂ´ Faine, & Breslau, 2009; Boyle, Green, 2001). Therefore, risk assessment (RAS) might be the first step in pressure ulcer prevention (Moore & Cowman, 2009) using a valid pressure ulcer risk assessment scale and instituting appropriate preventative interventions (Bergman-Evans et al., 1994).
Various risk assessment scales (RASs) have been developed in order to identify which patients are at high risk of developing PU (Reilly et al. 2007). There is evidence that a program of prevention guided by risk assessment can simultaneously reduce the institutional incidence of pressure ulcers by almost 60% and at the same time bring down the cost of prevention (Pancorbo-Hidalgo, Garcia-Fernandez, Lopez-Medina, & Alvarez-Nieto, 2006). The common used RASs are the Norton Scale, Braden Scale, and Waterlow Scale. However, according to some indications the present risk assessment scales do not lead to efficient use and allocation of preventive measures in patient care (Schoonhoven et al., 2002)
The Norton Scale uses five criteria to assess patients' risk for pressure ulcers, including patient's physical condition, mental condition, activity, mobility, and incontinent status (Anthony, Parboteeah, Saleh, & Papanikolaou, 2009). Scores of 14 or less indicate liability to ulcers; scores of <12 indicate very high risk (Pancorbo-Hidalgo et al., 2006). The Braden Scale, which has the best validity and reliability indicators, summarises the risk factors, including sensory perception, moisture, activity, mobility, nutrition, friction, and shear (Anthony et al., 2009). It verifies patients at low risk, moderate risk, high risk, or very high risk depending on the number scored. The Waterlow Scale was designed to guide professionals to plan their preventative and management interventions, and to promote nurses awareness of the risk factors of PU development. It involves the risk areas including; build/weight, continence, skin type, mobility, sex/age, appetite, tissue malnutrition, neurological deficit, surgery/ trauma, specific medication and additional risk factors (such as smoking). The higher the waterlow score, the higher the risk of PU formation, which found to have a good risk prediction capacity and high sensitivity (Gould et al., 2002).
However, many patients in ICU have decreased sensory perceptions, where Braden scale might not be a useful assessment tool to predict PU development (Chronakos & Nierman, 2003). Moreover, it was found that waterlow scale specificity is low, meaning the scale determines as at risk many patients who are not actually at risk, resulting in higher expenditure on preventative measures (Gould et al., 2002), and a cohort study provided further evidence of the poor predictive validity of the Waterlow scale (Webster, Gavin, Nicholas, Coleman, & Gardner, 2010). Shahin et al., (2008) conducted a longitudinal designed study and found that RASs include only a 22% of factors related to pressure ulcer prevalence. Moreover, Shahin et al. reported that there is a significant relationship between incontinence and pressure ulcer development because both have similar lesions occur at the similar site.
Introduction of several RASs raised a clinical issue of whether these tools can replace nurses' judgement on identifying the high risk patients and therefore, improve the prevention strategies' outcomes. Kim, Mi Lee, Lee, & Eom (2009) compared the effect of these tools with ward nurses' clinical judgement on the PU. Kim et al. used the cut off points to assess the validity of available RASs. They suggested that the ideal scale should have satisfies 100% of sensitivity, specificity, applicability and reality, but they found that most used scales are unrealistic in the real clinical practice. The study found that the nurses' clinical judgement was close to the expert opinions and did not match the identified risk assessment scale score.
The effectiveness of RASs in clinical practice can be affected by several factors including; different nurses perception of the interpretation (e.g. good or fair physical condition on Norton score meaning differs than clinical practice), insufficient nursing training and education related tools use guide, which may impact the prevention strategies based on the unreadable score and made those scale useless (Anthony et al., 2009). So, it has been recommended that advanced methods should be developed to evaluate whether exciting RASs are sufficient tools to differentiate between pressure ulcer lesion and incontinence lesion (Kaitani, Tokunaga, Matsui, & Sanada, 2010). It is highly recommended that a new risk assessment scale for predicting pressure ulcers needs to be developed and designed to meet intensive care assessment components (Suriadi et al. 2008). The accuracy of unevaluated scales also found to be difficult to estimate. Comparing the results of studies is also difficult because methods and materials are different and the pressure ulcer classifications used are seldom described. Furthermore, the scales do not take into account the structure of the healthcare organization or the use of preventive devices that have been developed (Lepistö, Eriksson, Hietanen, & Asko-Seljavaara, 2001).
Prevention and management of pressure ulcer
Preventing PU and managing an existing ulcer are usually having similar intervention principles, including; daily assessment, repositioning, use of appropriate support surfaces, (Bluestein & Javaheri, 2008). Although many therapeutic interventions follow same strategy, choosing the best treatment of existed PUs should be according to the ulcer's stage, size, odour, presence or absence of wound infection, patient's age and health status (Reilly et al. 2007).
The first step in managing PUs is by frequent skin inspection for PU assessment and daily monitoring for the wound progress (Kim et al., 2009). Some investigators reported that daily assessment of PU development with an established risk measuring tool better helps nurses to indicate specific risk factors and assists them with decisions on the frequency and method of PU precautions and treatment strategies to be taken (Weststrate et al., 1998). Careful examination should start on the day of admission of patients to detect early stages of disease are imperative (Bluestein & Javaheri, 2008).
Turning patients regularly to reduce interface pressures and prevent pressure ulcers is considered a standard nursing care to prevent PU development (Defloor et al. 2005; Vanderwee et al. 2007). Defloor et al. (2005) suggested that this intervention enhances maintaining the skin-support surface interface pressure below a capillary closing pressure of 32 mmHg, which is expected to reduce pressure ulcer risk. Turning patients highly recommended because it stimulates blood circulation, removes or redistributes pressure from a part of the body, and to improve skin integrity in critically ill patients (Defloor et al. 2005).
For years, nurses have been advised to turn their patients at least every 2 hours as a "golden standard" to prevent the tissue breakdown but there was no evidence of whether this strategy is enough to prevent PU development (Salcido, 2008). An experimental study evaluated the effective at patient's turning for preventing PUs (Vanderwee et al., 2007). Vanderwee et al. found that 2 hours and 4 hours patients' repositioning were statistically significant and have no difference in the incidence of grade II-IV pressure ulcers. They suggested that more or frequent turning does not necessarily lower pressure ulcer incidence. Moreover, Peterson et al. (2010) examined the effects of turning on skin-bed interface pressures and found that peri-sacral area, which is one of the high risk areas, were not significantly affected by lateral turning but in the elevated turned positions the result was statistically greater than their corresponding supine and laterally turned positions.
Frequent reposition is a core nursing intervention for immobilised patients with PUs, as an integral component of a pressure ulcer management strategy (Krishnamoorthy, Morris, & Harding, 2001). Patients repositioning is important to relief sustained pressure that obstructs the capillary flow to the affected area and to enhance tissue oxygenation required for wound healing (Moore, 2010). However, certain positioning techniques may increase the severity of the existed ulcers. For example, a 90-degree lateral rotation, which is used during bed rest, may exacerbate existed PU situation and cause complete tissue anoxia, which is a condition characterized by an absence of oxygen supply of the weight-bearing area, and this cause further tissue damage (Krapfl & Gray, 2008). The proper patient position might promote wound healing. Vanderwee et al. (2005) found that PU wound healing was facilitated by the frequent patients repositioning compared with PU conditions of un-mobilised patients. Even so, a recent systemic review reported that there is no evidence of whether repositioning makes any difference to PU healing (Moore, 2010).
Pressure varies according to weight and surface area tolerance; in terms of the wider the area of weight distribution, the less pressure will be exerted at one point (Reilly et al., 2007). Thus, using of a proper pressure relieving surface is a recommended strategy for PU prevention (Reilly et al., 2007). Examples of pressure-relieving devices include static overlays and pressure-reducing mattresses that are made of or contain gel material, foam, water, or air (EPUAP, 2010). However, several studies compared the effectiveness of these devices on PU preventions found that pressure relieving mattresses do not prevent PUs but it could reduce the severity of the developed ulcers (Malbrain et al., 2010 & Theaker et al., 2005).
Malbrain et al., (2010) conducted a single blinded RCT and allocated ICU patients into two types of pressure relief mattresses; ROHO (the manually inflatable reactive low pressure mattress), and NIMBUS3 (the fully automatic active alternating pressure mattress). Patients were managed using standard nursing PU prevention protocol, reposition protocol, and followed by a wound nurse specialist. Malbrain et al. found that in NIMBUS 3, 82% of PU improved, while 18% remained unchanged, and there was a significant decrease of PU surface area (-2.1 cm Â± 23). In contrast, it was found that in ROHO group a 33% of PU remained unchanged (P= NS), 67% deteriorated (P= 0.006), and two patients developed deep sacral PU. However, despite the standard nursing interventions for PU prevention accompanied by the use of the two pressure surface devices, patients were still developed PU in this study.
A recent introduced strategy involves applying of a prophylactic dressing to prevent the skin breakdown might be an effective way to prevent PU development in high risk patients (Brindle, 2010). A total of 41 patients at high risk of PU were involved in a trial of using a unique prophylactic dressing as an alternative PU prevention strategy (Brindle, 2010). Brindle introduced the use of a self absorbent, soft silicone self adherent foam dressing that is applied on the patients sacrum and heel to prevent PU formation. Although this trial was underpowered sample size, the result showed a significant PU prevention compared with other types of pressure relief surfaces. This study raised an interested PU prevention strategy by applying a prophylactic product, which reduces the skin breakdown and showed no side effect or patients' discomfort. This strategy might be considered useful and clinically applicable but it is necessary to be tested in a large sample size in order to prove its efficacy.
Pressure-relief devices may reduce tissue pressure to less than the capillary closing pressure of 32 mm Hg, which can be used to minimise tissue damage caused by shear forces and promote tissue perfusion for wound healing (Bluestein & Javaheri, 2008). However, using pressure surfaces devices should be in corporate with the standard nursing interventions to optimise high quality of care. An RCT conducted to determine whether APAM (a mattress generates alternating high and low interface pressure between the body and support), is more or equally effective as the standard nursing prevention strategy, which is turning and repositioning the patients, and minimizing moist and frictions(Vanderwee, Grypdonck, & Defloor, 2005). Vanderwee et al. allocated the patients either to the experimental group (APAM) or to the control group (the standard prevention). Results showed that more heel ulcers in the control group (14.5% vs 45.7%, P value = 0.006), while experimental developed more sacral ulcers (73.5% vs 53.5%). It was noticed that this study do not provide sufficient evidence to determine whether pressure devices are effective for preventing heel PU. However, the result can be used as an indication that pressure tolerating devices alone are not effective enough to prevent or manage pressure ulcers and nurses are still highly required to use their knowledge and skills to improve their patients' outcomes (Ã-zdemir & Karadag, 2008).
Preventing and managing PUs within critically ill patients is difficult due to the contributing factors associated with their severity of illness. Successful achievement of this goal is a signal sign of good nursing quality of care. PU prevention and management interventions are usually share similar fundamental strategies. Appropriate patient's assessment to identify high risk patients or to assess the degree of the existed PUs, patient repositioning and pressure relief devices are the standard of nursing care. Validity and efficiency of this standard have been raised and several contrasted issued have been explored. Critical care nurses should be qualified enough to use their skills and scientific knowledge to predict the high risk cases and to develop their planned intervention that reflects their high standard of nursing quality of care.