Tips for Protecting Critically Ill Patients From Pressure Ulcers

Abstract

An important focus in critical care units is maintaining circulatory, respiratory, and renal function. Care of critically ill patients also requires interventions that are designed to prevent pressure ulcers, an all-too-common complication of immobility, inadequate nutrition, and illnesses or medications that affect blood flow and perfusion. Pressure injuries may be avoidable when consistent attention is given to assessment, nutrition, and appropriate positioning within appropriate time frames.At least 10 published guidelines for the prevention and treatment of pressure ulcers can be found on the National Guidelines Clearinghouse Web site (www.guideline.gov). A planned repositioning schedule tailored to each individual patient is recommended in all pressure ulcer prevention guidelines. Recently, the National Pressure Ulcer Advisory Panel, in collaboration with the European Pressure Ulcer Advisory Panel, announced updated guidelines for prevention and treatment of pressure ulcers. Each guideline recommendation is supported by a rigorous review of the literature and a strength-of-evidence rating.1The goals in progressive mobility programs, specifically prevention of complications associated with immobility, are aligned with recommended interventions for pressure ulcer prevention. Techniques for progressive mobility can be combined with repositioning techniques recommended for prevention of pressure ulcers.Both progressive mobility programs and pressure ulcer prevention programs involve planned movements with various positioning techniques. With the progressive mobility program, changes in position for bedridden patients can include changes in head-of-bed elevation, continuous lateral rotation, and prone positioning. The patient is then progressed to chair sitting and ambulation. Recommended interventions for preventing pressure ulcers in bedridden patients taken from guidelines for prevention and treatment of pressure ulcers include maintaining the head of the bed at 30° or lower2 to prevent shearing injuries, especially to the sacral area, and complete changes in position using supine positioning and tilted side-lying 30° positions, alternating right, back, and left to ensure that pressure over bony prominences is avoided. Friction and shearing can be avoided when positioning patients by using transfer aids such as slide sheets and slings or by using at least 2 staff members and draw sheets to lift patients. The frequency of positioning, however, should be tailored to individual patients. According to the guidelines from the National and European pressure ulcer advisory panels, patients who are not on pressure redistribution mattresses require more frequent repositioning. Other considerations when positioning patients include using padding between the knees when patients are lying on their side and elevating or “floating” heels off the mattress to avoid pressure on the heels.The idea that all therapy beds prevent pressure ulcers is a common misconception. Actually, the therapy bed is an adjunct to repositioning patients and does not decrease the required frequency of repositioning. The selection of a therapy bed should be tailored to the specific needs of the patient. Goals for pressure ulcer prevention require the selection of a bed that has a pressure redistribution surface such as air bladders, high-density foam, or alternating pressure surfaces. In addition to pressure redistribution, some surfaces also provide low air loss for microclimate management. Bed manufacturers should be able to provide pressure mapping data to aid in appropriate selection of surfaces.Certain products may be designed to provide various turning features. Some beds offer only a “turn assist” that tilts the patient for a short period, thereby helping the caregiver to turn the patient during bathing or incontinence care. Other therapy bed products, usually limited to critical care units or pulmonary care units, may provide turning features that include a preset automatic turn designed to promote improved pulmonary outcomes. Various beds are available with a combination of complications related to pressure ulcer injuries such as sepsis related to wound care, amputations, and countless surgical procedures. Skin over bony prominences can be assessed by taking a quick look while measuring vital signs or performing incontinence care, making it possible to assess skin even more often than every 2 hours. If the patient has an existing pressure ulcer, CLRT can be stopped for a time—for example, up to 30 minutes—so that bolsters, pillows, and positioning features that can meet the needs of patients requiring both pulmonary support and pressure ulcer prevention.DeLaat et al3 described a prospective cohort study conducted in an intensive care unit that demonstrated a sustained reduction in intensive care unit–acquired pressure ulcers as a result of the introduction of a pressure ulcer prevention protocol that was supported by certain nurses who acted as “supporting innovators” of the project. The strongest significant intervention associated with the decrease in incidence of pressure ulcers was identified as the use of pressure redistribution mattresses.3Once an appropriate therapy bed is selected, nurses should avoid layering sheets, pads, diapers, and other items between the patient and the specialty bed surface. Such layering will interfere with the effectiveness of the pressure redistribution surface.4Continuous lateral rotation therapy (CLRT) is designed to support pulmonary toileting; however, not all therapy beds with this feature provide pressure redistribution surfaces such as low airloss surfaces. Even when a CLRT bed provides a pressure redistribution surface, CLRT alone (the right and left rotation of 20° to 40°) may not provide protection from pressure ulcers unless specific interventions for pressure ulcer prevention also are instituted. Even if the CLRT is set for the maximum rotation, the patient never breaks contact with the surface. Nurses must be vigilant, assessing patients’ skin frequently, particularly over bony prominences, for early signs of pressure injuries. Heels must be protected from prolonged pressure whether by the specialty therapy surface or by the use of positioning devices, unless the CLRT bed surface is equipped with air-only bladders designed to prevent heel ulcers.Frequent skin assessments while the patient is on CLRT may enable early detection of potential development of pressure ulcers. CLRT can be stopped for short periods to allow for skin assessments. Erythema can be an early sign of pressure ulcer potential and should trigger a change in the patient’s position whenever possible. Blanchable erythema, also known as reactive hyperemia, can be reversed simply by eliminating pressure for a short period. Such careful vigilance may save patients from months to years of wound care treatments and techniques can be used to offload pressure points and relieve pressure to injured areas. Bolsters and other positioning devices should be removed when CLRT is resumed. Keep in mind that CLRT may be most effective in facilitating optimal pulmonary outcomes when employed for at least 18 hours in a 24-hour period. It is appropriate to use pillows and other positioning devices during the 6 hours of non-CLRT therapy.5–11Even when the patient has progressed to the full upright chair position, important nursing interventions are still required for those patients at risk for pressure ulcers. Clinical guidelines from both the Wound, Ostomy and Continence Nurses Society and the national and European pressure ulcer advisory panels recommend encouraging the patient to shift weight frequently while in a chair. Some patients will require assistance with weight shifting. In addition, assisting a patient to a standing position will help prevent pressure ulcers and meet goals for progressive mobility. Pressure redistribution chair cushions can also be provided, and measures to protect skin from incontinence-associated skin breakdown such as moisture barrier ointments and other skin protective products still should be used. Once the patient is ambulatory, nurses should remain vigilant. Ambulation may begin with a few tentative steps, with the patient quickly returning to the bed or bedside chair, until he or she can tolerate an extended period of mobility.Careful and frequent skin assessments, frequent repositioning, managing moisture, and maximizing nutritional support are common interventions for prevention of pressure ulcers. Progressive mobility techniques and repositioning techniques used to prevent pressure ulcers are designed to promote the best outcomes while preventing dangerous complications.