Prevention of Pressure Ulcers in Critically Ill Patients

PICO Clinical Question

In hospitalized critically ill patients, how does turning and repositioning patients every 2 to 4 hours compared to the use of pressure-redistributing support surfaces prevent pressure ulcers from occurring?

• P: Hospitalized critically ill patients
• I: Turning and repositioning the patient every two to four hours
• C: Pressure redistributing support surfaces
• O: Prevent the occurrence of pressure ulcers

Introduction

In today’s healthcare, development of pressure ulcer during patients’ in-hospital stay is one of the major concerns. Management of the issue is expensive and subjects the patient to additional pain and discomfort. Such a circumstance also prolongs patient’s hospital stay and recovery process and increases the work of caregivers. This problem became worse in 2008 after the Centres for Medicare and Medicaid Services announced that they will no longer pay for the extra hospital cost incurred due to pressure ulcers. Critically ill patients have an increased risk of developing this condition because they are likely to experience loss of consciousness and thus, inability to move (Cooper, 2013).

The situation for critically ill patients with hemodynamic instability is further worsened by the several equipment and devices on them, such as respiratory equipment and catheters, which contribute to the inability to turn them. In these settings, nurses have the sole responsibility to use evidence-based practice to prevent pressure ulcers from developing (Cooper, 2013). This paper answers the above PICO clinical question by comparing the use of pressure redistributing support surfaces and turning and repositioning patients as interventions to prevent the development of pressure ulcers.

Recommended Change in Practice

Turning and repositioning of patient should be performed regularly in patients who are immobile. Most of the frequently used positions are lateral, prone or semi-fowlers. Patients, who suffer pain, have an increased risk of developing pressure injuries since they avoid moving. The nurse must ensure proper pain management so that turning will not cause any discomfort. They should also turn and reposition the patient regardless of the surface on which they are lying. It is important for the nurse to take care of the bony prominences, such as the pelvis, along with elbows, heels, and ankles. Massaging these sites ought to be avoided and rather pressure care can be introduced. Consulting a physiotherapist is important during the implementation and evaluation of turning and positioning (Cooper, 2013).

Turning and repositioning, unlike pressure redistribution, is manual and requires sufficient nurse’s and caregiver’s engagements. With the advent of technology, there have been innovations, including continuous lateral rotation therapy and alternating pressure beds. These equipment-related changes in patients’ positions in bed automatically. Such inventions help to reduce the effort and time needed to turn patients in bed manually. However, they are not as effective as the manual turning because they do not remove the pressure from the skin at any given time (Cooper, 2013).

On the other hand, pressure redistribution makes use of unique surfaces and devices. The strategy puts into consideration the fact that the whole pressure cannot be removed from the patient and that relieving pressure from one point of the body only increases it in another point. Therefore, pressure redistribution is a more reasonable goal of care as compared to its total elimination. The use of support devices and surfaces is the primary method used for pressure redistribution. These surfaces are modified to reduce interface pressure by increasing the surface area of the body that is in contact with support surface, or alternating the body part. The means in this category include beds, mattresses, seat cushions, and overlays. On the other hand, pressure redistribution devices help to redistribute the body weight. These devices are filled with foam gel or air (McInnes et al., 2011). Regardless of using these devices, there is still a need to turn the patient regularly. Before deciding on which device to use, caregiver must do a thorough assessment of the patient and establish the level of risk. Patients with hemodynamic instability are in a high-risk group. Other factors to consider are the patient’s level of mobility and their comfort. The nurse may have to consult an occupational therapist when using these devices. It is also not advisable to improvise the effects of these devices. For example, nurses often use water-filled gloves under the heel and ankles (McInnes et al., 2011).

Although turning and repositioning has been the mainstay in the prevention of pressure ulcers, many facilities are slowly embracing the use of pressure redistribution devices and surfaces. Collins, Kleckner and Sparks (2015) recommend the use of both methods to promote effective prevention of pressure ulcers. As mentioned before, while turning and repositioning the patient, it may be necessary to relieve pressure from bony prominences by using pressure redistribution devices. Similarly, patients on pressure surfaces and devices may still benefit from turning and repositioning. According to Brindle et al. (2013), in addition to pressure prevention, turning and repositioning helps in the early mobilization of bedridden patients, prevention of pneumonia, and post-operative fever and makes it positions changes more tolerable for patients.

Evaluation Strategies and Outcome Measures

Evaluation strategies and outcome measures are important in patient care as they enable health care providers to compare the care they provide and the results, determining the efficacy of the care. Evaluation is a part of the nursing process and, after every nursing care and management, it is important to evaluate the condition of the patient. Turning and repositioning the patient and use of pressure redistribution devices are both interventions put in place to prevent the occurrence of pressure ulcers. The first step in the evaluation strategies is the inspection of patients’ skin during every shift and more frequently applied for patients with increased risk of developing pressure ulcers. By performing this option, developing ulcers can be easily identified and proper interventions put in place. Such a circumstance will also help to assess whether the existing practice is effective when patients exhibit no signs of pressure ulcers on each assessment (Niederhauser et al., 2012).

The next strategy for evaluation and outcome measurement is proper documentation. First, any occurrence of pressure ulcers should be thoroughly recorded and documented. The patient’s biographical data, condition, duration of stay in hospital, and the prevention strategy must all be indicated by the nurse. In this way, every case can be easily studied and any similarities noted so that adjustments can be made in the nursing care. Other helpful documents can include records of the number of days that have passed without any cases of pressure ulcers in the particular ward or department. Such documents will clearly show the staff whether their actions are successful or not. This approach may also act as a motivation for more acute care to prevent pressure injuries (Niederhauser et al., 2012).

Conclusion

Pressure ulcers are a great nuisance in the care for critically ill patients. Although the analyzed frameworks can be used on their own, when combined, turning and repositioning patients and using pressure redistribution devices have more efficacy in preventing the development of pressure ulcers. Critical care nurses have the primary role to play in preventing pressure ulcers by not only providing proper nursing care but also developing and producing more studies on the topic.