Page 136 - ACCCN's Critical Care Nursing

Essential Nursing Care of the Critically Ill Patient 113

factors that need to be considered and monitored prior
to and during procedures for pressure prevention. TABLE 6.8 Risk of pressure sores from commonly used
Skin assessment for pressure should be scheduled at least equipment
daily and include a review of pressure relieving devices
for effectiveness or requirement for change. Skin assess- Risk factor Comments
ment should include testing for blanching response
and checking for areas of oedema, induration, redness or Endotracheal tubes The ETT should be repositioned from one
corner of the mouth to the other on a
(ETTs)
localised heat. 42 daily basis to prevent pressure on the
same area of oral mucosa and lips. Care
Pressure ulcer prevention practices include alternating the should also be taken when positioning
use of pressure-relief mattresses, low-pressure mattresses and tying ETT tapes: friction burns
and air-flow mattresses. 42,73 For bariatric patients (usually may be caused if they are not secure;
those heavier than 150 kg), specialist beds and mattresses pressure sores may be caused if they are
are required. too tight (particularly above the ears
and in the nape of the neck). Moist
Intensive care patients are at risk of pressure ulcers and tapes exacerbate problems and harbour
injury from a number of devices in everyday use, such as bacteria.
endotracheal tubes and blood pressure cuffs (see Table Oxygen saturation Repositioning of oxygen saturation probes
6.8). Close attention to detail with frequent observation probes 1–2 hourly prevents pressure on
of the patient, the patient’s position, and the presence potentially poorly perfused skin. If using
ear probes, these must be positioned
and location of equipment is required to prevent skin on the lobe of the ear and not on the
damage. It is important to remove aids such as compres- cartilage, as this area is very vulnerable
sion stockings and cervical collars to assess the skin. Vul- to pressure and heat injury.
nerable patients, such as those with poor tissue perfusion, Blood pressure Non-invasive blood pressure cuffs
anaemia, oedema, diaphoresis and poor sensory per- cuffs should be regularly reattached and
42
ception can develop pressure ulcers relatively quickly, repositioned. If left in position without
and pressure ulcers caused by equipment are entirely reattachment for long periods of time
they can cause friction and pressure
avoidable. damage to skin. Care should be taken
All pressure points and any pressure ulcers should be to ensure that tubing is not caught
under the patient, especially after
monitored closely. The key areas of monitoring are iden- repositioning.
tified in Table 6.9, and it is important to use standardised
methods to objectively assess pressure ulcers and their Urinary catheters, The patient should be checked often to
ensure that invasive lines are not
central lines and
response to therapy. If a patient develops one pressure wound drainage trapped under the patient. In addition
ulcer, there is a good chance he/she could develop to causing skin injury, they may function
another. Nursing intervention includes the placing of ineffectively.
patients in positions that avoid pressure on the affected Bed rails Limbs should not press against bed rails;
area(s), employing measures such as good fluid manage- pillows should be used if the patient’s
ment to improve tissue perfusion, reducing the risk of position or size makes this likely.
infection and promoting tissue granulation with the use Oxygen masks Use correct-size mask and hydrocolloid
of appropriate dressings. protective dressing on the bridge of the
nose to assist with prevention of
The International NPUAP–EPUAP Pressure Ulcer Classi- pressure from non-invasive or
42
fication System grades pressures ulcers as follows: continuous positive airway pressure
masks, especially when these are in
● Stage I: Non-blanchable redness of intact skin constant or frequent use.
● Stage II: Partial thickness skin loss or blister
● Stage III: Full thickness skin loss (fat visible) Splints, traction Devices such as leg/foot splints, traction
and cervical
and cervical collars can all cause direct
● Stage IV: Full thickness tissue loss (muscle/bone collars pressure when in constant use and
visible) friction injury if they are not fitted
properly. ICU patients often have rapid
The use of standardised tools to both assess pressure risk body mass loss (especially muscle)
and stage pressure ulcers is vital to effective continuity of following admission, so daily
care. Treatment of pressure ulcers is complex and based assessment is required.
on individual patient factors, however the main issues
include:

● protecting tissue from further damage with pressure Practice tip
re-distribution techniques
● preventing infection either localised or systemic by It is worthwhile knowing the key features of the beds and mat-
closely observing the ulcer for signs of infection such tresses commonly used in your area so that you can use them
as friable, oedematous, pale or dusky tissue effectively to match patient requirements for bed functions,
● aiding wound healing such as use of negative pressure bed type (e.g. bariatric suitability) and pressure prevention (e.g.
wound therapy for deep ulcers or foam and alginate high, medium or low risk mattress systems).
dressings to control heavy exudate. 42