Skin and Wound Care

Evidence-Based
Prevention of Pressure
Ulcers in the Intensive
Care Unit
KAREN L. COOPER, RN, MSN, CCRN, CNS, WOCN

The development of stage III or IV pressure ulcers is currently considered a never event. Critical care patients
are at high risk for development of pressure ulcers because of the increased use of devices, hemodynamic instabil-
ity, and the use of vasoactive medications. This article addresses risk factors, risk scales such as the Norden,
Braden, Waterlow, and Jackson-Cubbin scales used to determine the risk of pressure ulcers in critical care
patients, and prevention of device-related pressure ulcers in patients in the critical care unit. (Critical Care
Nurse. 2013;33[6]:57-67)

T
he development of hospital-acquired pressure ulcers is a great concern in health
care today. Pressure ulcer treatment is costly, and the development of pressure ulcers
can be prevented by the use of evidence-based nursing practice. In 2008, the Centers
for Medicare and Medicaid Services announced that they will not pay for additional
costs incurred for hospital-acquired pressure ulcers.1 The development of a stage III or
IV pressure ulcer is now considered a never event.2 This change has resulted in an increased focus
on preventive strategies and institutional scrutiny of pressure ulcers that develop in patients after
hospital admission. The cost of 1 stage III or IV pressure ulcer may be between $5000 and $50000.2
The actual cost of pressure ulcers is not known because it is unclear what costs were included in
estimates, such as nursing care costs, material costs, and added acute care days related to the devel-
opment of a pressure ulcer.3 In the intensive care unit (ICU), patients have multiple factors that
increase the risk of pressure ulcers developing. Typically the patient has respiratory equipment,
urinary catheters, sequential compression devices, multiple intravenous catheters, and the infusion
of vasoactive agents for hypotension that may contribute to inability to turn patients and increase
the risk of pressure ulcer development. This article discusses the multiple risk factors present in
critical care for the development of pressure ulcers, current practices, and evidence for interven-
tions aimed at preventing pressure ulcers.

CNE Continuing Nursing Education

This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:

1. Identify factors that place critically ill patients at increased risk for pressure ulcers
2. Describe the pressure risks associated with commonly used devices in the critical care setting
3. Apply evidence-based strategies for the prevention of pressure ulcers in critical care patients

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 Table 1 Classification of pressure ulcers

Classification Description
Stage I Nonblanchable area of redness over a bony prominence. If a stage I pressure ulcer is suspected, the nurse
should reevaluate the reddened area at the next skin inspection or turning activity to determine if the red-
ness is still present. Reactive hyperemia is a common condition that occurs with localized tissue pressure
such as occurs when legs are crossed, and normal tissue colors returns when the pressure is relieved. If
the reddened area is still nonblanchable, it should be considered to be a stage I pressure ulcer.
Stage II Partial-thickness skin loss (limited to the epidermis) that may be described as a clear fluid-filled blister or
shallow wound with a pink-red wound base.
Stage III Full-thickness wound, loss of the epidermis, and invasion into the dermis. Stage III pressure ulcers do not
involve loss of muscle, nor do they expose tendon, muscle, or bone tissue. In body areas that do not have
subcutaneous fat layers such as the ears, nose, scalp, or malleolus, pressure ulcers that appear to be par-
tial thickness should be considered a stage III pressure ulcer (Figure 1).
Stage IV Full-thickness loss of the epidermis and dermis and extension into muscle layers. Bone, tendon, and muscle may
be exposed. If cartilage, bone, or tendon is exposed in body areas that do not have layers of subcutaneous
fat such as the ear, nose, scalp, or malleolus, the wound should be classified as a stage IV pressure ulcer.8
Unstageable Ulcers in which the wound bed is covered with eschar or slough. Eschar is a hard, thick, black, brown, or
tan scablike covering of the wound. Slough is a white, tan, gray, or green tissue or mucuslike substance
covering the wound bed8 (Figure 2).
Deep tissue injury A bluish or purple area of discoloration over an area of pressure or shear that may also be described as a
blood-filled blister.
Kennedy terminal ulcer An ulcer that rapidly develops into a full-thickness wound. A pear, butterfly, or U-shaped ulcer in the sacrum,
or a very small stage I or II area that rapidly progresses to a stage III or stage IV ulcer within hours.

Incidence of Pressure Ulcers in ICUs malleolus, or ears, the lack of subcutaneous fat layers
Multiple studies of the prevalence and incidence of pres- makes progression of pressure ulcers from stage II to
sure ulcers have been done. Prevalence studies involve a stage III or IV a concern (Figures 1 and 2). A new classifi-
snapshot of current pressure ulcers in a given unit on a cation, deep tissue injury, is now included. Suspected
given day.3 Typically, the hospital assesses all patients skin deep tissue injury is described as a bluish or purple area
to determine if each patient exhibits the physical signs of of discoloration over an area of pressure or shear that may
a pressure ulcer, and if so, the pressure ulcer is staged. The be difficult to discern in patients with dark skin. It may
incidence of pressure ulcers indicates the number of patients also appear as a blood-filled blister. Deep tissue injury
in whom pressure ulcers develop in a given health care may develop into a full- or partial-thickness pressure ulcer.8
setting.3 Multiple studies1,4-7 show that the incidence of The depth of injury in a suspected deep tissue injury may
pressure ulcers in the ICU ranges from 10% to 41%. not be evident at the time of identification. This injury
may resolve or develop into a stageable pressure ulcer.
Classification of Pressure Ulcers (Table 2 lists websites offering additional information
The National Pressure Ulcer Advisory Panel (NPUAP) and pictures of pressure ulcers.)
revised its pressure ulcer classification in 20078 (Table 1). In 1989, Karen Lou Kennedy, RN, CS, FNP, first described
Previously, pressure ulcers were classified as stage I through a pressure ulcer seen in terminal patients receiving long-
stage IV, or as unstageable. In areas such as the heels, scalp, term care. This ulcer is a rapidly progressing pressure
ulcer seen in terminal patients with hours or days before
Author
death.9,10 The Kennedy terminal ulcer is not currently
described in national or international pressure ulcer
Karen L. Cooper is a clinical nurse specialist at Sutter Auburn Faith
Hospital in Auburn, California. guidelines, but critical care nurses should be aware of
Corresponding author: Karen L. Cooper, RN, MSN, CCRN, CNS, WOCN, Sutter Auburn Faith
this ulcer classification as a potentially unpreventable
Hospital, 11815 Education St, Auburn, CA 95602 (e-mail: [email protected]). pressure ulcer that may be seen in patients in whom death
To purchase electronic or print reprints, contact the American Association of Critical- is imminent. The Kennedy terminal ulcer is most often
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. seen in patients admitted to the ICU from long-termcare

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 facilities. I have seen 2 rapidly developing pressure ulcers
with the butterfly pattern in patients with septic shock
who died within hours of admission to the ICU.

Pressure Ulcer Risk Assessment Scales

Multiple risk factor scales have been developed, but
they do not reflect the additional risk factors present in
the ICU. The most common risk scales used in the United
States are the Braden Scale and the Norton Scale. These
2 pressure ulcer risk scales are recommended by the
Agency for Health Care Policy and Research.11 The most
common pressure ulcer risk scales used in Britain are the
Waterlow and Braden Scales.12 The Jackson Cubbin Risk
Assessment Score is a pressure ulcer risk tool specific to
European critical care units (Table 3).
Figure 1 Stage III pressure ulcer on heel. Other studies of risk factors have examined comor-
bid conditions such as diabetes and peripheral vascular
disease, score on the Acute Physiology and Chronic
Health Evaluation, ICU length of stay, presence of
mechanical ventilation, use of sedatives, and the use of
instruments to measure the pressure at the interface
between bed and patient.13-18 Unfortunately, the inde-
pendent and dependent variables in these studies do not
point to a single predictor for pressure ulcers in the
intensive care environment. Researchers have also stud-
ied patients mobility and risk for pressure ulcer develop-
ment. Progressive mobility protocols decrease the risk of
pressure ulcers developing, but do not address the
inability of patients to follow a progressive mobility pro-
tocol owing to hemodynamic instability or other physi-
Figure 2 Pressure ulcer with eschar and slough on heel. cal restraints.19 Prolonged stays in the ICU are related to
increased incidence of pressure ulcers, but study variables

Table 2 Websites providing information on pressure ulcers

Website Key information

http://www.npuap.org/resources.htm Pictures of various pressure ulcer stages
Quick reference guide to evidence-based prevention
Quick reference guide for treatment
http://woundconsultant.com/sitebuilder/staging.pdf Pictures of pressure ulcer stages
http://www.slideboom.com/presentations/82699/Test-Your-Pressure-Ulcer-Staging-Skills Self-test of staging pressure ulcers
http://emedicine.medscape.com/article/1293614-overview Pictures of pressure ulcers
History and assessment factors
Causes of pressure ulcers
Nonsurgical treatment options for pressure ulcers
http://www.bedsorefaq.com/what-is-a-kennedy-terminal-ulcer/ Picture and information on Kennedy terminal ulcer
http://www.kennedyterminalulcer.com/ Pictures for purchase only
Current information on Kennedy terminal ulcer

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 Table 3 Comparison of variables considered in various scales used to assess risk of pressure ulcers
Braden scale Norton scale Waterlow scale Jackson Cubbin scale
Sensory perception Physical condition Sex Age
Moisture Mental status Age Weight
Activity Activity Build Skin condition
Mobility Mobility Appetite Mental status
Nutrition status Continence Nurses visual assessment of skin condition Mobility
Friction/shear Mobility Nutrition
Continence Respiration
Factors contributing to tissue malnutrition Continence
Neurologic deficits Hygiene
Major surgery or trauma Hemodynamic status
Medication

do not discriminate if increased length of stay is due to the Friction and shear may remove epidermal layers and make
patients acuity or lack of bed availability in an appropri- the skin more vulnerable to injury and pressure effects.
ate lower level of care. Duration of mechanical ventilation Advanced age and nutritional deficiency also contribute to
is also associated with increased risk of pressure ulcer risk for pressure ulcer development.24 Elderly persons have
development.20-22 less subcutaneous fat, decreased dermal thickness, and
Variables in acuity in ICUs and lack of definitive stud- decreased sensory perception. These factors makes elderly
ies addressing use of mechanical ventilation, vasoactive patients prone to more rapid tissue injury and less likely to
medications, respond to tissue cues to change position. Poor nutritional
In addition to pressure, moisture,
and mobility status causes a decrease in protein and renders tissue more
friction, and shear contribute to the
affect the results susceptible to the effects of pressure24 (Table 4).
development of pressure ulcers.
in studies of Pressure on bony prominences such as the coccyx,
pressure ulcer development. Even if the opinion is that a trochanters, heels, and occiput have traditionally been
particular scale overestimates risk, it still identifies that the minimized by using turning schedules every 2 hours and
patient is at risk and encourages the use of preventive meas- elevating patients heels off of the mattress; however, the
ures to prevent pressure ulcers from developing.23 Research 2-hour repositioning regimen is not based on scientific
does show that increased nursing care directed at preven- study.3 It is suggested that the patient be turned every 2
tion decreases the development of pressure ulcers.20,21,23 hours to alternating lateral and supine positions. The
patients body should be turned laterally 30 and the head
Individual Risk Factors and Strategies for of the bed elevated no higher than 30 to prevent pressure
Prevention of Pressure Ulcers on the coccyx.24 This position may promote ventilator-
Pressure ulcers occur over bony prominences. The most associated pneumonia in intubated patients and patients
common areas for pressure ulcers include the sacrum, coc- receiving enteral feeding. To prevent ventilator-associated
cyx, heels, and ear.1,4 In addition to pressure, moisture, fric- pneumonia, it is suggested that the head of the bed be
tion, and shear contribute to the development of pressure elevated higher than 30.25 Frequently, intubated patients
ulcers.3 Pressure over a bony prominence causes tissue are restrained or treated with sedatives to prevent removal
ischemia in the skin, muscle, and the fascia between the skin of the endotracheal tube. Such precautions prevent the
surface and bone. The pressure compresses small vessels patient from changing position, and if the patient is also
and prevents both supply of oxygen and nutrients at the hemodynamically unstable, he or she may not tolerate
capillary interface as well as venous return of metabolic lateral position changes.
wastes. Metabolic wastes accumulate and cause local vasodi- In addition, patients with femoral sheaths, intra-
latation, which contributes to edema, which further com- aortic balloon pumps, and low blood pressure have restric-
presses small vessels and increases edema and ischemia. tions in repositioning and mobility. For these patients, it
Local tissue death then occurs, resulting in a pressure ulcer. may be necessary to use preventive measures to decrease
Moisture contributes to maceration, which may make epi- pressure between the mattress and the patient. Low-air-
dermal layers more vulnerable to breakdown from pressure. loss mattresses and pressure redistribution mattresses

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 Table 4 Risk factors for pressure ulcer development

Factor Effect
Risk scale score Higher scores indicate increased risk
Pressure Increased duration of pressure causes local tissue ischemia, edema, and ultimately
tissue death
Immobility Promotes unrelieved pressure on affected bony prominences
Moisture Contributes to maceration of epidermis, which makes tissue more vulnerable to pressure
Enzymes in fecal material can erode epidermal layers
Friction/shear Removes epidermal layers, reducing the number of layers protecting dermal tissue
Nutrition Decreased protein alters oncotic pressure and makes tissue prone to edema
Advanced age Decrease in subcutaneous fat, decreasing protection from pressure effects
Sensory deficits decrease cues to change position
Low blood pressure (hemodynamic instability) Increases local tissue responses
Duration of mechanical ventilation Indicates need to provide ventilation and oxygen
Decreased oxygen levels in arterial blood indicate decreased oxygen to tissue
Vasoactive medications Decreased blood pressure indicates decreased perfusion to tissues
Vasoactive medications to improve blood pressure increase vasoconstriction and may
decrease perfusion of distal tissues such as skin
Length of stay in intensive care unit Duration of critical illness is associated with pressure ulcer development because of
inability of the patient to change position, increased shear forces from sliding down
in bed while on bed rest

are often used in these high-risk patients. Most studies

of alternative mattress surfaces such as low-air-loss and
pressure redistribution mattresses compare the spe-
cialty surface and regular hospital mattresses. Although
manufacturers for both types of surfaces suggest that their
surface is superior, no studies have shown that low-air-
loss or pressure redistribution mattresses are superior.26
Pressure redistribution mattresses have not been shown
to decrease pressure on the heel, and heel elevation with
pillows or heel lift boots must be used with this therapy11,26
(Figure 3). Low-air-loss mattress replacement surfaces
are useful in patients with exudate or excessive moisture
Figure 3 Pressure redistribution device.
as the air loss through the mattress surface acts to dry
skin surfaces. Air fluidized beds without head-of-bed ele-
vation are used in the treatment of stage III and stage IV should not be plastic-backed because the plastic blocks
pressure ulcers and may be helpful in preventing pressure air flow and retains moisture. Certain populations of
ulcers in very high-risk patients.24 For all mattress surfaces, patients are not appropriate for low-air-loss mattresses,
the manufacturers recommendations must be followed. for example, patients receiving mechanical ventilation
When low-air-loss mattresses or mattress replace- with an oscillator or patients with unstable spinal frac-
ment therapy is used, the use of traditional linens is not tures. These patients need to be on a static mattress sur-
recommended. The use of bed linens and plastic-lined face. Many critical care beds provide pulmonary rotation
(nonbreathable) pads prevents the drying effects of or turn assist. Critical care nurses must be knowledgeable
low-air-loss therapy because air flow is blocked. In addi- about the therapies provided by the bed used and should
tion, the use of bed linens contributes to wrinkles in the not assume that rotation therapy makes positioning the
sheets, which may contribute to pressure. Underpads patient every 2 hours unnecessary.

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 Patients heels are particularly prone to both pressure
and shear. When in contact with the bed surface, heels
are prone to pressure ulcers. With maneuvers to raise
the patient in bed, the heels are also prone to the effects
of shear forces if not lifted off of the bed during move-
ment. Methods to reduce risk of pressure ulcers on the
heel include the use of pillows and heel lift boots. When
using pillows, it is important to ensure that the heel is
not in contact with the mattress (Figure 4). If a heel lift
boot device is used, it is important to ensure that the Figure 4 Heel elevated off mattress by using pillows.
device is properly applied. Not only must the heel be
properly placed, but the straps securing the device must
be properly applied to prevent development of pressure
ulcers (Figure 5). Ensure that the manufacturers recom-
mendations regarding appropriate sizing of the device
are followed. The heel must be centered in the device
properly (this may be difficult in patients who are able
to move the lower extremities). The straps that secure
the boot must not come in contact with skin surfaces or
they may cause constriction and pressure, which can
promote the development of pressure injury.
Nutrition is another identified criterion for pressure
ulcer risk. Patients who are malnourished have more
bony prominences and are therefore at greater risk for
Figure 5 Heel lift device.
pressure ulcers. A low albumin level is an indicator of
malnutrition (normal levels, 36-52 g/L). Prealbumin lev-
els (normal level, 16-35 mg/dL) may be a reflection of
current nutritional status. Albumin or prealbumin levels Device-Related Pressure Ulcers
should be assessed routinely (weekly or biweekly) to Approximately 10% of pressure ulcers are device
indicate trends in the adequacy of nutrition therapy. related.1 Unfortunately, no studies have addressed partic-
Decreasing or low serial albumin or prealbumin levels ular devices (eg, endotracheal tubes, tracheostomy tubes,
should alert the intensive care nurse to inform the physi- or fecal containment devices) and their impact on the
cian or nutritionist of the potential need to alter current development of pressure ulcers in the ICU.
nutrition Intubated patients are at risk for nontraditional pres-
Patients who are malnourished have more therapy. sure ulcers related to the endotracheal tube and the devices
bony prominences and are therefore at Nurses used to secure the endotracheal tube. Endotracheal tube
greater risk for pressure ulcers. should pressure can cause pressure ulcers on a patients lips
identify (Figure 6). Failure to follow manufacturers recommen-
patients upon admission for nutrition status and advo- dations for endotracheal securement devices may result
cate for the earliest possible nutrition supplementation. in the development of pressure ulcers. Most manufactur-
Ensuring adequate nutrition is particularly difficult in ers of endotracheal tube fastening devices recommend
patients receiving vasopressors because the vasoconstric- that use be restricted to patients who do not have facial
tive action of vasopressors constricts the gastric mucosa, edema, lip edema, or protruding teeth. The package
preventing absorption of nutrients. In addition, enteral insert for the Hollister Anchor Fast endotracheal tube
nutrition often causes loose stools. If patients are unable securement device suggests that the endotracheal tube
to indicate the need for a bedpan, they must rely on fre- be repositioned every 2 hours.27 The references noted in
quent nursing assessment of continence status. the package insert do not specifically identify the device

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but are based on general 2-hour positioning schedules to
prevent development of pressure ulcers.27
Cervical collars are another device that increases the
risk for pressure ulcer development at contact points on
the chin, shoulder, and ear. In studies of trauma patients
with cervical collars, longer duration of collar use was
associated with increased risk of pressure ulcer develop-
ment. Use of cervical collars for more than 5 days is asso-
ciated with a 38% to 55% risk of pressure ulcers
developing.28 Rigid collars made of foam or plastic are
associated with a higher risk of pressure ulcer develop-
ment than are padded collars.28 Padded collars such as
the Aspen or Miami cervical collar may prevent pressure Figure 6 Endotracheal tube securement device.
ulcer development if used appropriately28 (Figure 7). The
manufacturers guidelines should be used to ensure proper
sizing and cleansing of removable padding. The neck is
particularly prone to sweating, and moisture may macer-
ate skin and make it vulnerable to pressure. When padded
collars are used, it is advisable to order an extra set of
pads to replace used pads after cleansing so that they can
completely dry. The skin surfaces under the collar should
be visualized by the nurse according to hospitals policy
to determine if redness indicating pressure is present. If
redness is present, the patient should be evaluated for
appropriate size and application of the cervical collar.
Tracheostomy tubes also have the potential to con-
tribute to pressure ulcer development, especially for
patients receiving mechanical ventilation. Turning and posi-
Figure 7 Padded cervical collar.
tioning may cause tension on tubing, which can promote
displacement of the faceplate of the tracheostomy tube or
cause movement of the tube. Faceplate pressure may cause development of pressure ulcers at the points where the
pressure ulcers over the bony prominence of the clavicles(s) mask touches the patients face. These masks both have
at the sternal junction. The risk for pressure is higher when pressure points over the ears from the straps, and partial
the tracheostomy tube is still sutured because the tra- masks have pressure points over the nasal prominence.
cheostomy dressing cannot be easily inserted. Secretions Although no published studies have described preventive
from the stoma site and tracheostomy tube may collect measures other than making sure that the straps are not
under the tube and promote maceration of the skin. After too tight, alternating a partial face mask (Figure 8) with a
the sutures are removed, if a patient has excessive secretions full face mask (Figure 9) may be helpful in preventing
from the stoma, a foam dressing may be used to absorb exu- further skin breakdown. Other strategies to prevent pres-
date and prevent pressure from the faceplate. To prevent sure ulcer development on fragile nasal skin include the
pressure caused by ventilator tubing from causing torque on use of foam dressings to decrease pressure. Thin foam
the tracheostomy tube, place a rolled towel under ventilator dressings may be helpful as they not only decrease pres-
tubing near the connection to the tracheostomy tube so sure but also prevent air leaks that may compromise oxy-
that the tubing does not deflect downward, causing ten- genation. Hydrocolloid dressings do not relieve pressure,
sion and thus deflecting the faceplate downward. but they do reduce friction and shear.
Bilevel positive airway pressure and continuous positive Rigid transfer boards may produce shear injuries
airway pressure masks also predispose patients to the because the patient slides over a rigid surface. Multiple

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 Figure 8 Partial bilevel positive airway pressure (BiPAP) mask. Figure 10 Ergo Nurse device.

effort and shear forces on the patient. When the patient

is transferred and repositioned, the mattress is deflated
and the patient is turned from side to side to remove the
deflated mattress. The Ergo Nurse is a rigid frame with
straps that are connected to bar connectors for the
patients bed sheets. When the bed is lowered, the patient
is lifted and can be repositioned up in bed or from side
to side, preventing friction or shear injuries (Figure 10).
The Ergo Nurse device is also available in bariatric size.
Slip or slide sheets are made of material that slides over
bed surfaces and does not have edges or a rigid surface
that can cause friction or shear. There is no evidence
that one product is superior to another.
Fecal incontinence can contribute to skin breakdown
because of the enzymes present in fecal matter.5,29 Enzymes
in and the pH of fecal matter may act in conjunction
with moisture to promote skin maceration and epider-
mal erosion. Topical skin barriers assist in providing a
Figure 9 Full bilevel positive airway pressure (BiPAP) mask.
barrier between moisture and skin; however, frequent
cleansing because of diarrhea reduces the effectiveness
ergonomic products are available to prevent shear effects of the skin barrier. Fecal containment devices are an
during transfer and repositioning of patients. Among effective way to prevent skin damage due to moisture
these products are the Hover Matt (HoverTech Interna- and enzyme action on perianal tissues. Indwelling fecal
tional), Ergo Nurse (Ergonurse Inc), and slip sheets. The containment devices include products such as the Flexi-
Hover Matt is a lateral transfer device that uses an inflat- Seal (ConvaTec Inc), Actiflo (Hollister Global), and Zassi
able mattress that enables the patient to float on the mat- (Zassi Medical Evolutions Inc) devices. Topical fecal
tress during transfer. Use of this device reduces nursing containment pouches are also available. Appropriate

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 Table 5 Risk factors and interventions to prevent pressure ulcers
Who is at risk? Interventions
Identification of risk Use a risk-identification scale each shift to identify which patients are at risk
Devices Become familiar with the manufacturers recommendation for devices used in your unit
(endotracheal securement devices, bilevel and continuous positive airway pressure masks,
heel lift devices, mattresses)
Ensure that tubing and devices are not placed between skin surfaces; make sure ventilator tubing
is not causing tension on tracheostomy tube and faceplate
Friction/shear Is your unit using appropriate lift and turning devices?
Use assistive devices that reduce friction and shear; ensure the appropriate number of staff are
present to lift/turn patient
Pressure Consider the use of pressure-relief devices including specialty mattress surfaces, padded cervical
collars, heel lift devices, and pillows
Moisture Use skin barrier creams, topical or indwelling fecal containment devices
Nutrition Identify patients at risk and promote feeding at the earliest time possible; request specialty
mattresses as soon as risk is identified
Vasoactive medications, patient Provide a specialty mattress to reduce skin interface pressure
unable to be turned every 2 hours
Comorbid conditions that contribute Flag the patient at risk and use critical thinking to determine appropriate therapy: heel lift device,
to pressure ulcer formation specialty mattress, device
Quality assurance Identify unit-specific statistics
Track prevalence and report to staff
Celebrate decreases in occurrence
Identify best practices
Contribute to critical carespecific research in pressure ulcer prevention and risk

application and use of these devices may prevent pres- prevalence of pressure ulcers are particularly helpful in
sure ulcers from developing by preventing skin contact preventing pressure ulcers in patients.31-33
with fecal enzymes and moisture.29 Unit-based performance activities include teaching
nursing staff how to identify risk factors and how to
Bariatric Patients stage pressure ulcers, but the most important aspect of
Bariatric patients present a unique challenge to criti- the quality initiatives appears to be in communicating
cal care nurses and may be at increased risk for pressure the effectiveness of the therapy in terms of success in
ulcers because of moisture in skin folds, device pressure, days without pressure ulcer development.31-33
and inability to perform position changes due to issues Unit-based quality initiatives that document the num-
related to staffing and appropriate equipment.30 Bariatric ber of days that have passed between occurrences of
patients may be at higher risk for development of pressure hospital-acquired pressure ulcers are one way to commu-
ulcers because adipose tissue typically has a decreased nicate this
blood supply compared with muscle tissue and the increase success in Skin inspection should occur on each shift
in weight increases pressure on tissues. Adhering to man- preventing or more often in patients at risk of pressure
ufacturers guidelines for the use of equipment as well as pressure ulcer development.
using appropriate equipment and sufficient personnel ulcers from
for repositioning and lifting patients should assist in developing. Using a 2-nurse handoff report and assess-
reducing risk. ment on admission and shift change, which includes
conducting a skin assessment, reinforces individual
Use of Preventive Measures accountability in interventions to prevent development
Many recently published quality improvement arti- of pressure ulcers. These activities are a demonstrated
cles indicate that unit-based quality assurance projects quality tool for identifying pressure areas before they
that identify effectiveness of preventive measures and become stage I or greater pressure ulcers.32-34 Heightened

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awareness of patients risk for pressure ulcers and unit population. Int Wound J. 2010;7(1):28-40.
5. Ozedemit H, Karadag A. Prevention of pressure ulcers a descriptive study
pride contribute to highly effective preventive measures in 3 intensive care units in Turkey. J Wound Ostomy Continence Nurs.
(Table 5). Critical care nurses have the unique challenge 2008;35(3):293-300.
6. Nijs N, Toppets A, Defloor T, Bernarts K, Milisen K, Van Den Berghe G.
of identifying the appropriate interventions to prevent Incidence and risk factors for pressure ulcers in the intensive care unit.
J Clin Nurs. 2008;18:1258-1266.
pressure ulcer development and ensuring that they are 7. Bours G J, DeLaat E, Halfens R J, Lubbers M. Prevalence, risk factors
knowledgeable about the manufacturers recommenda- and prevention of pressure ulcers in Dutch intensive care units. Intensive
Care Med. 2001;27:1599-1605.
tions for devices used in the care of the patient. The 8. National Pressure Ulcer Advisory Panel. Pressure Ulcer Category/
Staging Illustrations. 2007. http://www.npuap.org/pr2.htm. Accessed
Institute for Clinical Systems Improvement suggests that September 17, 2013.
upon admission a risk assessment and skin assessment 9. Milne CT, Corbett CQ, DuBuc LQ. Wound, Ostomy and Continence Nursing
Secrets. Philadelphia, PA: Elsevier Health Sciences; 2003.
be performed, existing wounds be documented, and 10. Schank JE. Kennedy terminal ulcer: the ah-ha ! moment and diagnosis.
treatment goals be established.34 If a patient is at risk for Ostomy Wound Manage. 2009;55(9):40-44.
11. Jastremski CA. Pressure relief bedding to prevent pressure ulcer devel-
pressure ulcers or has an existing pressure ulcer, appropri- opment in critical care. J Crit Care. 2002;17(2):122-125.
12. Whiteing NL. Skin assessment of patients at risk of pressure ulcers.
ate referrals to nutrition services and wound care special- Nurs Stand. 2009;24(10):40-44.
ists should be initiated. Hospital protocols for prevention 13. Suriadi H S, Sugama J, Thigpen B, Subuh M. Development of a new risk
assessment scale for predicting pressure ulcers in an intensive care unit.
of pressure ulcer development, which should include Br Assoc Crit Care Nurs. 2008;13(1):34-43.
14. Manzano F, Navarro MJ, Roldan D, et al. Pressure ulcer incidence and risk
pressure relief, moisture management, and nutrition factors in ventilated intensive care patients. J Crit Care. 2010;25(3):469-476.
support, should be instituted. Skin inspection should 15. Keller PJ, Wille J, van Ramshorst B, van der Werken C. Pressure ulcers
in intensive care patients: a review of risks and prevention. Intensive Care
occur on each shift or more often in patients at risk of Med. 2002;28:1379-1388.
16. Frankel H, Sperry J, Kaplan L. Risk factors for pressure ulcer development
pressure ulcer development. in a best practice surgical intensive care unit. Am Surg. 2007;73:1215-1217.
17. Lindquist LA, Feinglass J, Martin GJ. How sedative medication in older
people affects patient risk factors for developing pressure ulcers. J Wound
Further Research Needed Care. 2003;12(30):272-275.
18. Jiricka MK, Ryan P, Carvallo, MA, Bukvich J. Pressure ulcer risk factors
Critical care nurses have many opportunities to develop in an ICU population. Am J Crit Care. 1995;4(5):361-367.
and produce studies on the prevention and treatment of 19. Reilly EF, Karakousis GC, Schrag SP, Stawicki SP. Pressure ulcers in the
intensive care unit: the forgotten enemy. Opus 12 Scientist. 2007;1(2):17-30.
pressure ulcers. Further research is needed to study the 20. Compton R, Hoffmann F, Straub M, Frey J, Zidek W, Schafer JH. Pressure
ulcer predictors in ICU patients: nursing skin assessment versus objective
prevalence of device-related pressure ulcers and effective parameters. J Wound Care. 2008;17(10):417-424.
nursing measures to prevent development of pressure 21. Defloor T, Grypdonk MF. Validation of pressure ulcer risk assessment
scales: a critique. J Adv Nurs. 2004;48(6):613-621.
ulcers. Research regarding vasoactive medications, pres- 22. Pender LR, Frazier SK. The relationship between dermal pressure ulcers,
sure ulcer risk scales appropriate to critical care nursing, oxygenation and perfusion in mechanically ventilated patients. Int Crit
Care Nurs. 2005;21:29-38.
and appropriate interventions also are needed. CCN 23. Griffiths P. How good is the evidence for using risk assessment to prevent
pressure ulcers? Nurs Time. 2010;106(14):10-13.
Financial Disclosures 24. Bryant RA, Nix DP. Acute and Chronic Wounds. St Louis, MO: Mosby,
None reported. Inc; 2007.
25. Augustyn B. Ventilator associated pneumonia assessment and prevention.
Crit Care Nurs. 2007;27:32-39.
26. Junkin J, Gray M. Are pressure redistribution surfaces or heel protection
devices effective for preventing heel pressure ulcers? J Wound Ostomy
Now that youve read the article, create or contribute to an online discussion Continence Nurs. 2009;36(6):602-608.
about this topic using eLetters. Just visit www.ccnonline.org and select the article
you want to comment on. In the full-text or PDF view of the article, click
27. Hollister Inc. Anchor Fast [package insert]. Libertyville, IL: Hollister
Responses in the middle column and then Submit a response. Inc; 2009.
28. Ackland HM, Cooper JD, Malham GM, Kossmann T. Factors predicting
cervical collar related decubitus ulceration in major trauma patients.
Spine. 2007;32(4):423-428.
29. Benoit RA, Watts C. The effect of a pressure ulcer prevention program
To learn more about preventing pressure ulcers, read Patient- and the bowel management system in reducing pressure ulcer prevalence
in an ICU setting. J Wound Ostomy Continence Nurs. 2007;34(2):163-175.
specific and Surgical Characteristics in the Development of Pres- 30. Charlebois D, Wilmoth D. Critical care of patients with obesity. Crit Care
sure Ulcers by Tschannen et al in the American Journal of Critical Nurse. 2004;24(4):19-27.
Care, March 2012;21:116-125. Available at www.ajcconline.org. 31. Ballard N, McCombs A, DeBoor S, et al. How our ICU decreased the rate
of hospital acquired pressure ulcers. J Nurs Care Qual. 2008;23(1):92-96.
References 32. Uzun O, Aylaz R, Karadag E. Prospective study reducing pressure ulcers
1. VanGilder C, Amlung S, HarrisonP, Meyer S. Results of the 2008-2009 in intensive care units at a Turkish medical center. J Wound Ostomy Con-
International Pressure Ulcer Prevalence Survey and a three year acute tinence Nurs. 2004;36(4):404-411.
care unit specific analysis. Ostomy Wound Manage. 2009;55(11):39-55. 33. Crumbley DR, Kane MA. Development of an evidence-based pressure
2. Lyon KC. High-tech/high-touch team-centered care provides best out- ulcer program at the National Naval Medical Center: Nurses role in risk
comes for wound prevention in critically ill patients. Crit Care Nurs Q. factor assessment, prevention and intervention among young service
2010;33(4):317-323. members returning from OIF/OEF. Nurs Clin North Am. 2010;45:153-168.
3. Clay KS. Evidence-Based Pressure Ulcer Prevention, A Study Guide for Nurses. 34. Perry D, Borchert K, Burke S, et al. Institute for Clinical Systems Improve-
2nd ed. Marblehead, MA: HCPro Inc; 2008. ment. Pressure Ulcer Prevention and Treatment Protocol. January 2012.
4. Campbell KE, Woodbury MG, Houghton PE. Implementation of best https://www.icsi.org/_asset/6t7kxy/PresUlcerTrmt-Interactive0112.pdf.
practice in the prevention of heel pressure ulcers in the acute orthopedic 2012. Accessed September 17, 2013.

66 CriticalCareNurse Vol 33, No. 6, DECEMBER 2013 www.ccnonline.org

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CNE Test Test ID C1363: Evidence-Based Prevention of Pressure Ulcers in the Intensive Care Unit
Learning objectives: 1. Identify factors that place critically ill patients at increased risk for pressure ulcers 2. Describe the pressure risks associated with
commonly used devices in the critical care setting 3. Apply evidence-based strategies for the prevention of pressure ulcers in critical care patients

1. Which of the following describes why there is increased concern over the 8. Which of the following should be considered when selecting a mattress to
development of hospital-acquired pressure ulcers (HAPUs)? reduce the risk of pressure ulcers?
a. There is little that can be done to treat a pressure ulcer once it occurs. a. Low-air-loss mattresses are beneficial for patients with excessive moisture.
b. Medicare and Medicaid Services will not pay for costs associated with a HAPU. b. Air fluidized beds are preferred for patients receiving mechanical ventilation.
c. Development of a stage I or II pressure ulcer is now considered a never event. c. Mattresses with pressure redistribution are considered superior to low-air-loss
d. The established cost of a pressure ulcer is more than $50 000 per event. surfaces.
d. Rotational surfaces eliminate the need for turning.
2. Which of the following factors does not specifically place critically ill patients
at increased risk for pressure ulcers? 9. Which of the following indicates an increased nutritional risk for development
a. Presence of multiple devices and equipment of pressure ulcers?
b. Infusion of vasoactive agents for hypotension a. An admission albumin level of 38 g/L
c. Length of time receiving mechanical ventilation b. Initiation of enteral nutrition
d. Increased incidence of urinary incontinence c. A decreasing trend in prealbumin levels
d. Infusion of vasodilators
3. Which of the following statements correctly describes deep tissue injury?
a. The injury always progresses to a full-thickness pressure ulcer. 10. Which of the following statements is true regarding device-related pressure
b. This classification excludes superficial blood blisters. ulcers?
c. The injury appears as a bluish or purple discoloration over an area of pressure. a. They account for approximately 10% of pressure ulcers.
d. The depth of the injury is clearly apparent at the time of identification. b. They only occur when the manufacturers directions are not followed.
c. They occur more frequently with endotracheal tubes than other devices.
4. The Kennedy terminal ulcer describes which of the following? d. They have been well-defined in a number of research studies.
a. A nationally recognized ulcer that is unique to the critical care setting
b. A rapidly progressing ulcer seen in terminal patients just before death 11. Which of the following interventions is recommended to reduce pressure
c. A chronic ulcer that develops primarily in long-term care facilities ulcers in patients with medical devices?
d. A preventable ulcer generally associated with patients in septic shock a. Repositioning of the endotracheal tube every 4 hours
b. Removing cervical collars every shift to perform a thorough skin assessment
5. Which statement is true regarding the 4 most common pressure ulcer risk c. Supporting ventilator tubing to prevent torque on the tracheostomy tube
assessment scales? d. Applying hydrocolloid dressings on the face to reduce pressure from continuous
a. None of the scales fully reflect the additional risk factors present in ICU patients. positive airway pressure/bilevel positive airway pressure masks
b. All of the scales are recommended by the Agency for Health Care Policy and Research.
c. Only the Waterlow Scale specifically addresses hemodynamic instability. 12. Bariatric patients are at higher risk for pressure ulcers because of which of
d. The Braden Scale is most effective for assessing risk in critically ill patients. the following?
a. Prolonged need for mechanical ventilation
6. Which of the following statements does not describe the pathophysiology b. Decreased blood supply to adipose tissue
underlying the development of pressure ulcers? c. Impaired gastrointestinal absorption of nutrients
a. Compression of vessels prevents the supply of oxygen and nutrients to the tissues. d. Increased reluctance to perform position changes
b. Metabolic wastes accumulate at the tissues, leading to further vasoconstriction.
c. Moisture contributes to maceration, making the skin more vulnerable to pressure. 13. Which of the following is true regarding unit-based quality improvement
d. Friction and shear may remove epidermal layers, making the skin vulnerable to injury. projects for pressure ulcer prevention?
a. They have little impact on pressure ulcer outcomes.
7. Positioning strategies to prevent pressure ulcers include which of the following? b. They focus primarily on teaching staff how to stage ulcers.
a. Turning patients every 4 hours c. They are effective in heightening staff awareness of pressure ulcer risk.
b. Maintaining the head of bed at an elevation greater than 30 d. They help identify staff who are not following hospital policies.
c. Elevating patients heels off the mattress
d. Avoiding the supine position whenever possible

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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qb qb qb qb qb qb qb qb qb qb qb qb qb
qc qc qc qc qc qc qc qc qc qc qc qc qc
qd qd qd qd qd qd qd qd qd qd qd qd qd
Test ID: C1363 Form expires: December 1, 2016 Contact hours: 1.0 Pharma hours: 0.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 10 correct (77%)
Synergy CERP Category A Test writer: Joni L. Dirks, RN-BC MS CCRN

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Evidence-Based Prevention of Pressure Ulcers in the Intensive Care Unit
Karen L. Cooper
Crit Care Nurse 2013;33 57-66 10.4037/ccn2013985
2013 American Association of Critical-Care Nurses
Published online http://ccn.aacnjournals.org/
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