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Introduction

A pressure ulcer can be described as a site of localized damage to the skin and the fundamental tissue caused by pressure, cut, rubbing and/or a mixture of these (EPUAP, 2003). Although it is typically preventable, pressure ulcers are frequently unfavorable events and correspond to a very serious health problem, not only in terms of patient morbidity and mortality but also in terms of health resource consumption (Grave 2005). The incidence of pressure ulcers (the number of the most recent cases anticipated yearly) is up to 5% in acute care hospitals (Evans 1995) and as high as 13% in long-term care services (Bennett 2004). Though, the regular account of the prevalence of pressure ulcers (the number of cases within a population throughout a definite era of time) differs widely (Clark 2002). The

European Pressure Ulcer Advisory Panel (EPUAP) accounted that an overall pressure ulcer occurrence rate of 18.1% from a sample of 5000 hospitalized patients in five European countries, ranging from 8.3% in Italy to 22.9% in Sweden (Clark 2002). Bours et al. accounted that 13.2% incidence rate of pressure ulcers in university teaching hospitals in the Netherlands range from 7.8-21% (2002). Data on the occurrence of pressure ulcers in acute hospitals in the Republic of Ireland are little, with only two studies in the literature accounting for the occurrence rates of 15% and 12%, correspondingly (Moore 2000).

On the other hand, it is complicated to precisely evaluate the results of such studies because of differences in methods. The risk factors and preventive approaches for the advancement of pressure ulcers are well-established (Lyder 2003). As a result, the incidence of pressure ulcers is rapidly becoming a quality of care assessment both in hospital and long-term care settings. It is significant to repeatedly review practice in terms of prevention, treatment and incidence of pressure ulcers (NICE 2005). But, to correctly explain the meaning and evaluate results of pressure ulcers it is necessary that reliable methodologies be utilized.

The growing utilization of innovative perception into the pathophysiological foundation of the development of pressure ulcers increases new questions for pressure ulcer researchers. For example, studies with laboratory animals have established that pressure ulcers are built up as a consequence of recurring ischemia-reperfusion events, in which poisonous oxygen-derived free radicals are formed (Houwing and Overgoor, 2000). This theory is supported by the discovery that oral management of antioxidants can be useful in avoiding the incidence of pressure ulcers (Frias Soriano et al., 2004). Regular review of pressure ulcer incidence, prevention and administration have a very significant role to play in increasing responsiveness about hospital-acquired pressure ulcers with the vital aim of making the most of patient care.

Pressure ulcers are widespread in acute and long-term care. The treatment and prevention of pressure ulcers spend large amounts of resources in terms of throwaway equipment and nursing time (Defloor and Grypdonck, 2005). Moreover, pressure ulcers have been explained as one of the most expensive and physically exhausting complications in the 20th century (Burdette-Taylor and Kass, 2002). Pressure ulcers are the third most costly disorder after cancer and cardiovascular diseases (A Health Council of the Netherlands: Pressure Ulcers, 1999). In adding up, about 5760% of all pressure ulcers take place within hospitals (Thomas, 2001). Up to 13% of patients develop pressure sores while being treated in an intensive care (Hunt, 1993). Though, seriously ill patients typically have numerous risk factors for the development of pressure ulcers (Peerless et al., 1999). The advancement of pressure ulcers requires considerable morbidity of critically ill and incapacitated patients (Eachempati et al., 2001). Patients in numerous intensive care units (ICUs) are sedated and ventilated and consequently incapable to move or care for themselves. Movement is usual protection to pressure, but this defense is gone during a critical illness due to conditions such as anemia, renal impairment, shock or vascular failure (Lowery, 1995).

Urinary and fecal incontinence have been quoted as risk factors for pressure ulcers, with fecal incontinence being the better predictor of pressure ulcer development (Clever et al., 2002). Furthermore, patients with fecal incontinence have more than 20 times the risk of pressure ulcers than continent patients (Shahin et al, 2009). Incontinence increases the risk of pressure ulcers by causing substance irritation and producing an extremely moist environment. Excoriation and maceration can take place even after a short period of incontinence (Calianno, 2000). So, actions focusing on the skincare of patients with incontinence are suggested to lessen the occurrence of pressure ulcers on the sacrum and ischium (Lowery, 1995). Also, there is a frequent misunderstanding between a pressure ulcer and a lesion caused by moisture which can be an effect of incontinence of urine and/or bowel (Shahin et al, 2009). As a result, the distinction between the two lesions is clinically significant because prevention and treatment procedures differ mostly. Wound distinctiveness such as causes, shape, depth, edges and color is useful to distinguish between a pressure ulcer and a moisture lesion (Defloor et al., 2005).

In order to find out the result of risk factors or to assess the efficiency of detailed precautionary intervention, incidence measurements are indicated (Halfens and Bours, 2002). Incidence has been described as assessing the number of persons developing new pressure ulcers during a period of time (EPUAP, 2002). There are only a few incidence studies regarding pressure ulcers in intensive care units, though it is a widespread difficulty in ICUs in different countries (Shahin et al, 2009). In Texas, Fife et al. (2001) establish a pressure ulcer incidence rate of 12.4% in neurological ICU. In Rotterdam, Weststrate et al. (1998) reported an incidence rate of 7.9% in surgical ICU. In Wales, Boyle and Green (2001) described a rate of 5.2% and in India, Wolverton et al. (2005) found a rate of 13.7% in general ICU. Furthermore, Brown (2003) discovered that 33.3% of ICU patients died 30 days after the onset of full-thickness pressure ulcers and 73.3% had died after 1 year. Though, incidence studies are more appropriate for giving perceptions regarding the factors connected to the advancement of pressure ulcers in intensive care than prevalence studies. The extent of pressure ulcers in intensive care cannot be determined precisely by prevalence studies since patients are frequently admitted to ICU with existing pressure ulcers (Shahin et al, 2009). Furthermore, evaluating the progress of pressure ulcers following admission to ICU can assist to discover whether pressure ulcers could be healed or whether they worsen to a higher grade (Shahin et al, 2009).

Research questions

What is the frequency of pressure ulcers in intensive care patients?
Which factors (avoidance, management or patient characteristics) are associated to pressure ulcer occurrence in intensive care patients?
What is the progress of pressure ulcers before admission to an intensive care unit?

Materials and methods

Design

In a longitudinal study design each patient was evaluated twice: leading to admission and upon discharge or death or after 2 weeks if the patient was still in the ICU (Shahin et al, 2009).

Instruments

A survey was developed including questions concerning the patient demographics, pressure ulcer incidence, grades, body sites of pressure ulcers, extent, and causes, kinds of dressing and protective measures (Shahin et al, 2009). The grading system of the European Pressure Ulcer Advisory Panel (EPUAP) was employed and stated as the following by Defloor and Schoonhoven (2004)

The consistency and clinical usefulness of EPUAP were tried, which discovered a kappa level of 0.308 with the conformity of 85.7% (Pedley, 2004). In addition, the inter-rater concurrence and accurateness of response using the EPUAP and Stirling scale was tried and the reliability was highest for the EPUAP scale (61.9% of cases) in contrast to 30.2% for the Stirling scale (Russell and Reynolds, 2001) In addition, the Braden scale was used to evaluate the risk of developing pressure ulcers. The prognostic strength of the Braden scale has been tested in more than one health care setting, which exposed that risk measurement with the Braden scale upon admission and is extremely predictive of pressure ulcer development in all settings (Bergstrom et al., 1998).

The second instrument was the APACHE II (Acute Physiology and Chronic Health Evaluation) which is used to evaluate the intensity of illness (Rao and Suhasini, 2003).

APACHE II is one of the most often used instruments for result prediction in adult critically ill patients (Rao and Suhasini, 2003). The capability of APACHE II to forecast hospital death was tested in 2795 patients from interdisciplinary intensive care units in a period of 3 years (Shahin et al, 2009). It revealed an acceptable prediction of 84.3% and an area under the receiver operating characteristic (ROC) curve of 0.832 (Rainer et al., 2000).

Sample

Shahin et al (2009) demonstrate that of 103 patients from two hospitals (53 from the university hospital and 50 from the general hospital) declined to partake in the study, while 121 patients (67 from the nephrological ICU of the university hospital and 54 from surgical and cardiological ICU of the general hospital) volunteered to partake in the study.

The cause for non-response was the incapability to read and sign the informed permission, a few accepted to take part but declined to sign the consent (Shahin et al, 2009). Furthermore, families of comatose patients did not want their patients to take part in the study because they did not know whether their patients would agree or not.

Data collection

Shahin et al, (2009) trained two assistants (ICU nurses), one in each hospital. The researcher explained in detail with the assistants when and how the patients were to be evaluated and how the research instruments were to be used. In addition, pictures and descriptions of each pressure ulcer grade and information on how to distinguish between pressure ulcer lesions and other lesions resulting from urine or bowel incontinence were given to each assistant (Defloor and Clark, 2005). Every nurse filled out the questionnaire for pressure ulcers instantly after patient evaluation and the APACHE II score was also filled out by the same nurse using the patients file. The outline of APACHE II scores at admission and at discharge was computed.

The mean of the outline was used to explain the distinction between patients with and without pressure ulcers. The data were collected from April until October 2006 (Shahin et al, 2009).

Ethical consideration

Consent to carry out the study was acquired from the medical ethical committee. Previous to data collection, informed consent was obtained from conscious patients, and agreement was obtained from relatives of comatose patients (Shahin et al, 2009).

Data analysis

The data were examined using the Statistical Package of Social Science (SPSS) version 13. The determined incidence was supported on the EPUAP definition (EPUAP, 2002): incidence = (new pressure ulcer/patients at risk) ×100. The distinctions between the groups of patients with pressure ulcers and without pressure ulcers were illustrated using patients numbers, percentage, mean and standard deviation regarding the factors gender, age, body mass index, Braden score, the severity of illness (APACHE II score), length of stay, unconsciousness, urinary catheter at admission and patients with a pressure ulcer at admission (Shahin et al, 2009).

Results

The entire sample study of Shahin et al (2009) of 121 patients was composed of 56.2% males and 43.8% females. Twenty-three (19%) patients of the sample were comatose. The means length of stay for all patients was 7 days (S.D. ± 8.6 days), while the length of stay for patients with new pressure ulcers was 9.5 days (S.D. ± 5.1 days). The outcomes also discovered a total incidence of 3.3%, which was 4.5% for the nephrological patients and 2.9% for the surgical patients, whereas none of the cardiologic patients developed a pressure ulcer. Additionally, 16 patients had a pressure ulcer at admission. The highest pressure ulcer grade was grade 2 (Shahin et al, 2009).

Body sites of pressure ulcers and duration

The most frequent body sites of pressure ulcers among those patients who were admitted with an existing pressure ulcer were sacrum, heel and ischium. However, shoulder, sacrum, heel and ear were the preferred sites of newly developed pressure ulcers. The duration of 71.4% of existed pressure ulcers at the time of the admission to the ICU was unidentified, while 19% had developed within 2 weeks. Additionally, 25% of new pressure ulcers had developed in patients who stayed less than 1 week in ICU, whereas 75% of them developed in patients who stayed more than 1 week and less than 2 weeks in ICU (Shahin et al, 2009).

The course of pressure ulcers after admission to an intensive care unit shows that 16 patient with a total of 21 pressure ulcers were admitted to intensive care unit (Shahin et al, 2009). Additionally, four persons developed six new pressure ulcers during their stay in the ICU, and five ulcers in four patients were healed during patients stay in ICU (Shahin et al, 2009). Moreover, one pressure ulcer grade 1 worsened to grade 2 and one pressure ulcer grade 3 worsened to grade 4. Also, grade 2 was the highest pressure ulcer grade upon admission (9 ulcers) in eight patients, upon discharge (12 ulcers) in eight patients and two patients developed four new pressure ulcers grade 2. Shahin et al (2009) shows a total of 16 patients having pressure ulcers at admission whereas adding the numbers in the collum would result in 17 patients having pressure ulcers at admission. However, one patient is listed twice because of having two ulcers (grades 2 and 3). Therefore the total patient score was adjusted to 16. Shahin et al (2009) shows that three of the healed pressure ulcers in two patients were grades 1 and 2 ulcers in two patients were grade 2. Moreover, all healed ulcers were those of females, whose age ranged from 63 to 83 years, and all patients were overweight (BMI e 25). No change in the intensity of the illness from the time of admission to the time of discharge was found, except in one patient (Shahin et al, 2009).

Prevention

This study of Shahin et al (2009) shows that foam mattresses were used for 43%, typical mattresses for 23% and irregular air pressure mattresses were used for 33% of the patients.

One patient had a low air loss bed. Heel and elbow guards and artificial sheepskin were not used at all throughout their study. The most commonly applied precautionary nursing care procedures were skin assessment with 89.3%, mobilization with 79.3% and massage with 40.5%. Avoiding inadequate nutritional and fluid intake was a gauge used for 21.5 % of the ICU patients. The outcomes extend beyond to a definite degree because some nursing measures were merged.

Treatment

Shahin et al, (2009) show that no dressing was used for the majority of the patients who undergo pressure ulcers, while hydrocolloid was the dressing most usually used for patients who had pressure ulcers.

Incontinence supplies

Eighty-six patients (71.1%) had a urinary catheter and 45 (37.2%) patients had plastic linen. Urine collectors were used for 14 (11.6%) patients (Shahin et al, 2009). Other incontinence supplies were seldom used and ranged from 0.95% to 6%. All patients who developed a new pressure ulcer were catheterized and three of them had plastic linen. Shahin et al, (2009) show some differentiation between patients with new pressure ulcers and patients without pressure ulcers about gender, age, Braden score, and severity of illness, length of stay, unconsciousness and catheterization at admission. Furthermore, there are also a number of clear dissimilarities between patients with pressure ulcers at admission and patients without pressure ulcers about gender, age, overweight, Braden score <14, and urinary catheterization at admission (Shahin et al, 2009).

Discussion

Incidence

The results of the study of Shahin et al (2009) disclose that a lower pressure ulcer incidence compared to other studies. The uppermost incidence was established in the nephrological specialty, whereas no pressure ulcers developed in the cardiologic specialty. The result of the study by Shahin et al (2009) can give details to the short period of patients stay in an intensive care unit. In addition, the structures of the hospitals contributing to this study did not take in the recovery and intermediate wards. As a result, all surgery patients were admitted to the ICU, even though they only stayed there for a short period of time (23 days). Moreover, some patients had not been in fact seriously ill for admission to the ICU or may have only required a transfer to an intermediate ward. This may give details why the mean APACHE II score (14.6) was lower than other studies, however, in more than one other study in ICU, it was 18 and higher (Theaker et al., 2005).

Furthermore, the sample size of the study by Shahin et al (2009) was not large enough to put on accurate insight into the pressure ulcer incidence in intensive care settings. This reduces the capability to evaluate it to other studies and/or to generalize the outcomes. Moreover, the incidence of pressure ulcers in this study is very low, therefore; the outcomes as regards the influencing factors have to be understood cautiously. One more factor influencing the outcomes was the complexity to get informed approval from aware patients and consent for comatose patients. This is supported by a study conducted by Harvey et al. (2006) on 498 intensive care patients concerning the recognition of the amount of critically ill patients capable of approval to partake in a randomized controlled test and the evaluation as to what degree the patients approval and families consent are necessary to get the permission of the ethics commission. It was recognized that only 13 (2.6%) patients were able to provide their informed consent independently, which leads to the end that only a very little proportion of patients was able to provide consent before performing the study (Shahin et al, 2009).

Body sites of pressure ulcers

The sacrum, heel and ischium were the most frequent body sites of pressure ulcers in this study. The outcomes are supported by a study by Carlson et al. (1999) who established that the majority of common body sites of pressure ulcers were sacrum, coccyx and heel. In addition, the study by Calianno (2000) established that heel ulcers are the second most recurrent ulcers connected to pressure. The explanation of these results led to the termination that sacrum and heel were the most ordinary body sites of pressure ulcers in intensive care patients. Or else the shoulder and ear were found as locations of pressure ulcer in this study. This result has not been established yet by other studies and could be regarded in more research.

Prevention

Foam mattresses and alternating air pressure mattresses were the defensive equipment most often applied to patients in this study. In this respect, an RCT study discovered that a foam substitute to the usual hospital mattress can decrease the incidence of pressure ulcers in at-risk patients (Russell et al., 2003). Moreover, Reddy et al. (2006) evaluated 48 randomized controlled trials inspecting the function of support surfaces in avoiding pressure ulcers in diverse health care settings (acute care, long-term care, operating room and intensive care). Two trials examine the effect of low air loss mattresses. The first one evaluated low air loss mattresses versus alternating air pressure mattresses, Theaker et al. (2005), and the second one compared low air loss mattresses versus standard ICU beds (Inman et al., 1993). Both of the tests discovered a decrease in pressure ulcer occurrence with applying low air loss mattresses and alternating air pressure mattresses without important dissimilarity between both of them. Shahin et al (2009) also exposed that massage was used as a protective measure for 40.5% of the ICU patients, though national and international rules for the prevention of pressure ulcers explain that massage is not being helpful for pressure ulcer prevention (EPUAP, 1998). Avoiding insufficient nutritional and fluid intake applied just for 21.5% of the ICU patient. In this respect, the study by Hengstermann et al. (2007) establishes that the proportion of malnourished pressure ulcer patients (39.5%) was more than twice the proportion of non-pressure ulcer patients with malnutrition (16.6%). furthermore, the body mass index in (42.9%) of patients with pressure ulcers was <20 in the same study. Based on these results avoiding insufficient nutrition might be considered as a gauge for pressure ulcer prevention.

Treatment

No dressing was used for most of the patients in the study of Shahin et al (2009) during treatment for pressure ulcers. The most regularly applied dressing was the hydrocolloid dressing. Additionally, a study by Chang et al. (1998) contrasting the performance of hydrocolloid dressings and saline gauze dressing in the treatment of pressure ulcers grade 2 and more exposed than patients treated with the hydrocolloid dressing experienced a decrease of an average of 34% in their baseline surface area measurement in contrast to patients treated with gauze dressing where it increased by an average of 9%. An RCT study also discovered that hydrocolloid was more successful in the entire healing of pressure ulcers than plain dressing and phenytoin (Hollisaz et al., 2004). This can be explained by the performance of hydrocolloid, which not only develops healing but also decreases bacterial colonization and guarantees autodebridement of the ulcer. In addition, Barr et al. (1995) recognized that a mixture of hydrocolloid and alginate dressing on full-thickness pressure ulcers led to an important increase in the granulation tissue/epithelium and to a reduced as regards the quantity of devitalized tissue. The outcomes could not be established by the result of the study of Shahin et al, (2009) due to the small number of patients treated with a dressing for their pressure ulcers.

Related factors

Shahin et al (2009) exposed some differences between groups of patients with pressure ulcers and without pressure ulcers. In their study, three patients with new pressure ulcers were males; three patients had a Braden score between 14 and 18. In addition, there is a small difference between both groups about the length of stay, while all patients with new pressure ulcers were catheterized. This may guide us to think about the association between urinary catheterization and the development of pressure ulcers. Furthermore, only one comatose patient developed a new pressure ulcer while the other comatose patients did not develop pressure ulcers, whereas the study by Boyle and Green (2001) discovered that coma/unresponsiveness and paralysis were considerably linked with pressure ulcer development. Additionally, Reed et al. (2003) found that bewilderment is considerably connected to pressure ulcer development. This study also exposed that plastic linen was used for 75% of patients with new pressure ulcers. With consideration to this, Jeter and Lutz (1996) affirmed that plastic linen should by no means be placed under a patient since it holds back the moisture, thus exasperating the skin surface. Therefore, the application of plastic linen could be linked with pressure ulcer development. Moreover, this study discovered that patients with new pressure ulcers had APACHE II score higher than patients without new pressure ulcers. In this respect, Theaker et al. (2005) found out, that there was no important relationship between pressure ulcer development and the APACHE II score or the length of stay among 323 intensive care patients. The study of Wolverton et al. (2005) on 422 intensive care patients showed that 55% of pressure ulcers developed within 2 weeks upon admission as this study also showed. Furthermore, it should be taken into deliberation that the group of patients with new pressure ulcers is too small for comparing them to the group without new pressure ulcers which limits the simplification of factors associated with developing new pressure ulcers.

The course of pressure ulcers

The results of the study by Shahin et al (2009) revealed that five pressure ulcers were healed after patients admission to intensive care units of which three ulcers were grade 1. This may be explained by the fact that patients being admitted to ICU often have multiple diagnoses that require frequent general assessment and more care, which might also help in curing and preventing other health problems such as pressure ulcers. Furthermore, pressure ulcers grade 1 is difficult to measure reliably and can be healed within 1 day (EPUAP, 2002). It may be also due to the use of some preventive measures such as mobilization and skin inspection which were applied to most of the patients in this study.

Study limitations

One of the limitations of the study by Shahin et al (2009) was the decreasing number of patient admissions during the period of the data collection. A lot of patients were also too weak to read and sign the informed consent or even did not want to sign it at all. In the event of unconsciousness, the patients assent was obtained. However, some relatives did not wish their patients to participate in the study, because they claimed that they did not know if the patients accepted participation or not.

Conclusion

Shahin et al (2009) suggest that pressure ulcers can be healed in intensive care patients. Further observation and frequent assessment may help to reduce pressure ulcer incidence. Some preventive measures, such as foam mattresses and alternating air pressure mattresses, probably have a positive effect on preventing pressure ulcers among intensive care patients as well. However, the use of some incontinence supplies like plastic linen can be associated with pressure ulcer development. Hydrocolloid dressing may be helpful in increasing the healing rate. More research is required to establish those factors that are definitely related to pressure ulcer incidence in intensive care patients. The body sites of pressure ulcers, though, are comparable in more than one study on intensive care patients.

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