6 Essential Nursing Care of the Critically Ill Patient
After reading this chapter, you should be able to:
• identify risks posed to critically ill patients relating to inadequate physical care and hygiene
• describe best practice in the provision of physical care and hygiene
• understand the key elements of safe transfer of critically ill patients within the hospital setting
• understand the principles of infection-control risk identification and management for critically ill patients
Introduction
Comfort is a paramount concern in intensive care. The two key areas of care – reducing risk and providing quality care – are closely related and served by a series of principles (see Table 6.1). Good risk management is an important component of quality care; if patients are assessed thoroughly and on a continuing basis then problems may be detected and treated early, preventing the development of unnecessary complications. These principles underpin this chapter. Additionally, it is important always to treat the patient as a person. Although this chapter focuses on the physical dimension of nursing care, patients’ psychosocial care should not be ignored (see Chapters 7 and 8). Further, while this chapter describes essential nursing care, care bundles, which encompass a number of these activities, are described in Chapter 3.
TABLE 6.1 Principles of practice
Personal Hygiene
It is important to provide the critically ill patient with effective personal hygiene as poor hygiene may increase the risk of bacterial colonisation and subsequent infection,1 or lead to surgical infection.2 Daily bed-baths are usually provided for most critically ill patients, although their effectiveness at reducing bacterial colonisation is questionable.1 Personal hygiene is also closely related to an individual’s esteem and sense of wellbeing. It may also influence family members’ perception of the quality of care the patient is receiving and the confidence they have in the staff’s ability to care for their loved one.
Assessment of Personal Hygiene
Assessment of critical care patients’ personal hygiene should be undertaken on two levels: first, determining what patients are able to do for themselves and what they want and second, the nurse’s professional assessment of what is required. As with all aspects of care, the patient has the right to refuse personal hygiene measures. Many critical care patients are unable to participate in decision making, and in these cases it falls to the nurse at the bedside to determine what level of care is necessary.Washing patients provides opportunities for the nurse to assess the patient’s skin and tissue. Often this enables the nurse to: pick up vital clues about the patient’s health status; identify tissue damage that requires treatment; and identify dressings or wounds that require attention. There are a number of areas to consider when assessing the skin (see Table 6.2). Excessive moisture on the patient’s skin from sweat can be problematic, particularly in skinfolds. Perspiration is a normal insensible loss, and is invisible. Body sweat is usually related to temperature and is observed on all skin surfaces, especially the forehead, axillae and groins. Emotional sweating is stress-related and is observed on the palms of the hands, soles of the feet, forehead and axillae.
TABLE 6.2 Skin and tissue assessment
| Factor | Observations |
|---|---|
| Colour of the skin | |
| Condition of the skin | |
| Tissue perfusion | |
| Moisture | |
| Wounds, drains, cannulae, catheters |
Basic Hygiene
The length of time taken to wash a patient and the environmental temperature are factors that affect cooling. Water on exposed skin causes rapid heat loss through conduction, convection and radiation, and for many years tepid sponging was used in critical care as a method of cooling pyrexic patients.3 Vasoconstriction increases the patient’s perception of cold and the possibility of shivering,4 which can affect the patient’s cardiovascular stability. When shivering occurs, vulnerable patients, with low energy reserves, can rapidly use energy to keep warm. The higher oxygen consumption associated with shivering may be particularly significant in elderly patients.4
A range of cleansing solutions is available for washing. Although soap is effective in facilitating the removal of bacteria, it can cause dryness of the skin. Aqueous cream, which can be used as a soap substitute, or emulsifying ointments are preferable, as they have moisturising properties, although the latter is greasier.5 Topical emollients (moisturisers) either trap water or draw water into the dermis, and help to protect damaged skin by creating a waterproof barrier.5 Baby care products are often used, although these may be the least effective due to their low oil content.5 Specific topical treatments may be required for patients with skin diseases such as dermatitis. Disposable cloths should be used for washing, as linen flannels have been shown to harbour bacteria. Complete disposable wash kits are available with potential advantages of being effective for patient’s skin cleaning without requiring rinsing and therefore drying the skin, and being disposable may reduce potential for infection and certainly reduces linen costs.1
Personal hygiene involves washing the patient’s hair as necessary, shaving the patient, management of cerumen in ears and care of finger and toe nails. While normal shampoo can be used, hair caps and washing products are available that are easier to use for bed ridden patients. Male facial hair should be managed as per the patient’s normal routine, such as maintaining a beard or shaving. Ears should be gently inspected for debris or injury. If assessed as appropriate, wax softening drops may be needed for 3–5 days if cerumen is present and causing the patient difficulties with their hearing.6 Maintaining clean nails is another aspect of personal hygiene. Care should be taken if nails require trimming, especially if the patient has brittle nails or is diabetic.
Skin Tears
Dependent patients who require total care are at greatest risk of skin tears. Injuries result from routine activities such as dressing, bathing, positioning and transferring.7 The elderly, those with fragile skin (particularly those with a history of previous skin tears), those who require the use of devices to assist lifting, those who are cognitively or sensorily impaired, and those who have skin problems such as oedema, purpura or ecchymosis are at greatest risk. Most skin tears occur on the arms and the back of the hands. The Payne-Martin classification system8 uses three categories to describe skin tears: skin tears without tissue loss; skin tears with partial tissue loss; and skin tears with complete tissue loss.
Skin tears can be prevented by careful handling of patients to reduce skin friction and shear during repositioning and transfers. Padded bed rails, pillows and blankets can be used to protect and support arms and legs. Paper-type or non-adherent dressings should be used on frail skin, and should be removed gently and slowly. Wraps or nets can be used instead of surgical tape to secure dressings and drains in place. Application of a moisturising lotion to dry skin helps to keep it adequately hydrated. Treatment of skin tears7 is outlined in Table 6.3. The focus of nursing care should be on careful cleansing and protection of the skin tear to prevent further damage and documentation of interventions and healing progress.
TABLE 6.3 Treatment of skin tears
Eye Care
The eyes are one of the most sensitive parts of the human body. If their eyes are not properly cared for, critical care patients may spend many hours in unnecessary discomfort. Simple bedside procedures like turning on lights at night or assessing pupil reactions can be uncomfortable. There are a number of physiological processes that protect the eye. For example, the eye is protected from dryness by frequent lubrication facilitated by blinking. Antimicrobial substances in tears help prevent infection, and the tear ducts provide drainage. When the eye is unable to close properly, tear film evaporates more quickly.8 If any of these defence mechanisms are compromised the eyes are at greater risk.
There is considerable risk to patients’ eyes while they are in the ICU.9 The blink response may be slowed or absent in some patients, such as individuals receiving sedatives and muscle relaxants, or those with Guillain–Barré syndrome.10 A number of complications can result, such as keratopathy, corneal ulceration and viral or bacterial conjunctivitis.9 Corneal abrasions may occur within 48 hours of ICU admission11,12 and in up to 40–60% of critically ill patients.8,12 When the eyes are exposed they are at greater risk of injury and infection, and conjunctival oedema can lead to subconjunctival haemorrhage.13 For the intensive care patient, who often has multiple intravenous lines, nasogastric tubes, ventilation tubes and their various connections, there is potential to unintentionally damage one of the eyes with one of these devices during position changes.
Eye Assessment
Eye assessment should be undertaken at least every 12 hours, even for the conscious patients who are able to blink spontaneously and usually require minimal eye care. The risk of corneal abrasion or iatrogenic trauma is greatest when patients are unable to close their eyes spontaneously,14 so these patients are at greatest risk of injury. The second at-risk group is those patients receiving positive pressure ventilation, who may develop conjunctival oedema (chemosis), sometimes referred to as ‘ventilator eye’.9 Third, patients who are exposed to high flows of air/oxygen, such as that with continuous positive airway pressure (CPAP) systems, may be vulnerable to its drying effects. Finally, all patients are at risk of eye inflammation and infection. Serious infections with bacteria such as pseudomonas can progress rapidly, resulting in blindness if not treated promptly.
Initial assessment should focus on whether the patient belongs to an at-risk group. Most critically ill patients are at some risk, but particularly those who are unable to close their eyes adequately. If the cornea is exposed, the patient is considered to be in a high-risk group.14 Based on the groups identified above, initial assessment should help determine how often eye assessment and eye care is required.
The general principles of eye assessment are shown in Table 6.4, which should include a full examination of the eye’s external structure, colour and response. A number of assessment tools have been developed for this purpose.9 Thorough eye assessment should assess appearance (which may provide indications of disease or trauma) and physical and neurological functions. If there is concern about any aspect of a patient’s eyes, a referral for assessment should be made to an ophthalmologist.
TABLE 6.4 Assessment of the eyes
| External structure | Colour | Reaction |
|---|---|---|
Essential Eye Care
The goals of eye care are to provide comfort and protect the eyes from injury and infection. Eye care and the administration of artificial tears should be provided as required, if the patient complains of sore or dry eyes, or if there is visible evidence of encrustation. If a patient is receiving high-flow oxygen therapy via a mask, they may benefit from regular 4-hourly administration of artificial tears to lubricate the eyes,9 although this may be unnecessary while they are sleeping.
Dawson offers an eye care protocol for critically ill patients, which clarifies the type of eye care required according to the patient’s ability to maintain eye closure.14 The protocol requires an assessment to be made once per shift. Initially, eye closure is assessed to determine whether it is complete or whether the conjunctiva and/or the cornea are exposed. Suggested treatment is 1–4-hourly eyedrops, with further assessment to exclude keratitis or conjunctivitis. Unconscious or paralysed patients are likely to require more eye care than conscious patients. Basic eye care consists of cleaning the sclera and surrounding tissue and moistening the eyes by administering artificial tears.
For at-risk patients, the general consensus is that eye care should be performed using a sterile technique, cleansing the eye from the inside to the outside usually with saline and gauze; however, eye care regimens have not been rigorously researched.9 Cotton wool is not recommended because of the presence of particulates that may cause corneal abrasions. Eyedrops should be administered gently, inserting the drop in the uppermost part of the opened eye and as close to the eye as possible without touching it. Sometimes eyedrops can sting, so it is advisable to warn the patient of this possibility. Regular scheduled eye care with an ocular lubricant plus eye closure with tape or wrap is used to reduce the potential for corneal abrasions or subsequent corneal ulceration or infection in patients who are either paralysed or heavily sedated.15–17
Conjunctival Oedema (Chemosis)
Conjunctival oedema (chemosis) is a common problem associated with positive pressure ventilation, high positive end-expiratory pressure (PEEP) above 5 cmH2O18 and prone positioning.9 While the oedema itself usually resolves without treatment when ventilation is discontinued, it may be advisable to seek an ophthalmic opinion if there is concern. The literature is inconclusive concerning the best method of treatment for conjunctival oedema, but evidence supports the use of artificial tear ointment and maintaining eye closure as effective measures to reduce corneal abrasions.9
Severe oedema often results in the patient’s inability to maintain eye closure. Under such circumstances, the majority opinion is that eye closure may be maintained by applying a wide piece of adhesive tape horizontally to the upper part of the eyelid.9 This usually anchors the lid in the closed position, while allowing the eyelid to be opened for pupil assessment and access for eye care. It is not necessary to change the tape at each pupil assessment using this method. However, the use of tape may be inappropriate for patients whose skin is very friable. Furthermore, if the eyelid becomes sore and inflamed, taping should be discontinued and an alternative method employed to close the eyes, e.g. gel eye pads.19 When it is not possible to close the eyes, artificial tear ointment has been shown to reduce the incidence of corneal abrasion.15
If it is difficult to maintain eye closure by taping the upper part of the eyelid, the entire eye can also be covered with polyethylene film, which has been shown to reduce the incidence of corneal abrasion.18 This should be changed 4-hourly with eye care and assessment. Commercially available eye-closing tape products are also available along with gel eye dressings which may be used instead of polyethylene film.20,21 Current evidence indicates that polyethylene film is the superior and most cost-effective product for maintaining the ocular surface.9,21
Oral Hygiene
Poor oral hygiene is unpleasant, causing halitosis and discomfort. Although mouth care is one of the most basic nursing activities,22 in some cases lack of oral hygiene can lead to serious complications or increase their risk, such as ventilator-associated pneumonia in the ventilated patient. Attendance to oral hygiene including the removal of dental plaque which harbours pathogens is an imptant component of nursing care.23–26 Using a well-developed oral protocol can improve the oral health of ICU patients.27 However, the practice of mouth care is not always evidence-based,28 although evidence supports having a standardise oral care protocol to improve oral hygiene.25 Factors associated with poor quality of oral care include lack of education, insufficient time, non-prioritising of oral care, and the perception that it is unpleasant.29
Oral Assessment
Mouth care should be reviewed regularly based on a thorough assessment of the oral cavity.22 Several oral assessment tools have been designed specifically for intubated patients.30–32 Essentially, a healthy mouth is characterised by several factors,33 as identified in Box 6.1, and all of these areas should be assessed as a basis for good oral care.
Box 6.1
Characteristics of a healthy mouth
Essential Oral Care
Oral care aims to ensure a healthy oral mucosa, prevent halitosis, maintain a clean and moist oral cavity, prevent pressure sores from devices such as ETTs, prevent trauma caused by grinding of teeth or biting of the tongue, and reduce bacterial activity that leads to local and systemic infection.22
Oral care for an un-intubated conscious patient with a healthy mouth generally involves daily observation of the mucosa and twice-daily toothbrushing with a non-irritant fluoride toothpaste.22 In general, for unconscious patients oral care should be attended to 2-hourly, although the evidence is inconclusive and frequency ranges from 2- to 12-hourly.28 If the mouth is unhealthy, it may be necessary to provide oral hygiene as often as every hour.
The basic method for oral care is to use a soft toothbrush and toothpaste (even for intubated patients), as this will assist with gum care as well as cleaning teeth.25 Toothpaste loosens debris34 and fluoride helps to prevent dental caries.35 However, if it is not rinsed away properly, toothpaste dries the oral mucosa. The practice of using mouth swabs only for oral hygiene is ineffective,36 and toothbrushes perform substantially better than foam swabs in removing plaque.25,36,37 Mouth rinses have not conclusively shown benefit,26 however they may be comfortable for the patient to use. Toothbrushing every 8 hours was recommended in a recent study as being an adjunct to other ventilator associated pneumonia prevention practices38 while use of chlorhexidine toothbrushing was found to be of benefit in another study.39
Although it is an effective saliva stimulant, practices such as the use of lemon and glycerine are outdated, as glycerine causes reflex exhaustion of the saliva process, resulting in a dryer mouth.22,25 Lemon juice is to be avoided, as it can decalcify enamel.37 Commercial mouthwashes moisten and soften the mucosa and help to loosen debris, which can be washed away.26 They must be used with caution in patients with oral problems, due to their potential to cause irritation and hypersensitivity.22
There are many oral hygiene products and solutions available to suit the needs of all patients.22 Commercial mouthwashes should be used as a comfort measure to supplement toothbrushing.26 A range of other products are available to treat oral problems, for example benzydamine hydrochloride (anti-inflammatory), aqueous lignocaine (anaesthetic) and nystatin (antifungal). For patients intubated for more than 24 hours, rates of nosocomial pneumonia may be reduced by using twice-daily chlorhexidine gluconate mouthwashes,25,37,39,40 which also prevent plaque accumulation.25 This has the disadvantage of an unpleasant taste and can discolour teeth.32 For patients with crusty build-up on their teeth,25 a single application of warm dilute solution of sodium bicarbonate powder with a toothbrush is effective in removing debris and causes mucus to become less sticky, although its use has not be definitively tested. However, it can cause superficial burns and its use should be followed immediately by a thorough water rinse of the mouth to return the oral pH to normal. Hydrogen peroxide has an antiplaque effect,22 but if incorrectly diluted it can cause pain and burns to the oral mucosa41 and a predisposition to candida colonisation.22 It is not pleasant tasting and sometimes rejected by patients although it is the substance that impregnates some of the foam sticks available for oral care.37 As a preventive measure, to reduce the incidence of fungal colonisation, natural yoghurt may be used. Normal oral hygiene is followed by coating the mouth and tongue with yoghurt.
Patient Positioning and Mobilisation
Positioning patients correctly is important for their comfort and the reduction of complications associated with pressure areas42 and joint immobility. Lying in bed for long periods can be a painful experience.43 Several researchers44–48 describe neuromyopathy from critical illness and disuse atrophy from prolonged immobility contributing to intensive care acquired weakness. This weakness may contribute to prolonged ventilation, intensive care length of stay as well as delayed return to physical normality.44–53 Cardiovascular stability, respiratory function and cerebral or spinal function are all factors that influence the positioning of patients in critical care areas. Modern beds and pressure-relieving devices have helped considerably to enhance the care of critically ill patients.
The primary goals of essential nursing care for patient positioning are:
• to position the patient comfortably
• to enhance therapeutic benefits
• to ensure the limbs are supported appropriately and to maintain flexible joints
• to facilitate patient activity to minimise muscle atrophy
• to implement early mobilisation as the patient’s condition allows.
There is growing evidence that early mobilisation is an important aim for critically ill patients51–55 and an essential goal of nursing care is to support the patient in maintaining or attaining a normal level of physical function for mobility. As with many other aspects of care for the critically ill, this is best achieved through multidisciplinary team members working together. Here, physiotherapists and occupational therapists have a lead role in assessing patients and planning programs of care and activity to facilitate attaining the goals of normal physical function, while nurses contribute by ensuring the programs of care are delivered when other personnel are not available.
Assessment of Body Positioning
Body positioning assessment is based on the goals of nursing care. First, a risk assessment is made and those patients at highest risk of complications related to their position are those who are unable to move for long periods, for whatever reason.56 For example, unstable patients whose status is compromised when they are moved, patients who are in critical care for a long time, elderly and frail or malnourished patients, and patients who are unable to move themselves (e.g. due to sedation, trauma, surgery or obesity) are all at risk. Batson et al. identified several significant risk factors: patients receiving adrenaline and/or noradrenaline infusions; patients with restricted movement; and diabetic and unstable patients.57 However, even previously fit patients who experience a critical illness can develop severe limitations in their mobility. The common short- and long-term complications of immobility are pressure ulcers, venous thromboembolism and pulmonary dysfunction, each of which carries a significant co-morbidity.56
Positioning and Mobilising Patients
Positioning the patient to achieve maximum comfort, therapeutic benefit and pressure area relief and employing active and passive exercises to maintain muscle and joint integrity and progress to regaining mobility are important nursing activities. Provided there are no specific contraindications, the immobile patient should be positioned with the head raised by 30 degrees or more, as research has demonstrated that it improves mortality58 and helps reduce ventilator-associated pneumonia.59 When combined with thromboembolic prophylaxis, gastric ulcer prophylaxis and daily sedation assessment, ventilator-associated pneumonia may be reduced by around 45%.59 Good body positioning and alignment helps prevent muscle contracture, pressure ulcers and unnecessary pain or discomfort for the patient.60,61
Mobilisation for the critically ill patient can be described as a graduated increase in range of activity from positioning, passive movement, sitting upright in bed, sitting in a chair to actually ambulating.49–5153 Stiller62 describes a range of safety factors that need to be considered prior to mobilising the critically ill patient, which fall into two groups; those specific to the patient and their physical and physiological condition, and those extrinsic to the patient such as the environment, staffing and patient devices attached. Creating an individualised mobility plan which can be adapted according to patient assessment and general health progress, will optimise early movement and mobilisation.53,54,62,63
Regular musculoskeletal assessment should be made, focusing on the patient’s major muscles and joints and the degree of mobility. Table 6.5 offers a simple guide to assessment, which should include a visual and physical assessment of all limbs and joints. Provided there are no contraindications, function should be stimulated by regular passive then active movements of all limbs and joints to maintain both flexibility and comfort (see below).
TABLE 6.5 Musculoskeletal assessment
| Muscles and joints | Mobility |
|---|---|
Active and Passive Exercises
It takes only seven days of bed rest to reduce muscle mass by up to 30%,64 and physical activity is essential to healthy functioning and beneficial for the cardiovascular system.54 Active exercises are those that can be performed by the patient with no, or minimal, assistance. Passive exercises are performed when patients are either too weak or incapable of active exercise. Exercises can be employed to help the recovering patient develop power and regain function, to assist in venous return and maintain the normal sensation of movement.64 They should be performed at least daily. Passive exercises put the main joints through their range of movement, which helps reduce joint stiffness and maintain muscle integrity, preventing contractures. Shoulders, hands, hips and ankles are particularly at risk of stiffness and muscle contracture.64 It is important, however, to ensure that joints and muscles are not overstretched, as this is painful for patients and can cause permanent injury. Splints may be used when the patient is resting, to maintain joints in a neutral position.64 The physiotherapist’s advice should be sought regarding the correct range of movement and the frequency of passive exercises. This is particularly important for burn-injured patients. Concern has been expressed about the effects of limb movements on head-injured patients; however, Koch et al.65 detected no significant cardiovascular or neurological changes during passive exercises in neurosurgical patients,65 and Brimioulle et al. found no detrimental effects on cerebral perfusion or intracranial pressure (ICP), whether the ICP was raised or not.66
Changing Body Position
Mobility is defined as the ability to change and control body position.67 The complications of immobilisation in critically ill patients are well documented, and include decubitus ulcer, venous thromboembolism and pulmonary dysfunction such as atelectasis, retained secretions, pneumonia, dysoxia and aspiration.56 The routine standard for immobilised patients in ICU is 2-hourly body repositioning, although this does not always happen,56 and the optimal interval for turning critically ill patients is unknown.68 In addition to providing pressure relief, it is recommended that the patient’s position be changed often to ensure comfort, relaxation and rest, to inflate both lungs, improve oxygenation69 and help mobilise airway secretions, to orient the patient to the surroundings and for a change of view, and to improve circulation to limbs through movement.50 The frequency of body repositioning should be determined according to the patient’s pressure ulcer risk (preferably using one of the assessment tools described below), clinical stability and comfort.
Good body alignment helps prevent pressure points, contractures and unnecessary pain or discomfort for the patient.60 The nurse caring for the immobile critically ill patient is most often responsible for determining patient positioning.70 Here, careful consideration should be given to factors (outlined in Table 6.6) such as haemodynamic and cardiopulmonary responses of the patient,71 the timing and method of positioning patients, and whether there are any restrictions on movement. It is important to fully consider the individual needs of patients: they may have a history of back or neck problems, and the selective use of soft or firm pillows and mattresses may be relevant. Pillows can optimise the patient’s position so that the shoulders and chest are squared, and may reduce the work of breathing for patients with chronic airways disease.42 Some pressure-relieving mattresses have an adjustable pressure control, which can be changed according to pressure relief assessment and patient comfort.42 When patients are positioned lying on one side, consideration should be given to their feeling of security; for example, ensuring that they are well supported by pillows and the bed rails are raised. Provided cerebral perfusion pressure is maintained above 50 mmHg, even severely head-injured patients can be moved safely,66 however it is important to maintain the neck in alignment to promote venous drainage (see Chapter 17), and for those with spinal injuries, log-rolling may be required (see Chapter 17).
TABLE 6.6 Factors to consider when positioning patients
| Factors | Comments |
|---|---|
| Haemodynamic and cardiopulmonary responses | |
| Timing | |
| Method | |
| Restrictions on positioning |
Pressure Area Care
The prevalence of pressure ulcers in an ICU ranges from 5% to 18%72 and the risk of developing a pressure sore is cumulative: 5% risk after 5 days; 30% risk after 10 days; and 50% risk after 20 days in the ICU.72 Pressure area risk for critically ill patients can be attributed to their immobility, lack of sensory protective mechanisms, suboptimal tissue perfusion and environmental factors that cause pressure and friction.42 The commonest locations for pressure ulcers are the sacrum, the heels and the head.72 Significant risk factors include the age of the patient, the number of days since admission, malnutrition,42,49 and delays in the use of pressure-relieving mattresses.72,73
Pressure risk assessment tools can help nurses identify at-risk patients.42 However, it is unusual for a patient in critical care to be assessed as low-risk. There are several pressure area risk assessment tools available such as Braden score67 and the revised Jackson/Cubbin pressure risk calculator74 (Table 6.7) that was designed specifically for use in ICU and provides an awareness of the many factors that need to be considered and monitored prior to and during procedures for pressure prevention. Skin assessment for pressure should be scheduled at least daily and include a review of pressure relieving devices for effectiveness or requirement for change. Skin assessment should include testing for blanching response and checking for areas of oedema, induration, redness or localised heat.42
TABLE 6.7 Components of the revised Jackson/Cubbin pressure area risk calculator74
| Risk assessment categories | Scoring |
|---|---|
Pressure ulcer prevention practices include alternating the use of pressure-relief mattresses, low-pressure mattresses and air-flow mattresses.42,73 For bariatric patients (usually those heavier than 150 kg), specialist beds and mattresses are required.
Intensive care patients are at risk of pressure ulcers and injury from a number of devices in everyday use, such as endotracheal tubes and blood pressure cuffs (see Table 6.8). Close attention to detail with frequent observation of the patient, the patient’s position, and the presence and location of equipment is required to prevent skin damage. It is important to remove aids such as compression stockings and cervical collars to assess the skin. Vulnerable patients, such as those with poor tissue perfusion, anaemia, oedema, diaphoresis and poor sensory perception42 can develop pressure ulcers relatively quickly, and pressure ulcers caused by equipment are entirely avoidable.
TABLE 6.8 Risk of pressure sores from commonly used equipment
| Risk factor | Comments |
|---|---|
| Endotracheal tubes (ETTs) | The ETT should be repositioned from one corner of the mouth to the other on a daily basis to prevent pressure on the same area of oral mucosa and lips. Care should also be taken when positioning and tying ETT tapes: friction burns may be caused if they are not secure; pressure sores may be caused if they are too tight (particularly above the ears and in the nape of the neck). Moist tapes exacerbate problems and harbour bacteria. |
| Oxygen saturation probes | Repositioning of oxygen saturation probes 1–2 hourly prevents pressure on potentially poorly perfused skin. If using ear probes, these must be positioned on the lobe of the ear and not on the cartilage, as this area is very vulnerable to pressure and heat injury. |
| Blood pressure cuffs | Non-invasive blood pressure cuffs should be regularly reattached and repositioned. If left in position without reattachment for long periods of time they can cause friction and pressure damage to skin. Care should be taken to ensure that tubing is not caught under the patient, especially after repositioning. |
| Urinary catheters, central lines and wound drainage | The patient should be checked often to ensure that invasive lines are not trapped under the patient. In addition to causing skin injury, they may function ineffectively. |
| Bed rails | Limbs should not press against bed rails; pillows should be used if the patient’s position or size makes this likely. |
| Oxygen masks | Use correct-size mask and hydrocolloid protective dressing on the bridge of the nose to assist with prevention of pressure from non-invasive or continuous positive airway pressure masks, especially when these are in constant or frequent use. |
| Splints, traction and cervical collars | Devices such as leg/foot splints, traction and cervical collars can all cause direct pressure when in constant use and friction injury if they are not fitted properly. ICU patients often have rapid body mass loss (especially muscle) following admission, so daily assessment is required. |
All pressure points and any pressure ulcers should be monitored closely. The key areas of monitoring are identified in Table 6.9, and it is important to use standardised methods to objectively assess pressure ulcers and their response to therapy. If a patient develops one pressure ulcer, there is a good chance he/she could develop another. Nursing intervention includes the placing of patients in positions that avoid pressure on the affected area(s), employing measures such as good fluid management to improve tissue perfusion, reducing the risk of infection and promoting tissue granulation with the use of appropriate dressings.
TABLE 6.9 Monitoring pressure ulcers
| Factor | Actions |
|---|---|
| Size | |
| Stage/grading | |
| Documentation | |
| Treatment | |
| Observing other sites | • Dependent areas of the body are susceptible: sacrum, heels, back of the head, hips, shoulders, elbows, knees. • Areas of the body where equipment is causing pressure are susceptible: nose, ears, corners of the mouth, fingertips. • Areas of the body where tissue perfusion is poor are susceptible: extremities. |
The International NPUAP–EPUAP Pressure Ulcer Classification System42 grades pressures ulcers as follows:
• Stage I: Non-blanchable redness of intact skin
• Stage II: Partial thickness skin loss or blister
• Stage III: Full thickness skin loss (fat visible)
• Stage IV: Full thickness tissue loss (muscle/bone visible)
• protecting tissue from further damage with pressure re-distribution techniques
• preventing infection either localised or systemic by closely observing the ulcer for signs of infection such as friable, oedematous, pale or dusky tissue
• aiding wound healing such as use of negative pressure wound therapy for deep ulcers or foam and alginate dressings to control heavy exudate.42
Rotational Therapy
Continuous Lateral Rotation Therapy (CLRT) or Kinetic bed therapy is an intervention in which the patient is rotated continually, on a specialised bed, through a set number of degrees; it helps to relieve pressure areas and can significantly improve oxygenation.75–77 Continual lateral rotational therapy may reduce the prevalence of ventilator-associated pneumonia in patients requiring long-term ventilation.76 Appropriate evaluation of the benefits and suitability of the patient for CLRT should be undertaken by the team and the therapy implemented according to local protocols.75 In implementing this therapy, the goal is to achieve continuous rotation through the maximum angle that the patient tolerates for 18 hours per day.75,78
Venous Thromboembolism (VTE) Prophylaxis
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are separate conditions collectively referred to as venous thromboembolism (VTE).79,80 DVT is a blood clot in a major vein of the lower body, i.e. leg, thigh, pelvis, which causes disruption to venous blood flow and is often first noticed by pain and swelling of the leg. The blood clot forms due to poor venous flow, endothelial injury to the vein or increased blood clotting which may be caused by trauma, venous stasis or coagulation disorders.81 Pulmonary emboli occur when a part of a thrombosis moves through the circulation and lodge in the pulmonary circulation. VTE is a major risk factor for hospitalised patients80–83 in general and critically ill patients in particular, due to blood vessel damage, coagulation disorders and limited mobility leading to venous stasis.79 Further, around 50% of patients with DVT will also suffer a pulmonary embolism, which can be fatal causing around 10% of hospital deaths in Australia.80,82 Patients with VTE may also develop post-thrombotic syndrome where tissue injury occurs leading to pain, paraesthesia, pruritis, oedema, venous dilatation and venous ulcers.79,81
It is important to consider the individual patient (age, BMI) and their history (previous VTE, coagulation disorders) along with their current condition whether it be surgical or medical and features of their treatment (immobilisation) when determining risks for VTE.80,81,84–86 Both the risk assessment and the patient’s current condition will determine the most appropriate VTE prophylaxis strategy.80,81 Prophylaxis consists of a combination of pharmacological and mechanical interventions that may be used together or separately according to the degree of risk for VTE and/or contra-indications to particular therapies. The use of combined therapies is supported by recent reviews and guidelines.80,84,86 It is important to be guided by current best evidence in choosing the most appropriate prophylaxis regimen for your patient. The NHMRC Clinical practice guideline for the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals80 provides a comprehensive guide to risks and management relating to VTE for critical care in Australia.
Low molecular weight heparin or unfractionated heparin is the most common pharmacological therapy prescribed in Australia, while other medications will be prescribed for patients according to individual factors.80,87 Special consideration of an appropriate regimen for pharmacological prophylaxis will need to be given to patients with renal and hepatic impairment.87 Heparin-induced thrombocytopenia (HIT) may develop in some patients88 so as with all heparin therapy, close monitoring of the patient’s platelet count and assessing for signs of bleeding such as bruising or haematuria will form part of the nurse’s role in managing VTE prophylaxis.
In principle, it is advised that graduated compression stockings are used for all general, cardiac, thoracic and vascular surgical patients until full mobility is achieved irrespective of pharmacological prophylaxis.80,86 Mechanical prophylaxis is provided through a range of graduated compression stockings and various pneumatic venous pump or sequential compression devices.80,81,84,86,89,90 It is important to make sure that the relevant devices are fitted correctly and monitored closely. Comparisons between a number of pneumatic pumps have been studied88–90 with all displaying relative effectiveness. The availability of battery-operated sequential compression devices can assist with the continuous application of the therapy during patient transports away from their bedside, such as to the imaging department for radiological procedures.90
Along with pharmacological and mechanical venous thromboembolism prophylaxis, maintaining patients’ hydration and implementing early mobilisation are key components of care in preventing VTE.79,80,84 Rauen et al.79 describe the most common reasons cited for lack of proper VTE prophylaxis as being lack of knowledge among healthcare providers and under-estimation of risk of VTE along with over-estimation of the potential risk of bleeding from prophylaxis. Given the risks of VTE for critically ill patients, it is clearly important that nurses contribute to lowering risks for their patients by knowing the range of risk factors for their patients, along with the appropriate pharmacological prophylaxis that may be prescribed, how to appropriately implement and manage the mechanical prophylaxis devices and most importantly facilitate the early mobilisation of the patient.
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