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Introduction
Prolonged immobility is one of the most common factors causing pressure ulcers in patients in the emergency department. Most often, such injuries are hospital-acquired and caused by improper skincare. The consequences of pressure ulcers can be critical because, in addition to external tissues, internal organs are also deformed. This problem is serious for public healthcare and requires implementing appropriate preventive measures. This paper aims to present the definition and epidemiology of pressure ulcers, their clinical presentation and complications, the diagnosis of such injuries, and a potential intervention by formulating a PICOT question with a relevant solution.
Definition
Pressure ulcers appear on the skin due to prolonged immobility, and in intensive care units (ICUs), this problem is particularly acute. Due to pressure on soft tissues and bones, certain parts of the body are deformed. Gefen et al. (2020) consider the manifestations of this issue and note that a pressure ulcer is a localised damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device (p. S5). As a result, the structure of external tissues changes, and infections can develop, which also affects the functioning of internal organs.
Epidemiology
The issue of pressure ulcers is global and requires attention from medical personnel. According to Mervis and Phillips (2019), from 5% to 15% of patients face this problem, but, as the authors state, in emergency departments, this rate can be significantly higher due to prolonged immobility (p. 883). The researchers also noted that, based on their findings, pressure ulcers were seen in 21.5% of patients in ICUs, and the risk of affecting the elderly population is higher (Mervis & Phillips, 2019, p. 883). The most common clinical conditions that lead to the development of such hospital-acquired injuries are spinal traumas, cognitive disabilities, sensory impairment, and other factors that lead to prolonged immobility. The risk of developing pressure ulcers is increased in older people, but the problem can also occur in younger patients.
Clinical Presentation
The main factor contributing to pressure ulcers is pressure on the skin and bones. As Gefen et al. (2020) note, if compression does not stop, tissue necrosis can develop, and most often, this process is observed in the sacral region, ischial tuberosities, trochanters, ankles, and heels. Rubbing against clothing or bedding can damage the skin by causing local erosion and the rupture of the epidermis and superficial dermis. Shear forces also contribute to pressure ulcers but are not the direct cause. For instance, when a patient is tilted, supporting tissues are damaged, muscles and subcutaneous tissues are moved downward by gravity, while the more superficial tissues in contact with external surfaces remain stationary. Pressure ulcers can be painful or itchy, but they can also go unnoticed in patients with reduced levels of consciousness or sensitivity. Moreover, as Mervis and Phillips (2019) argue, there are six stages, and for each of them, the corresponding manifestations and depth of erosion are characteristic. Ignoring pressure ulcers at an early phase is fraught with severe tissue damages subsequently.
Complications
Pressure ulcers are reservoirs for nosocomial antibiotic-resistant microorganisms that may cause severe infections. A high number of bacteria in a wound can interfere with tissue healing. According to Tashiro et al. (2016), if there is a slow wound healing, despite proper treatment, osteomyelitis can develop. In addition, in their study, the authors provide the statistics of patients with complications and note such dangerous manifestations as hematoma, seroma, wound infection, or dehiscence, which occurred at a rate of 13% (Tashiro et al., 2016, p. 93). Since internal organs are also deformed due to pressure, non-healing ulcers can cause fistulas, and infections of the intestines and other body systems are likely. In this regard, preventing the development of such injuries is crucial in the context of ensuring patient health as a whole but not only locally.
Diagnosis
The diagnosis of pressure ulcers is based on clinical assessment, in particular, the determination of the stage of injury. However, as Okhovati et al. (2019) remark, nurses decision-making skills are significant factors that influence the quality of work on the prevention of skin lesions and patient care. As a rule, visual inspection is the main algorithm that allows determining the stage of the pressure ulcer, the cause of its occurrence, and the procedure for intervention to eliminate it. As effective tools, Gefen et al. (2020) mention special protocols aimed to optimize the work of medical personnel. Such protocols contribute to implementing appropriate preventive measures to stop the development of pressure ulcers and treating them in accordance with their severity. If the diagnosis is confirmed, a suitable care regimen is prescribed.
Conclusion
Pressure ulcers are a health hazard, and in ICUs, they have severe consequences for patients. The evaluation of their manifestations, epidemiology, causes of development, and diagnosis helps obtain a comprehensive picture of the issue and propose relevant care algorithms. Based on the information received, to conduct an effective intervention, a PICOT question can be a tool to investigate a specific improvement practice. The question is as follows: in patients that are identified as high risk for developing a pressure ulcer (P), does the implementation of a pressure ulcer protocol initiated in the emergency department (I) as compared to patients who receive usual care (C), reduce the incidence of hospital-acquired pressure ulcers (O) on a week (T)?
References
Gefen, A., Alves, P., Ciprandi, G., Coyer, F., Milne, C. T., Ousey, K., Ohura, N., & Worsley, P. (2020). Device-related pressure ulcers: SECURE prevention. Journal of Wound Care, 29(Sup2a), S1-S52.Â
Mervis, J. S., & Phillips, T. J. (2019). Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), 881-890.Â
Okhovati, S., Esmaeili, M., & Shariat, E. (2019). Effect of intensive care unit nurses empowerment program on ability in visual differential diagnosis of pressure ulcer classification. Critical Care Nursing Quarterly, 42(1), 89-95.Â
Tashiro, J., Gerth, D. J., & Thaller, S. R. (2016). Pedicled flap reconstruction for patients with pressure ulcers: Complications and resource utilization by ulcer site. JAMA Surgery, 151(1), 93-94.Â
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