In Our Unit

Pressure Ulcers in the Intensive Care Unit:

New Perspectives on an Old Problem
Maria Esperanza L. Estilo, RN, MS, CCRN, CNS-BC
Angel Angeles, RN, MBA, CCRN
Teresita Perez, RN, MSN, CCRN, ACNP-BC
Marnalyn Hernandez, RN, BSN
Marie Valdez, RN, BSN, CCRN

he skin is the largest nonsolid

organ in the human body.
However, the skin does not
receive the same kind of attention
that solid organs such as the heart,
lungs, or brain do. The skin certainly does not receive the kind of
urgent attention that solid organs
receive when they display signs of
compromise.

Intensive Care Patients

at Higher Risk for
Pressure Ulcers
Patients admitted to the intensive care unit (ICU) are the most disadvantaged when it comes to
maintaining intact skin, starting from
day one of their stay.1,2 Critically ill

Authors
Maria Esperanza L. Estilo is a clinical nurse
specialist for cardiac surgery at New York
Presbyterian Hospital in New York. Angel
Angeles is the Patient Care Director of the
cardiothoracic ICU at New York Presbyterian
Hospital. Teresita Perez, Marnalyn Hernandez, and Marie Valdez are clinical nurses
in the cardiothoracic ICU, cardiothoracic
stepdown unit, and surgical ICU, respectively, at New York Presbyterian Hospital.
For questions related to this article, contact
Maria Estilo at mae9007@nyp.org.
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ccn2012637

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patients may be sedated, receiving

mechanical ventilation, and confined to bed for long periods. Prolonged pressure on areas where
bony prominences are located predisposes these patients to pressure
ulcers.1(p1383) Because of critically ill
patients inability to turn themselves, caregivers must reposition
them in bed. If improperly performed, repositioning can cause
friction and shearing, which lead to
pressure ulcers.
Many of these patients also
receive vasopressors to support
blood pressure and maintain adequate cardiac output. Unfortunately, the same infusions that
control patients blood pressure also
constrict peripheral circulation and
deprive the capillary beds that supply the skin of the oxygen and nutrients that it needs.1,2
Although research has not
proven a link between poor nutrition and development of pressure
ulcers, weight loss in ICU patients
has been observed. As a result of
feeding often being delayed, the
loss of subcutaneous tissue, especially over bony prominences, can
cause pressure ulcers to develop
more easily.

In the cardiothoracic ICU, patients

can also be highly unstable hemodynamically. Patients chests can stay
open for some time, and therefore,
turning the patients requires great
caution. Multiorgan failure, which
causes cytokine release and starts the
inflammatory process, leads to
edema, and fluid-overloaded skin is a
pressure ulcer waiting to happen. In
addition, incontinence is common in
ICU patients. If the skin is left in contact with caustic substances from
urine and feces for prolonged periods, it can become macerated, and
the resultant skin impairment can
lead to pressure ulcers.

Prevention
In the past, the development of
pressure ulcers has been considered
a problem belonging to long-term
facilities, nursing homes, and institutions providing care for chronically
ill patients. In the past few years,
however, regulatory agencies in
health care have started looking into
new indicators of quality care in
acute care facilities. One of the
National Patient Safety Goals put
forth by the Joint Commission is prevention of hospital-acquired complications. Some complications

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Table

Pressure ulcer prevention protocol: pressure ulcer care map

CTICU Admission Stay
1st

ICU nursing activity with

corresponding actions for
skin integrity preservation
1. Assessment

2nd

Hour

Initial nursing
assessment
Initial Braden
Scale Score
Skin integrity
assessment

2. Turning and positioning

Identify turning
cell partners

4th Hour

Hour

Care of a new
postoperative patient

8th

Preparing to extubate

Assess need for

adequate
hydration

6. Managing incontinence

Urinary catheter
from operating room

Documentation

Visual skin check

Visual skin check

Raise head of bed to 30

Use turning clock

Turn patient to left side
with turning partner

Turn patient per

turning clock
schedule with
turning partner

Turn patient per

turning clock
schedule with
turning partner

Use pressure-relieving
devices (pillows, heel
pads, etc.)

Assess for excessive

moisture

Use protective
ointment or extra
protective

Assess need for specialty

bed

5. Nutrition assessment

AM/PM care

Assess potential
increase in risks for
pressure ulcer
- Increased need for
vasopressors
- Increased edema
- Increased bleeding
- Decreased oxygenation
- Decreased perfusion
- Decreased hemodynamic stability

3. Moisture barrier

4. Specialty bed

10th Hour

Hour

Order
FlexiCare MC3 for
high-risk patients

7. Skin Rounds
Abbreviations: , carry over to the next hour; CNS, clinical nurse specialist; OOB, out of bed; WOC, wound ostomy and continence.
Used with permission from New York Presbyterian Hospital.

considered indicative of poor quality

care are catheter-associated bloodstream infections, catheter-associated urinary tract infections, and
the development of pressure ulcers.3
The Commission on Medicare
and Medicaid Services (CMS) has
also developed new criteria for
reimbursement. Starting in October

2008, CMS has withheld reimbursements for what it considers complications unrelated to the original
diagnosis or the original reason for
hospitalization.4 Examples include
surgical site infection after coronary
artery bypass graft, air embolism,
blood transfusion incompatibility,
and, again, pressure ulcers.

New Perspective:
New Initiative
At New York Presbyterian Hospital, the senior leadership started
to look at this problem from a new
perspective. We started institutionwide initiatives that gave the integumentary system more attention
than it used to get.5 Best practice

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12th Hour

24th Hour

48th Hour

72nd Hour

Report

Ongoing care

Ongoing care

Ongoing care

Reassess skin
integrity

Braden Scale

Evaluate risks

Visual skin
check

OOB as tolerated

Assess need for multiPodus boots

Patient on FlexiCare
MC3

Evaluate need for

Clinitron Bed

Initial nutrition consult

done
Calorie requirement
Diet appropriate for
patient

Nutrition followup 4-5

days or as needed

Assess for potential

fecal incontinence

Seen by CNS or skin

champions

Zassi Rectal Tube

as needed

Bowel modification
as needed

WOC nurse consult

as needed

also have a micro-cooling air management system that ensures a

breathable ventilated surface,
thereby reducing heat buildup in
regions prone to skin breakdown.
Every unit identified a staff
member who focuses on prevention
of pressure ulcers; they are called
skin champions. The skin champions make sure that pressure ulcer
prevention protocols are put in
place in their units. If the skin
becomes impaired despite these
efforts, or if an already existing
impairment gets worse, the skin
champion, in collaboration with the
physician, requests a consultation
with a wound ostomy and continence (WOC) nurse to help with the
management and recommendations
for treatment.
Rounds with the WOC nurse to
monitor progress of these patients
are planned weekly or more often if
necessary. The skin champions meet
monthly to discuss problems, evidence-based practices and treatments, and implementation of
solutions and to hear about new
products and learn through educational lectures and presentations. In
addition, the skin champions
moved better products for prevention of skin breakdown to
the forefront.

Raising the Standard in

the Cardiothoracic ICU
efforts continued, such as benchmarking with hospitals and sharing
information with the National Database for Nursing Quality Indicators.
Use of the Braden scale to evaluate
risk of pressure ulcers also continued.
In addition, new initiatives were
instituted. One of the earliest initiatives was to invest in new beds for

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patients. Our new beds with a pressure redistribution surface provide

protection from skin breakdown in
several ways. Pressure is redistributed by separate cushion channels
in the head, sacrum, and heel, preventing blockage of circulation and
allowing adequate blood flow to different areas of the body. The beds

A new protocol for pressure

ulcer prevention and treatment was
implemented in the cardiothoracic
ICU, almost simultaneously with
the hospital-wide initiatives. The
new protocol allows skin care and
assessment to be incorporated into
the nursing care activities that start
from the time patients are admitted

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and throughout their average stay

in the cardiothoracic ICU.
Instead of waiting until the
patient is awake and able to be
turned before checking the skin
visually, we start pressure ulcer prevention when the patient arrives in
the unit. Interventions for preservation of skin integrity are incorporated into corresponding nursing
activities performed during admission into the ICU (see Table).
Care of a newly admitted patient
is a very involved process that
includes initial assessment, continuous monitoring, titration of dosage
of vasoactive intravenous medications, implementing interruptions
in sedation, preparing for extubation, physical care, and documentation. The main interventions for
pressure ulcer prevention are assessing risk for pressure ulcers, turning
and positioning, use of moisture
barriers and skin protectants, use of
specialty beds, nutrition screening,
managing incontinence and initiating skin rounds. Marrying critical
care nursing actions with pressure
ulcer prevention in a combined care
map forces the interdisciplinary
team to give the integumentary system the attention that it needs early
in the patients ICU stay.
The new protocol also provides
the ICU staff with a decision-making structure that allows immediate
response to patients identified as at
high risk for pressure ulcers (see
Figure).

Documenting Pressure
Ulcers: Calling It the
Right Thing
Being able to differentiate a
pressure ulcer from fungal rash,
incontinence-related dermatitis, a

diabetic ulcer, an arterial wound,

and a venous wound is extremely
important to determine subsequent
treatment options.6 According to the
National Pressure Ulcer Advisory
Panel (NPUAP), a pressure ulcer is a
localized injury to the skin and/or
underlying tissue, usually over a
bony prominence, as a result of pressure, or in combination with shear
and/or friction.7 In 1989, NPUAP
developed a 4-stage classification
system for pressure ulcers. This system did not recognize unstageable
and deep tissue injury. In 2007,
NPUAP updated the staging system
by addressing the causes of wounds.
This method has improved the
understanding of pressure ulcers
and the treatment of wounds caused
by pressure. The classification system is described as follows.7
Stage I is characterized by intact
skin with localized redness that does
not blanch when light pressure is
applied specifically over a bony
prominence. When skin is darkly
pigmented, blanching might not be
visible, but the sores color may
appear different from the surrounding area.
Stage II is characterized by a partial loss of thickness of the dermis. A
stage II pressure ulcer is shallow and
open, with a red or pink wound bed,
and has no slough. It may also manifest as an intact or ruptured serumfilled blister.
Stage III pressure ulcers are characterized by a loss of the full thickness of tissue; subcutaneous fat may
be visible, but bone, tendon, or muscle are not exposed, and undermining or tunneling may be present.
Stage IV pressure ulcers are characterized by a loss of the full thickness of tissue, with exposed bone,

tendon, or muscle. Undermining,

tunneling, or both are often present.
In addition to these 4 stages,
NPUAP has added 2 more classifications: (1) unstageable, described as
a loss of full thickness of tissue but
with the wound covered by slough
and/or eschar and (2) suspected
deep tissue injury, an area of localized, discolored (purple or maroon)
intact skin resulting from damage of
the underlying soft tissue caused by
pressure or by shear.
Despite the improvements in the
classification system, disagreements
still exist among staff nurses and
WOC nurses in identification of
pressure ulcers and different types
of wounds.8

More Work
Needs to Be Done
Historically, in nursing schools,
the integumentary system has been
the last organ about which students
learned. In case presentations, it is
the organ least presented or
addressed. Even today, at hand-off
communication, the integumentary
system is often the last system mentioned. In ICUs, if the patient is in
critical condition and dependent on
life-support measures, the condition
of the patients skin might not even
be mentioned. When life and death
decisions are being made in the care
of critically ill patients, it is easy to
put aside skin care and pressure
ulcer prevention as a nonpriority
item in ICUs. However, the degree of
patients suffering, the dissatisfaction among family members, the
prolonged length of stay, and the
increase in the cost of care are
enough reasons to keep the issue of
skin care and pressure ulcer prevention constantly in our minds. We

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Complete postoperative skin assessment

Risk
factors
Reassess every
shift and as skin
condition changes

Cardiac risk
factors

Braden Scale
Score <18

No

Presence of diabetes
Diastolic blood pressure
<60 mm Hg during procedure
More than 4 hours on
operating room bed
Use of IABP
Use of extracorporeal
circulation.
Low hemoglobin, hematocrit,
and albumin level
Emergent surgery or procedure

Yes

Ambulate often
and reassess

Reassess
every shift
and as skin
condition
changes

No

No

Bed rest

Moisture

Yes

No

Initiate Prevention Protocol:

Head of bed <30
Follow CTICU turning clock schedule
Keep heels off the bed/mattress
Optimize nutrition
Manage bowel incontinence
Use lifting sheets to minimize shearing
Consider use of specialty beds

Skin breakdown

Yes

Assess area:
Document length and
width in cm
Reassess daily or with
each dressing change
Notify physician

Is breakdown from
pressure ulcer?

Yes

No

Describe and document skin

area (blister, skin tear, etc).

Frequent linen change

Moisture barrier

Yes

Stage pressure ulcer and

document.
Treat accordingly.
Refer to WOC nurse for
pressure ulcer >Stage 3.

Can patient be turned?

Yes

Establish
aggressive turning every 2 hours
Document and
reassess

No

Assess need for specialty bed

Does not tolerate position change
Presence of LVAD, ECMO, IABP
Unable to make position change on his own
Long-term sedation and/or use of pressors

Figure Pressure ulcer prevention protocol.

Abbreviations: CTICU, cardiothoracic intensive care unit; ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; LVAD, left ventricular assist
device; WOC, wound ostomy and continence.
Used with permission from New York Presbyterian Hospital.

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CriticalCareNurse Vol 32, No. 3, JUNE 2012 69

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need to continuously look for innovative ways to make sure we keep

the occurrence of pressure ulcers to
a minimum.

Not All Pressure

Ulcers Are Preventable
Recent articles have suggested
that not all pressure ulcers can be
prevented.9 Furthermore, CMS
acknowledges that not all pressure
ulcers are unavoidable in long-term
care settings.9
Interventions used in ICUs are
sometimes contradictory to good
skin care practices. For instance,
prevention of ventilator-associated
pneumonia recommends that the
head of a patients bed be raised to a
40 angle. Pressure ulcer prevention, however, states that keeping
the head of a bed that high predisposes the patient to sliding down
the bed, causing shearing and friction, and leading to development of
pressure ulcers. As a compromise,
protocols in our institution now recommend that the head of the bed be
elevated no higher than 30. Further
complicating matters are the
comorbid conditions that many ICU
patients have that predispose them
to skin breakdown and the procedures that prevent the staff from
turning patients at the accepted and
prescribed frequency of every 2 hours.

Conclusion
New technology and new products will certainly help prevent pressure ulcers. However, key factors to
reduce the incidence of pressure
ulcers include changing our perspective of the importance of the
integumentary system and strong
collaboration among multidisciplinary team members. CCN

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Acknowledgments
The authors would like to thank Catherine Halliday, Director of Cardiac Services at New York
Presbyterian Hospital-Columbia University, for
her support, encouragement, and advice during
the writing of this article. The authors also thank
all fellow skin champions for their inspiration
and hard work in the prevention of pressure
ulcers.

Financial Disclosures
None reported.

References
1. Keller BP, Wille J, van Ramshorst B, van
der Werken C. Pressure ulcers in intensive
care patients: a review of risks and prevention. Intensive Care Med. 2002;28:13791388.
2. Pokorny ME, Koldjeski D, Swanson M.
Skin care intervention for patients having
cardiac surgery. Am J Crit Care.
2003;12:535-544.
3. Keefe S. Ahead of the game. Adv Nurses.
2007;9:23-26.
4. Krapfl LA. Inpatient prospective payment
changes: a guide for the WOC nurse. WOC
News. 2008;3:16-17.
5. Ayello E, Lyder C. A new era of pressure
ulcer accountability in acute care. Adv Skin
Wound Care. 2008;21:134-140.
6. Doughty D, Raymundo J, Bonham P, et al.
Issues and challenges in staging pressure
ulcers. J Wound Ostomy Continence Nurs.
2006;33:125-130.
7. Updated Staging System. National Pressure
Ulcer Advisory Panel. http://www.npuap
.org. Accessed April 21, 2011.
8. Black J, Baharestani MM, Cuddigan J, et al.
National Pressure Ulcers Advisory Panels
updated Pressure Ulcer Staging System.
Adv Skin Wound Care. 2007;20:269-274.
9. Wallis L. Some pressure ulcers are unavoidable. Am J Nurs. 2010;110:16.

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Pressure Ulcers in the Intensive Care Unit: New Perspectives on an Old Problem
Maria Esperanza L. Estilo, Angel Angeles, Teresita Perez, Marnalyn Hernandez and Marie Valdez
Crit Care Nurse 2012;32 65-70 10.4037/ccn2012637
2012 American Association of Critical-Care Nurses
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