ICU PROCEDURES: Wound and Pressure Ulcer Care

by | Sep 13, 2024 | Nurse Article | 0 comments

ICU PROCEDURES: Wound and Pressure Ulcer Care

ICU Procedures: Wound and Pressure Ulcer Care – Nursing Management

In the ICU, patients are often immobile, sedated, or critically ill, making them more prone to developing wounds and pressure ulcers (also known as bedsores). Effective nursing management of these conditions is essential for preventing complications, promoting healing, and improving patient outcomes.

Wound and Pressure Ulcer Care: Overview

Wounds in ICU patients can result from trauma, surgery, or other procedures. Pressure ulcers develop due to prolonged pressure on the skin, particularly over bony prominences, leading to tissue ischemia and necrosis. Nursing management focuses on prevention, early detection, and effective treatment.

Common Sites for Pressure Ulcers:

  1. Sacrum
  2. Heels
  3. Elbows
  4. Hips
  5. Occiput (back of the head)
  6. Shoulders

Pressure Ulcer Stages (According to NPUAP – National Pressure Ulcer Advisory Panel):

  1. Stage I: Non-blanchable erythema of intact skin.
  2. Stage II: Partial-thickness skin loss involving epidermis and/or dermis.
  3. Stage III: Full-thickness skin loss with damage or necrosis of subcutaneous tissue, which may extend to underlying fascia.
  4. Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Nursing Management: Wound and Pressure Ulcer Care

1. Assessment:

  • Skin Inspection:
    • Conduct a full-body skin assessment daily, paying close attention to pressure points (e.g., sacrum, heels).
    • Look for early signs of pressure ulcers, including redness, warmth, swelling, or changes in skin texture.
  • Wound Evaluation:
    • Assess the wound’s location, size, depth, and the presence of exudate, odor, and necrotic tissue.
    • Use wound classification tools like Bates-Jensen Wound Assessment Tool (BWAT) to document wound status.
  • Risk Assessment:
    • Use a pressure ulcer risk assessment tool like the Braden Scale to evaluate the patient’s risk level based on factors like mobility, nutrition, moisture, and sensory perception.

2. Prevention:

  • Repositioning:
    • Turn and reposition the patient every 2 hours to relieve pressure on vulnerable areas.
    • Use pillows or foam wedges to support positioning and avoid pressure on bony prominences.
  • Pressure-Relieving Devices:
    • Use pressure-relieving mattresses (e.g., air-fluidized or low-air-loss beds) and cushions to reduce pressure.
  • Skin Care:
    • Keep the skin clean and dry. Cleanse gently with mild soap and water, and dry thoroughly to prevent moisture-associated skin damage.
    • Use barrier creams or films on areas at risk of moisture damage (e.g., sacrum, perineum) to protect against incontinence.
  • Nutrition Support:
    • Ensure adequate nutritional intake, including protein, vitamins (C and A), and zinc, to support wound healing. Malnutrition is a major risk factor for pressure ulcers.
    • Collaborate with dietitians to provide enteral or parenteral nutrition if oral intake is inadequate.

3. Wound Care:

  • Cleansing:
    • Cleanse wounds with normal saline or prescribed solutions (e.g., wound cleansers) using a sterile technique to avoid infection.
    • Avoid harsh chemicals like hydrogen peroxide or iodine, which can damage granulating tissue.
  • Debridement:
    • If there is necrotic tissue present, the wound may require debridement. This can be done through autolytic, enzymatic, mechanical, or surgical debridement, depending on the patient’s condition.
  • Dressings:
    • Select the appropriate dressing based on wound characteristics:
      • Hydrocolloid dressings for shallow wounds.
      • Alginate dressings for wounds with moderate to heavy exudate.
      • Foam dressings to absorb excess moisture and cushion pressure areas.
      • Transparent films for covering non-infected stage I or stage II pressure ulcers.
      • Gauze dressings for wounds that require frequent inspection or packing.
    • Change dressings according to the wound care protocol or as needed based on exudate and wound condition.
  • Negative Pressure Wound Therapy (NPWT):
    • This therapy applies suction to the wound bed to promote healing by removing exudate and encouraging tissue growth.
    • Monitor NPWT systems closely for proper function, exudate levels, and wound healing progress.

4. Monitoring for Infection:

  • Signs of Wound Infection:
    • Redness, increased warmth, swelling, purulent drainage, foul odor, and increased pain.
    • Monitor for systemic signs such as fever, increased white blood cell count, or sepsis.
  • Infection Control:
    • Use aseptic technique for dressing changes and wound care.
    • Follow isolation precautions for infected wounds (e.g., MRSA, VRE).
    • Administer antibiotics as prescribed if there are signs of infection.

5. Pain Management:

  • Pain Assessment:
    • Assess the patient’s pain using a pain scale, and provide pain relief before dressing changes or debridement.
  • Pain Medications:
    • Administer analgesics (e.g., opioids or non-opioid pain relief) as prescribed. Use topical analgesics or local anesthetics if necessary to reduce wound care-related pain.

6. Documentation:

  • Wound Characteristics:
    • Record the wound size, depth, and any changes in the wound bed (e.g., granulation tissue formation, necrosis).
  • Treatment and Interventions:
    • Document all interventions, including dressing changes, wound cleansing, patient repositioning, and use of pressure-relieving devices.
  • Progress Tracking:
    • Take wound photographs (with consent) to monitor healing progress over time.

7. Patient and Family Education:

  • Prevention Education:
    • Teach patients and families about the importance of repositioning, skin care, and nutrition for wound prevention.
    • Educate on the proper use of pressure-relieving devices at home, if applicable.
  • Wound Care at Home:
    • Provide instructions for home wound care, including how to cleanse wounds, apply dressings, and monitor for signs of infection.

Complications to Monitor for:

  1. Wound Infection: This can delay healing and lead to sepsis or other systemic complications.
  2. Osteomyelitis: Bone infection in cases of deep pressure ulcers, particularly stage IV.
  3. Sepsis: A life-threatening condition that can occur if wound infection spreads.
  4. Fistula Formation: Abnormal connections can form between wounds and other body cavities.
  5. Delayed Wound Healing: Contributing factors may include poor nutrition, infection, or comorbidities (e.g., diabetes).

Key Nursing Considerations:

  1. Frequent Monitoring: Perform regular wound and skin assessments to detect changes early.
  2. Early Intervention: Begin preventive measures as soon as risk factors are identified to prevent the development of pressure ulcers.
  3. Multidisciplinary Approach: Collaborate with the wound care team, nutritionists, and physicians to provide holistic care.
  4. Patient Comfort: Ensure patient comfort by managing pain, keeping the skin dry, and using pressure-relieving devices effectively.
  5. Education: Empower patients and families to participate in wound care and pressure ulcer prevention.

Conclusion:

Nursing management of wounds and pressure ulcers in the ICU requires a comprehensive approach that focuses on early identification, prevention, and effective treatment. By closely monitoring the patient’s skin, utilizing appropriate interventions, and collaborating with the healthcare team, nurses can help reduce the incidence of pressure ulcers and promote healing of existing wounds, ultimately improving patient outcomes.