Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiological changes to the patient’s skin when in the intensive care unit
- Describe the medical assessments and therapies that apply to the critical care patient’s integumentary system
- Apply nursing concepts and plan associated nursing care for the critical care patient’s integumentary system
The skin, which is part of the integumentary system, is the largest organ of the body. It serves several important purposes, including thermoregulation and protection of internal body structures from injury and infection. The most-encountered integumentary system issue in critically ill patients is the development of pressure injuries and ulcers. In fact, studies have shown that anywhere from 8% to 23% of patients in the ICU will develop a pressure ulcer during their hospital stay (Krupp & Monfe, 2015). Because the development of hospital-acquired pressure injuries (HAPIs), or pressure ulcers that are acquired during an inpatient hospital stay, increases health-care costs and negatively affects patient outcomes, it is an area of nursing research that has received a lot of attention in recent years.
Pathophysiological Insult to the Critical Care Patient’s Integumentary System
Nursing care in the ICU is usually focused on performing life-saving medical interventions, so taking care of the patient’s skin is often not treated as a high priority. However, skin breakdown can lead to necrosis, or tissue death, and contribute to the development of life-threatening infections, increasing the overall length and cost of hospitalizations. As a result, it is important for the critical care team to prioritize patient skin care (Spader, 2018).
Exemplar: HAPIs
In addition to negatively affecting patient outcomes, the development of pressure injuries while in the hospital is especially concerning because the Centers for Medicare & Medicaid Services will not reimburse hospitals for their treatment. These factors have resulted in many hospitals conducting their own research and implementing unit-specific policies to promote the prevention of skin breakdown.
Although pressure injuries can occur in any area of the hospital, it is common to see the highest rates within critical care settings. There are many factors specific to critical care settings that increase the risk of skin breakdown and the development of pressure injuries, including
- fluid volume replacement and resulting fluid overload causing edema and tissue breakdown
- hemodynamic instability that worsens with immobility
- medical device placement that puts pressure on the skin surface
- poor nutritional status resulting in delayed wound healing
- prolonged periods of immobility
- urinary and fecal incontinence
- vasoactive IV medications resulting in decreased tissue perfusion
Integumentary System in Critical Care
Although a thorough skin assessment should be conducted by the critical care nurse at a minimum of once per shift, special attention should be given to the most common sites of skin breakdown. These sites, which are found over bony prominences, include the coccyx, buttocks, sacrum, and heels.
Risk Assessment Scales
The use of assessment scales to calculate the risk of skin breakdown can be helpful for determining who will benefit from more frequent interventions to prevent skin breakdown. The most-used skin risk assessment scale in critical care settings is the Braden Scale. This scale assesses risk factors for skin breakdown, including the patient’s sensory perception, skin moisture, mobility level, and nutrition status, to calculate a score that indicates their risk level. A low score on the Braden Scale indicates the patient has an increased risk for skin breakdown and subsequent pressure injury development. Hospital and unit protocols will vary, but it is typical to perform and document this scale score at least once per shift. Given the propensity for a critically ill patient to be bed bound, use of the Braden Scale identifies risk for skin integrity issues (Kennerly et al., 2022).
Link to Learning
Visit this source from the Agency for Healthcare Research and Quality to see a copy of the Braden Scale and to learn more about preventing pressure injuries.
Nursing Care for the Prevention of Pressure Injuries
Many critical care units have implemented care bundles—groups of related, evidence-based care interventions—designed to decrease the incidence of pressure injuries. The included interventions will vary depending on the specific hospital and unit, but they often involve manual turning, specialty beds, and prophylactic dressings.
Manual Turning Protocols
Most critical care units have adopted some kind of manual turning protocol in which the nursing staff physically turns and repositions patients in bed when the patient cannot do it themselves (Padula & Black, 2019).. This is especially important for patients who are immobile or have difficulty repositioning themselves. Protocols usually call for manual patient repositioning every 2 hours, alternating the side of the body that the patient is lying on by placing pillows underneath them and elevating their heels (Figure 35.13). This practice has been shown to improve the incidence of skin breakdown in the ICU, but it can be difficult for nursing staff to keep up with the frequent manual turns, indicating the need for other options such as specialty beds and mattresses. It is also important to note that some patients in the ICU are not hemodynamically stable enough to tolerate even slight turns, so these patients are at an even higher risk for skin breakdown.
Specialty Pressure Beds
Over the last 2 decades, there has been an increase in the development of specialty hospital beds to reduce the incidence of skin breakdown. These beds work by redistributing air pressure under different parts of the patient’s body to keep them from always lying on one side. The main drawback of these beds is the expense: some hospitals are unable to afford more than a few, if any, for their critical care units. In these cases, use of the manual turning protocol will suffice, but it is important to note that the use of specialty beds has been shown to decrease the incidence of HAPIs in critical care settings (McNichol et al., 2020).
Prophylactic Dressings
In addition to manual turning protocols and specialty mattresses, many critical care units have implemented the use of foam dressings that can be used prophylactically to prevent skin breakdown. These dressings act as a thick barrier between the skin and the potential cause of the breakdown, which may be the bed itself or some kind of medical device that is lying against the skin. The dressings used in critical care settings are usually placed on the coccyx and heels, but there are many other dressing styles available for other body parts at risk for pressure injuries.
Interdisciplinary Plan of Care
Interdisciplinary Roles and Plan of Care for a Patient with a HAPI
- Nurse: performs daily skin assessment; repositions patient manually every 2 hours; applies prophylactic dressings on bony prominences
- Physical and occupational therapists: perform range of motion exercises; assist with manual patient repositioning
- Wound care team: assesses, manages, and cares for pressure injury wounds
- Dietitian: develops and implements nutrition plans that help improve wound healing and promote new tissue growth
- Pharmacist: monitors dosage of vasoactive medications to limit risk of tissue breakdown and potential necrosis