1. Skin Care
Tissue viability care is required whenever there is a potential or actual risk to tissue health.
Tissue health is affected by both irreversible and reversible factors - therefore, reducing these threats promotes tissue health.
One irreversible factor is the ageing process. Reversible factors include poor perfusion, oxygenation and nutrition (Mallet 2013).
The first section of this article will briefly focus on reducing reversible factors that can cause pressure injuries.
Pressure injuries are a localised injury to the skin and underlying tissue, usually over a bony prominence. They are caused by constant focused pressure, shear force or friction to one spot (EPUAP NPIAP & PPPIA 2019). All critically ill patients are at especially high risk and therefore require pressure area care.
Factors that contribute to pressure injury include:
- Pressure - any intense or prolonged pressure, usually from body weight, deprives skin and soft tissue cells of oxygen and nutrients
- Shear force, which results from two parts of body tissue moving in opposing directions
- Friction, which is caused by two objects rubbing against each other, possibly due to poor moving and handling techniques. Friction injuries can also cause abrasions, superficial ulceration and blistering.
(Hampton and Collins 2004; Reger et al. 2010)
Risk factors for pressure injury include:
- Severe illness
- Inadequate tissue perfusion due to haemodynamic instability
- Co-morbidities, especially vascular disease
- Faecal incontinence
- Inability to reposition self
- Significant loss of sensation
Pressure Ulcer Risk Assessment
Pressure care management is essential in critically ill patients, as they generally have several risk factors present. Consider using a validated risk assessment tool to support your clinical judgement. Any indication of risk should be followed by action.
Performing a Pressure Injury Risk Assessment
Risk assessment should be undertaken within 8 hours of admission to the hospital (NICE 2014).
- Examine the patient’s entire skin for skin damage by looking at and touching the skin from head to toe, with an emphasis on bony prominences and skin folds.
- Reassess pressure injury risk if there is a change in the patient’s clinical condition such as deterioration or surgery.
- The patient’s skin should be inspected on an ongoing basis, depending on the clinical setting and the patient’s degree of risk.
- The patient’s skin should be examined before the patient is discharged.
- Always follow your local policies and recommendations for risk assessment, documentation and how to communicate information to the interprofessional team.
Every skin assessment should include any pain or discomfort reported by the patient. Check for:
- Skin temperature
- Colour changes or discolouration.
These symptoms may be warning signs of pressure ulcer development (NPUAP 2014).
Skin Risk Prevention
Some risk factors can be reduced by:
- Optimising hydration, as dehydration impairs perfusion
- Maximising nutrition, as malnutrition increases pressure injury occurrence. Enteral nutrition can reduce the incidence of pressure injury
- Repositioning helps to minimise shear and friction. Encourage patients to change their position frequently. If patients are unable to reposition themselves, a careful risk assessment should be made by the interprofessional team to formulate an individual care plan
- Pressure-redistributing equipment: Selection of suitable equipment should be based on individual risk assessment, the care setting and the patient’s clinical condition.
(Wakefield et al. 2009; Terekeci et al. 2009; Stratton et al. 2005; Takahashi et al. 2010; Bell 2008)
Any signs of actual or potential risks should be assessed and documented, and appropriate action taken to promote healing and prevent further skin damage.
2. Mouth Care
Oral care is an essential nursing activity that provides relief and comfort to patients who are seriously ill and cannot perform simple activities of daily living themselves.
The oral cavity and other parts of the mouth are perfect media in which bacteria can live and thrive. Therefore, all parts of the oral cavity should be assessed each time the mouth is cleaned (Mallet 2013).
Assessment of Oral Cavity
- Follow any oral assessment tool available within your organisation to ensure consistency and facilitate a thorough examination
- Ensure you have sufficient light to visualise as much of the oral cavity as possible
- Ensure the patient’s head is appropriately supported (e.g. with pillows) to prevent trauma or discomfort
- Ensure linen is not touching the patient’s lips as linen can cause drying and discomfort
- Document care and any abnormalities in order to provide an accurate record, monitor the effectiveness of the procedure, and facilitate communication and continuity of care.
Oral Cavity Care
- Lips: Assess for ulceration or ‘cracking’, which is mainly caused by dryness, dehumidified oxygen via facemasks, or damage from endotracheal tape/holder. Provided there is no sign of infection, apply a lubricant such as soft yellow paraffin, humidify face mask oxygen, and, if possible, prevent the tape securing the endotracheal tube from touching the patient’s lips (especially at the corners of the mouth). If not possible, change the position of tapes on lips at least once daily and use any available aids to reduce trauma.
- Teeth: Assess for damaged or broken teeth caused by trauma or poor oral hygiene. Sit the patient upright (unless contraindicated) and clean their teeth with a toothbrush, usually twice daily.
- Gums: Assess for bleeding, possibly caused by trauma or poor hygiene. Clean gums when cleaning teeth.
- Saliva: Assess for excess saliva, lack of high viscosity (possibly caused by objects in the mouth such as an endotracheal tube) or dehydration. Moisten mouth if dry and increase the frequency of moistening mouth.
- Tongue: Assess for dark colour and dryness, possibly caused by reduced perfusion and dehydration.
- If the patient can clean their own teeth, they should be encouraged to do so.
- Remove dentures from an unconscious patient to prevent airway obstruction
- Remove dentures overnight from patients who are conscious in order to facilitate cleaning
- Brush dentures with a toothbrush to remove debris
- Rinse dentures under running cold water and dry thoroughly. Dentures can be damaged if left dry or cleaned in hot water
- If not worn by the patient during the day, store dentures safely in a labelled denture pot within the patient’s own property.
(Clarke 1993; Mallet 2013)
3. Eye Care
Vision is one of the main senses and a means of communication for most people. Impaired vision can, therefore, contribute to delirium.
Ocular diseases rarely require critical care admission, but pre-existing conditions may need continuing treatment, such as eye drops (Dawson 2005).
Eye care refers to measures that maintain ocular health and comfort. In critical care, this usually means care given to protect eye surfaces from potential harm, treatments for specific (acute or chronic) problems, and care of visual aids such as glasses and contact lenses (Mallet 2013).
The aim of eye care is to:
- Prevent potential harm/trauma
- Treat any identified problems
- Care for and clean any visual aids.
Factors that expose eyes to potential damage in critical care may include:
- Inability to protect own eyes
- Impaired tear production
- Intraocular hypertension
- Drying with oxygen from face masks (un-humidified oxygen or non-invasive ventilation)
- Deep sedation, which impairs blink reflexes and possibly tears production
- Trauma from equipment such as ventilator tubing, tapes to secure ETT and linen.
(Parkin and Cook 2000; Mallet 2013)
Suspected ocular infections should be recorded and communicated to relevant staff members.
Eye health assessments should be part of a routine patient physical assessment and be performed on admission, followed by an ongoing assessment at the beginning of each new nursing shift.
Assessment should include:
- Following any eye assessment tools used within your organisation
- Ensuring the patient’s head is supported at a sufficient angle to prevent periorbital oedema and intraocular hypertension
- Ensuring linen (especially seams) and equipment are not in direct contact with either eye. Anything touching the eye surface can cause trauma
- Visualising both eyes for assessment
- If the patient normally uses visual aids (glasses or contact lenses), this should be documented, whether aids are present or absent, in use or not
- Visual aids should only be used if the patient wishes to and if they are conscious and in a suitable position (upright).
(Cooke et al. 2011; Mallet 2013)
- Bell, L 2008, ‘Evaluation of and Caring for Patients With Pressure Ulcers’, American Journal of Critical Care, vol. 17, no. 4, p. 348, https://aacnjournals.org/ajcconline/article-abstract/17/4/348/695/Evaluation-of-and-Caring-for-Patients-With?redirectedFrom=fulltext
- Clarke, G 1993, ‘Mouthcare and the Hospitalised Patient’, British Journal of Nursing, vol. 2, no. 4, pp. 225-7, https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.19184.108.40.206
- Dawson, D 2005, ‘Development of a New Eye Care Guideline for Critically Ill Patients’, Intensive and Critical Care Nursing, vol. 21, no. 2, pp. 118-22, https://www.sciencedirect.com/science/article/abs/pii/S0964339705000169?via%3Dihub
- Cooke, K, Doyle, N & Farley, A 2011, ‘Patient Comfort’, in Dougherty, L & Lister, S (eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 8th edition, Oxford: Wiley-Blackwell.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance 2019, Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide 2019, EPUAP NPIAP & PPPIA, viewed 27 September 2021, http://www.internationalguideline.com/static/pdfs/Quick_Reference_Guide-10Mar2019.pdf
- Hampton, S & Collins, F 2004, Tissue Viability, Whurr Publishers, London.
- National Institute for Health and Care Excellence 2014, Pressure Ulcers: Prevention and Management, NICE, viewed 18 June 2018, https://www.nice.org.uk/guidance/cg179/chapter/1-recommendations#prevention-adults
- National Pressure Ulcer Advisory Panel 2015, Preventative Skin Care, NPUAP, viewed 18 June 2018, https://www.npuap.org/wp-content/uploads/2015/02/2.-Preventive-Skin-Care-M-Goldberg.pdf
- Mallet, J, Albarran, J & Richardson, R 2013, Critical Care Manual of Clinical Procedures and Competencies, Wiley-Blackwell, Oxford.
- Takahashi, M, Black, J, Dealay, C & Gefan, A 2010, ‘Pressure in Context’, in Baharestani, M, Black, J, Clark, M et al. (eds) International Review: Pressure Ulcer Prevention: Pressure, Shear Friction and Microclimate, a Consensus Document, pp. 11-8, Wounds International, London, https://www.woundsinternational.com/resources/details/international-review-pressure-ulcer-prevention-pressure-shear-friction-and-microclimate-context
- Reger, S I, Ranganathan, V K & Orsted, H L et al. 2010, ‘Shear and Friction in Context’, in Baharestani, M, Black, J, Clark, M et al. (eds) International Review: Pressure Ulcer Prevention: Pressure, Shear Friction and Microclimate, a Consensus Document, pp. 11-8, Wounds International, London, https://www.woundsinternational.com/resources/details/international-review-pressure-ulcer-prevention-pressure-shear-friction-and-microclimate-context
- Stratton R J, Ek, A C, Engfer, M, Moore, Z, Rigby, P, Wolfe, R & Elia, M 2005, ‘Enteral Nutritional Support in Prevention and Treatment of Pressure Ulcers: A Systematic Review and Meta-Analysis’, Ageing Research Reviews, vol. 4, no. 3, pp. 422-50, https://www.sciencedirect.com/science/article/pii/S1568163705000176?via%3Dihub
- Terekeci, H, Kucukardali, Y, Top, C, Onem, Y, Celik, S & Oktenli, C 2009, ‘Risk Assessment Study of the Pressure Ulcers in Intensive Care Unit Patients’, European Journal of Internal Medicine, vol. 20, no. 4, pp. 394-7, https://www.ejinme.com/article/S0953-6205(08)00305-1/fulltext
- Parkin, B & Cook, S 2000, ‘A Clear View: The Way Forward for Eye Care on ICU’, Intensive Care Medicine, vol. 26, no. 2, pp. 155-6, https://link.springer.com/article/10.1007%2Fs001340050038
- Wakefield, B J, Mentes, J, Holman, J E & Culp, K 2009, ‘Postadmission Dehydration: Risk Factors, Indicators and Outcomes’, Rehabilitation Nursing, vol. 34, no. 5, pp. 209-16, https://pubmed.ncbi.nlm.nih.gov/19772119/