Prevention of Pressure Ulcers in Critical Care Patients

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Introduction:
Pressure ulcers also known as Pus are widely prevalent among the patients of the
intensive care unit. The problem is characterized by a localised injury over the surface of the
skin or the underlying tissues located above a bony framework which manifests itself on
account of pressure (Baath et al., 2014; Sving et al., 2014). As stated by Lala et al. (2014), it
has been reported that the incidence of pressure injuries is highest among the patients of the
Intensive care unit on account of two major reasons that include restricted mobility and
confinement to the bed. Research studies suggest that the most common sites where pressure
injuries manifests itself includes the shoulder blades, hip-region, the lower back and the
tailbone, within the skin behind the knees, heels or the ankles and back or at the sides of the
head (Meddings et al., 2013; Mallah et al., 2015). It should be noted in this context that
improper management of pressure ulcers could trigger a number of complications such as
cellulitis, squamous cell carcinoma, sepsis or bone and joint infections (Liao et al., 2013;
Cooper, 2013). This paper in particular aims to critically appraise the available scholarly
literatures in order to address the research question that whether or not a pressure ulcer risk
assessment and repositioning intervention can help in the prevention of pressure ulcers
among the patients of the critical care unit.
Search Strategy and justification:
The research question for the assessment is “Is there any evidence that conducting a
risk assessment and changing position reduces the development of pressure ulcers among
immobilized critical care patients in comparison to not changing the posture?”
In order to address the research question, an exhaustive search was conducted on three
popular electronic databases that included Google Scholar, PubMed and MedLine. In orderto
conduct the search an effective search strategy was used, which specifically used a set of

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inclusion and exclusion characteristics. Also, the search was conducted using key terms that
closely aligned to the concept of the research question.
Inclusion and Exclusion Criteria:
The exclusion and inclusion criteria that was used to conduct the search helped in
narrowing down the search so as to retrieve relevant research studies. As stated by Harriss et
al. (2017), exclusion criteria forms the set of characteristics that are used in order to exclude
research studies that do not align to the research question. The list of exclusion criteria that
was followed while conducting a search on the electronic databases comprised of four
characteristics. The first criterion comprised of papers that were published in foreign
languages. The second criterion comprised of papers that were published before 2013. The
third criterion included research papers that were not full-text accessible and the fourth
criterion included papers that were case control studies or quasi-experimental studies. On the
other hand, as stated by Walliman (2017), inclusion criteria forms the set of characteristics
that are used to include relevant scholarly journals. In this case, the inclusion criteria
comprised of characteristics that included, scholarly journals published in between 2013 to
2018, papers that were published in English language, papers that were full text accessible
and papers that followed a study design of randomised controlled trials and systematic
review. Also, the inclusion criteria comprised of a sample size that included patients admitted
within the critical care unit. The flow diagram of the search strategy that was followed to
conduct a search on the electronic database of Google scholar is shown in appendix 1. A
similar strategy was used to conduct a thorough search on the electronic database of PubMed
and MedLine.

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Key terms:
According to Faden et al. (2013), key terms can be defined as terms and short phrases
that are used while conducting a search on the popular electronic databases. It should be
noted in this context that electronic databases are unable to retrieve relevant results when
long sentences are used. In this case, the key words that were used included, pressure ulcers,
intervention, critical care patients, bed sores, risk assessment, effective intervention,
changing posture and effective clinical outcome.
Further, in order to refine the search, Boolean operators like ‘OR’ and ‘AND’ was
used. The key terms were used in combination with the Boolean operators in order to retrieve
relevant research studies, for instance, Pressure ulcers OR bedsores AND critical care
patients. The effective search with the help of the key terms helped in retrieving 50 relevant
research papers on google scholar. Additional, 23 articles were retrieved through other
electronic databases that included PubMed and MedLine. The total number of research
records after the removal of duplicates comprised of 67 research articles. All 67 research
articles were screened. A total of 27 research articles were removed as the articles were not
full-text accessible and only comprised of the abstract. 40 research articles were full-text
accessible which were thoroughly evaluated for inclusion in the review. A total of 21 articles
were excluded as the research studies did not meet the specific inclusion criteria of research
designsthat was considered for the research study. A total of 12 articles were excluded as the
research studies included the sample population that comprised of elderly patients within
Geriatric care unit. A total of 9 research papers were considered for the review and appraisal.
The search strategy was same for all databases.
The rationale for the selection of the 9 articles included their close relevance with the
research question. Also, the articles that stringently qualified the inclusion criteria were only

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included in the review. The inclusion criteria was specifically devised and considered the
appropriate sample size of patients within the critical care unit and also included the research
designs that included randomised control trials and systematic reviews.
Critical appraisal:
According to Walliman (2017), critical appraisal is broadly defined as the method of
systematic evaluation where clinical research papers are thoroughly evaluated in order to
address a specific research question. The use of a critical appraisal tool helps in appraising
the quality of a research paper in order to evaluate its strengths and weaknesses and
accordingly derive conclusions so as to understand whether or not the results can be
generalized. In this case, the CASP critical appraisal tool was used in order to critique the
research papers that were included in the review. The critical appraisal checklist for
randomized control trail and systematic review was browsed and downloaded online and was
then used to critique the research papers.
Discussion:
A research study undertaken by Peterson et al. (2013) made use of a randomized
control trail in order to evaluate that whether or not routine repositioning among high risk
patients can help in envisioning relief from high-risk peri-sacral area using the technique of
interface pressure mapping. The authors collected the research data from the tertiary care unit
and considered 23 participants in total. The sampling method that was followed included the
convenience sampling method and constituted of the patients admitted within the
intermediate and intensive care unit. The participants were recruited from the intensive and
the intermediate care unit on the basis of the inclusion criteria that comprised of the risk of
pressure injury formation based on the Braden risk score<18. The patients had their peri-
sacral skin-bed interfaces documented post 30 seconds and the patients were given a

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repositioning care every four to six hours. There was no control group. The results revealed
that the enrolled participants had characteristic skin areas (206+ /- 182 cm2) where the
pressure thresholds had exceeded more than 95% during the entire research period. An
observation was conducted on 13 participants for the specific postures that included the
supine, right turned and left turned position and the areas exceeded 95% of the pressure
threshold. Further, the risk probability did not change for high risk patients during their
complete hospital stay despite the repositioning. The findings of the research therefore
suggested that the repositioning strategies are not effective in mitigating the risks of ulcers.
Therefore, it can be mentioned that the results overall helped in evaluating that the change of
positioning intervention within the critical care unit does is not much effective in acquiring
positive outcome in terms of reducing risks of pressure ulcers among bedridden patients.
However, the sample size considered by the researchers is not significant in order to
generalize the findings of the research study.
Moore and Cowman (2015) conducted a systematic review in order to evaluate if
repositioning as an intervention could prevent pressure injuries. The researchers conducted an
exhaustive review of literatures on four electronic databases that included Cochrane Register
of Controlled Trials (CENTRAL), Ovid (MedLine), Ovid (EMBASE) and EBSCO CINAHL.
The researchers made use of RCTs (randomised controlled trials) that compared the
repositioning intervention in relation to no repositioning. In addition to this, in the absence of
randomised controlled trails, the researchers considered controlled trials, which suggested
clarity in relation to research design.The review was conducted by two authors independently
which suggests that biases in relation to research outcome or influence was avoided. The
overall conclusion suggested that despite the prevalent use of repositioning as a therapeutic
intervention to treat pressure ulcers among critical care patients, the evidence base does not
confirm that repositioning can help in achieving positive outcome. In addition to this the