氧合作用和血流灌注指标对ICU患者压疮发生的预警作用

目的 了解ICU压疮发病特征及氧合作用和血流灌注指标与压疮发生的相关性,为临床预防压疮提供依据.方法 采用自行设计问卷,通过皮肤检查和查阅病历,收集ICU患者的压疮发病情况及氧合作用和血流灌注指标等资料,将226例分为压疮组52例(为医院获得性压疮),非压疮组174例,并用SPSS15.0对各因素进行统计分析.结果 两组在年龄、动脉血酸碱度、动脉二氧化碳分压、收缩压、舒张压、平均动脉压及Braden评分等方面的差异有统计学意义(P<0.05);经多因素非条件Logistic回归分析,平均动脉压和Braden评分增加为ICU压疮的保护因素,呼吸系统疾病、外伤和其他类型疾病是ICU压疮的危险因素.结论 ICU患者是压疮的危险人群,平均动脉压和Braden评分高者发生压疮的危险较小,呼吸系统疾病、外伤和其他类型疾病的患者发生压疮的危险较大,年龄可能是压疮的间接危险因素.建议临床医护人员加强对ICU患者的血流动力学和动脉血气分析指标的监测,从中获取压疮预警信息,采取适当的预防措施,以降低压疮的发生率.     

Designing devices to communicate effectively with intensive care nurses to prevent pressure injuries: A qualitative study

ObjectivesThe aim of this research was to identify “what” key design elements of a device for detecting hospital acquired pressure injuries should do and “how” these elements should function. The goal of the resulting design was to prompt intensive care unit nurses to intervene appropriately to reduce the incidence/severity of pressure injuries, while minimizing workflow disruptions.MethodsA mixed method study was performed in an intensive care unit, which included shadowing, interviewing, surveying and conducting focus groups with individuals knowledgeable about pressure injuries and related patient care. This study focused on identifying and prioritizing the needs/wants of nurses regarding devices aimed at detecting hospital acquired pressure injuries. These needs were then used as the foundation for designing key elements of such a device.FindingsIntensive care nurses indicated that a device for the early detection of pressure injuries should communicate information as real-time summaries about the severity of a skin issue in an easy-to-understand manner and provide reminders for them to take action when needed without unnecessarily interrupting their workflow.ConclusionThe findings regarding nurses’ needs will be useful for the future development of technologies/devices that help reduce the incidence/severity of hospital acquired pressure injuries. In turn, nurses may be more likely to use such a device to enhance patient care.     

Predictive risk scales for development of pressure ulcers in pediatric patients admitted to general ward and intensive care unit

BACKGROUNDMore than ten special scales are available to predict the risk of pressure ulcers in children. However, the performances of those scales have not yet been compared in China. AIMTo compare the Waterlow, Braden Q, and Glamorgan scales, and identify more suitable pressure ulcer evaluation scale for the pediatric intensive care unit (PICU).METHODSTrained nurses used the Waterlow, Braden Q, and Glamorgan scales to assess pediatric patients at Sun Yat-sen Memorial Hospital (China) within 24 h of admission from May 2017 to December 2020 in two stages. Skin examination was carried out to identify pressure ulcers every 3 d for 3 wk. RESULTSThe incidence of pressure ulcers was 3/28 (10.7%) in the PICU and 5/314 (1.6%) in the general pediatric ward. For children in the general ward, the Waterlow, Braden Q, and Glamorgan scales had comparable area under the operating characteristic curve (AUC) of 0.870, 0.924, and 0.923, respectively, and optimal cut-off values of 14, 14, and 29 points. For PICU, the Waterlow, Braden Q, and Glamorgan scales had slightly lower AUC of 0.833, 0.733, and 0.800, respectively, and optimal cut-off values of 13, 16, and 27 points. Braden Q demonstrated a satisfactory specificity, and during the second stage of the study for PICU patients, the AUC of the Braden Q scale was 0.810, with an optimal cut-off value of 18.35 points.CONCLUSIONThe Waterlow, Braden Q, and Glamorgan scales have comparable performance, while the Braden Q scale demonstrates a better specificity and can be successfully used by pediatric nurses to identify patients at high risk of pressure ulcers in PICU.     

Alternating pressure air mattresses as prevention for pressure ulcers: a literature review

OBJECTIVES: The purpose of this paper is to examine and synthesise the literature on alternating pressure air mattresses (APAMs) as a preventive measure for pressure ulcers. DESIGN: Literature review. DATA SOURCES: PubMed, Cinahl, Central, Embase, and Medline databases were searched to identify original and relevant articles. Additional publications were retrieved from the references cited in the publications identified during the electronic database search. RESULTS: Thirty-five studies were included. Effectiveness and comfort of APAMs were the main focuses of the studies evaluating APAMs. Pressure ulcer incidence, contact interface pressure, and blood perfusion were the most frequently used outcome measures to evaluate the effectiveness of APAMs. Fifteen randomised controlled trials (RCTs) analysed the pressure ulcer incidence. One RCT compared a standard hospital mattress with an APAM and found that the APAM was a more effective preventive measure. RCTs comparing APAMs with constant-low-air mattresses resulted in conflicting evidence. There was also no clear evidence as to which type of APAM performed better. All RCTs had methodological flaws. The use of contact interface pressure and blood perfusion measurements to evaluate the effectiveness of APAMs is questionable. Comfort of APAMs was the primary outcome measure in only four studies. Different methods for assessment were used and different types of APAMs were evaluated. Better measures for comfort are needed. A few studies discussed technical problems associated with APAMs. Educating nurses in the correct use of APAMs is advisable. CONCLUSION: Taking into account the methodological issues, we can conclude that APAMs are likely to be more effective than standard hospital mattresses. Contact interface pressure and blood perfusion give only a hypothetical conclusion about APAMs' effectiveness. Additional large, high-quality RCTs are needed. No conclusions can be drawn regarding the comfort of APAMs. A number of technical problems associated with APAMs are related to nurses' improper use of the devices.     

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BackgroundPressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit.ObjectivesThe objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations.MethodsA prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1–18; period 2, weeks 19–28; and period 3, weeks 29–52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist.ResultsOver the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20–0.97, p = 0.0126).ConclusionsWe found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.     

Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit

Aims and objectives: The study aimed to evaluate the predictive validity and accuracy of a new pressure ulcer risk assessment scale in two Indonesia intensive care units (ICUs). Background: Several risk assessment scales have been designed to identify patients at risk of developing pressure ulcers in ICU. However, the relative weight of each variable that contributes to pressure ulcer development in these scales is not described to enable designing of a risk assessment scale. Currently, the risk factors contributing to pressure ulcer development include interface pressure, body temperature and cigarette smoking. Design: A prospective cohort study was conducted in two ICUs in Pontianak, Indonesia. Methods: A total of 253 patients were recruited to the study from both hospitals. Data collection included new risk assessment scale [i.e. the Suriadi and Sanada (S.S.) scale] scoring, demographic, pressure ulcer severity scores (based on the National Pressure Ulcer Advisory Panel) and skin condition measures. Using the S.S. scale, trained data collectors scored patients once and assessed the body temperature daily until patients were discharged. Additionally, daily data were also collected in relation to the patient‘s skin condition and stage of pressure ulcer. Results: Out of the 253 patients, 72 (28·4%) developed pressure ulcers. In ICU A, the incidence was 27%; pressure ulcers developed into stage I (41·7%), stage II (45·8%), stage III (10·4%) and stage IV (2·1%). In ICU B, the incidence was 31·6%; the development of pressure ulcers was 48% in stage I and 52% in stage II. Using the predictive validity test, the S.S. scale balanced sensitivity (81%) and specificity (83%) at a cut‐off score of 4. The area under the receiver‐operating characteristic curve was 0·888 (confidence interval: 0·84–0·93). Conclusion: The S.S. scale was found to be a valid risk assessment tool to identify the patients at risk of developing pressure ulcers in Indonesia ICU.     

循证护理干预方案在ICU压疮高危患者中的应用

目的探讨循证护理干预方案在ICU压疮预防中的作用。方法将227例Braden评分≤12分的压疮高危患者按照入院的顺序分为对照组102例和观察组125例。对照组采用常规护理方法。观察组进行循证护理干预,予每2h翻身1次,左右30°侧卧位交替进行;平卧位时抬高患者床头不超过30°,足跟处垫软枕;对Braden评分〈7分、颈椎骨折及病情限制翻身的患者必须使用气垫床;在受压皮肤处及可能发生压疮的皮肤区域喷赛肤润;在皮肤受压部位应用康惠尔透明贴;根据患者营养状况给予肠内外营养;保持肛周皮肤干燥。比较2组的压疮发生情况。结果观察组的压疮发生率明显低于对照组,发生时间延迟,压疮严重程度轻。结论在ICU压疮高危患者中应用循证护理干预方案,能体现护理工作的科学性和艺术性,更有效地分配有限的护理资源,减少压疮的发生。     

Exploring medical device-related pressure injuries in a single intensive care setting: A longitudinal point prevalence study

ObjectivesTo report longitudinal prevalence rates of device-related pressure injuries in critically ill adult patients in the intensive care unit and to explore the patient characteristics associated with the development of device related pressure injuries.Research designA prospective observational design where observations of patients’ skin integrity were conducted on one day each week for 52 weeks.SettingThe study was conducted in the 36-bed intensive care unit of a major metropolitan tertiary referral hospital in Queensland, Australia. The sample included all patients aged 18 years or older admitted to the intensive care unit before midnight on the day preceding the observation, with a medical device in situ.Main outcome measuresThe primary outcome measure was device related pressure injuries identified at the weekly observations and defined as a pressure injury found on the skin or mucous membrane with a history of medical device in use at the location of the injury. Patient demographic and clinical characteristics were recorded.ResultsOver the study period, 11.3% (71/631) of patients developed at least one hospital-acquired DRPI.The most common devices associated with injury were nasogastric/nasojejunal tubes (41%) and endotracheal tubes (27%). Significant predictors of device related pressure injuries were the total number of devices (OR 1.230, 95% CI 1.09–1.38, p < 0.001), the length of time in the ICU (OR 1.05, 95% CI 1.02–1.09, p = 0.003), male sex, (OR 2.099, 95% CI 1.18–3.7, p = 0.012), and increased severity of illness score on admission (OR 1.044, 95% CI 1.01–1.09, p = 0.013).ConclusionDevice related pressure injuries are an all-too-common iatrogenic problem for this vulnerable patient cohort.     

Incidence and risk factors of pneumonia acquired in intensive care units

Objective To estimate the incidence of pneumonia acquired in the intensive care unit (ICU), and to define risk factors for developing such an event.Design European prospective survey, in which all patients admitted to the participating ICU from January, 17 to 23, 1990, were followed until ICU discharge.Setting 107 general ICUs from 18 countries.Patients Of 1078 admitted to the ICUs, 996 patients without pneumonia at admission were studied.Measurements Pneumonia was diagnosed by the staff physician on the basis of clinical, radiological and microbiological criteria, secondly validated by an expert committee who reviewed all the forms and even recontacted ICU physicians. Crude incidence and time to occurrence of pneumonia were estimated, then both used as endpoints for prognosis analysis.Results 89 pneumoniae were observed: crude incidence was estimated at 8.9%, 7-day and 14-day pneumonia rates at 15.8% and 23.4%, respectively. The risk of developing pneumonia increased when either coma, trauma, respiratory support, Apache II >16 and/or impaired airway reflexes were present at ICU admission. To predict time to occurrence of pneumonia, only two variables remained significant: the presence of impaired airway reflexes at admission and the use of mechanical ventilation during ICU course.Conclusion The role of the injury to the respiratory system — with the subsequent need for respiratory support-appears central in determining the risk to acquire pneumonia in ICU. In the future, the predictive value of severity scores during ICU course should be otherwise assessed.     

ICU患者压疮发生危险因素分析

目的：探讨导致ICU患者压疮发生的危险因素。方法：采用自行设计的“ICU患者压疮风险因素调查表”记录735例ICU患者的患病情况、主要治疗情况等资料。结果：性别、糖尿病、脑卒中、入ICU时间、是否持续进行动脉血压监测、水肿、平均动脉压、乳酸Lac、心率、Apachell评分是ICU患者发生压疮的影响因素。结论：ICU患者压疮发生是多因素共同参与的病理生理过程,护理人员应充分认识各种危险因素对ICU患者发生压疮的影响,对存在或可能存在危险因素的ICU患者实施重点防护以减少压疮的发生。     

支撑性工具在压疮防治中的循证评价

压疮是局部皮肤组织长期受压,导致缺血缺氧性损伤的病变,是长期住院、活动障碍及老年患者常见的并发症.选择合适支撑工具来减少局部长期压迫,是压疮防治的重要措施[1-2].     

Post-traumatic stress symptoms in family caregivers of intensive care unit patients: A longitudinal study

ObjectivesTo describe the prevalence and trajectory of family caregivers’ post-traumatic stress symptoms during the first year after a patient’s admission to the intensive care unit and identify associations between family caregivers’ background characteristics, hope and post-traumatic stress symptoms.Research methodology/designsFamily caregivers of intensive care unit patients (n = 211) completed questionnaires at patient admission to the intensive care unit and thereafter at 1, 3, 6, and 12 months. Mixed-model analyses were performed.SettingFour intensive care units in a university hospital in Norway.Main outcome measuresImpact of Event Scale—Revised and Herth Hope Index.ResultsOn admission, 54% of family caregivers reported high post-traumatic stress symptom levels, which decreased during the first six months after patient discharge. Lower levels of hope, being younger, having more comorbidities and being on sick leave were associated with higher post-traumatic stress symptom levels. Being the parent of the patient was associated with decreased post-traumatic stress symptom levels.ConclusionsFamily caregivers of intensive care unit patients report high levels of post-traumatic stress symptoms. Higher levels of hope were associated with fewer post-traumatic stress symptoms.     

Prevalence of pressure injuries among critically ill patients and factors associated with their occurrence in the intensive care unit: The PRESSURE study

BackgroundThe prevalence of pressure injuries (PIs) in critically ill patients has been extensively studied, but there is uncertainty regarding the risk factors. The main objective of this study was to describe the prevalence of PIs in critically ill patients. Secondary objectives were to describe PI, use of preventive measures for PI, and factors associated with occurrence of PI in the intensive care unit (ICU).Material and methodsThis was a 1-day point-prevalence study performed on a weekday in June 2017 in ICUs in France. On the same day, we noted the presence or absence of PI in all hospitalised patients of the participating ICUs, data on the ICUs, and the characteristics of patients and of PI.ResultsEighty-six participating ICUs allowed the inclusion of 1228 patients. The prevalence of PI on the study day was 18.7% (95% confidence interval: 16.6–21.0). PIs acquired in the ICU were observed in 12.5% (95% confidence interval: 10.6–14.3) of critically ill patients on the study day. The most frequent locations of PI were the sacrum (57.4%), heel (35.2%), and face (8.7%). Severe forms of PI accounted for 40.8% of all PIs. Antiulcer mattresses were used in 91.5% of the patients, and active and/or passive mobilisation was performed for all the patients. Multiple logistic regression analysis identified longer length of stay in the ICU, a higher Simplified Acute Physiology Score, higher body weight, motor neurological disorder, high-dose steroids, and absence of oral nutrition on the study day as factors independently associated with occurrence of PI in the ICU.ConclusionThis large point-prevalence study shows that PIs are found in about one of five critically ill patients despite extensive use of devices for preventing PI. Acquisition of PI in the ICU is strongly related to the patient's severity of illness on admission to the ICU and length of stay in the ICU.     

Intervention studies for prevention of pressure ulcers in Turkey: a literature review

AIM: To examine critically the literature published in the Turkish language (1955-2004) related to risk assessment tool(s), their application to nursing care and prevention of pressure ulcers (PrUs). Specific objectives were to identify the advantages of risk assessment and prevention of PrUs in hospital; to establish the most valid and reliable methods available to evaluate the effectiveness of PrU prevention programmes; to determine methodological problems encountered by researchers and explore how these were overcome; and to present the findings so they could be used to develop a valid and reliable audit tool based upon the empirical evidence. METHODS: All journals and convention booklets published in Turkey related to nursing between the years 1955-2004 were examined. Because many journals in Turkey are not yet available by electronic means, the published Turkish articles were all examined by hand. A total of 3031 articles in 17 nursing journals and 36 congress books (convention booklets) were examined. Five articles were found to meet the study criteria and were taken into the study and evaluated. CONCLUSION: There is a need to determine valid and reliable assessment methods, and the results need to be recorded on standard forms. In addition, it is important to increase the motivation of nursing personnel who give direct patient care to use the tools available in order to prevent the development of PrUs. From the review findings it is apparent that in Turkey, there is a dearth of research evidence upon which to base practice in the sphere of PrU prevention, and further research is urgently required.     

Value of pressure injury assessment scales for patients in the intensive care unit: Systematic review and diagnostic test accuracy meta-analysis

ObjectivesTo review and examine the evidence of the value of pressure injury risk assessment scales in intensive care patients.Research methodologyWe searched MEDLINE, Embase, CINAHL, Web of Science, the Cochrane Library, China Biomedical Literature Service System, VIP Database and CNIK from inception to February 2019. Two reviewers independently assessed articles’ eligibility and risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-II (QUADAS-2). We used a hierarchical summary receiver operating characteristics (HSROC) model to conduct the meta-analysis of diagnostic accuracy.ResultTwenty-four studies were included, involving 16 scales and 15,199 patients in intensive care settings. Results indicated that the top four risk assessment scales were the Cubbin & Jackson Index (SEN = 0.84, SPE = 0.84, AUC = 0.90), the EVRUCI scale (SEN = 0.84, SPE = 0.68, AUC = 0.82), the Braden scale (SEN = 0.78, SPE = 0.61, AUC = 0.78), the Waterlow scale (SEN = 0.63, SPE = 0.46, AUC = 0.56). The Norton scale and the other eleven scales were tested in less than two studies and need to be further researched.ConclusionThe Braden scale, most frequently used in hospitals, is not the best risk assessment tool for critically ill patients. The Cubbin & Jackson Index has good diagnostic test accuracy. However, low quality of evidence and important heterogeneity were observed.