The effect of pH-compatible cleansing cloths on skin pH and the development of pressure ulcers

AimSkin care plays an important role in the prevention of the development of pressure ulcers. The aim of this study was to determine the effect of skincare with a body pH-compatible cleansing cloth on the development time of pressure ulcers and on skin pH.MethodsThis experimental research was conducted with 156 patients hospitalized in intensive care clinics of a state hospital between September 2019 and 2020. The sample was calculated with a power of 80% and a significance level of 0.05 (α error) and as a result, 78 elderly patients formed the intervention group and another 78 elderly patients made up the control group. Data were collected using the Elderly Information Form, Braden Risk Assessment Scale, Pressure Ulcer Staging Tool and Skin pH Measurement Form. The pre- and post-care skin pH of both groups was measured with a skin pH meter. P < 0.05 was considered statistically significant.ResultsThe average development time for pressure ulcers was 14.9 days in the control group, 18.9 days in the intervention group and the difference was not statistically significant (p > 0.05). Skin pH decreased in the intervention group after the skin care routine was applied, whereas it increased in the control group.ConclusionIt can be said that care of one's skin with a body pH-compatible cleansing cloth has a positive effect on the development time of pressure ulcers and also positively changes the skin pH to acidic.     

A quantitative study of hydration level of the skin surface and erythema on conventional and microclimate management capable mattresses and hospital beds

BackgroundIn addition to pressure itself, microclimate factors are gaining more attention in the understanding of the development of pressure ulcers. While there are already various products to reduce pressure on sore-prone areas to prevent pressure ulcers, there are only a few mattresses/hospital beds that actively influence skin microclimate. In this study, we investigated if microclimate management capable mattresses/hospital beds can influence skin hydration and skin redness/erythema.MethodsWe included 25 healthy subjects in our study. Measurements were made using Courage & Khazaka Multi Probe Adapter MPA with Corneometer CM825 and Mexameter MX18 to determine skin hydration of the stratum corneum and skin redness/erythema before and after the subjects were lying in conventional (Viskolastic® Plus, Wulff Med Tec GmbH, Fedderingen, Germany and Duo™ 2 mattress, Hill-Rom GmbH Essen, Germany) or microclimate management capable mattresses/hospital beds (ClinActiv + MCM™ and PEARLS AFT, Hill-Rom GmbH Essen, Germany).ResultsWhile there was no difference in skin redness/erythema on the different mattresses/hospital beds, skin hydration of the stratum corneum decreased significantly in an air fluidized bed compared to baseline values and values measured on standard mattress/Viskolastic® Plus.ConclusionAir-fluidized therapy reduces skin hydration and therefore could contribute to prevent moisture associated ulcers. Changes in skin hydration as one important factor of skin microclimate can be detected after a short time of incubation and even before an erythema appears.     

Patterns and associations of structural and functional cutaneous responses during loading at heel and sacral skin in aged females: A reanalysis of clinical study data

Aim of the studyThe aim of this study was to explore possible interrelationships and cutaneous response patterns at the heel and sacral skin due to prolonged loading.Materials and methodsSkin stiffness, elasticity, roughness and transepidermal water loss, stratum corneum hydration, erythema, and temperature of n = 20 aged females (mean age 69.9 years) were measured before and after 90 and 150 min loading in supine position. Delta values were calculated and correlated using Spearman's rho. Strengths and directions of associations and similar patterns were subsequently identified for the heel and sacrum areas.ResultsAt the sacral area decreased stiffness (Uf) was associated with increased TEWL and there was a positive relationship between mean roughness (Rz) and erythema. At the heel there was a positive association between TEWL and decreasing stiffness (Uf).ConclusionsOur results indicate a dynamic interaction between skin changes during loading and different physiological response patterns for sacral and heel skin. There seems to be close association between transepidermal water loss and stiffness changes during loading.     

A knowledge test on pressure injury in adult intensive care patients: Development,validation, and item analysis

BackgroundPressure injuries are a major problem in critically ill patients, but both students' and intensive care nurses’ knowledge about these injuries leaves room for improvement. As no knowledge test is currently available that focuses on pressure injuries in adult intensive care patients, we aimed to develop such tool, establish the content validity, and perform item analysis using Classical test theory.MethodsTest development followed established multiple-choice question-writing guidelines. Content validation used a Delphi procedure including eight international experts. Item analysis (question difficulty and discrimination power, and quality of the distractors) was based on the test results of a convenience sample who completed the test online, based on ready knowledge.ResultsFour Delphi validation rounds resulted in a 24-item multiple-choice test within seven categories: Epidemiology, Aetiology, Prevention, Classification, Risk factors and risk assessment, Wound care, and Skin care. The content validity index was 0.96. The median score of 12 students and 38 qualified nurses was 12.5/24 (interquartile range 11–14.25; range 4–17; 52%). Least correct answers were in the categories Classification and Wound care. Item analysis revealed several knowledge gaps and misconceptions.ConclusionsThe test has excellent content validity. The sample's overall score was low. Item analysis identified various training needs. Future users are recommended to further validate the test and establish its reliability, and to tailor it to their individual context and evaluation requirements.     

Reliability and validity of the Turkish version of pressure ulcer knowledge assessment tool-updated version (PUKAT 2.0)

ObjectiveThis study aimed to determine the reliability and validity of the Turkish version of the measurement tool developed and updated by Manderlier et al. to evaluate the nurses’ evidence-based knowledge about pressure ulcers.Materials and methodsA methodological study design was used. The instrument was translated to Turkish and back-translated to English. A group of faculty members, including physicians and nurses who are experts in the subject area, evaluated the content validity of the tool with the Lawshe technique. A group of 240 nurses who met the inclusion criteria were reached, and then a pilot study was conducted with 35 nurses by using the test-retest method to determine the invariance of the tool over time. The nurses in the pilot study were excluded from the overall sample, and the evaluations were performed with 205 nurses. Item difficulty index and discrimination index were used for the validity of the items since they were multiple-choice items; Kuder-Richardson 20 analysis was used to determine the internal consistency.ResultsThe translated and modified instrument demonstrated acceptable psychometric properties as follows: 1) overall content validity index was 0.90, 2) overall test-retest reliability was 0.83 (0.70–0.92 for the sub-themes), 3) item difficulty indexes were 35–75%, 4) discrimination indexes were 0.44–0.92, and 5) overall Cronbach's alfa for the internal consistency was 0.72.ConclusionsSimilar to the earlier version, the Turkish version of PUKAT 2.0 was demonstrated to be a valid and reliable tool to evaluate the nurses’ knowledge of evidence-based current information about pressure ulcers.     

The uptake of the international pressure ulcer/injury prevention and treatment guidelines in the scientific literature: A systematic analysis of two major citation databases

BackgroundThe European Pressure Ulcer Advisory Panel, the National Pressure Injury Advisory Panel and the Pan Pacific Pressure Injury Alliance developed international Clinical Practice Guidelines of the prevention and treatment of pressure ulcers/injuries in 2009, 2014, and 2019. Despite substantial dissemination efforts, evidence about guideline dissemination and uptake in the international literature is lacking.AimThe aim of this review was to capture to the greatest detail possible the number of the citations of the three published Clinical Practice Guidelines.MethodsThe citation databases Web of Science and Scopus were searched for citations of the 2009, 2014 and 2019 Clinical Practice Guidelines including all derivative products including short versions and translations. Two separate search strategies were iteratively developed to ensure highest sensitivity.ResultsThe Cited Reference Search in Web of Science identified hundreds of different referencing formats with more than 2000 citing articles. The Scopus search revealed 250 different reference formats and more than 2000 citation counts. After publication there was a gradual increase of citations that peaks approximately after four years.ConclusionThe three Clinical Practice Guidelines including all derivate versions had a substantial uptake in the scientific literature. This supports the assumption that the guideline dissemination strategies were and are successful.     

Skin damage prevention in the prone ventilated critically ill patient: A comprehensive review and gap analysis (PRONEtect study)

BackgroundVentilating critically ill patients with acute respiratory distress syndrome in the prone position is a life-saving strategy, but it is associated with adverse consequences such as skin damage.AimTo identify, review and evaluate international proning and skin care guidelines and make an inventory of commonly used equipment and training resources.DesignA gap analysis methodology was applied.Methods1) Comprehensive search and evaluation of proning and skin care guidelines, 2) extensive search and listing equipment and educational resources, and 3) international consultation with 11 experts (8 countries).Data sourcesA variety of sources researched through July 2021 were used to identify relevant literature: (1) scientific literature databases and clinical trials registries, (2) intensive care and wound care associations, (3) healthcare organisations, (4) guideline development organisations, and (5) the Google search engine. Eleven international experts reviewed the literature and provided insights in two, 2-h online sessions.FindingsThe search yielded 24 guidelines. One clinical practice guideline had high methodological quality. Twenty-five devices/equipment and sixteen teaching materials were identified and discussed with the expert panel. The gap analysis identified a lack of concise, accessible, evidence-based guidelines and educational materials of short duration.ConclusionThis analysis forms the basis for designing a competency-based education and training intervention for an interdisciplinary team caring for the skin of critically ill patients in the prone position.ImpactThe results can assist the multidisciplinary team to review their current protocol for prone positioning. This is a first step in developing a training package for clinicians.     

Factors related to knowledge,attitude, and practice of nurses in intensive care unit in the area of pressure ulcer prevention: A multicenter study

IntroductionAs one of the main members of the health team, nurses have an important role in pressure ulcer prevention in health care centers. The aim of this study was to investigate knowledge, attitude, and practice of nurses on the prevention of pressure ulcers and their related factors.MethodsThis cross-sectional study was carried out in 2018. The total number of ICU nurses employed in educational-health centers affiliated to Iran University of Medical Sciences were examined. Among a total of 328 nurses, 308 questionnaires were completed by the participants. Pressure Ulcer Knowledge Questionnaire, Attitude Toward Pressure Ulcer, and Practice of Pressure Ulcer Prevention questionnaires were used to collect data. SPSS software version 16 and independent t-test, Chi-square, Fisher exact, one-way Analysis of variance, and multiple linear regressions tests were used for data analysis.FindingsBased on the mean score of knowledge, attitude, and practice of the nurses about the pressure ulcer prevention were 63.47 ± 10.31, 39.10 ± 40.22, and 32.03 ± 6.17, respectively. There was a positive and significant relationship between these three variables. Findings revealed that knowledge was increased by 0.051 units, with a one-year increase in work experience of nurses in the ICU. Moreover, women's knowledge and their attitude were higher than those of men as 3.132 and 1.65 units, respectively. Based on the findings, attitude of nurses increased by 0.43 units for an hour of extra work per week. Nurses' attitude score in the General ICU and their practice were higher than scores of other nurses as 2.144 and 2.574 units, respectively. Moreover, practice of nurses increased by 0.162 unit with one-year increase of their age.ConclusionGiven the undesirable level of knowledge and attitude and relatively desirable practice of nurses in the field of pressure ulcer prevention and the importance of improving the safety of patients admitted to the ICU, it is suggested that appropriate educational planning be developed to raise the level of knowledge, attitude, and practice of health care providers, especially nurses, in the area of pressure ulcer prevention.     

Comparison of interface pressures in two dynamic pressure ulcer prevention supports (NIMBUS 3 and SUMMIT): A randomized controlled trial

BackgroundPressure ulcers are a risk for bedridden patients and various supports exist to prevent them. The Pressure Relief Index (PRI) evaluates pressure relief of dynamic mattresses over time. This study compared the PRI of the SUMMIT mattress (AKS-France) and the NIMBUS 3 (HNE Medical).MethodsIn this non-blinded, randomized, crossover, non-inferiority study, patients aged ≥60 with a BMI of 16–35 kg/m2, predominantly confined to bed, able to walk with aid and with pelvic symmetry were recruited from a hospital rehabilitation department from March–April 2012. Exclusion criteria included past or present pressure ulcers, inability to remain supine and deep vein thrombosis. Peak pressures of the sacrum were recorded at 0.1 Hz during a single complete 10-min inflating cycle on both mattresses, with the order determined via electronic randomization allocation.ResultsThirty-one subjects were included and randomized; with 14 finally analyzed in the SUMMIT-NIBMUS 3 order group and 16 in the NIMBUS 3-SUMMIT group. The difference in PRI <30 mmHg between the two mattresses was 13.2% [0.3–26.1] (p < 0.05), allowing a non-inferiority - superiority switch. The SUMMIT mattress demonstrated a significantly higher percentage of time <30 mmHg (p = 0.0454). No significant difference in mean minimal pressure was seen (p = 0.3231) and mean maximal pressure was in favor of SUMMIT mattress (p = 0.0096). BMI did not affect pressure profile. There were no adverse events.ConclusionsEvaluated by the PRI, the SUMMIT mattress had a better interface pressure profile than the NIMBUS 3 in older patients. The PRI is a promising tool for clinical decision-making and research, warranting validation.     

Knowledge,attitude, and practice of Iranian nurses towards pressure ulcer prevention: A systematic review

IntroductionPressure ulcer (PU), as a long-term disabling condition, is an important indicator for patient safety and quality of nursing care in hospitals. This systematic review aimed to evaluate the knowledge, attitude, and practice of Iranian nurses towards PU prevention.MethodsA systematic search was conducted on PubMed, Web of Science, Scopus databases, Google Scholar Search Engine, as well as Magiran, Iranmedex, and Scientific Information Database (SID) Persian databases using the relevant keywords, from the earliest date available to August 21, 2020. Studies were appraised using the appraisal tool for cross-sectional studies (AXIS tool).FindingsAmong a total of 1,543 Iranian nurses included in the 9 studies, 80.53% were female with a mean age of 31.14 (SD = 5.52) years. The mean work experience of the participants was 7.94 years (SD = 5.44). The knowledge and practice of Iranian nurses toward PU prevention were insufficient and relatively desirable, respectively. Also, the present study showed that nurses' attitudes toward PU prevention were contradictory. Age, gender, level of education, work experience, and participation in previous educational workshops were possible factors related to nurses' knowledge about PU prevention. Women with higher work experience had a more positive attitude.ConclusionThis review found inappropriate knowledge, attitude, and practice of Iranian nurses toward PU prevention and highlights the importance of regular upgrading of nurses' knowledge and practice related to PU prevention.     

Tissue temperature,flux and oxygen of sacral and trochanteric area under pressure of healthy subjects: A quasi-experimental study

AimTo evaluate the changes that take place in the perfusion, oxygenation and local temperature of the skin of the sacrum and trochanter when subjected to direct pressure for 2 h.MethodsQuasi-experimental study in the preclinical phase with healthy subjects acting as their own controls (intrasubject control). The outcome variables were measured with a laser Doppler system (local temperature and oxygenation) and by near-infrared spectroscopy (perfusion). The pressure exerted was measured with a capacitive pressure sensor. No more than one week elapsed between the sacrum and trochanter measurements.ResultsThe study sample consisted of 18 persons. The comparative analysis of the fluctuations in the parameters measured on the skin of the trochanters and sacrum, according to the time elapsed, revealed a statistically significant increase in temperature and in the pressure exerted. On the other hand, the changes in capillary blood flow and in SaO2 were not statistically significant.ConclusionOur study results show that changes found in terms of temperature and pressure should be taking into account when planning personalised repositioning to patients according to biomechanical and biological situations that vary between anatomical areas. In future research, the changes reported could be evaluated in patients with risk factors for the development of pressure ulcers, thus facilitating the introduction of more personalised planning in the care and prevention of these injuries.     

The effect of pressure and shear on tissue viability of human skin in relation to the development of pressure ulcers: a systematic review

Pressure ulcers are a significant problem in health care, due to high costs and large impact on patients' life. In general, pressure ulcers develop as tissue viability decreases due to prolonged mechanical loading. The relation between load and tissue viability is highly influenced by individual characteristics. It is proposed that measurements of skin blood flow regulation could provide good assessment of the risk for pressure ulcer development, as skin blood flow is essential for tissue viability. . Therefore, the aim of this systematic review is to gain insight in the relation between mechanical load and the response of the skin and underlying tissue to this loading measured in-vivo with non-invasive techniques.A systematic literature search was performed to identify articles analysing the relation between mechanical load (pressure and/or shear) and tissue viability measured in-vivo. Two independent reviewers scored the methodological quality of the 22 included studies. Methodological information as well as tissue viability parameters during load application and after load removal were extracted from the included articles and used in a meta-analysis.Pressure results in a decrease in skin blood flow parameters, compared to baseline; showing a larger decrease with higher magnitudes of load. The steepness of the decrease is mostly dependent on the anatomical location. After load removal the magnitude of the post-reactive hyperaemic peak is related to the magnitude of pressure. Lastly, shear in addition to pressure, shows an additional negative effect, but the effect is less apparent than pressure on skin viability.     

The Chinese version of the skin tear knowledge assessment instrument (OASES): Cultural adaptation and validation

BackgroundSkin tear knowledge is an important predictor of the decreased incidence and management of skin tears, and the knowledge level among Chinese nurses is unknown so far. A validated instrument for measuring skin tear knowledge is urgent.ObjectiveTo culturally adapt the skin tear knowledge assessment instrument (OASES) into Chinese and verify its validity and reliability in the Chinese context.MethodsThe cultural adaptation process for OASES into Chinese was established on Beaton's translation model. Content validity was determined by the 8-expert group in wound care. A nationwide psychometric validation study was performed on a convenience sample of 3333 nurses from 113 tertiary hospitals, of whom 98 nurses finished the test-retest procedure for reliability analysis. Item validity (item difficulty and discriminating index) and construct validity (known-groups technique) were tested.ResultsThe content validity index was 0.88–1.00. The item validity was as follows: Item difficulty ranged from 0.16 to 0.86, with an average value of 0.52; the discriminating index varied between 0.05 and 0.61. The known-group technique demonstrated excellent construct validity with a significant difference between predefined groups with theoretically expected higher knowledge scores and theoretically expected lower knowledge scores (P < 0.001). For the test-retest reliability, the Intraclass correction coefficient (ICC) during a 14-day interval for the overall tool was 0.79 (95% CI = 0.71–0.86), and Cohen's kappa value for each item varied from 0.17 to 0.62.ConclusionsThe Chinese version of OASES was validated to be suitable for skin tear knowledge assessment with acceptable psychometric properties, through which the knowledge and training priorities of skin tear among Chinese nurses can be quantified.     

Knowledge,attitude, and practice of Iranian critical care nurses related to prevention of pressure ulcers: A multicenter cross-sectional study

IntroductionPressure ulcers (PU) are a major, but preventable health problem in all health settings, but especially in intensive care units (ICUs). This study aimed to investigate the knowledge, attitude, and practice (KAP) of Iranian ICU nurses related to the prevention of PU.MethodsIn a cross-sectional study, data obtained from 183 ICU nurses working in four hospitals affiliated to Mazandaran University of Medical Sciences, Sari, Iran were evaluated. The study was conducted from July to October 2020. Data were collected using a four-part questionnaire including demographic characteristics, Pieker Pressure Ulcer Knowledge Test (PPUKT), Attitude toward Pressure Ulcer Prevention (APUP) tool, and the practice of nurses related to the prevention of PU.FindingsThe mean scores of KAP of ICU nurses toward PU prevention were 70.57 (SD = 13.51), 52.82 (SD = 6.16), and 22.44 (SD = 5.20), respectively. There was a positive correlation between nurses' attitude and practice (r = 0.232, P = 0.002), and a negative correlation between knowledge and attitude (r = ?0.156, P = 0.035) of nurses regarding PU prevention. Additionally, a positive correlation was found between nurses' years of working experience in ICU and their knowledge regarding PU prevention (r = 0.159, P = 0.032).ConclusionAccording to the results of the present study, the level of KAP of Iranian ICU nurses related to PU prevention were desirable, positive, and relatively desirable. Therefore, nurse managers and policymakers should try to eliminate the main barriers such as heavy workload, inadequate nurse staffing, and lack of appropriate guidelines for PU prevention which consequently affect the practice of ICU nurses in the prevention of PU.     

The effect of sub-epidermal moisture on pressure injury prevention strategies and incidence of pressure injuries: A feasibility pilot randomised controlled trial

AimSub-epidermal moisture scanning (SEMS) is a novel point-of-care technology that measures localised oedema and detects early tissue damage that may develop into a pressure injury (PI). It provides objective data that may assist PI prevention (PIP) decision making. This study aimed to determine the feasibility of undertaking a definitive randomised controlled trial (RCT) to test the effectiveness of SEMS.Materials and methodsThis pilot RCT recruited medical and surgical patients at risk of developing a PI in one Australian hospital. All participants received routine PIP care and daily visual skin assessment to determine the presence of a PI. The intervention group also received daily SEMS. Clinical staff were told if the sub-epidermal moisture (SEM) value was abnormal but were not given advice for PIP. Blinding of patients, care staff and outcome assessors was not practical. Feasibility outcomes included recruitment, retention, intervention fidelity, and patient outcomes.ResultsOf 1185 patients screened prior to eligibility, 950 were excluded (80%); 235 were then assessed for eligibility and 160 met the inclusion criteria (68.1%); 100 were recruited (70.0%) and randomised and 99 completed the trial (intervention n = 50; control n = 49) with one person withdrawn due to inappropriate recruitment (100% retention). Of the 657 expected SEMS observations, 598 were completed (91% intervention fidelity). Only 34 of 454 (7.4%) patient outcome data points were missing.ConclusionsMost feasibility criteria were met, indicating a definitive trial to assess the effectiveness of SEMS in a medical-surgical patient population is realistic. However, recruitment may be resource intensive and require specific strategies.     

A quantitative study of transepidermal water loss (TEWL) on conventional and microclimate management capable mattresses and hospital beds

BackgroundTransepidermal water loss (TEWL) is regarded as one of the most important parameters characterizing skin barrier integrity and has found to be higher in impaired skin barrier function. Reduced or low TEWL instead indicates skin barrier integrity or improvement. We evaluated if different mattresses/hospital beds can influence this skin barrier function by measuring TEWL before and after subjects lying in conventional and microclimate management capable mattresses/hospital beds.MethodsWe included 25 healthy subjects in our study. Measurements were made using Courage & Khazaka Multi Probe Adapter MPA with Tewameter TM300 to determine TEWL before and after the subjects were lying in conventional (Viskolastic® Plus, Wulff Med Tec GmbH, Fedderingen, Germany and Duo? 2 mattress, Hill-Rom GmbH Essen, Germany) or microclimate management capable mattresses/hospital beds (ClinActiv + MCM? and PEARLS AFT, Hill-Rom GmbH Essen, Germany).ResultsWhile there was no statistically significant difference in standard mattresses/hospital beds (22.19 ± 12.99 and 19.80 ± 11.48 g/hm²), the decrease of TEWL was statistically significant in both microclimate management capable mattresses/hospital beds we investigated (16.89 ± 8.586 g/hm² and 17.41 ± 7.203 g/hm²) compared to baseline values (35.85 ± 24.51 g/hm²).ConclusionAs higher TEWL announces impaired skin barrier function these findings indicate that the choice of the mattress/hospital bed is important for skin barrier function and microclimate management systems improve skin barrier function of the skin.