of 13

Predictors of Pressure Ulcers in Adult Critical Care Patients.pdf

Published on December 2016 | Categories: Documents | Downloads: 7 | Comments: 0
64 views

Comments

Content

Predictors of Pressure Ulcers in Adult Critical Care Patients
Jill Cox
Am J Crit Care 2011;20:364-375 doi: 10.4037/ajcc2011934
© 2011 American Association of Critical-Care Nurses
Published online http://www.ajcconline.org
Personal use only. For copyright permission information:
http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

Subscription Information
http://ajcc.aacnjournals.org/subscriptions/
Information for authors
http://ajcc.aacnjournals.org/misc/ifora.shtml
Submit a manuscript
http://www.editorialmanager.com/ajcc
Email alerts
http://ajcc.aacnjournals.org/subscriptions/etoc.shtml

AJCC, the American Journal of Critical Care, is the official peer-reviewed research
journal of the American Association of Critical-Care Nurses (AACN), published
bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049.
Copyright © 2011 by AACN. All rights reserved.

Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

Pressure Ulcer Management

P

REDICTORS OF

PRESSURE ULCERS IN
ADULT CRITICAL CARE
PATIENTS
By Jill Cox, RN, PhD, APN, CWOCN

C E 1.0 Hour
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Identify the stages of pressure ulcers as defined
by the National Pressure Ulcer Advisory Panel.
2. Describe the components of the Braden Scale
for assessing risk for pressure ulcers.
3. Discuss potential factors not included in the
Braden Scale that can be predictors for pressure ulcers in critical care populations.
To read this article and take the CE test online,
visit www.ajcconline.org and click “CE Articles
in This Issue. No CE test fee for AACN members.


This article is supplemented by an AJCC Patient Care
Page on page 376.
©2011 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2011934

364

Background Pressure ulcers are one of the most underrated
conditions in critically ill patients. Despite the introduction of
clinical practice guidelines and advances in medical technology, the prevalence of pressure ulcers in hospitalized patients
continues to escalate. Currently, consensus is lacking on the
most important risk factors for pressure ulcers in critically ill
patients, and no risk assessment scale exclusively for pressure ulcers in these patients is available.
Objective To determine which risk factors are most predictive
of pressure ulcers in adult critical care patients. Risk factors
investigated included total score on the Braden Scale, mobility,
activity, sensory perception, moisture, friction/shear, nutrition,
age, blood pressure, length of stay in the intensive care unit,
score on the Acute Physiology and Chronic Health Evaluation
II, vasopressor administration, and comorbid conditions.
Methods A retrospective, correlational design was used to
examine 347 patients admitted to a medical-surgical intensive
care unit from October 2008 through May 2009.
Results According to direct logistic regression analyses, age,
length of stay, mobility, friction/shear, norepinephrine infusion,
and cardiovascular disease explained a major part of the variance in pressure ulcers.
Conclusion Current risk assessment scales for development
of pressure ulcers may not include risk factors common in
critically ill adults. Development of a risk assessment model
for pressure ulcers in these patients is warranted and could
be the foundation for development of a risk assessment tool.
(American Journal of Critical Care. 2011;20:364-375)

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

www.ajcconline.org

D

evelopment of pressure ulcers is complex and multifactorial. In critical care
patients, pressure ulcers are an additional comorbid threat in patients who are
already physiologically compromised. In fact, pressure ulcers are one of the
most underrated medical problems in critical care patients.1 Despite advances
in medical technology and the use of formalized prevention programs based
on clinical practice guidelines, the prevalence of pressure ulcers during hospitalization continues to increase. In 2008, Russo et al2 of the Health Care Cost and Utilization Project reported
an 80% increase in the occurrence of pressure ulcers from 1993 to 2006 in hospitalized adult
patients and estimated that total associated health care costs were $11 billion. Among all hospitalized patients, prevalence rates of acquired pressure ulcers are the highest in patients in the
intensive care unit (ICU), from 14% to 42%.3-5
In 2006, the Centers for Medicare and Medicaid
Services6 declared that hospital-acquired stage III or
stage IV pressure ulcers are adverse patient safety
events, or “never events,” that could reasonably be
prevented by implementing evidence-based prevention guidelines. As a result, beginning in 2008, reimbursement limitations were enacted for acute care
hospitals for care associated with stage III or stage
IV pressure ulcers not documented as present when
a patient was admitted.7 This change has sparked a
renewed urgency and awareness related to preventing
pressure ulcers. Although the implementation of
comprehensive prevention programs can reduce the
prevalence of hospital-acquired pressure ulcers,8,9
pressure ulcers do develop in hospitalized patients,
despite quality care and best practice. Furthermore,
the risk for pressure ulcers may be greater for ICU
patients than for other patients.10-12
The first step in preventing pressure ulcers is determining what constitutes appropriate risk. Many risk
factors have been identified empirically; however, consensus on the most important risk factors is lacking.

Review of Relevant Literature
The lack of a risk assessment scale exclusively for
determining the risk for pressure ulcers is an impediment to accurately determining risk in critical care
patients.3,13 In the United States, the Braden Scale14 is
the most widely used risk assessment tool in most
care settings, including the ICU, and current clinical
practice guidelines15-17 recommend its use. With the
Braden Scale, derived from the conceptual framework
About the Author
Jill Cox is an advanced practice nurse and a wound,
ostomy, continence nurse at Englewood Hospital and
Medical Center, Englewood, New Jersey.
Corresponding author: Jill Cox, RN, PhD, APN, CWOCN,
Englewood Hospital and Medical Center, 350 Engle St,
Englewood NJ, 07631 (e-mail: [email protected]).

www.ajcconline.org

of Braden and Bergstrom,18 6 subscales are used to
measure risk for pressure ulcers: sensory perception,
activity, mobility, nutrition, moisture, and friction/
shear. Potential scores range from 6 to 23; lower
scores indicate greater risk. Scores of 15 to 18 indicate risk or mild risk; scores of 13 to 14, moderate
risk; scores of 10 to 12, high risk; and scores of 9 or
less, very high risk.19 Stratification of risk for pressure
ulcers can be useful clinically for determining and
implementing the appropriate level of prevention.20
Although evidence4,21-23 supports the total score
on the Braden Scale as a predictor of pressure ulcers
in critical care patients, investigation of the contributions of the subscale scores has been limited, and the
findings have been inconclusive. Although the subscales of sensory perception,22,24 moisture,21,24 mobility,21 and friction/shear24 have been found to be
significant predictors of pressure ulcer
development in ICU patients, the activity and nutrition subscales have not.
Other factors not included in
the Braden Scale may also increase a
patient’s level of risk for pressure ulcers
and thus be important determinants
in adult critical care patients. Empirical
evidence suggests that the following
factors can be predictive of pressure
ulcers in critical care patients:
advanced age1,4,21,25,26; low arteriolar pressure27-29; prolonged ICU stay1,21,26,30; severity of illness as indicated
by scores on the Acute Physiology and Chronic
Health Evaluation (APACHE) II1,31; comorbid conditions, including diabetes mellitus, sepsis, and vascular
disease21,25,27; and iatrogenic factors, such as the use
of vasopressor agents.1,25,27 Although research has
indicated that many of these factors are significantly
related to the development of pressure ulcers in ICU
patients, the findings were not consistent in all of
the studies in which these relationships were tested.

Pressure ulcers
are one of the
most underrated
medical problems
in critical care
patients.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

365

Table 1
Pressure ulcer staging system of the
National Pressure Ulcer Advisory Panela
Stage

Description

Suspected deep Purple or maroon localized area of discolored intact skin
tissue injury
or blood-filled blister due to damage of underlying
soft tissue from pressure and/or shear
The area may be preceded by tissue that is painful, firm,
mushy, boggy, and warmer or cooler than adjacent tissue
I

Intact skin with nonblanchable redness of a localized
area, usually over a bony prominence
Darkly pigmented skin may not have visible blanching;
its color may differ from that of the surrounding area

II

Partial-thickness loss of dermis manifested as a shallow,
open ulcer with a red-pink wound bed, without slough
May also be manifested as an intact or open/ruptured
serum-filled blister

III

Full-thickness tissue loss
Subcutaneous fat may be visible, but bone, tendon, or
muscle are not exposed
Slough may be present but does not obscure the depth
of tissue loss

IV

Full-thickness tissue loss with exposed bone, tendon, or
muscle
Slough or eschar may be present on some parts of the
wound
Often includes undermining and tunneling

Unstageable

Full-thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green, or brown)
or eschar (tan, brown, or black) in the wound bed

a

Based on data from the National Pressure Ulcer Advisory Panel.

The purpose of my study was to determine which
risk factors derived from the Braden Scale and the
empirical literature are the best predictors of pressure
ulcers in adult critical care patients. The following
risk factors were examined: total Braden score, mobility, activity, sensory perception, moisture, nutrition,
friction/shear, ICU length of stay,
age, arteriolar pressure, vasopressor
administration, score on APACHE
II, and comorbid conditions.

Braden subscales
of activity and nutrition have not been
useful as risk predictors in intensive
care patients.

Methods

This study received exempt
status from the hospital’s institutional review board. The study
posed no risk to the participants
because the variables abstracted
reflected care parameters implemented and recorded
during routine patient care. All patient information
recorded was deidentified to ensure patient anonymity.
Study Design and Setting
A retrospective descriptive, correlational design
was used. The setting was an intensivist-led, 12-bed

366

medical-surgical ICU (MSICU) in Englewood Hospital and Medical Center, a suburban Magnet teaching hospital in Englewood, New Jersey.
Sample
All adult patients admitted to the MSICU from
October 2008 through May 2009 who met the
inclusion criteria were included in this convenience
sample. Patients were included if they were 18 years
or older and had an MSICU stay of 24 hours or greater.
Patients were excluded if they had an MSICU stay
of less than 24 hours or had a pressure ulcer at the
time of admission to the MSICU. A power analysis
was conducted for regression analysis to determine
an appropriate sample size.32 In order to achieve a
power of 80%, a minimum sample size of 163 was
needed for a moderate effect size, a significance level
of α = .05, and 22 predictor variables.
Data Collection
Data were abstracted from the hospital’s existing computerized documentation systems and
included the following study variables: pressure
ulcer (recorded as present or absent at discharge
from the MSICU); score on Braden Scale at the
time of admission to the MSICU; scores on
Braden subscales at admission to the unit; age;
arteriolar pressure (defined as the total number
of hours in the first 48 hours that the patient had
mean arterial pressure <60 mm Hg, and/or systolic blood pressure <90 mm Hg, and/or diastolic
blood pressure <60 mm Hg); length of MSICU
stay; total number of hours of administration of
any of the following vasopressor agents during
the MSICU stay: norepinephrine, epinephrine,
vasopressin, dopamine, and phenylephrine; severity of illness according to the APACHE II score;
and presence or absence of any of the following
comorbid conditions: diabetes mellitus, cardiovascular disease, peripheral vascular disease, and
concomitant infection/sepsis. During the study
period, routine protocols for prevention of pressure ulcers were in place in the MSICU. The protocols were based on the clinical practice
guidelines33,34 current at that time.
Demographic data and patient characteristics
included ethnicity, sex, and admitting MSICU
diagnosis. In addition, for patients in whom a
pressure ulcer developed, the number of hours
into the admission the pressure ulcer occurred and
the anatomical location and stage of the pressure
ulcer according to the 2007 National Pressure
Ulcer Advisory Panel staging system35 (Table 1)
were recorded.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

www.ajcconline.org

Data Analysis
SPSS, version 16.0 for Windows, software (SPSS
Inc, Chicago Illinois) was used for data analysis.
Descriptive statistics included frequency distributions for study variables and demographic data. The
Pearson product moment correlation was used for
correlational analyses of the study variables. Direct
logistic regression was used to create the best model
for predicting the development of pressure ulcers in
ICU patients. For comparison of study variables
between patients with and without pressure ulcers,
t tests and χ2 analysis were used.

Results
Description of the Sample
Of the 579 patients admitted to the MSICU
during the study period, 347 met the inclusion criteria and were included in the final sample. The
patients were 20 to 97 years old (mean, 69; SD, 17).
The top 3 admitting diagnoses were respiratory failure or distress (20.7%), sepsis or septic shock (17.3%),
and neurological problems (15%). Demographic
characteristics of the sample are summarized in
Table 2.
Descriptive Statistics of the Study Variables
Descriptive statistics of the study variables are
summarized in Table 3. Among the 347 patients in
the sample, a pressure ulcer developed in 65 (18.7%).
Of these ulcers, most (35%) were stage II, and the
sacrum was the most common anatomical location
(58%). Mean time until development of a pressure
ulcer was 133.61 hours (median 90.0; range, 5-573;
SD, 120.13). The distribution of pressure ulcers by
stage and hours to development is summarized in
Table 4.
Mean Braden Scale scores were 14.28 (SD, 2.68;
range, 6-23) for the entire patient sample, 12.73
(SD, 2.65) for patients in whom pressure ulcers
developed, and 14.63 (SD, 2.65) for patients who
remained ulcer-free. Of the 65 patients in whom a
pressure ulcer developed, 28% (n = 18) were classified as at risk, 28% (n = 18) as at moderate risk,
35% (n = 23) as at high risk, and 9% (n = 6) as at
very high risk. Predictive validity of the Braden Scale
was measured by using sensitivity and specificity
values in addition to negative and positive predictive values36 (Table 5). At a cut-off score of 18, the
sensitivity was 100%, specificity was 7%, positive
predictive value was 20%, and negative predictive
value was 100%. According to the scores on the
Braden Scale, 94% of the sample was predicted to
be at risk for pressure ulcers; the actual occurrence
rate was 18.7%.

www.ajcconline.org

Table 2
Demographic characteristics
of the study sample (n = 347)
Valuea

Characteristic
Age, mean (SD), range, y

69 (17.0), 20-97

Sex
Male
Female

171 (49.3)
176 (50.7)

Race
White
Black/African American
Asian/Pacific Islander
Hispanic
Other

255 (73.5)
48 (13.8)
26 (7.5)
17 (4.9)
1 (0.3)

Intensive care unit admitting diagnosis
Respiratory arrest/distress
Sepsis/septic shock
Neuromedical problem
General medical problem
Gastrointestinal bleeding
Neurosurgical problem
Gastrointestinal surgical problem
Vascular surgical problem
Other surgical problem
Cardiac condition
Cardiac arrest
a

72
60
52
44
24
24
23
17
13
12
6

(20.7)
(17.3)
(15.0)
(12.7)
(6.9)
(6.9)
(6.6)
(4.9)
(3.7)
(3.5)
(1.7)

Values are number (%) unless otherwise indicated. Because of rounding, not all
percentages total 100.

Logistic Regression Analyses
Independent variables significantly associated
with the dependent variable development of a pressure ulcer were included in direct logistic regression
(Table 6). The following risk factors were significant
predictors of pressure ulcers: mobility (B = -0.823;
P = .04; odds ratio [OR] = 0.439; 95% confidence
interval [CI], 0.21-0.95), age (B = 0.033;
P = .03; OR = 1.033; 95% CI, 1.0031.064), length of ICU admission
(B = 0.008; P < .001; OR = 1.008; 95%
CI, 1.005-1.011), and cardiovascular
disease (B = 1.082; P = .007; OR = 2.952;
95% CI, 1.3-6.4; Table 7).
In order to better understand the
risk factors that lead to actual breaks
in skin integrity, a second direct logistic
regression was done for a subsample of
the population (n = 327) that excluded all patients in
whom a stage I pressure ulcer developed. The following risk factors were significantly predictive of
the development of a stage II or greater pressure
ulcer: friction/shear (B = 1.743; P = .01; OR = 5.715;
95% CI, 1.423-22.950), length of ICU stay (B = .008;
P < .001; OR = 1.008; 95% CI, 1.004-1.012), norepinephrine administration (B = .017; P = .04; OR = 1.017;
95% CI, 1.001-1.033), and cardiovascular disease

A pressure
ulcer developed
in 18.7% of the
sample; most
were stage II
sacral ulcers.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

367

Table 3
Descriptive statistics of study variables and comparison of patients
with acquired pressure ulcers and patients without pressure ulcers
Valuea
Independent variables

All patients
(n = 347)

Total Braden score
Sensory perception subscale
Moisture subscale
Activity subscale
Mobility subscale
Nutrition subscale
Friction/shear subscale

14.28 (2.68)
2.85 (0.936)
3.40 (0.756)
1.08 (0.442)
2.53 (0.829)
2.29 (0.655)
2.10 (0.473)

Hours in intensive care unit

Statistic

12.73 (2.65)
2.40 (0.884)
1.75 (0.729)
1.00 (0.000)
2.06 (0.788)
2.06 (0.555)
1.90 (0.491)

14.63 (2.65)
2.94 (0.928)
1.55 (0.758)
1.09 (0.489)
2.64 (0.801)
2.35 (0.665)
2.14 (0.458)

t = 5.9b
t = 3.95b
t = -1.93
t = 1.63
t = 5.31b
t = 6.38b
t = 3.71b

73 (15)

68 (18)

t = -2.72b

2.41 (4.96)
3.65 (6.74)
23.12 (15.39)

3.67 (5.83)
5.61 (7.72)
30.43 (15.26)

2.12 (4.71)
3.20 (6.42)
21.43 (14.95)

t = -2.00c
t = 2.33c
t = -4.35b

118.84 (155.58)

Arteriolar pressure, h
Mean arterial pressure <60 mm Hg
Systolic <90 mm Hg
Diastolic <60 mm Hg

No pressure ulcer
(n = 282)

69 (18)

Age, y

Pressure ulcer
(n = 65)

281.21 (256.14)

81.41 (85.78)

t = -6.20b

14.63 (2.65)

t = -5.58b

Severity of illness (APACHE II score)

17.268 (7.72)

21.89 (6.71)

Vasopressor administration, h
Norepinephrine
Epinephrine
Phenylephrine
Dopamine
Vasopressin

13.87 (50.05)
0.29 (3.69)
1.29 (8.80)
1.70 (9.44)
3.76 (22.24)

54.98 (101.50)
0.892 (0.700)
2.05 (7.83)
3.41 (12.16)
16.15 (47.59)

Comorbid conditions, No. of patients (%)
Peripheral vascular disease

4.39 (16.05)
0.152 (2.34)
1.12 (9.02)
1.30 (8.67)
0.909 (7.09)

t = -4.00b
t = -1.45
t = -0.770
t = -1.627
t = -2.57c

30

Yes, 4 (6)
No, 61 (94)

Yes, 26 (9)
No, 256 (91)

χ2 = 0.6d

145

Yes, 37 (57)
No, 28 (43)

Yes, 108 (38)
No, 174 (62)

χ2 = 7.5b

Diabetes

97

Yes, 19 (29)
No, 46 (71)

Yes, 78 (28)
No, 204 (72)

χ2 < 0.1

Infection

120

Yes, 36 (55)
No, 29 (45)

Yes, 84 (30)
No, 198 (70)

χ2 = 15.3b

Cardiovascular disease

Abbreviation: APACHE, Acute Physiology and Chronic Health Evaluation.
a All values are mean (SD) unless indicated otherwise.
b Significant at P ≤ .01.
c Significant at P ≤ .05.
d For all χ2 values, df = 1 and n = 347.

(B = 1.218; P = .02; OR = 3.380; 95% CI, 1.2239.347; Table 7).

Discussion
In this study sample, a Braden Scale score of 18
was not predictive of the development of a pressure
ulcer. In fact, 75% (n = 261) of the patients were
classified as at risk for pressure ulcers (Braden Scale
score ≤18) but remained ulcer-free (see Figure).
When the Braden Scale was used, the risk for pressure ulcers was overpredicted, as indicated by the
low specificity and low positive predictive value.
Because of the overprediction, drawing any important conclusions about the capability of the scale in
predicting development of pressure ulcers in the
patients in the study is difficult. Either use of the

368

Braden Scale led to successful identification of
patients at risk, subsequently mobilizing clinicians
to implement appropriate strategies to prevent pressure ulcers and thus averting the occurrence of the
ulcers, or potentially unnecessary strategies to prevent pressure ulcers were implemented, resulting in
excessive health care costs and potential inefficient
use of caregivers’ time.
Of the 6 Braden subscales, only mobility and
friction/shear were significant predictors of pressure
ulcers. Mobility is defined on the Braden Scale as
the ability of a patient to turn and control body
movement.18 Compared with patients who were
ulcer-free, patients in whom pressure ulcers developed had significant lower scores on the mobility
subscale, with a mean subscale score of 2.0, defined

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

www.ajcconline.org

Table 4
Analysis of patients with pressure ulcers

as very limited mobility. Turning and repositioning
an immobile patient is a basic tenet of nursing care
and is recommended in all current practice guidelines as a strategy to prevent pressure ulcers. Although
evidence for the optimal frequency for repositioning immobile patients is lacking,37 the guidelines16,17
indicate that regular repositioning is vital. Some
evidence38 also supports the use of low air loss mattresses for pressure redistribution in ICU patients.
The use of low air loss mattresses and regular turning and repositioning of immobile patients may be
2 essential strategies for preventing pressure ulcers
in critical care patients. The effect of progressive
mobility programs on reduction of pressure ulcers
in ICU patients is an area ripe for empirical study.
Development of a stage II or greater pressure
ulcer was almost 6 times more likely in patients with
higher exposure to friction/shear than in patients
with low exposure. Previous studies in critical care
patients have yielded inconclusive evidence for this
subscale. Although Jiricka et al24 found a significance
difference in the mean Braden friction/shear subscale scores between patients in whom pressure ulcers
developed and patients who remained ulcer-free,
other investigators21,22 found no relationship between
the subscale and development of pressure ulcers in
critical care patients. In a recent study39 in a surgical
trauma ICU, 41 patients at high risk for pressure
ulcers received an application of a silicone-bordered,
nonadherent foam dressing to the sacral area to
minimize the forces of friction, shear, and moisture.
Application of this topical dressing significantly
reduced the occurrence of pressure ulcers to zero.
The study is being replicated to validate the findings.
Immobile, critically ill patients are totally
dependent on caregivers for both repositioning and
transfers, increasing the risk for exposure to the
forces of friction/shear and subsequent development of pressure ulcers. Advocates of safe patient
handling procedures recommend the use of glide
sheets and patient transfer devices to reduce the
deleterious effects of friction/shear on the skin and
simultaneously protect staff from musculoskeletal
injuries.40 Additional factors such as prolonged head
elevation in critically ill, intubated patients to prevent ventilator-associated pneumonia or in enterally
fed patients to prevent aspiration also increase the
risk for exposure to friction/shear. Continued research
into the effects of prolonged head elevation on skin
integrity is warranted to better understand the
sequelae of shear forces and to develop interventions
to counteract these forces.
In my study, patients in whom pressure ulcers
developed had lower mean scores on the Braden

www.ajcconline.org

Characteristic

No. (%)a

Pressure ulcer

65 (18.7)

Pressure ulcer stage
I
II
III
IV
Deep tissue injury
Unstageable

20 (31)
23 (35)
1 (2)
1 (2)
15 (23)
5 (7)

Pressure ulcer location
Sacrum
Buttocks
Heels
Other

38
22
3
2

Hours to pressure ulcer detection
1- 8
49-72
73-144
≥145

21 (32)
7 (11)
15 (23)
22 (34)

(58)
(34)
(5)
(3)

No. of pressure ulcers by stage and hours to detection

Hours to
detection Stage I Stage II Stage III Stage IV

Deep
tissue
injury

Unstageable
Total

1-48

8

7

0

0

5

1

21

49-72

2

2

0

0

2

1

7

73-144

3

6

1

0

3

2

15

≥145

7

8

0

1

5

1

22

a

Because of rounding, not all percentages total 100.

Table 5
Predictive validity criteria of a pressure
ulcer risk assessment scalea
Criterion

Description

Sensitivity

What percentage of patients who actually had a
pressure ulcer develop were classified as at risk?

Specificity

What percentage of patients who remained free of a
pressure ulcer were accurately classified as not at risk?

Predictive value of How accurate is the risk assessment scale as a
a positive test
prospective predictor of which patients will have a
pressure ulcer develop?
Predictive value of How accurate is the risk assessment scale as a
a negative test
prospective predictor of which patients will not
have a pressure ulcer develop?
a

Based on data from Bolton.36

sensory perception subscale than did patients who
remained ulcer-free. However, this subscale was not
a significant predictor. Diminished levels of sensory
perception experienced by all patients in the sample
may have rendered this risk factor nonsignificant

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

369

Table 6
Bivariate correlations: independent variables and
dependent variable (pressure ulcer development)
Independent variable

r

Total Braden score
Mobility
Activity
Sensory perception
Moisture
Friction/shear
Nutrition
Age
Mean arterial
pressure <60 mm Hg
Systolic pressure
<90 mm Hg
Diastolic pressure
<60 mm Hg

-0.276a
-0.275a
-0.088
-0.208a
0.104
0.196a
-0.175a
0.130b
0.122b
0.140a
0.228a

Independent variable

r

Severity of illness
(APACHE II score)

0.288a

Vasopressor administration
Norepinephrine
Phenylephrine
Epinephrine
Dopamine
Vasopressin

0.395a
0.041
0.078
0.087
0.268a

Comorbid conditions
Cardiovascular disease
0.147a
Peripheral vascular disease -0.043
Diabetes mellitus
0.014
Infection
0.210a

0.502a

Hours in intensive
care unit

Abbreviation: APACHE, Acute Physiology and Chronic Health Evaluation.
a Significant
b Significant

at P ≤ .01.
at P ≤ .05.

Table 7
Logistic regression analyses
Logistic regression (n = 347)

Variable

B

Standard
error
Wald
4.725

P

Exp (B)

95%
Confidence
interval

.03

1.033

1.003 to 1.064

1.008

1.005 to 1.011

Age

0.033

0.015

Hours in
intensive care
unit

0.008

0.002

Cardiovascular
disease

1.082

0.401

7.288

.007

2.952

1.3 to 6.4

Mobility

-0.823

0.398

4.262

.04

0.439

0.210 to 0.95

Constant

-7.049

2.857

6.087

.01

0.001

21.996 <.001

Nagelkerke R2 = 0.512.
Hosmer and Lemeshow test: χ2 = 6.993, df = 8, P = .54.

Logistic regression (n = 327), subsample of all patients excluding patients
with stage I pressure ulcers

Variable

B

Standard
error
Wald

P

Exp (B)

95%
Confidence
interval

1.008

1.004 to 1.012

Hours in intensive care unit

0.008

0.002

Cardiovascular
disease

1.218

0.519

5.510

.02

3.380

1.223 to 9.347

Friction/shear

1.743

0.709

6.039

.01

5.715

1.423 to 22.95

Norepinephrine

0.017

0.008

4.223

.04

1.017

1.001 to 1.033

-10.512

3.779

7.737

.005

0.000

Constant

18.063 <.001

Nagelkerke R2 = 0.569.
Hosmer and Lemeshow test: χ2 = 5.836, df = 8, P = .67.

370

when analyzed with other risk factors. In 2 previous
studies22,24 in critical care patients, however, scores
on the Braden sensory perception subscale were
predictive of pressure ulcers. Current pressure ulcer
guidelines17 recommend that practitioners consider
the impact of the score on the Braden sensory perception subscale when determining a patient's risk
for pressure ulcers.
In my sample, the activity subscale was not
related to development of pressure ulcers, a finding
consistent with the results of previous studies21,22,24
in critical care patients in which the Braden activity
subscale was used. Because most patients in the
MSICU were bed bound, the patients in my sample
had little variation in activity levels.
A possible explanation for the finding that the
score on the Braden moisture subscale was not predictive of pressure ulcers in my study is the frequent
use of indwelling devices that minimize skin exposure to moisture from 2 primary sources: urine
(indwelling urinary catheters) and liquid stool
(fecal containment devices). In 2 previous studies21,24
in ICU patients, scores on the Braden moisture subscale were predictive of pressure ulcers, and in another
study,1 fecal incontinence was a significant risk factor for pressure ulcers. Bowel management systems,
also called fecal containment devices, were introduced to the clinical market in 2004, after the
aforementioned studies were published. In a study
by Benoit and Watts,41 use of these devices in combination with strategies to prevent pressure ulcers
decreased the prevalence of pressure ulcers for
patients exposed to high levels of moisture from
liquid stool incontinence.
Although scores on the Braden nutrition subscale
were related to the development of pressure ulcers
in my study, the scores were not a significant predictor, consistent with the findings of previous
studies21,22,24 in ICU patients. The score on this subscale is a measure of the usual food intake of a
patient, and most critically ill patients may have
difficulty articulating a diet history or be unable to
do so, especially in the initial days of an ICU admission, diminishing the value of the subscale in these
patients. In a previous study26 in ICU patients, however, nutrition, measured as the number of days
without nutrition, was a significant predictor of the
development of pressure ulcers. Additionally, the
results of measurements of many biological markers of nutrition, such as body weight, serum levels
of albumin, and, in some instances, serum levels of
prealbumin, may be erroneous because of fluid shifts
that occur in critical illness, thus creating greater
challenges in determining appropriate objective

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

www.ajcconline.org

125

www.ajcconline.org

100
75
No. of patients

nutritional markers. Currently, there is a lack of
consensus among researchers and clinicians regarding the best metric of nutritional status.42
In my study, risk factors not included in the
Braden Scale, that is, age, length of ICU stay, norepinephrine administration, and cardiovascular disease,
were all significant predictors. The mean age of patients
in whom pressure ulcers developed was 73 years,
whereas the mean age in patients who remained
ulcer-free was 67 years. Strong empirical evidence
supports the relationship between advanced age
and development of pressure ulcers in critical care
patients, and perhaps this risk factor should be
given stronger consideration for inclusion in a risk
assessment scale.1,4,21,25,26
In my study, development of pressure ulcers
was more likely in patients with longer ICU stays
than in patients with shorter stays. This result is
consistent with the findings of previous studies.1,21,26
In my study, the mean MSICU stay was 281 hours
(11.7 days) for patients in whom a pressure ulcer
developed and 81 hours (3.3 days) for patients who
remained ulcer-free.
The most vulnerable time for development of
pressure ulcers during the MSICU stay was the first
week; 66% of the sample had development of a
pressure ulcer in the first 6 days of their MSICU
stay, a finding consistent with the results of other
studies22,23,43 in critical care patients. On the basis of
this finding, the first week of a patient’s ICU stay
should be a period of hypervigilance to assess the
risk for pressure ulcers, and strategies to prevent
such ulcers should be aggressively implemented. Paradoxically, the first week of an ICU stay may also be
the most likely period in which a patient experiences the greatest physiological instability, requiring
nurses and other members of the health care team
to manage multiple life-saving technologies while
simultaneously preventing pressure ulcers. During
this time, communication among all members of
the health care team of the potential for pressure
ulcers is crucial. Moreover, a multidisciplinary forum
can underscore the premise that prevention of pressure ulcers is the responsibility of all members of
the health care team, not just nurses.
In my study, norepinephrine was the only vasopressor that was a significant predictor for pressure
ulcers, a finding consistent with the results of previous studies1,27 in ICU patients. Of note, 32 of the 65
patients (49%) in my study who had a pressure ulcer
develop received norepinephrine. Moreover, the mean
number of hours of norepinephrine infusions in
patients who had stage II or higher pressure ulcers
was significantly higher (55 hours) than in patients

50

25

0

19-23

15-18
13-14
10-12
Score on Braden Scale

6-9

Figure Score on the Braden Scale and occurrence of pressure
ulcers (blue bars, present; red bars, absent).

who remained ulcer-free (4 hours). Evidence to
support norepinephrine as a predictor of pressure
ulcers in critical care patients is increasing.1,27
Cardiovascular disease was the only comorbid
condition in my study that was a significant predictor of pressure ulcers. In my sample, 57% of patients
in whom pressure ulcers developed had cardiovascular disease. Although cardiovascular disease has
been associated with the development of pressure
ulcers in non-ICU patients and in cardiac surgery
patients,44-47 this comorbid condition has not been
studied extensively as a risk factor in
general ICU patients. Further research
is needed to elucidate the importance
of this unmodifiable risk factor in the
development of pressure ulcers in
general critical care patients.
In my study, patients in whom a
pressure ulcer developed had significantly lower mean diastolic blood
pressures, lower mean arterial pressure, and lower mean systolic blood
pressures than did patients who
remained free of pressure ulcers.
However, none of these variables was a significant
predictor. In 3 previous studies27,28,43 in ICU patients,
no significant relationships were found between any
measure of blood pressure and development of
pressure ulcers. In another study,29 diastolic blood
pressure was lower in critical care patients in whom
pressure ulcers developed; however, this relationship
was not statistically significant. The finding that
none of the blood pressure variables was a predictor
of pressure ulcers in my study and in other studies
is noteworthy and may be due to the frequent monitoring of blood pressure in critical care patients,
resulting in quicker implementation of interventions

The first week
of stay in the
intensive care unit
should be a period
of hypervigilance
for pressure
ulcer risk.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

371

to increase arterial pressure. In my study, the finding
may also represent a methodological limitation,
because measurement of blood pressures was confined to the first 48 hours of the MSICU stay.
Although severity of illness was not predictive
of pressure ulcers in my sample, patients in whom
pressure ulcers developed had significantly higher
mean APACHE II scores (21.89; SD, 6.71) than did
patients who remained ulcer-free (mean, 14.63; SD,
2.65), suggesting that patients
with pressure ulcers had a greater
disease burden. This finding is
consistent with the results of a
previous study31 in ICU patients.
The APACHE II score (at ≥13)
was predictive of pressure ulcers
in only one study.1 A total of 36
of the 347 patients in my sample
died, an overall mortality rate of
10%. Among the patients who died during their
MSICU stay, almost half (17) had a pressure ulcer
at the time of death. Although APACHE II scores are
a valid measure of severity of illness and mortality
risk, they may not be a reliable empirical indicator
for severity of illness as a risk for development of
pressure ulcers.

Only mobility and
friction/shear
Braden subscales
were predictors of
pressure ulcers.

Limitations
The retrospective nature of this study is a limitation. However, most of the data abstracted represent objective clinical data that would not vary on
the basis of the study design. Using only the Braden
Scale measurements recorded in the first 24 hours
of the ICU stay may also be a limitation; however,
determining risk early during a
patient’s stay is crucial because
the determination may result in
earlier implementation of prevention strategies. The inability
to assess and stage developing
pressure ulcers is also a limitation of a retrospective design.
Pressure ulcers were staged and
recorded in the patients’ record
by staff nurses who are educated annually on assessment and staging of pressure ulcers and use of the
Braden Scale. Use of a single study site also diminishes the generalizability of the study findings.

A model for
assessing pressure
ulcer risk in intensive care patients
is needed.

Conclusions
Critical care patients are a unique subset of hospitalized patients and are the sickest patients in the
health care system. ICU patients are repeatedly confronted with multiple, concomitant risk factors for

372

development of pressure ulcers, and no consensus
exists on how best to measure these factors.3,13
Although specific measures of risk for pressure ulcers
are available for other populations of patients, including children, neonates, patients who receive care at
home, patients who receive hospice and palliative
care, and patients with spinal cord injuries,17,18,48 no
such tool exists for critical care patients, creating a
barrier to accurate assessment of risk for pressure
ulcers in ICU patients.
Accurate identification of risk factors is a prerequisite for determining appropriate strategies to
prevent pressure ulcers. However, even with consistent and ongoing skin assessment, early identification
of skin changes, and the implementation of appropriate prevention strategies to minimize damage,
skin and tissue damage can occur in critically ill
patients.49 Certain prevention strategies, such as
turning of a patient whose hemodynamic status is
unstable, may be medically contraindicated, and
adequate prevention of pressure ulcers in patients
with multiple risk factors is difficult.50 Paradoxically,
occurrence of pressure ulcers in hospitalized patients,
including critical care patients, is considered an
adverse event by the Centers for Medicare and Medicaid Services, leaving caregivers in a challenging situation of trying to prevent a pressure ulcer that may
not realistically be preventable. Continued research
on risk factors for pressure ulcers in critical care
patients is imperative, not only to ultimately decrease
the prevalence of pressure ulcers but also to help
caregivers identify and implement risk appropriate
evidence-based strategies to prevent the ulcers. Additionally, research will validate the existence of risk
factors for pressure ulcers that cannot be controlled
and thus are not preventable.
My results demonstrate the multifactorial causes
of pressure ulcers in critical care patients. Although
scores on 2 Braden subscale risk factors (mobility,
friction/shear) were predictive of pressure ulcers,
other risk factors not measured by the Braden Scale,
including age, length of ICU stay, norepinephrine
administration, and cardiovascular disease, also
were significant predictors in multivariate analysis.
My findings underscore the need for development and testing of model for assessing the risk for
pressure ulcers in ICU patients, in order to provide
a basis for explaining the development of pressure
ulcers in these patients. This model could serve as
the foundation for development of a pressure ulcer
risk assessment scale for critical care patients. Although
Pancorbo-Hildago et al51 have stated that use of a
risk assessment scale increases the implementation
of pressure ulcer initiatives, the ultimate test is the

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

www.ajcconline.org

ability to translate the findings of such an assessment
into a reduction in the occurrence of pressure
ulcers. Little evidence supports such a reduction
when current risk assessment tools are used.16,17,51-53
Many opportunities exist for research on the
effects of various prevention strategies, such as support surfaces, fecal containment devices, frequency
of repositioning, the use of topical dressings applied
to the sacrum to minimize friction/shear, progressive mobility programs, and the use of glide sheets
and patient transfer equipment, on the development
of pressure ulcers in ICU patients. Ultimately, accurate identification of the risk factors for pressure
ulcers and testing and implementing evidence-based
prevention strategies can lead to reductions in both
the occurrence of pressure ulcers and health care
costs and can promote positive health outcomes in
critical care patients.
ACKNOWLEDGMENTS
This research was done at Englewood Hospital and
Medical Center.

8.

9.

10.

11.

12.

13.

14.

FINANCIAL DISCLOSURES
None reported.

15.

eLetters
Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click “Respond to This Article” in either the full-text or
PDF view of the article.

16.

17.

SEE ALSO
For more about preventing pressure ulcers, visit the
Critical Care Nurse Web site, www.ccnonline.org, and
read the article by Jankowski, “Tips for Protecting
Critically Ill Patients From Pressure Ulcers” (April
2010).

REFERENCES
1. Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anaesthesia. 2000;55:221-224.
2. Russo C, Steiner C, Spector W. Hospitalizations related to
pressure ulcers among adults 18 years and older, 2006.
Healthcare Cost and Utilization Project, Statistical Brief 64.
Agency for Healthcare Quality and Research Web site.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf.
Published December 2008. Accessed June 3, 2011.
3. Keller P Wille J, van Ramshorst B, van der Werken C. Pres,
sure ulcers in intensive care patients: a review of risks and
prevention. Intensive Care Med. 2002;28(10):1379-1388.
4. Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence
in intensive care patients: a cross-sectional study. J Eval
Clin Prac. 2008;14:563-568.
5. VanGilder C, Amlung S, Harrison P Meyer S. Results of the
,
2008-2009 International Pressure Ulcer Prevalence Survey
and a 3-year acute care, unit-specific analysis. Ostomy
Wound Manage. 2009;55(11):39-45.
6. Centers for Medicare and Medicaid Services. Eliminating
serious, preventable and costly medical errors–never
events. Centers for Medicare and Medicaid Services Web
site. http://www.cms.hhs.gov/apps/media/press/release
.asp?Counter=1863. Published May 18, 2006. Accessed
June 3, 2011.
7. Centers for Medicare and Medicaid Services. CMS proposes
additions to hospital-acquired conditions for fiscal year

www.ajcconline.org

18.

19.

20.
21.

22.
23.

24.

25.

26.

27.

28.

29.

2009. Centers for Medicare and Medicaid Services Web
site. http://www.cms.gov/apps/media/fact_sheets.asp. Published April 14, 2008. Accessed June 3, 2011.
Institute for Healthcare Improvement. Relieve the pressure
and reduce harm. Institute for Healthcare Improvement
Web site. http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/ImprovementStories/FSRelievethePressureand
ReduceHarm.htm. Published May 21, 2007. Accessed June
4, 2011.
Agency for Health Care Research and Quality, Innovations
Exchange. Comprehensive, interdisciplinary guidelines,
combined with tools to increase adherence, significantly
reduce hospital-acquired pressure ulcers. Agency for
Health Care Research and Quality Web site. http://www
.innovations.ahrq.gov/content.aspx?id=2589. Published
March 3, 2010. Updated April 13, 2011. Accessed June 4,
2011.
Baumgarten M, Margolis D, Berlin J, et al. Risk factors for
pressure ulcers among elderly hip fracture patients. Wound
Repair Regen. 2003;11(2):96-103.
Baumgarten M, Margolis DJ, Localio AR, et al. Extrinsic risk
factors for pressure ulcers early in the hospital stay: a
nested case-control study. J Gerontol A Biol Sci Med Sci.
2008;63(4):408-413.
Krapfl L, Mackey D. Medicare changes to the hospital inpatient prospective payment systems: commentary on the
implications for the hospital-based wound care clinician.
J Wound Ostomy Continence Nurs. 2008;35(1):61-62.
de Laat E, Schoonhoven L, Pickkers P Verbeek A, vanAch,
terberg T. Epidemiology, risk and prevention of pressure
ulcers in critically ill patients: a review of the literature.
J Wound Care. 2006;15(6):269 275.
Bergstrom N, Braden B, Laguzza A, Holman V. The Braden
Scale for predicting pressure sore risk. Nurs Res. 1987;36(4):
205-210.
Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue.
In: Hughes R, ed. Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Rockville, MD: Agency for
Healthcare Quality and Research; 2008. AHRQ publication
08-0043.
Wound Ostomy and Continence Nurses Society. Guideline for
the Prevention and Management of Pressure Ulcers. Mt Laurel,
NJ: Wound, Ostomy and Continence Nurses Society; 2010.
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of
Pressure Ulcers: Clinical Practice Guideline. Washington,
DC; National Pressure Ulcer Advisory Panel; 2009.
Braden B, Bergstrom N. A conceptual schema for the study
of the etiology of pressure sores. Rehabil Nurs. 1987;12(1):
8-12,15.
Braden B. Protocols by level of risk. http://www.bradenscale
.com/images/protocols_by_level_of_risk.pdf. Published
2001. Accessed June 4, 2011.
Ayello EA, Braden B. How and why do pressure ulcer risk
assessment? Adv Skin Wound Care. 2002;15(3):125-133.
Bours G, De Laat E, Halfens R, Lubbers M. Prevalence, risk
factors and prevention of pressure ulcers in Dutch intensive care units. Intensive Care Med. 2001;27:1599-1605.
Carlson E, Kemp M, Shott S. Predicting the risk of pressure
ulcers in critically ill patients. Am J Crit Care. 1999;8(4):262-269.
Fife C, Otto G, Capsuto E, et al. Incidence of pressure ulcers
in a neurologic intensive care unit. Crit Care Med. 2001;29(2):
273-290.
Jiricka M, Ryan P Carvalho M, Bukvich J. Pressure ulcer risk
,
factors in an ICU population. Am J Crit Care. 1995;4(5):
361-367.
Frankel H, Sperry J, Kaplan L. Risk factors for pressure
ulcer development in a best practice surgical intensive care
unit. Am Surg. 2007;73:1215-1217.
Eachempati S, Hydo L, Barie P Factors influencing the
.
development of decubitus ulcers in critically ill surgical
patients. Crit Care Med. 2001;29(9):1678-1682.
Batson S, Adam S, Hall G, Quirke S. The development of a
pressure area scoring system for critically ill patients: a
pilot study. Intensive Crit Care Nurs. 1993;9:146-151.
Pender L, Frazier S. The relationship between dermal ulcers,
oxygenation and perfusion in mechanically ventilated
patients. Intensive Crit Care Nurs. 2005;21:29-38.
Seturan L, Karabacak U, Ozdilek S, et al. The relationship
among pressure ulcers, oxygenation, and perfusion in
mechanically ventilated patients in an intensive care unit.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

373

J Wound Ostomy Continence Nurs. 2009;36(5):503-508.
30. Sayar S, Turgut S, Dogan H, et al. Incidence of pressure
ulcers in intensive care unit patients at risk according to
the Waterlow scale and factors influencing the development of pressure ulcers. J Clin Nurs. 2008;18(5):765-774.
31. Shahin E, Dassen T, Halfens R. Incidence, prevention and
treatment of pressure ulcers in intensive care patients: a
longitudinal study. Int J Nurs Stud. 2009;46:413-421.
32. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Assoc; 1988.
33. Wound Ostomy and Continence Nurses Society. Guideline
for the Prevention and Management of Pressure Ulcers.
Glenview, IL: Wound, Ostomy and Continence Nurses Society;
2003.
34. Agency for Health Care Policy and Research. Pressure Ulcers
in Adults: Prediction and Prevention. Rockville, MD: Agency
for Health Care Policy and Research; 1992. AHCPR publication 92-0047.
35. National Pressure Ulcer Advisory Panel. Updated staging
system: pressure ulcer stages revised by NPUAP National
.
Pressure Ulcer Advisory Panel Web site. http://www.npuap
.org/pr2.htm. Published 2007. Accessed June 4, 2011.
36. Bolton L. Which pressure ulcer risk assessment scales are
valid for clinical use? J Wound Ostomy Continence Nurs.
2007;34(4):368-381.
37. Krapfl L, Gray M. Does regular repositioning prevent pressure ulcers? J Wound Ostomy Continence Nurs. 2008;35(6):
571-577.
38. McInnes E, Bell Syer SE, Dumville JC, Legood R, Cullum NA.
Support surfaces for pressure ulcer prevention. Cochrane
Database Syst Rev. 2008;8(4):CD001735.
39. Brindle CT. Outliers to the Braden Scale: identifying high
risk ICU patients and the results of prophylactic dressing
use. WCET J. 2010;30(1):11-18.
40. Sibbald R, Norton L, Woo K. Optimized skin care can prevent
pressure ulcers. Adv Skin Wound Care. 2009;22(9):392.
41. Benoit R, Watts C. The effect of a pressure ulcer prevention
program and the bowel management system in reducing
pressure ulcer prevalence in an ICU setting. J Wound
Ostomy Continence Nurs. 2007;34(2):163-175.
42. Doughty DB. Prevention and early detection of pressure
ulcers in hospitalized patients. J Wound Ostomy Continence
Nurs. 2008;35(1):76-78.
43. Compton F Hoffmann F Hortig T, et al. Pressure ulcer predic,
,

374

44.

45.

46.

47.

48.

49.
50.

51.

52.

53.

tors in ICU patients: nursing skin assessment versus objective parameters. J Wound Care. 2008;17(10):417-420, 422424.
Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E.
Multi-site study of incidence of pressure ulcers and the
relationship between risk level, demographic characteristics,
diagnoses and prescription of preventive interventions.
J Am Geriatr Soc. 1996;44(1):22-30.
Lindgren M, Unosson M, Fredrickson M, Ek A. Immobility—
a major risk factor for development of pressure ulcers
among adult hospitalized patients: a prospective study.
Scand J Caring Sci. 2004;18(1):57-64.
Lewicki L, Mion L, Splane K, Samstag D, Secic M. Patient
risk factors for pressure ulcers during cardiac surgery.
AORN J. 1997;65(5):933-942.
Pokorny M, Koldjeski D, Swanson M. Skin care interventions for patients having cardiac surgery. Am J Crit Care.
2003;12(6):535-544.
Spinal Cord Injury Rehabilitation Evidence. Outcome Measures. Spinal cord injury pressure ulcer risk scale. Spinal
Cord Injury Rehabilitation Evidence Web site. http://www
.scireproject.com/outcome-measures. Published 2010.
Accessed June 6, 2011.
Langemo D, Brown G. Skin fails too: acute, chronic and endstage skin failure. Adv Skin Wound Care. 2006;19(4):206-211.
Wound, Ostomy and Continence Nurses Society. Wound,
Ostomy and Continence Nurses Society position statement
on avoidable versus unavoidable pressure ulcers. J Wound
Ostomy Continence Nurs. 2009;36(4):378-381.
Pancorbo Hildago T, Garcia Fernandez F Lopez Madina I,
,
Alvarez Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006;54(1):94-110.
Anthony D, Papanikolaou P Parboteeah S, Saleh M. Do risk
,
assessment scales for pressure ulcers work? J Tissue Viability.
2010;19(4):132-126. doi:10.1016/j.jtv.2009.11.006.
Stechmiller J, Cowan L, Whitney J, et al. Guidelines for the
prevention of pressure ulcers. Wound Repair Regen. 2008;
16(2):151-168.

To purchase electronic or print reprints, contact The
InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,
(949) 362-2049; e-mail, [email protected]

AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2011, Volume 20, No. 5
Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

www.ajcconline.org

CE Test Test ID A112005: Predictors of Pressure Ulcers in Adult Critical Care Patients. Learning objectives: 1. Identify the stages of pressure ulcers as
defined by the National Pressure Ulcer Advisory Panel. 2. Describe the components of the Braden Scale for assessing risk for pressure ulcers. 3. Discuss potential factors not included in the Braden Scale that can be predictors for pressure ulcers in critical care populations.
1. Which of the following is the estimated percentage of hospital
acquired pressure ulcers in intensive care patients?
a. 13% to 35%
c. 16% to 63%
b. 14% to 42%
d. 17% to 71%
2. Which of the following explains the reasoning for the Centers
for Medicare and Medicaid Services’ limited reimbursement
for “never events?”
a. They can be prevented by implementing evidence-based preventive measures
b. They are grounds for malpractice against the nursing staff
c. They are unavoidable consequences of properly organized care
d. They are inexpensive to treat
3. Which of the following Braden scores belongs to the patient
with a high risk for developing a pressure ulcer?
a. 16
c. 11
b. 13
d. 8
4. Which of the following pressure ulcer risk factors was not
included as part of the Braden Scale?
a. Sensory perception
c. Low arteriolar pressure
b. Mobility
d. Nutrition
5. Which of the following was included in the def inition of
low arteriolar pressure in the study?
a. Number of hypotensive hours during intensive care unit (ICU) stay
b. Mean arterial pressure <60
c. Systolic blood pressure <100
d. Diastolic blood pressure <70
6. In this study, which of the following were the most common
anatomical location and stage of pressure ulcers?
a. Buttocks; stage II
b. Sacrum; stage I
c. Sacrum; stage II
d. Buttocks; stage I

7. In this study, which of the following Braden Scale categories
was signif icant for predicting pressure ulcers?
a. Nutrition and mobility
b. Moisture and friction/shear
c. Moisture and nutrition
d. Mobility and friction/shear
8. Which of the following factors increases the risk of exposure
to friction and shear?
a. Using a glide sheet
b. Applying a silicone bordered dressings
c. Elevating the head of the bed for a prolonged period
d. Using a low air loss mattress
9. Use of which of the following explains the lack of predictability
of the moisture subscale in this study compared to previous
studies?
a. Silicone bordered dressings
b. Less indwelling urinary catheters
c. Bowel management systems
d. Low air loss mattresses
10. Which of the following vasoactive drug infusions was a statistically signif icant predictor for pressure ulcers in the study?
a. Neosynephrine
c. Vasopressin
b. Norepinephrine
d. Epinephrine
11. Which of the following comorbidities had statistical
signif icance as a predictor for pressure ulcers in the study?
a. Cardiovascular disease
c. Infection
b. Diabetes
d. Peripheral vascular disease
12. If a patient has a 5 cm shallow ulcer into the dermal layer
that has a pink wound bed but no sloughing, this would be
categorized as which of the following?
a. Stage I pressure ulcer
c. Unstagable
b. Stage II pressure ulcer
d. Suspected deep tissue injury

Test ID: A112005 Contact hours: 1.0 Form expires: September 1, 2013. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1. ❑ a
❑b
❑c
❑d

2. ❑ a
❑b
❑c
❑d

3. ❑ a
❑b
❑c
❑d

4. ❑ a
❑b
❑c
❑d

5. ❑ a
❑b
❑c
❑d

6. ❑ a
❑b
❑c
❑d

7. ❑ a
❑b
❑c
❑d

8. ❑ a
❑b
❑c
❑d

9. ❑ a
❑b
❑c
❑d

10. ❑ a
❑b
❑c
❑d

11. ❑ a
❑b
❑c
❑d

12. ❑ a
❑b
❑c
❑d

Fee: AACN members, $0; nonmembers, $10 Passing score: 10 correct (77%) Category: A, Synergy CERP A Test writer: Marylee Bressie, MSN, RN, CCRN, CCNS, CEN.

Program evaluation

Name
Yes




For faster processing, take
this CE test online at
www.ajcconline.org (“CE
Articles in This Issue”) or
mail this entire page to:
AACN, 101 Columbia,
Aliso Viejo, CA 92656.

Objective 1 was met
Objective 2 was met
Objective 3 was met
Content was relevant to my
nursing practice

My expectations were met

This method of CE is effective
for this content

The level of difficulty of this test was:
❑ easy ❑ medium ❑ difficult
To complete this program,
it took me
hours/minutes.

No







Member #

Address
City
Country

State
Phone

ZIP

E-mail address

RN License #1

State

RN License #2

State

Payment by:

❑ Visa

❑ M/C

❑ AMEX

Card #

❑ Check
Expiration Date

Signature

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

Downloaded from ajcc.aacnjournals.org by guest on March 29, 2012

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close