FACULTY OF HEALTH AND OCCUPATIONAL STUDIES NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE Department of Health and Caring Sciences Lishui University, China

How pressure ulcers can be prevented in intensive

care unit (ICU) patients

A descriptive literature review

Lu Yongli (Emma) & Wang Chengcheng (Rita)

2018

Student thesis, Bachelor degree, 15 credits

FACULTY OF HEALTH AND OCCUPATIONAL NursingSTUDIES NURSING DEPARTMENT, MEDICINE AND HEALTH COLLEGE Department of Health and Caring Sciences Degree Thesis in Nursing Sciences Lishui University, China

Supervisor:Zhu Kewen（Keelia）

Examiner: Annica Björkman

Abstract

Background: Pressure ulcers are a potential problem influencing the patient's recovery in Intensive Care Unit (ICU). They are a costly but preventable complications. There are few articles related to the intensive care unit pressure ulcer prevention measures, only some are scattered and not for these measures to consolidate. The prevention for pressure ulcers is a vital issue in nursing care.

Aim: The aim of the literature review was to describe how pressure ulcers can be prevented by nurses for Intensive Care Unit (ICU) patients.

Method: We had conducted a descriptive literature review. Articles were found through searching in the databases “PubMed” with certain limits. In the preliminary search (see table 1), the titles and abstracts of 188 articles were skim-read, and 36 articles deemed to be of potential interest for the literature review, eventually 11 articles were selected. Our further interpretation of the 11 articles is followed by extracting the information we need to consolidate and compare.

Result: Four types of interventions considered to decrease the occurrence of pressure sores were sorted out, namely risk assessment, relief of skin stress, nutritional support and education. Measures to relieve the compression of the skin tissues are the most adopted ones in authors’ found.

Conclusion: Pressure ulcers bring physical and mental pain to the patients, a large number of measures proved to be effective in reducing the occurrence of pressure sores.

Key words: intensive care unit (ICU), pressure ulcers, prevention measures

摘要

背景：压疮是影响重症监护室病人康复的潜在问题,其治疗费用高昂但可以预防。

目前国内外发表的文章中，与重症监护室压疮预防措施相关的占少数，仅有的一

些也较为零散，且很少有对这些措施进行整合评价的文章。压疮的预防是护理中

一个重要的问题。

目标：描述如何预防重症监护室病人的压疮。

方法：通过限定的条件在数据库“PubMed”中搜索文章，初步搜索了 188 篇文章并 对其标题和摘要进行浏览，其中 36 篇文章被确认与综述主题相关，最终 11 篇文 章被选定。作者对 11 篇文章进行更深入的分析，提取出需要的信息并进行整合与 比较, 得出预防压疮的相关措施。

结果：4 种被认为能改善压疮发生情况的干预措施被整理出来，分别是风险评 估、减轻皮肤组织的压力、营养支持和教育。作者发现减轻皮肤组织的压力是最

常用的措施。

结论：压疮给病人带来了身心上的痛苦，大量的措施被证明是能有效的减少压疮 的发生。然而，也存在一些困难和不足。在预防方面还存在一些问题，以及需要

改进措施。

关键词：重症监护室，压疮，预防措施

Content

1. Introduction ...... 1

1.1 Background ...... 1

1.2 Pressure ulcer ...... 1

1.2.2 Classification of pressure ulcers ...... 1

1.2.3 Result of pressure ulcers ...... 2

1.3 Intensive care unit (ICU ) ...... 2

1.3.1 Definition ...... 2

1.3.2 Causes of high incidence of pressure ulcers in intensive care unit ...... 3

1.4 Braden Scale ...... 3

1.5 Nurses’ role ...... 4

1.6 Nursing theory---- Neuman Systems Model ...... 5

2. Aim and Research question ...... 8

3. Methods ...... 8

3.1 Design ...... 8

3.2 Search strategy ...... 8

3.3 Selection criteria ...... 13

3.4 Selection process ...... 14

3.5 Data analysis ...... 14

3.6 Ethical considerations ...... 15

4. Result ...... 15

4.1 Study characterics ...... 15

4.2 Characteristics of the samples ...... 16

4.3Intervention methods ...... 17

4.3.1 Risk assessment ...... 17

4.3.2 Measures to relieve the compression of the skin tissues ...... 18

4.3.3 Nutritional support ...... 20

4.3.4 Education ...... 20

4.4 Outcomes analysis ...... 21

5. Disscussion ...... 23

5.1 Main results ...... 23

5.2 Results discussion ...... 23

5.2.1 Risk assessment ...... 23

5.2.2Measures to relieve the compression of the skin tissues ...... 24

5.2.3 Nutritional support ...... 26

5.2.4 Education ...... 26

5.3 Discussion about the characteristics of the samples ...... 27

5.4 Methods discussion ...... 28

5.5 Clinical implications for nursing ...... 29

5.6 Suggestions for future research ...... 29

5.7 Conclusion ...... 30

Reference ...... 31

Table 2. Overview of selected articles.

Table 3. Overview of selected articles’ aims and main results.

Table 4. Classification of intervention measures for prevention of pressure ulcers

1. Introduction

1.1 Background

Medical institutions in the United States have estimated that there are about 2500000 patients with pressure ulcers and 60000 people died of pressure ulcer complications annually (VanGlider, et al., 2009). HealthGrades, Inc. (2009) recently reported between 2005 and 2007 , nearly 14 million medical insurance patients ( 32 / 1,000 patients ) experienced 445,028 pressure ulcers , exceeding health care costs of $ 24.100 million , showing a gap with the intended target. Intensive care unit patients at higher risk for pressure ulcers (Estilo, et al., 2012). Preventing pressure ulcers has become a key focus of many healthcare institutions in the US and throughout the world (VanGlider, et al., 2009). Pressure ulcer was a common and potential complications that influence a large number of patients, especially the patients and pressure ulcer it was a costly but could be preventable complication (Pickham et al,.2016).

1.2 Pressure ulcer

1.2.1 Definition

Pressure ulcer (PU) is defined as “any area of skin or hypodermatic tissue that has been damaged by the pressure of unrelieved or the combination with friction and shear” (Tschannen et al., 2012), which is a serious patient safety concern associated with poor patient outcomes and high health care costs. The patient’s recovery and health are seriously affected. Pressure ulcers appear as areas of reddened skin initially but they can develop into large open wounds quickly if the pressure is not relieved (Pickham et al.2016).

1.2.2 Classification of pressure ulcers

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According to National Pressure Ulcer Advisory Panel (2007), pressure ulcers are categorized from stage I, stage II, stage III and stage IV. Stage I being opaque erythema of intact skin; stage II partial thickness skin loss involving epidermis, dermis or both; stage III full thickness skin loss involving damage to necrosis of subcutaneous tissue, in other words, the dermis is completely involved but does not involve muscles, bones or tendons; and stage IV extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures,in short, it include muscles, bones or tendons, visible tendons, and unstoppable ulcers (National Pressure Ulcer Advisory Panel, 2007) .

1.2.3 Result of pressure ulcers

Pressure ulcers often affect the recovery of the patient’s condition, and even make patients’ condition worse. It occurs in 3%~34% of hospitalized patients and can result in longer hospital staying, increased morbidity, and increased human suffering (Cremasco et al., 2013; Frankel et al., 2007; Graves et al., 2005 ; Slowikowski & Funk, 2010). According to National Pressure Ulcer Advisory Panel (2014) , pressure ulcer is a potential complication that affects about 2.5 million patients and account for about US $11 billion in health care expenditures each year. The National Database of Nursing Quality Indicators (2014) estimate that the average costs of pressure ulcers $38,700. Others have estimated the cost of pressure ulcers to the US economy was $3.8 billion in 2008 (Shreve et al., 2010). Although development of pressure ulcers when admitted to an ICU has no direct effect on mortality, it indirectly contributes to mortality risk. Clough (1994) and colleagues’ study compared the patients with and without pressure ulcers and reported a mortality rate in the group with pressure ulcers (63%) as compared to a rate in the group without pressure ulcers (15%).

1.3 Intensive care unit (ICU )

1.3.1 Definition

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The intensive care unit (ICU) is a place for the most serious and most life-threatening diseases and injured patients provide continuous surveillance and care (Eftekearian et al., 2015). These diseases and injuries require the continuous monitoring and support of the experts, equipment and drugs to cure and maintain normal physical functions (Eftekearian et al., 2015). The staff of the intensive care unit are trained doctors and intensive care nurses, they take care of patients with serious illness (Eftekearian et al., 2015).

1.3.2 Causes of high incidence of pressure ulcers in intensive care unit

When it comes to maintaining intact skin, most intensive care patients are at high risk for pressure ulcers starting from the moment they were admitted into the hospital (Estilo, et al., 2012). They may be always lethargic, long-term bed and receiving prolong intravenous infusion and mechanical ventilation, as well as their inability to turn themselves and the incorrect way of turning over by the caregivers (Estilo, et al., 2012). Hemodynamic instability, received vasopressin treatment, changes of sensory perception and organ failure will lead to increase the risk of pressure ulcers (Källman & Suserud, 2009). Patients undergoing surgery usually perform long periods of time on a fixed operating table, where they develop symptoms of hypotension, paralysis and high selenium levels, and injuries caused by anesthesia (Junkin, et al., 2007). Patients may be unstable and may be difficult to treat when they are sent to ICU after the surgery (Junkin, et al., 2007). These are all the causes of pressure ulcers in the intensive care unit that are more likely to occur and seriously affect their rehabilitation (Estilo, et al., 2012). Care givers need to provide measures to prevent pressure ulcers (Estilo, et al., 2012).

1.4 Braden Scale

Braden Scale is made up of six sub scales including sensory perception, skin moisture, nutritional intake, mobility, friction, and shear that are used to point out the correct steps of inpatient management (Maklebust, et al., 2005). The nurses evaluated the patients and matched their clinical observations with the Braden Scale (Maklebust, et

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al., 2005). In other words, a patient's risk for developing a pressure ulcer can be ascertained by calculating score on Braden scale (Serpa et al., 2011).In addition to friction and shear, the scores of these sub scales are 1 to 4, while friction and shear are 1 to 3 (Maklebust, et al., 2005). When the six sub scales were added together, the total risk score of Braden scale was 6-23 (at risk: 15-18; moderate risk: 13-14; high risk: ≤12) (Maklebust, et al., 2005). If an adult patient's Braden score of 18 or less will be considered a predictor of pressure ulcer, nurses must take appropriate precautions (Bergstrom, et al., 1998). According to European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009), prevention of hospital acquired pressure ulcer (HAPU) begins with a nursing assessment the risk of pressure ulcers using a valid risk instrument. Although there is insufficient evidence to suggest that the use of risk assessment scales can reduce the incidence of PU , the use of risk assessment scales has shown to aid nurses in designing and implementing an personalized prevention plan (Magnan & Maklebust, 2009).

1.5 Nurses’ role

Prevention of pressure ulcers is an important index to measure nursing quality, in which nurses play a vital role (Roberts et al., 2016).Specialists have adopted many strategies for prevention, most of these interventions require the coordination of medical staff. Those critically ill patients were forced to stay in bed for long periods and not be able to turn themselves. Nurses play an important role in the caring process.Nursing is considered an important factor in the prevention of hospital acquired pressure ulcers( Özdemir &Karadag, 2008). It has been reported that the planned implementation of nursing measures can reduce the incidence of pressure ulcers( Yava A& Hatipo˘ glu S, 2002; Hamilton & Cleverly, 1994). Nurses also need to be fully aware of the hazards, and to study the prevention and nursing of pressure ulcers to breakthrough. Källman &Suserud (2009) believed that the prevention of pressure ulcers is an important part of nursing and is a priority for daily care so that most pressure ulcers can be avoided. The significant differences in attitude between nursing staff with education in critical care or anesthesia is quite consistent with research that showed that patients in the ICU are at high risk (Elliott et al., 2008). Also, pressure ulcer prevention is an important part of care 4

in the ICU (Nijs et al., 2009). It showed that the nurse's attitude towards prevention of pressure ulcer is important in ICU and plays an important roles for the evaluation of pressure ulcers and nursing (Strand & Lindgren 2010). In Roberts’ et al. (2016) research, nurses received training on how to cooperate with patients to prevent pressure ulcers, and encouraged them to take an active part in nursing (Roberts et al., 2016). In this process, nurses play the role as a collaborator.The cooperation between nurses and pressure ulcer prevention patients may be one of the effective strategies to reduce pressure ulcer (Roberts et al., 2016). At the same time, nurses also play an important role in educating patients and their families how to cooperate effectively with nurses. It is very important to understand the nurses' experience and the views on intervention, especially the experience and opinions of the cooperation between nurses and patients in nursing(Roberts et al., 2016).

1.6 Nursing theory---- Neuman Systems Model

The Neuman Systems Model is a dynamic, open, systematic nursing approach , which describes the areas of nursing concern where patients as a whole interact with the environment (Neuman, 2011). The client is regarded as a whole, and part of it is in dynamic interaction to make the holistic system maintain stable (Alligood & Marriney, 2014; Neuman, 2011). Newman's (2011) model of nursing consists of client , stressor and and prevention to response the stress. Stressors are stressful stimuli that can result in positive or negative influence (Alligood & Marriney, 2014). Various sources of stress affect human defense in different ways. In Neuman Systems Model, the most important component and related to prevention the pressure ulcers is the three levels prevention (Neuman, 2011). Interventions are purposeful actions to help patients to maintain, achieve, or maintain stability in the client system, in other words “ prevention as intervention”(Neuman, 2011). The prevention may occur before the protective line or after the resistance is penetrated (Alligood & Marriney, 2014). The Neuman’s model shown new explanation of prevention, and identified three levels of intervention (Neuman, 2011). (1)When a pressure source is suspected or confirmed , the primary prevention is used to take prevention to reduce possibility of encounter with stressors, and to prevent the injury to the body (Neuman, 2011). (2)Secondary prevention involves

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intervention or treatment that begins after stress symptoms, in order to prevent the holistic getting worse (Neuman, 2011). (3)Tertiary prevention occurs after active treatment, and its focus is to adjust to the stability of the best customer system (Neuman, 2011). （See figure 1.）

The Neuman’s (2011) model also provided a systematic perspective to help nurses achieve high quality nursing through evidence based on practice.Nurses play an important role in the prevention of pressure ulcer, and nurses need to help patients maintain overall health. Nurses try to find the stressor of pressure ulcers as early as possible, take prevention in time, cooperation with patients and their families, so that patients can avoid the harm of pressure ulcers.

1.7 Problem statement

Pressure ulcer is still a common health problem in different medical institutions all over the world, especially in intensive care units (Jiricka et al., 1995). It is a significant health care problem, which is closely related to the morbidity and mortality of intensive care unit patients (Kurtulus & Pınar, 2003). According to National Pressure Ulcer Advisory Panel (2014), it is an expensive but preventable complication. In order to reduce the cost of patients and hospitals, and promote the recovery of patients and hospital efficiency, it’s important for nurses to explore the intervention which can prevent pressure ulcer in ICU patients. The authors has read a lot of literature and found that there are many studies focus on some interventions to prevent pressure ulcers (Levy et al., 2015; Wong et al., 2015), whereas a little review of multiple interventions for prevention of pressure ulcers, Pancorbo-Hidalgo’s et al. (2006) only showed a review of the same type intervention of pressure ulcer prevention. Therefore, it’s necessary for the nurses to compare their differences and explore how pressure ulcers can be prevented in ICU patients, and to make future clinical work easier.

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2. Aim and Research question

The aim of the literature review was to describe how pressure ulcers can be prevented by nurses for ICU patients, and to review the characteristics of the sample used in the scientific articles, with the help of the following questions:

-What intervention can nurses adopt to prevent pressure ulcer in ICU?

-What are the characteristics of the samples in the included studies?

3. Methods

3.1 Design

A descriptive literature review was conducted (Polit &Beck, 2012).

3.2 Search strategy

Articles were found by searching in the databases PubMed with certain limits (See table 1). The search terms include “pressure ulcer” AND “prevention ”AND “nursing”AND “intensive care units OR ICU”, we selected some search terms, one by one and in different combinations with each other. When combining search terms, the Boolean term AND was used. In addition, the authors used some limitations to qualify the articles with 10 years and must be full text, the language was English and species was humans.

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Table 1. Search strategy methods and results.

Database Limits and Search terms Number of Possible articles search data hits (exclude doubles)

Medline via 10 years, “Pressure ulcer” 2726 PubMed English, (MeSH)

humans,

full text.

2017-05-16

Medline via 10 years, “Intensive care 31180 PubMed English, units”

humans, (MeSH)

full text.

2017-05-16

9

Medline via 10 years, “ICU” 38781 PubMed English, (free text) humans,

full text.

2017-05-16

Medline via 10 years, “prevention” 417187 PubMed English, (free text) humans,

full text.

2017-05-16

Medline via 10 years, “nursing” 139110 PubMed English, (MeSH) humans,

full text.

2017-05-16

Medline via 10 years, “ICU”(free text) 38781 PubMed English, AND “intensive

humans, care units”

full text. (MeSH)

2017-05-16

Medline via 10 years, “Pressure ulcer” 1390 PubMed English, (free text)

humans, AND “nursing”

full text. (MeSH)

2017-05-16

Medline via 10 years, “Pressure ulcer” 108 PubMed English, (free text) AND

humans,

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full text, “intensive care University of units” Gävle (MeSH) OR 2017-05-16 “ICU”(free text)

Medline via 10 years, “Pressure ulcer” 80 32 PubMed English, (free text) humans, AND “intensive full text, care units” (MeSH) University of Gävle OR “ICU”

2017-05-16 (free text) AND “nursing”

(MeSH) AND “prevention”

(free text)

Total 32

11

32 articles identified articles from PubMed

6 articles were reviews

22 articles remained

2 articles were guidelines

20 articles remained

4 articles were descriptive articles

16 articles remained

3 articles focus on risk of pressure ulcers

13 articles remained

12 2 articles, ICU was not the only research site

Final 11 articles were

Figure 2. Flow diagram of document screening

3.3 Selection criteria

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The inclusion criteria are as follows:

 Studies should focus on patients admitted to ICU .

Empirical scientific articles using quantitative approach.

Articles relevant for the aim of the review study (that is, nursing intervention for ICU patients to prevent pressure ulcers).

The exclusion criteria were as follows:

 Patients other than intensive care units.

 Empirical scientific articles didn’t use quantitative approach.

Articles applied by the authors were only concerned with physicians’, clients’ or family members’ measures to prevent pressure ulcers.

3.4 Selection process

In the preliminary search, the titles and abstracts of 80 articles were skim-read. In the identification stage of the article screening, the authors identified 32 articles that can be referenced by the database search. The authors selected the literature and excluded 21 articles according to the selection criteria and exclusion criteria. Finally, 11 articles were identified to be used in the result. Figure 2 show the selection processes.

3.5 Data analysis

The results sections of the selected articles were processed with the help of three tables and in relation to two research questions. All articles were initially read individually by each author, and read together several times after exchanging the ideas. The authors coded the selected articles from A~K to facilitate the search for corresponding articles and related interventions. In order to gain a comprehensive understanding of the articles contained, the author used three different tables to make the analysis of the material easier. Appendix 1, table 2 summarizes the selected articles’

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authors, titles, designs (possibly approaches), participants, data collection methods and data analysis methods. Appendix 2, table 3 list the aim and result of all articles. Appendix 3, table 4 list the classified result of the interventions for pressure ulcers. 11 articles were analyzed in-depth and interpreted by authors, and relevant prevention measures were found by authors, and combined.

3.6 Ethical considerations

The present literature review was based on published articles that have been reviewed and ethically recognized. There have been no incidents of plagiarism. Appropriate reference techniques enable readers to check for plagiarism. The results had been analyzed and consolidated by authors. With the supervisor's guidance and modification for many times, any subjective behavior involved against the author thought or may violate the original author thought will be put forward and make changes.

4. Result

4.1 Study characterics

Eleven studies were eligible to be included in the review (Kelleher et al., 2012; Jackson et al., 2011; Still et al., 2013; Santamaria et al., 2015; Schindler et al., 2011; Sakai et al., 2009; Visscher et al., 2013; Brennan et al., 2013; Behrendt et al., 2014; Swafford et al., 2016; Serra et al., 2015)The studies were based in 4 different countries in American, Japan, Australia and Italy. Eight studies were conducted in American (Kelleher et al., 2012; Jackson et al., 2011; Still et al., 2013; Schindler et al., 2011; Visscher et al., 2013; Brennan et al., 2013;Swafford et al., 2016; Behrendt et al., 2014), one in Japan(Sakai et al., 2009), one in Australia (Santamaria et al., 2015), and one in Italy (Serra et al., 2015). All studies were quantitative articles, among these articles, 4 of them were randomized controlled trials (Swafford et al., 2016; Behrendt et al., 2014; Serra et al., 2015; Santamaria et al., 2015), 7 of them were quasi-experimental studies

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(Brennan et al., 2013; Visscher et al., 2013; Kelleher et al., 2012; Jackson et al., 2011; Schindler et al., 2011; Sakai et al., 2009; Still et al., 2013). All total of 11 trials that studied 9902 patients were included as participants in a study on the prevention of pressure ulcers.

4.2 Characteristics of the samples

The characterstics of samples in the studies mainly considered in the following aspects: populations, average age, male of patients, and mean length of stay days/ hours, department, the participants section in Table 2 described in detail. The participants were chosen for the studies all came from different intensive care unit. Four studies implemented in surgical intensive care unit (Swafford et al., 2016; Kelleher et al., 2012; Sakai et al., 2009; Still et al., 2013), two researches carried out in medical intensive care unit (Swafford et al., 2016; Behrendt et al., 2014 ), two studies happened in intensive care unit (Serra et al., 2015; Santamaria et al., 2015), two researches occurred in pediatric intensive care unit (Visscher et al., 2013; Schindler et al., 2011), one study happened in cardiothoracic intensive care unit (Brennan et al., 2013), one study implemented in neonatal intensive care unit (Visscher et al., 2013), one research carried out in cardiothoracic vascular intensive unit (Jackson et al., 2011). Participants had a significant reduction in activity, or were unable to complete or change their body position. They were almost all high risk groups of suffering pressure ulcers, and the participants of one experiment (Still et al., 2013) had been suffered from pressure ulcers before implementing intervention of different severity. The average age of participants ranged from 39.3 weeks to 86 years. In addition, there were two studies (Visscher et al., 2013; Schindler et al., 2011) the participants in pediatric intensive care units and neonatal intensive care units account for 68% of the total participants. There was no mention of gender distribution in the five trials(Brennan et al., 2013; Santamaria et al., 2015; Kelleher et al., 2012; Schindler et al., 2011; Still et al., 2013 ),and the proportion of men in the remaining six studies (Swafford et al., 2016; Behrendt et al., 2014; Serra et al., 2015; Visscher et al., 2013; Jackson et al., 2011; Sakai et al., 2009 ) was more than 50 percent, in other words, gender distribution was dominated by male participants. Length of stay days /hours was also taken into account in some trials (Swafford et al., 2016; 16

Behrendt et al., 2014; Brennan et al., 2013; Visscher et al., 2013; Jackson et al., 2011; Schindler et al., 2011; Sakai et al., 2009 ) in the inclusion criteria for participants.

4.3Intervention methods

4.3.1 Risk assessment

Assessment tool

Establishing a good risk assessment scale is the first step to manage pressure ulcers. Six of the eleven articles involved Braden scale as risk assessment tool (Swafford et al., 2016; Behrendt et al., 2014; Visscher et al., 2013; Kelleher et al., 2012; Schindler et al., 2011; Still et al., 2013). The completion of pressure ulcers risk assessment with a Braden Scale was the nursing standard for surgical intensive care unit (ICU) in Kelleher’s et al. (2012) research. In Visscher’s et al. (2013)study of the clinical utility of the Braden Scale, pediatric intensive care unit patients completed a daily risk assessment (Braden Q) (Visscher et al., 2013), High risk level factors were screened from each assessment, and preventive measures were taken for high-risk factors of the patient. In Schindler’s et al. (2011) research, identifying the patients at risk of pressure ulcers, taking targeted preventive measures correctly, increasing the attention of the nursing staff to pressure ulcers all relied on a good risk assessment tool, and the participants in their research were using the Braden Q Scale currently. All patients who participated in the Behrendt’s et al. (2014) study, were admitted accepted risk assessment of pressure ulcers, which is scored by using the standard of Braden scale. Swafford et al. (2016) used a comprehensive program to reduce the incidence of nosocomial pressure ulcer in intensive care unit, and the Braden sores were used to identify the risk for pressure ulcers. In Still’s et al. (2013)study, the Braden scale was used as an indicator to assess the risk of pressure ulcers in patients to test the effectiveness of changing posture every two hours.

Skin assessment It is important to detect the early skin compromise and due to pressure and excess moisture based on close monitoring and skin assessment (Visscher et al., 2013). According to Visscher’s et al. (2013) quality- improvement collabrative project, daily

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head-to-toe skin assessment, daily documentation of skin status and every 2 weeks patient evaluation to determine new pressure ulcer in order to identify the skin features associated with pressure ulcers, which can help nursing staff take early precautions.

4.3.2 Measures to relieve the compression of the skin tissues

Pressure is an important factor in the occurrence of pressure ulcers. Relieving the long-term compression of local tissues was the most important measure to prevent pressure sores. The authors searched the relevant literature, analyzed and summarized the prevention in three ways .

Regular replacement of posture

Four articles dealt with nursing measures for turning over and repositioning to prevent pressure ulcers (Schindler et al., 2011; Still et al., 2013; Behrendt et al., 2014; Visscher et al., 2013). In the research of Still et al. (2013), before frequent turning, a total of 42 pressure ulcers were identified in 278 patients. After the implementation of the intervention, a total of 12 pressure ulcers were identified in 229 patients (p < 0.0001), also there was a marked decrease in stage I and stage II ulcers and anatomic location of pressure ulcers after the intervention. It was considered necessary to turn over the patient at least every two hours to relieve the patient's local pressure (Schindler et al., 2011). Although two hours of change of position was considered feasible, the frequency was not certain, and two hours was not considered the most accurate frequency (Still et al., 2013; Behrendt et al., 2014; Visscher et al., 2013).

Application of some monitoring or decompression device

Providing air fluidized therapy bed or other speciality bed or fluidized repositioner for critical patients had great influence on reducing the pressure on the skin surface of ICU(Jackson et al., 2011;Schindler et al., 2011; Swafford et al., 2016). The incidence of pressure ulcers decreased significantly after using air fluidized bed, and the cost of the air 18

fluidized bed is much more economical than that of the patient's treatment cost after the pressure ulcers (Jackson et al., 2011). Jackson’s et al. (2011) study showed that patients spent a average of 7.9 days on the mattress, and the cost of bed are about $18000, which is more economical than the treatment cost of stage III or stage IV pressure ulcers (about $40000). Interface press mapping as a new technology has been used in medical intensive care unit patients by identifying the body pressure points and helped improve body positioning to achieve the aim of decompression (Behrendt et al., 2014; Sakai et al., 2009). Continuous beside pressure mapping device (CBPM) provides real-time feedback on the optimal body position by a pressure sensor pad that displays a pressure image at the patient's bedside (Behrendt et al., 2014). Sakai et al. (2009) developed a new mattress with the fibre-optic sensor monitoring the distribution of skin pressure in order to prevent the occurrence of pressure ulcers(Sakai et al., 2009). In some studies, using pillows or mattress rollout or blanket roll was also considered as a decompression tool to reduce the development of pressure ulcers (Schindler et al., 2011;Visscher et al., 2013). There was also a device (Brennan et al., 2013), fluidized positioning device (FPD), as a kind of conformational positioning, it can provide the patient with the ability of three- dimensional contour, has the function of shaping, and provides the necessary support for the patient to maintain the treatment position at the same time (Brennan et al., 2013). It keeps patients where they need to and improves local compression, provide more timely and accurate patient monitoring, and achieve an effective prevention of pressure ulcers effect (Brennan et al., 2013).

Applying of protective measures

The protective measures can be used to reduce the formulation of pressure ulcers by applying protective measure in the bone joint place, heels, and the sacral part of the bone ( Santamaria et al., 2015). The most common protective measure is the use of dressings, there are many kinds of decompression dressings to prevent pressure ulcers, such as silicone adhesive dressings, soft silicone multi-layered foam dressing, some of them are different in the prevention effect of pressure ulcers( Santamaria et al., 2015; Swafford et al., 2016).

Santamaria’s et al. (2015) finding had indicated clinically significant benefit for the application of multi-layered soft silicone foam dressings for the prevention of sacral and 19

heel pressure ulcers ( Santamaria et al., 2015). In Santamaria’s et al. (2015) experiment, before using multi-layered soft silicone foam dressings, the rate of pressure ulcers was 13.1%, after the experiments, the rate was 3.1%, which means that the incidence of pressure ulcers was reduced by 10%.

Swafford et al. (2016) found that the number of hospital acquired pressure ulcers associated with medical devices decreased from 9 out of 461 patients in 2011(2%) to 2 out of 563 patients in 2013(0.4%).This reduction was in part due to the use of silicone adhesive dressings ( Swafford et al., 2016).

4.3.3 Nutritional support

There are two studies referred to the the role of nutritional support in the prevention of pressure ulcers (Serra et al., 2015; Visscher et al., 2013)

Serra’s et al. (2015) study showed that intravenous infusion of albumin can reduce the incidence of pressure ulcers in intensive care unit patients and alleviate the severity of the pressure ulcers to a certain extent. The intervention group patients received albumin infusion three days before the first week of intensive care unit, while the control group patients didn’t (Serra et al., 2015). 27.27% of the patients in the intervention group and 70% of the patients in the control group got pressure ulcers, these lesions were classified into 66.66% in stage I and 33.33% in stage II with pressure ulcers in the intervention group. Compared with pressure ulcers in the control group , 14.28% in stage I, 28.57% in stage II, 28.57% in stage III and 28.57% in stage IV (Serra et al., 2015).

Patient care indrectly related to skin(nutrition) was one key drivers in Visscher’s et al. (2013) quality-improvement collaborative project.

4.3.4 Education

Education is a comprehensive, active and collaborative preventive measure based on employee education (Visscher et al., 2013). Six out of the eleven articles (Swafford et al., 2016; Brennan et al., 2013; Visscher et al., 2013; Kelleher et al., 2012; Still et al., 2013; 20

Schindler et al., 2011) referred to the positive role of education in the prevention of pressure ulcers.

Schindler‘s et al. (2011) research showed that although Braden scales had been used in hospitals, learning about them continues to ensure that nurses had a good understanding of risk assessment tools and knew how to use them properly. All registered nurses needed online training in pressure ulcer prevention and Braden scores scoring (Still et al., 2013). Staff needed to learn how to use fluidized positioning device appropriately, which they can achieve the effect of preventing pressure ulcers (Brennan et al., 2013). The purpose of education was to improve effective method to reduce the incidence of pressure ulcers in the intensive care unit (Swafford et al., 2016). Staff participated in training provided by the quality improvement collaborative leadership team in Visscher’s et al. (2013) study. In Kelleher’s et al. (2012) research, nutrition addressed and staff education about the skin prevention assessment management program for hostipal-acquired pressure ulcer prevention were mentioned.

4.4 Outcomes analysis

Based on the above results , most studies have shown a decrease in the incidence of pressure ulcers in intensive care units after implementing interventions (Jackson et al., 2011; Santamaria et al., 2015; Still’s et al., 2013; Serra et al., 2015; Swafford et al., 2016; Brenna et al., 2014). In addition to the incidence of pressure ulcers, a reduction in the number of pressure ulcers (Santamaria et al., 2015) , a reduction in anatomical sites (Santamaria et al., 2015) , a reduction in the degree of pressure ulcers (Serra et al., 2015), a reduction in cost (Jackson et al., 2011; Brenna et al., 2014) , and an increase in patient comfort and employee satisfaction (Swafford et al., 2016) all can be used as an outcome indicator to monitor the effectiveness of the intervention. The incidence of hospital acquired pressure ulcers was found to decrease from 40% in August 2007 to 15% in June 2007 in patients after using air fluidized therapy beds (Jackson et al., 2011). Jackson et al. (2011) also found that after using an air fluidized therapy bed, the cost of the mattress was reduced by about $22000 compared to the cost of treatment after pressure ulcers. 21

Santamaria’s et al. (2015) finding shown that nurses could delay or potentially eliminate hospital acquired pressure ulcers in critically ill patients by adding the use of soft silicone multi-layered foam dressings. The intervention group used soft silicone multi-layered foam dressings resulted in a 10 % reduction (P=0.01) in pressure ulcer incidence (Santamaria et al., 2015). Santamaria et al. (2015) also demonstrated that a large number of pressure ulcers have dropped into a smaller number by anatomical sites, when compared wtih control group, there were significant reductions in both scaral (P=0.05) and heel pressure ulceration (P=0.002).

Still’s et al. (2013) study dedicated that turning surgical intensive care unit patients every 2 hours could significantly reduce the incidence of pressure ulcer, before frequent turning, a total of 42 cases of pressure ulcers were found in 278 patients, after implementation of the turning team, a total of 229 patients were found to have 12 pressure ulcers (P< 0.0001). The total number of patients also showed a downward trend, which indicated that the regular changing of patients’ position can reduce the incidence of pressure ulcers effectively (Still’s et al., 2013).

In Serra’s et al. (2015) study, 27.27% of patients in intervention group with intravenous albumin acquired pressure ulcers, whereas 70% of patients in control group. The study also showed that intravenous administration of albumin in ICU patients could alleviated the severity of the pressure ulcer, pressure ulcers in the intervention group were classified into stage I (66.66% )and stage II (33.33% ), while the pressure ulcers in the control group were classified into stage I (14.28%), stage II (28.57% ), stage III (28.57% ) and stage IV (28.57% ) (Serra et al., 2015).

Swafford et al. (2016) used silicone adhesive dressings and found that the number of hospital acquired pressure ulcers associated with medical devices decreased from 2% in 2011 to 0.4% in 2013.

In the study of Brenna et al.(2014), the comfort degree of patients increased and the satisfaction of staffs also increased, after the use of fluidized positioning device, 60% of the staff thought this device was exllent and 35% as good. The cost of the fluidized positioning device about $ 175 per device, which was expensive, however, compared with the amount spent on treatment of pressure ulcers (estimated at $ 3500 up to $ 60000), the cost of these device was inconsequential (Brenna et al., 2014).

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5. Disscussion

5.1 Main results

After carrying out risk assessment, measures to relieve the compression of the skin tissues, nutritional support and education(Kelleher et al., 2012; Jackson et al., 2011; Still et al., 2013; Santamaria et al., 2015; Schindler et al., 2011; Sakai et al., 2009; Visscher et al., 2013; Brennan et al., 2013; Behrendt et al., 2014; Swafford et al., 2016; Serra et al., 2015 ), the pressure ulcer problem of intensive care unit has been well prevented and the incidence of pressure ulcers has also declined. The authors found that among all these nursing measures, the measures to relieve the compression of the skin tissues are the most adopted ones. It indicated that the occurrence of pressure ulcer was closely related to the magnitude of pressure, and health care workers should put more effort into stress relief.

5.2 Results discussion

5.2.1 Risk assessment

Assessment tool

Nursing assessment is the most important and crucial step, no matter what kind of assessment tool is used, such as Braden scale, or any other assessment tool. The positive role of the risk assessment scale can not be ignored, which has been proved to help nurses plan and implement prevention plans (Magnan & Maklebust, 2009). It is consistent with the primary prevention in Neuman systems model that the risk of pressure ulcers is predicted in advance by risk assessment and effective intervention is taken to prevent or delay the occurrence of pressure ulcers in patients (Neuman, 2011). In some other literature, the authors have found that the use of Braden scales can reduce the incidence of pressure ulcers (Liu G.W., 2005), however, in the study of Still et al. (2013), after intervention, the average Braden score decreased, suggesting a higher risk of pressure sores in these patients (Still et al., 2013). Pancorbo-Hidalgo et al. (2006) thought that

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there is no enough evidence to suggest whether risk assessment scales can reduce the incidence of pressure ulcers. This may be due to the existence of other factors during the implementation of nursing measures, such as changes in shear and friction forces during rollover, patients' own age problems, and reasons for drug use. Maybe risk assessment scale is only a predictor of pressure ulcers risk and does not contribute to a reduction in pressure sore rates. In the research of Kelleher et al. (2012), after the intervention, the incidence of pressure ulcers was reduced, but it is not clear whether surgical intensive care unit nurses have applied risk assessments into personalized care programs to prevent hospital acquired pressure ulcers.

Skin assessment Skin integrity was added to the personal care plan, Visscher et al. (2013) used the head-to-toe skin assessment daily to identify whether skin with damage or there is a risk of pressure ulcers. However, the assessment is mainly qualitative and largely depends on the perception and interpretation of the evaluator (Borzdynski et al., 2017). In other words, with regard to erythema, epidermal hydration and the relationship between epidermal lipids and the risk of pressure ulcers, the assessment of these skin was questioned since the evaluator's subjectivity (Borzdynski et al., 2017). Borzdynski et al. (2017) also show that nowadays, the clinical application of biophysical skin analysis instrument can provide a feasible choice for subjective assessment in the assessment of skin.

5.2.2Measures to relieve the compression of the skin tissues

Regular replacement of posture

Still’s et al. (2013) study had shown that turning every 2 hours almost eliminates the incidence of stage I and stage II pressure ulcers in surgical intensive care. However, patients in surgical intensive care units are in critical condition and hemodynamic change which can be aggravated by turning patients, which increases the patient's risk of pressure ulcers (Bours et al., 2001; Kelleher et al., 2012). According to National Pressure Ulcer Advisory Panel (NPUAP) (2001), hemodynamic instability in patients with ICU also affected patient turning and repositioning, and lead to unavoidable the risk of pressure ulcers. Hemodynamics and turning are interactions. In addition, in some studies it is not 24

clear whether the frequency of changing positions every two hours is optimal for the prevention of pressure ulcers, encouraging frequent turning and repositioning, no standard frequency to measure and the optimal frequency of turning has been confirmed (Defloor et al., 2005; Vanderwee et al., 2007; Visscher et al., 2013; Still et al., 2013), every 2 hours to change the position is only as a guideline(Behrendt et al., 2014; Schindler et al., 2011; Still et al., 2013), this frequency may need to be further verified.

Application of some monitoring or decompression device

As a scientific and technological product equipment, the use of the equipment is high , and the staff needs education to properly use the equipment (Brennan et al., 2013). For critically ill patients, although it is expensive to use this special bed unit, it is much more economical and feasible than the cost of treatment after pressure ulcers (Jackson et al., 2011). According to Healthcare Management Council Inc. (2010), the device is cost- effective when compare the $9134 ancillary cost of treating a single stage III or IV pressure ulcers with a bed rent of $643 per patient. But, as a device, their use also has a certain period of time. Some device maintains its effectiveness for 4 months and then begins to lose its ability, after that time it no longer has the ability to contour as well to the shape of the body (Brennan et al., 2013).

Continuous pressure sensor monitoring device reduces the amount of labor of medical staff, and can help nurses to detect the occurrence of pressure ulcers in time. In Sakai’s et al. (2009) research, continuous monitoring of the strength and duration of systemic interface pressure is feasible in intensive care patients. However, these devices also have some limitations, they can monitor and evaluate the pressure of the interface without discounting or distorting (Sakai et al., 2009). In addition, as for the Sakai’s et al. (2009) study, due to the difference in body shape and physical condition of patients in intensive care unit, it is still uncertain whether the device is tolerant to all patients with different characteristics. In addition, patients with high risk of pressure ulcers, such as senile bony protrusion, paralysis and / or contracture of joints, were not included in the Sakai’s et al. (2009) study. Wong’s et al. (2015) study used the continuous pressure imaging (CPI) to reflect the interracial pressure between body and support surface directly and showed the important effect of CPI in modifying interracial pressures. It also has an important influence for predicting pressure ulcers (Wong et al., 2015). 25

Applying of protective measures

The use of protective sticking to the patient's skin has played a protective effect. In the study of Levy et al. (2015), the use of multi-layer dressings on the heel effectively reduced the pressure ulcer of soft tissue. However, the tolerance of different patients to adhesive materials is different, and there are still some restrictions, because the individual dissection may be different among the elderly and the vulnerable. Similarly, some other pathological factors such as diabetes can also affect the organization. The use of dressings may be affected (Levy et al., 2015).

5.2.3 Nutritional support

Nutritional condition is intrinsic factors development of pressure ulcers, the main physiological functions of albumin include maintaining colloid osmotic pressure, binding and transporting metabolic active molecules (Serra et al., 2015). There are another study have shown that protein levels were inversely proportional to mortality and risk of complications, and hypoproteinemia was an independent risk factor for adverse outcomes. Prolonged hospitalization, deterioration of psychosocial conditions and increased public expenditure (Serra, et al. 2012). Although albumin may be useful in establishing the overall prognosis of pressure ulcers, they still do not represent nutritional status well (Saghaleini et al., 2018).In the study of Covinsky et al., 2002. and (Ferguson et al., 1993), serum albumin was not a sensitive indicator of malnutrition, since its level was affected by a variety of nutritional factors, such as protein loss, liver dysfunction, acute infection and inflammation.The intravenous infusion of albumin is only a preventive measure of ulcer to improve nutritional status.

5.2.4 Education

The holistic view of the Neuman’s (2011) system model provided an effective framework for nursing education at all levels (Alligood & Marriney, 2014). Nurses' knowledge of prevention and management of pressure ulcer is an important and first step 26

in providing the best care (Gul et al, 2017). The education involved in these articles includes: nurses' learning of assessment scale, online training in the prevention of pressure ulcers, (Still et al., 2013；Kelleher et al., 2012; Schindler et al., 2011) and the correct use of nursing device to relieve the compression of the skin tissues (Brennan et al., 2013). It is good to treat education as an intervention to prevent the incidence of pressure ulcers, but it’s not clear about how much time and investment it takes to educate. Whether a nurse has enough time for re-education or not is a matter of consideration. In addition, some education is targeted at specific groups of people. In the study of Still et al. (2013), only registered nurses are allowed to receive the online training and Braden scale scoring.

5.3 Discussion about the characteristics of the samples

The result were based on 11 quantitative studies. Quantitative researchers select samples so that they could ensure the validity and generalization of statistical results and conclusions beyond the range of samples used (Polit & Beck 2012). There are some basic terms like populations, eligibility criteria are used to approve whether he sample is representative of the target population (Polit & Beck 2012). Researchers always made a sample plan in advance how participants are selected and how many people are included (Polit & Beck 2012). The participants were came from different intensive care unit, including surgical intensive care unit (Swafford et al., 2016; Kelleher et al., 2012; Sakai et al., 2009; Still et al., 2013), medical intensive care unit (Swafford et al., 2016; Behrendt et al., 2014 ), intensive care unit (Serra et al., 2015; Santamaria et al., 2015), pediatric intensive care unit (Visscher et al., 2013; Schindler et al., 2011), cardiothoracic intensive care unit (Brennan et al., 2013), neonatal intensive care unit (Visscher et al., 2013),cardiothoracic vascular intensive unit (Jackson et al., 2011).The researchers chose those who were in intensive care units to fit the purpose of the study, because they aimed at the results would apply to all patients in intensive care units.

There were two studies (Visscher et al., 2013; Schindler et al., 2011) the participants account for 68% of the total participants. And in four of selected studies, 21-53 participants were included (Brennan et al. 2013; Serra et al., 2015; Jackson et al., 2011; 27

Sakai et al., 2009). The external validity and structural validity of the study are at risk since the sample is not fully representative of the population ( Polit & Beck 2012). The proportion of male in six studies (Swafford et al., 2016; Behrendt et al., 2014; Serra et al., 2015; Visscher et al., 2013; Jackson et al., 2011; Sakai et al., 2009 ) was over than 50 %, while the population of the female was close to 50%, it can be said that these were representative samples, since the gender distribution is similar in the study ( Polit & Beck 2012).

5.4 Methods discussion

A literature review can be used within a research report as well as in the form of a free-standing publication, such as the present study. According to Polit & Beck (2012), a literature review is a good way to critically scrutinize and summarize previous research. The authors of the present study have used clear and specific inclusion and exclusion criteria, which strengthens the reproducibility of the study, according to Polit & Beck (2012).

In order to obtain more valuable literature, the author searches for a large number of documents, which may be regarded as a force. The article should be published between 2007-01-01 and 2017-12-31 to limit the search results, which ensure that the data is in the latest state; those old methods are not within the scope of our collection. It can also be considered an advantage that has been excluded over 10 years, because this ensures a more advanced and modern result (Polit & Beck, 2012).

Another excluded criterion is that articles only relate to patients in ICU, this can be seen as an advantage, because it helps us to clearly screen out what articles we really need, and the author chose a descriptive design.

To improve the credibility of the results, the two authors searches items in PubMed. The sources of science may help to strengthen the results of the current review. The author uses MeSH terms, titles, and synonymous dictionaries, and combines free text search to get a more relevant result. According to Polit & Beck(2012) , this is a strength, because the result of the article will be smaller, but it will be more relevant to the goals and research questions, and the result will be more credible. The selection search for synonyms will be important information, and the fact that they do not use the search may 28

cause the related materials to be ignored. This may be regarded as a limitation. However, at this point, the author carried out second database searches in Medline. The authors of this study believe that this is a kind of strength, because this form produces further relevant information.

One of the criteria chosen by the author is that the article must be written in English and cannot be written in Chinese. This may be regarded as an advantage and a limitation. The difference between Chinese and English makes the author's intention not very good to be expressed in English with the use of linguistic research standards; the author may omit the related studies of other languages. This means that many Chinese literatures that are helpful to authors but they can’t be used, which leads to some restrictions on the author's creative thinking.

5.5 Clinical implications for nursing

The results of the current literature review show the importance of different nursing measures to reduce the incidence of pressure ulcers in ICU patients. The national quality of care database (NDNQI) (2014) estimates that the average HAPU cost in the United States is $38700, except for patients with obvious adverse medical outcomes. These data indicate that pressure sores have a considerable burden on patients well-being, society and the state. The implementation of complete nursing measures to prevent pressure ulcer can improve the patient's comfort, relieve the pain of the patients, promote the recovery of the patients, improve the satisfaction of the patients, reduce the occurrence of pressure sore, shorten the time of hospitalization, and reduce the burden of family and society.(Brennan et al., 2013; Jackson et al., 2011; Still et al., 2013). The increase of patients' and their families' satisfaction with medical staff will help to ease the relationship between nurses and patients and reduce the disputes between nurses and patients.

5.6 Suggestions for future research

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The development of pressure ulcer is still an important clinical problem of ICU (Schindler et al. 2011). Timely, comprehensive and effective nursing intervention can reduce the occurrence of pressure ulcers. After integrating different nursing measures, the authors putted forward the following suggestions.

Some patients cannot cooperate well with the nursing staff due to lack of professional guidance. Nurses can provide health education to patients and their families to improve the prognosis of patients at risk of pressure ulcers (Gunningberg, 2005). Try to set up a network nursing education resource sharing platform to improve the defects caused by communication inconvenience.

Borzdynski et al. (2017) indicates that the current clinical application of biophysical skin analysis instruments can provide a feasible choice for the subjective evaluation of skin assessment.Hope that the future can focus on this point and apply some biophysical skin analysis instrumentsto the clinic to improve the shortcomings caused by subjective assessment.

In the survey of (Jackson et al., 2011), the psychological care of patients is also used as an intervention to influence the incidence of pressure sores. It is suggested that nurses should strengthen psychological nursing.

In addition, it may be better to apply different measures to patients at the same time.

5.7 Conclusion

Pressure ulcers bring physical and psychological pain to the patients. Lots of measures nurses can perform are proved to be efficient in decreasing the occurrence of pressure ulcers. However, some difficulties and deficiencies still exist in its prevention, and some measures need to be improved. All in all, it needs constant clinical practice to improve the situation.

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Serra, R., Caroleo, S., Buffone, G., Lugara, M., Molinari, V., Tropea, F., Amantea, B., & de Franciscis, S. (2012). Low serum albumin level as an independent risk factor for the oneset of pressure ulcers in intensive care unit patients. Int Wound J, 11(5), 550-553. doi: 10.1111/iwj.12004.

Serra, R., Grande, R., Buffone, G., Gallelli, L., Caroleo, S., Tropea, F., Amantea, B., & de Franciscis, S. (2015). Albumin administration prevents the onset of pressure ulcers in intensive care unit patients. International Wound Journal, 12, 432-435. doi: 10.1111/iwj.12131

Slowikowski, G. C., & Funk, M. (2010). Factors associated with pressure ulcers in patients in a surgical intensive care unit. J. Wound. Ostomy Continence Nurs. 37 (6), 619– 626. doi: 10.1097/WON.0b013e3181f90a34.

Still, M. D., Cross, L. C., Dunlap, M., Rencher, R., Larkins, E. R., Carpenter, D. L., Buchman, T. G., & Coopersmith, C. M. (2013). The Turn Team: A Novel Strategy for

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Visscher, M., King, A., Nie, A. M., Schaffer, P., Taylor, T., Pruitt, D., Giaccone, M. J., Ashby, M.,& Keswani, S. (2013). A Quality-Improvement Collaborative Project to Reduce Pressure Ulcers in PICUs. Pediatrics, 131, 1950-1960. doi:10.1542/peds.2012- 16

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Wong, H., Kaufman, J., Baylis, B., Conly, J. M., Hogan, D. B., Stelfox, H. T., Southern, D. A., Ghali, W. A., & Ho, C. H. (2015). Efficacy of a pressure-sensing mattress cover system for reducing interface pressure: study protocol for a randomized controlled trials. Trials. 16, 1-11. doi:10.1186/s13063-015-0949-x

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Appendix 1

Table 2. Overview of selected articles.

Code Year/Author(s)/cou Title Design(possibly Participants Data Data analysis ntry approach) collection method(s) method(s) A Year of publication: Use of a Comprehensive Randomized contr Number :1458 1. Cumulativ 1. T- test Program to Reduce the olled trial e number of 2016 participants 2. X2 tests Incidence of Hospital- HAPUs at (Quantitative Acquired Pressure Ulcers end of month Swafford, K., approach) Duration : From in an Intensive Care Unit Culpepperm, R., 2011 to 2013 2. Incidence of pressure Dunn, C. Mean age(Y): 51.5 ulcers (stage) Country: American Estimated Male of patients: cost 60.7%

Mean length of stay days:12.5

Department:Medical/ surgical intensive care unit

B Year of publication: Albumin administration Randomized Number: 21 patients Incidence of T test 2015 prevents the onset of controlled trial pressure pressure ulcers in Duration : 1-year ulcers Serra, R., intensive care unit (Quantitative period 2.NPUAP/E patients approach) PUAP Grande, R., From 1 January 2012 classification system to 31 December 2012 Buffone, G., (stage) Mean age(Y): 74±12 Gallelli, L., Male of Caroleo, S., patients:66.7% Tropea, F., Mean length of stay Amantea, B., days:

de Franciscis, S. Not mentioned

Country: Italy Department: Intensive care unit

Albuminaemia (mg/dl): 2.9±1.7

C Year of publication: A randomised controlled Randomized Number: 440 trauma 1. Number of 1. intention to 2015 trial of the effectiveness controlled trial and critically ill patients who treat (ITT) of soft silicone multi- developed layered foam dressings in patients Santamaria, N., (quantitative a pressure 2. Fishers Exact the prevention of sacral study ) Duration: From ulcer test Gerdtz, M., and heel pressure ulcers in trauma and critically April 2011 to 2. the 3.Kaplan–Meier Sage, S., ill patients: the border incidence December 2012 survival analysis trial rate per McCann, J., Age(Y): Over 18 group of pressure Freeman, A., years ulcers

Vassiliou, T., Male of patients: Not 3.number of pressure mentioned DeVincentis, S., ulcers developed by Mean length of stay Ng, A. W., anatomical days: site. Manias, E., Not mentioned Liu, W., Department: Knott, J. Intensive care unit

Country: Australia

D Year of publication: Continuous bedside Randomized Number :422 Incidence of 1.Wilcoxon 2014 pressure mapping and controlled trial participants pressure Mann-Whitney rates of hospital ulcers tests, Behrendt, R., associated pressure (Quantitative Duration : 2- month ulcers in a medical approach) 2 Ghazanavi, A. M., intensive care unit. study period 2. X tests, Mahan, M., Craft, Mean age(Y): 57.9 3. Fisher exact S., Siddiqui, A. tests Male of patient: 51% Country: American

Mean length of stay

days: 5.45

Department:Medical intensive care unit E Year of publication: Using conformational Quasi-experiment Number: 20 patients 1. Incidence T test 2013 positioning to reduce (Quantitative who had decreased of hospital- hospital- study) acquired mobility or were Brennan, M., R., acquired pressure ulcers pressure unable to ulcers Laconti, D., independently turn 2. cost of the fluidized Gilchrist, R. and position positioning Country: American device (FPDs)

Duration : Approximately 4 months

Mean age(Y): Not mentioned

Male of patients:Not mentioned

Mean length of stay days:

Remained on the unit

Department: Cardiothoracic intensive care unit

F Year of publication: A quality-improvement quasi-experiment Number :1425 1. The PICU 1. Statistical run 2013 collaborative project to (quantitative patients rates of charts reduce pressure ulcers in study ) stages I, II, 2.t test PICUs. Visscher, M., and III procedures conventional

King, A., Total patient-days : and device- (SigmaStat; Over 54351 related PUs SPSS, IBM Nie, A. M., Corporation, 2. Number of Mean age(Y): 7.65 Y Schaffer, P., patients who Somers, NY) (PICU) 39.3 developed Taylor, T., wk (NICU) a pressure ulcer Pruitt, D., Male of patients: 3. Mean Giaccone, M. J., 55% (PICU) hospital stay

Ashby, M., 56% (NICU)

Keswani, S. Mean length of stay Country: days:

American 34.1 (PICU)

44.4 (NICU)

Department: Pediatric intensive care unit and Neonatal intensive care unit

G Year of publication: The Turn Team: A Novel quasi-experiment Number :507 patients 1. Baseline 2013 Strategy for Reducing (quantitative with pressure ulcers data study ) of different severity collection 1. t-test Still, M. D., Pressure Ulcers in the Duration : From (Baseline 2. Fisher’s test Surgical Intensive Care December 2008 to pressure Cross, L. C., Unit ulcer rates) September 2010. Dunlap, M., 2. pressure Mean age (Y): 61 ulcer rates Rencher, R.,

Male of patients: Not Larkins, E. R., mentioned Carpenter, D. L., Buchman, T. G., Mean length of stay Coopersmith, C. M. days: 27.2

Country: American Department: Surgical intensive care unit

H Year of publication: Peer-to-Peer Nursing quasi-experiment Number :180 patients 1. Unit T test 2012 Rounds and (quantitative pressure study ) Duration: From ulcer Kelleher, A. D., Hospital-Acquired January 2008 to prevalence rates Pressure Ulcer December 2010 Moorer, A.,

Makic, M. F. Prevalence in a Surgical Mean age(Y): 58.25 2. question Intensive format Country: American Male of patients: Not mentioned 3. Prevalenc Care Unit a quality e Study Data improvement project Mean length of stay by Quarter days: 4. a chart review and Not mentioned visual skin assessment. Department: Surgical intensive care unit I Year of publication: Pressure Ulcer quasi-experiment Number: 53 patients 1. Incidence T test (quantitative of pressure 2011 Prevention in Duration : From study ) ulcers February 2008 to Jackson, M., High-Risk Postoperative 2. quality August 2008 and McKenney, T., Cardiovascular Patients Mean age(Y): 60.1 financial Drumm, J., outcomes. Male of patients: Merrick, B., 58.5% LeMaster, T., Mean length of stay VanGilder, C. hours: 6.35

Country: American Department: Cardiothoracic vascular intensive care unit

J Schindler, C. A., Protecting fragile skin: quasi-experiment Number: 5346 1. retrospecti 1. χ2 analysis nursing interventions to (quantitative patients ve chart 2. logistic Mikhailov, T. A., decrease development of study ) Duration : From Review regression. pressure ulcers in Kuhn, E. M., pediatric intensive care March 2006 through 2. aggregate unpaired incidence of 3.t tests Christopher, J., December 2007. pressure ulcers 4.Mann- Conway, P., Mean age(Y): Not Whitney 3. risk mentioned Ridling, D., factors for tests. development Male of patients: Not Scott, A. M., of mentioned Simpson, V. S. pressure Mean length of stay ulcers Year of publication: days:at least 6 2011 months Country: American

Department: Pediatric intensive care unit

K Year of publication: Continuous monitoring quasi-experiment Number:30 patients 1. Total IP maps 2009 of interface pressure (quantitative Duration : From duration of study ) distribution in intensive October 2006 to June each period Sakai, K., 2007. 2. Mean care patients for pressure Sanada, H., duration ulcer prevention Mean age (Y): 62 of each Matsui, N., period Male of patients: Nakagami, G., 57% 3. The period Sugama, J., of the Komiyama, C., Mean length of stay longest hours: 28.1 duration Yahagi, N. Department: Surgical Country: Japan intensive care unit

Appendix 2

Table 3. Overview of selected articles’ aims and main results.

Code Year/Author(s)/country Aim Results A Year of publication: 2016 A goal of pressure ulcers is After a comprehensive ulcer prevention achieving at least a 50% reduction program was implemented in the adult ICU, Swafford, K., Culpepperm, R., in 2013, compared with 2011. HAPUs were reduced by 69%. Dunn, C.

Country: American

B Year of publication: 2015 To test the efficacy of Intravenous administration of albumin can reduce the oneset of PUs in patients Serra, R., intravenous administration of albumin in patients with low serum admitted to the ICU, and in some extent, it albumin<3·3 g/dl. Grande, R., also can reduce the severrity of the lesions Buffone, G.,

Gallelli, L.,

Caroleo, S.,

Tropea, F.,

Amantea, B.,

de Franciscis, S.

Country: Italy C Year of publication: 2015 Investigate the effectiveness of Results revealed that there were multi-layered soft silicone foam significantly fewer patients with pressure Santamaria, N., dressings in preventing intensive care unit (ICU) pressure ulcers ulcers in the intervention group Gerdtz, M., when applied in the emergency compared to the control group. department to 440 trauma and Sage, S., critically ill patients.

McCann, J.,

Freeman, A.,

Vassiliou, T.,

DeVincentis, S.,

Ng, A. W.,

Manias, E.,

Liu, W.,

Knott, J.

Country: Australia D Year of publication: 2014 Explore the effectiveness of real- Significantly fewer HAPUs occurred in the time visual feedback in CBPM group than the control group. Behrendt, R., Ghazanavi, A. repositioning of patients to prevent M., Mahan, M., Craft, S., the formation of new HAPUs. Siddiqui, A.

Country: American

E Year of publication: 2013 To understand how turning and Families are satisfied with the device as positioning were being implemented patients report increased comfort when Brennan, M., R., Laconti, D., in our ICUs and whether we could reduce the incidence of hospital- being positioned and the CTICU has Gilchrist, R. acquired pressure ulcers. maintained the decline in hospital-acquired Country: American pressure ulcers.

F Year of publication: 2013 Develop and implement a quality- The PU rate in the PICU was 14.3/1000 improvement (QI) intervention to patient-days during the QI development and Visscher, M., reduce PUs by 50% in our ICUs. 3.7/1000 patient-days after QI King, A., implementation (P<0.5), achieving the aim

Nie, A. M., of 50% reduction.

Schaffer, P., The PU rate in the NICU did not change significantly over time but remained at a Taylor, T., mean of 0.9/1000 patient-days. Pruitt, D.,

Giaccone, M. J.,

Ashby, M.,

Keswani, S.

Country:

American

G Year of publication: 2013 To determine if a dedicated team A team dedicated to turning SICU patients tasked with turning and every 2 hours dramatically decreased the Still, M. D., repositioning all hemodynamically stable SICU patients could decrease incidence of pressure ulcers. Cross, L. C., the formation of pressure ulcers.

Dunlap, M.,

Rencher, R.,

Larkins, E. R., Carpenter, D. L., Buchman, T. G., Coopersmith, C. M.

Country: American H Year of publication: 2012 To evaluate the effect of nurse-to- Prior to focused nursing rounds, the highest nurse bedside “rounding” as a HAPU preva-lence rate was 27%. After Kelleher, A. D., strategy to decrease hospital- acquired pressure ulcers (HAPU) in implementing focused nursing Moorer, A., a surgical intensive care unit.

Makic, M. F. rounds,HAPU rates trended down and were 0% for 3 consecutive quarters. Country: American I Year of publication: 2011 To present a possible prevention Cost-effective and the incidence of pressure strategy for postoperative sores decreased. Jackson, M., cardiovascular

McKenney, T., surgery patients at high risk for development of pressure ulcers. Drumm, J.,

Merrick, B.,

LeMaster, T.,

VanGilder, C.

Country: American J Schindler, C. A., To determine the incidence of Nursing interventions play an important pressure ulcers in critically ill role in the prevention of pressure ulcers. Mikhailov, T. A., children, to compare the characteristics of patients in whom Kuhn, E. M., pressure ulcers do and do not develop, and to identify prevention Christopher, J., strategies associated with less frequent development of pressure Conway, P., ulcers.

Ridling, D.,

Scott, A. M.,

Simpson, V. S.

Year of publication: 2011 Country: American K Year of publication: 2009 To examine whether continuous Continuous monitoring of the intensity and interface pressure monitoring of duration of whole-body interface pressure Sakai, K., postoperative patients in an intensive care unit is feasible in using the KINOTEX sensor is feasible in Sanada, H., clinical practice. intensive care patients. Matsui, N., Nakagami, G., Sugama, J., Komiyama, C.,

Yahagi, N.

Country: Japan

Appendix 3

Table 4. Classification of intervention measures for prevention of pressure ulcers

Category Subcategory Intervention Assessment tool Use of the Braden scores (A) (K)

Risk assessment Using the standard Braden scale (D) Appropriate assessment tools(Braden Q) (F) Braden Scale risk assessment scorecard (H) Using the Braden Q Scale (J) Skin assessment Every 2 wks patient evaluation to determine new PUs (F) Daily head-to toe skin assessment (F) Daily documentation of skin status (F) Measures to relieve the compression of the Regular replacement of posture Turning every 2 hours (D) skin tissues Reposition regularly, minimum Q4 hrs (F)

Elevation of the head of the bed (J) Turning the patient at least every 2 hours (J) Turning SICU patients every 2 hours (G) Application of some monitoring or Fluidized repositioner(A) decompression device Continuous beside pressure mapping device(D)

Using fluidized positioning device (E) Products related to pressure (Mattress rollout; wheel chair cushions; stimulite) (F) Air fluidized therapy Beds (I)

Use of a specialty bed (J) Use of a blanket roll (J) Use of a new mattress with the fibre-optic sensor (K) Applying of protective measures Allevyn life silicone adhesive dressings(A) Soft silicone multi-layered foam dressing(C)

Nutritional support Albumin administration（B）

Patient care indrectly related to skin(nutrition)(F) Education Face to face staff education(A) Staff needed education to use the fluidized positioning device (E)

Education of staff and parents (F) Staff education about the Skin Prevention Assessment Management (H) Nutrition addressed (H) Education was implemented Braden Q (J) (G)