Critically ill hospital patients typically face prolonged periods of immobility due to the severity of their illness; in addition, hemodynamic instability, mechanical ventilation therapy, monitoring devices, and medical treatments make immobility necessary and inevitable.1 Immobility is a factor in a variety of severe complications, including deep vein thrombosis, pulmonary insufficiency, muscular atrophy, decreased functional capacity, and pressure injuries.1,2
A pressure injury is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.”3 Pressure injuries are one of the most significant health concerns and descriptive, observational, and experimental studies have shown they may involve severe pain, discomfort, impaired quality of life, prolonged hospital stay, increased health care costs, mortality, and morbidity.4-6
Pressure injury development is a complex process with many contributory risk factors, especially among critically ill patients.3,4 Immobility affects individual organ systems and has been shown to be the most important risk factor contributing to pressure injury occurrence.1,4,6 The highest pressure injury rates among hospitalized individuals are reported in the critical care population. The NPUAP7 reported pressure injury incidence rates vary between 13.1% and 45.5% in critical care settings. In a cross-sectional, retrospective Turkish study8 conducted among a population of 20 175 patients, the pressure injury prevalence rate was found to be 3.3% and the overall pressure injury incidence rate for 5 years was 1.8%. A systematic review9 found pressure injury rates vary between 15% and 63% in Turkish intensive care units (ICUs).
Treating pressure injuries in immobile patients can be a clinical challenge due to complex treatment, slow healing, and contributing adverse effects such as such as bone and joint infections, cellulitis, and sepsis.3,4,6 Therefore, evaluating the healing process of pressure injuries is important in determining treatment progress and/or effectiveness.10,11
The Pressure Ulcer Scale for Healing (PUSH) Tool. The PUSH Tool is a reliable, easy-to-use instrument developed to monitor the change in pressure injury status over time. The Tool assesses 3 parameters: surface area, exudate, and type of wound tissue. Surface area is determined by multiplying the greatest length by the greatest width. Wound area values between 0 cm2 and 24 cm2 then are scored on a 0 (0 cm2) to 10 (>24 cm2) scale. The amount of exudate (drainage) is determined at dressing removal before applying a topical agent and is assessed on a scale of 0 to 3, where 0 = none, 1 = light, 2 = moderate, and 3 = heavy. Tissue type is specified as necrotic tissue/eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin; score = 4), slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous; score = 3), granulation tissue (pink or beefy red tissue with a shiny, moist, granular appearance; score = 2), epithelial tissue (for superficial ulcers, new pink or shiny tissue/skin that grows in from the edges or as islands on the ulcer surface; score = 1), and closed/resurfaced (the wound is completely covered with epithelium/new skin; score = 0). The total PUSH score ranges from 0 to 17 and is obtained by summing the 3 parameter scores (see Figure 1). Changes in the score represent variation in injury healing. If the score decreases, the pressure injury is healing; if the score increases, the pressure injury is deteriorating.12
A prospective, methodological study10 conducted in a Turkish university hospital among 72 people with 86 pressure injuries showed total PUSH scores decreased significantly over the 8-week study period and significant differences in total PUSH scores were noted between healed and unhealed ulcers.
Alderden et al4 conducted a retrospective chart review of data from 87 patients treated at a level I trauma center and safety net hospital in Seattle, Washington. Among 111 hospital-acquired pressure injuries, 45.9% healed and 54.1% remained at discharge or death.
A retrospective study by Karahan et al11 of 4 years of data from a private Turkish university hospital found 79.5% of the pressure injuries were stage 2, 75.6% were located in the sacral area, and 65.4% were present upon discharge or death. However, international research reflecting the healing status of pressure injuries among critically ill immobile patients is lacking. The aim of this study was to determine the healing status of pressure injuries among critically ill immobile patients.