Nuru et al19 provided evidence from their cross-sectional research (N = 248) that 48.4% of nurse interventions for patients with pressure ulcers were good/satisfactory and that 54.4% of nurse study participants had good knowledge of pressure ulcers. A cross-sectional, multicenter study (N = 145) of the knowledge level of nurses in terms of the pressure ulcer prevention by Demarre et al20 found an accurate/satisfactory rate of 29.3%; the same research further documented that 78.3% of the nurses exhibited a positive attitude toward of pressure ulcer prevention implementation. The current research did not examine the knowledge of nurses regarding MDR pressure ulcers; it only focused on the related interventions. The research also aimed to determine which medical devices, in the opinion of the nurses, cause pressure ulcers. Among participants, 80.1% believed medical devices can cause pressure ulcers of different categories/stages (see Table 2).
However, nurses responded that not all devices present a risk for pressure injury. Specifically, most nurses believed that PEG/PEJ tubes (80.5%), orogastric catheters (78.7%), arterial catheters (74.6%), central venous catheters (71.1%), peripheral venous catheters (71%), Foley catheters (62.9%), SpO2 probes (62%), ECG leads and electrodes (59.7%), cervical collars (58.4%), oxygen masks (55.4%), splints (55.4%), and nasogastric tubes (52.6%) do not pose a MDR pressure injury risk. This outcome was found to be important from 2 points of view. First, even though the nurses know medical devices can cause pressure ulcers, they may need more information about which devices are likely to cause them. Second, this outcome supports the presumption that although nurses may recognize general reasons for the occurrence of pressure ulcers, they may have difficulty realizing a medical device as a cause.
Approximately half of the nurses in the study did not receive any education on pressure ulcers after graduation. Although MDR pressure ulcers have garnered the attention of adminstrators and practitioners for the past 5 years in Turkey, these findings clearly demonstrate nurses need education about MDR pressure ulcers. Black et al3 concluded from their study that pressure ulcers developing at areas where such ulcers rarely occur (such as lips, cheeks, ears, nose bridge, back of the head, finger tips) are to be automatically categorized as pressure ulcers caused by medical devices. Of the nurses participating in the current research, 59.2% stated they have experience with MDR pressure ulcers (see Table 1).
In the current research, nurses were asked to specify which medical devices could cause pressure injuries; intubation tubes were chosen by the majority (59.7%) of participants. In prospective research in intensive care units (N = 483), Coyer et al2 found 8 out of 20 MDR pressure ulcers were caused by nasogastric tubes and 7 pressure ulcers had developed due to intubation tubes. In the research by Schlüer et al15 (N = 155), most pressure ulcers developed due to medical devices such as tubes, splints, and monitoring cables.
Preventing pressure ulcers caused by medical devices in the course of proper nursing interventions is considered to be an indication of quality of care.5 According to pressure ulcer guidelines,1 nurses should be able to identify patients at risk as early as possible and accordingly implement preventive interventions.1 In this regard, nurses should be especially careful of placing and fixing medical devices to avoid friction and pressure on the skin.9 In the current study, nurses frequently knew to “properly position medical devices so as to prevent friction and pressure on the skin.” However, almost half of the nurses think TEDs do not cause MDR pressure injuries, and more than half believe urinary/urethral catheters do not cause MDR pressure ulcers. This represents a critical outcome in terms of nursing care and may be attributed to nurses’ lack of awareness of the possible risks of these devices.
The current authors believe nurses have the responsibility to conduct head-to-toe skin inspections and to check medical devices. Ong et al21 reported a case where pressure ulcers developed in a patient because a compression stocking was improperly folded at the popliteal fossae; this inappropriate care was traced to an improper fitting of the stocking. Sivaraman Nair et al22 reported 2 cases where improperly positioned and fixed indwelling urethral catheters caused a Stage 2 pressure ulcer between the thighs.
In the current research, 79% of the participating nurses said they inspected the area beneath the medical device for pressure damage. In a prospective, epidemiological study by Compton et al,23 regular skin inspections performed by nurses could be more effective in determining pressure ulcer risk than specific objective data used for the diagnosis of pressure ulcers. Several researchers have proposed that regular skin inspection is important for both non-MDR as well as MDR pressure ulcers.3,5,24 Another finding with regard to skin inspection is that 77.4% of nurses knew to take special care to avoid placing medical devices where skin integrity has been compromised and, when possible, to place devices in a manner that avoids contact with the skin. When the medical condition of the patient allows, it is recommended that skin around and beneath devices be inspected at least twice a day.17
In this study, most of the nurses stated they inspected the skin at least once every shift by loosening devices such as splints, corsets, nasal cannulas, and SpO2 probes when the medical condition of the patient allowed it (80%) and ensured medical devices were not tightly fixed and were repositioned during every nursing shift (63.2%). In addition, because the most basic factor with respect to the prevention of pressure ulcer is the definition and elimination of the cause of the pressure, it is essential to remove the medical devices as early as possible to minimize the risk of MDR pressure ulcer development. A prospective, descriptive study conducted by Powers et al8 demonstrated that skin breakdown increased with the number of days of cervical collar wear (P <.0001). Coyer et al2 showed that while the average number of medical devices per patient is 7.6, patients in whom MDR pressure ulcers develop had an average number of 8.6 devices.
Medical devices made of hard materials and that are improperly positioned on the skin increase pressure and friction, increase the risk of pressure ulcers,5,18 and account for frequent peristomal skin complications.25 Therefore, it may be essential for patients with a tracheostomy, colostomy, or other type of stoma that the peristomal area be inspected at every shift for indications of pressure ulcers. Among the nurses participating in the research, 72.4% stated they regularly inspected the peristomal area at every shift for probable inflammation and pressure ulcer development. In particular, tracheostomy tubes can compromise skin integrity because of the continuous pressure and moisture created by perspiration-respiration secretions.24 Descriptive pilot research by Jaul9 (N = 32) demonstrated 4 pressure ulcers occurred around the neck at the edges of a tracheostomy tube. In the study by Boesch et al24 (N = 834), 100 tracheostomy-related pressure ulcers occurred — among them, 14% were Stage 1, 50% were Stage 2, and 36% were Stage 3 ulcers. Most (73%) pressure ulcers developed around the stoma and 4% formed under twill ties.
Placement of protective supporting materials such as gel pads, film dressings, sprays, and foam dressings at areas where medical devices contact the skin has been shown to decrease the risk of MDR pressure ulcers.5 Dressing materials can be placed underneath medical devices at areas of risk such as ears and noses. In this research, 78.5% of nurses stated “they are using supportive or protective dressing materials where medical devices and fixing elements are placed” to protect new pressure injuries. The study by Acorda10 reported that placing supporting foam materials such as Mepilex (Mölnlycke Health Care, Norcross, GA) between the mask and skin in patients receiving bilevel positive airway pressure therapy gradually reduced the prevalence of pressure ulcers to 0. Weng14 conducted a quasi-experimental study (N = 90) using protective dressing materials in noninvasive ventilation treatment to examine the effects of lack of protective materials on the development of pressure ulcers. The research found that while Stage 1 pressure ulcers developed at a rate of 96.7% in the group not using protective materials, the rate of development was reduced to 53.3% and 40% in the groups where protective materials were used. The study also showed pressure ulcers developed in a much shorter time. Pressure ulcers developed in 1 group where no protection and 2 groups where protection was provided in 1111 ± 2169 minutes, 2628 ± 1655 minutes, and 3272 ± 2566 minutes, respectively (P <.01).