Prevention of Pressure Sores on the Front of the Head - Essay Example

?Facial Nasal Bridge Pressure Sore Prevention Related to NIPPV: Evidence-Based Practice Introduction Nasal intermittent positive pressure ventilation(NIPPV) is a useful strategy to prevent control of symptoms and cause improvement in the quality of life of those patients with not only acute respiratory failure but also chronic respiratory failure. In acute respiratory failure, NIPPV prevents the needs for intubation and tracheostomy (Weng, 2008). In chronic respiratory failure, it helps the patient oxygenate btter and prevents accumulation of carbon-di-oxide in the body. NIPPV is applied mainly through face mask orally or through a nasal prong. Despite its several advantages, the procedure is fraught with several disadvantages and complications. One of the complications of such an intervention is development of pressure sores over the nasal bridge (Callghan and Trapp, 1998). Pressure sores are a common cause of concern in those treated with NIPPV because of the consequences of the sores and associated morbidity and mortality. Several strategies have been defined and developed to prevent or minimize the development of pressure sores. However, which strategy is most suitable for the patient can be ascertained only through suitable literature review done through research. According to Polit and Hunger (1999; cited in Melnyk et al, 2000), "research utilization is the use of some portion of research in practice that is similar to the manner in which it was used in the original study. Making clinical decisions based on appropriate evidence is known as evidence-based practice. According to McKibbon (1998), "Evidence-based practice (EBP) is an approach to health care wherein health professionals use the best evidence possible, i.e. the most appropriate information available, to make clinical decisions for individual patients. EBP values, enhances and builds on clinical expertise, knowledge of disease mechanisms, and pathophysiology. It involves complex and conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences." Literature review is the most critical exercise for EBP. Literature search for EBP can be done effectively by creating appropriate question in PICO format. In this essay, strategies to prevent facial nasal bridge pressure sore related to NIPPV will be discussed through suitable literature review for evidence based practice. Aims and objectives To ascertain various strategies to prevent facial nasal bridge sores due to noninvasive ventilation and to provide solutions for questions related to prevention of facial nasal bridge sores in those ventilated using NIPPV for evidence based practice in a clinical setting. Search strategy The commencement of search in electronic databases was based on the inclusion/exclusion criteria and knowledge of the hierarchies of evidence. Hierarchy provides a confidence measure to the end-user (Evans, 2003). According to Evans (2003), randomized control trials can be considered of good standard and they are in fact labeled as the gold standard of research for providing optimal research designs to answer pertinent questions. However, systemic reviews and meta-analysis have topped the hierarchy list. Google Scholar and PubMed were the databases used for search. The search words used were “pressure sores”, “non invasive ventilation” or “face masks” and “prevention”. Though the searches yielded several articles, most of them were irrelevant and hence only a few which were relevant were reviewed. It was noted that both search engines placed the results in a hierarchical order with the most relevant articles coming first or accorded higher star ratings. This search yielded valuable papers. Background and rationale NIPPV causes improvement in the gaseous exchange. It also reduces the risk for development of respiratory tract infection and also excessive production of secretions. However, long term application of NIPPV can lead to discomfort and other complications like gastric distension, accidental removal, leakage from the masks and pressure necrosis of the skin of the face, especially over the nasal bridge. Pressure ulcers occur as a consequence of long term application of pressure over the skin leading to ischemia, necrosis of the tissue of the skin and finally ulceration of the skin. In NIPPV, a facial or nasal mask is used. The masks are fitted to the face tightly to prevent any air leakage. This leads to application of pressure over the skin and subsequent ulceration. It is often difficult to treat pressure ulcers because of lack of proper understanding of the complexities involved in the causes of breakdown of skin (Riordan and Voegeli, 2009). Pressure ulcers are "areas of localized damage to the skin and underlying tissue caused by exposure to pressure, shear or friction, or a combination of these" (Riordan and Voegeli, 2009). While most of the pressure ulcers affect only the skin, severe forms of ulcers involve other structures like muscle, bone and tendons. Pressure ulcers develop because of sustained high pressure in an area of the body, mostly over the prominences of bones. Due to the raised pressure, the capillaries supplying blood supply to a particular region get compressed resulting in ischemia of the tissue. Other than ischemia, thrombosis of the venous system and occlusion of the lymphatic vessels of the area also are affected because of pressure. All these eventually lead to increased permeability of the capillaries, interstitial edema and tissue death. Risk assessment forms the first step in the prevention and management of any pressure wounds. According to Riordan and Voegeli (2009), risk assessment must be applied within 6 hours of admission to any setting with frequent updates as early as every week. The grading of ulcers recommended by these authors is the European Pressure Ulcer Advisory Panel Grading System. According to the authors, "pressure-relieving strategies form the cornerstone of prevention and treatment" and "treatment should be directed towards improving the overall condition of the patient and providing an optimum wound environment for healing." The management of wounds include strategies to reduce pressure, friction and shear through proper positioning, appropriate nutrition and wound care. The management of wounds include strategies to reduce pressure, friction and shear through proper positioning, appropriate nutrition and wound care. Pressure injury and sores in the facial and nasal region occur because of tight seals of mask which are used to delivery desired inspiratory volumes. Pressure injuries can be minimized by application of noninvasive ventilation intermittently whenever possible and by allowing scheduled breaks of 30- 90 minutes for minimizing the effects of the pressure of the mask, by balancing strap tension to minimize the leaks of the mask without any excessive pressures over the mask and by covering various areas of vulnerability with some protective dressings (Hoo, 2011). Holistic management of wound is necessary to facilitate maximum healing and this is based on holistic assessment of the patient with reference to factors affecting healing of the wound. The goals of wound management are to maintain a moist environment of the wound, to control the type of exudate and debris through appropriate dressing like absorb dressing, to facilitate autolytic debridement, to insulate and protect the wound, to maintain and improve blood circulation to the wound so that appropriate nutrients are supplied for wound healing and wastes of metabolism are removed timely, and to improve hydration and nutrient supply to the wound. Factors which affect wound healing adversely are dry dressings because the fibers stick to the wound, wring dressings, scabs, increased moisture in the wounds because it leads to wound maceration, wound interference due to frequent wound dressing, poor circulation, poor nutrition, dehydration, oldage, diabetes mellitus and smoking (Kunimoto, 2001). Several strategies have been developed to relieve the pressure of skin during NIPPV. The first step is the assessment of the integrity of the skin at regular intervals. It is very important to keep the skin clean and moisturized in order to increase the tolerance of the tissue to pressure injury. There has been enormous input about the use of various types of dressings for prevention of pressure sores. During assessment, the skin integrity must be correlated to the developmental status, age, interface device used, the disease process, medications, level of consciousness, infection, sensory impairment, hydration status, positioning, activity level of the patient, bladder and bowel incontinence and presence of edema. It is also important to assess various areas under the interface of the device for pain, decrease in sensation, discomfort, fragility nature of the skin and location of previous or present ulcers (Reddy et al, 2006). Skin integrity must be promoted by scheduled breaks and rotation of the interfaces for the purpose of changing the distribution of friction and pressure, by providing oral care and also skin care, by frequently changing the position of the patient and, by head end elevation. It is also important to maintain good hydration and nutrition status of the individual and also maintain normothermia for optimum skin integrity. Another strategy to minimize skin disintegrity is to minimize various environmental factors leading to drying of skin like avoiding excessive bathing or lack of humidity and at the same time avoiding excessive humidity (Czervinske, 2004). Some authors state that the best way to prevent skin irritation of the nasal bridge is to apply correct size and type of mask and also facial straps. The tension of the straps must be adjusted in such a way that only 2 fingers can be accommodated under the straps. In patients in whom NIPPV is expected to be applied for a longer duration of time, several products like duoderm, which is also known as artificial skin can be applied. There are many wound dressings available in the market. Alginate is useful for wounds with copious exudate. Hydrofiber is also useful for exudate wounds. Debriding agents like hypertonic saline, papain urea and collagenase can be used in necrotic wounds. Polyurethane foam is useful for cleaning wounds with granulation tissue. Hydrocolloid is useful for necrotic wounds which are dry and have clean granulation tissue and minimal exudate. Hydrogel dressings can be used in wounds with eschar (Stillman, 2008). Another useful strategy is to line the mask with a soft strip that is toweling, that protects the skin beneath the mask from irritation. Some researchers have proposed topical steroids and antibiotics for the prevention of pressure sores (Mitka, 2009). This literature review mainly focuses on strategies to prevent pressure sores using risk assessment and dressings. Literature review Weng (2008) conducted a study to compare the efficacy of various types of protective dressings that are used for prevention of pressure ulcers over the nasal bridge. He compared the efficacy as against use of no materials also. The materials studied were tegaderm and tegasorb. The study included 90 participants and the type of study was randomized controlled trial. From the results of the study it was evident that those belonging to either material group had definitely lower incidence of pressure sores when compared to the control group in which the patients did not receive any application for prevention of pressure ulcers. No significant difference was noted between the material groups. From the results of the study, the authors opined that both tegaderm and tegasorb are use to prevent development of pressure sores due to NIPPV application. In a study by Weng et al (2008), the researchers studied the effectiveness prophylactic dressings with hydrocolloid which applied to the faces of those who were subjected to NIPPV and were selected randomly. The control group received no such precautions. From the results of the study, it was evident that those who received hydrocolloid dressings were at lesser risk of development of pressure sores than those who did not receive any such application. Similar benefits were observed in yet another study by Smith (2006) who evaluated the benefits of hydrocolloid dressings in NIPPV for premature babies. However, in this study, the author observed that removal of the dressing was difficult and caused pain and skin tears at the bridge of the nose in these small babies. In some units, silicone foam dressings have been a practice as one of the alternatives to hydracolloid. One of the major benefits of silicone foam dressing over hydracolloid dressing was that is is easy to apply and move. The dressing also does not cause stripping of the skin at the time of removal, thus decreasing pain and discomfort to the patient. In a study by Hsu et al (2010), application of silicone foam dressing significantly decreased the incidence of pressure sores from 5.9 percent to 0.9 percent. Other than local dressings, sealing the face mask with water seal also has been found to be an useful strategy in preventing pressure sores. Lloys et al (2003) demonstrated the usefulness of water seal for prevention facial pressure ulcers when applied to face masks for NIPPV. The study was a prospective study in which 47 persons with NIPPV were studied. In some patients who were selected randomly, the interface of the face mask was filled with either air or water. The length of NIPPV and the appearance of facial ulcer were recorded. From the results of the study, it was clear that using water to seal face masks in NIPPV causes significant delay in the appearance of facial ulcers. The researchers however, suggested more research in this perspective. Risk assessment forms the first step in the prevention and management of any pressure wounds. Several researchers have provided elaborate information about strategies and importance of risk assessment in the prevention of pressure ulcers. Indiana initiative is one of the most successful initiatives to prevent and manage pressure ulcers effectively (Gudell et al, 2009). The Indiana initiative stresses on the need to use assessment tools to evaluate for pressure ulcers within 24 hours of admission (Gudell et al, 2009). The scale recommended is the Braden Scale which can effectively identify the risk to develop pressure ulcers. The initiative recommends that all staff members must be provided with the guidelines to prevent and manage pressure ulcers in a timely manner. The initiative stresses on the need to standardize transfer reports through appropriate communication strategies and give due importance to information and training of aides of the patients. Moore and Cowman (2008) conducted a review to determine, evaluate and ascertain the role of risk assessment tools in the reduction of pressure ulcers in any health care setting. The study is a systematic review of various other studies conducted to evaluate the effectiveness of risk assessment tools in the prevention and management of pressure ulcers in various types of health care settings. The systematic review was conducted on randomized controlled trials which are at a high hierarchy level for evidence-based information. According to the study, there are no established randomized controlled trials to ascertain and evaluate the usefulness of structured risk assessment tools in the prevention and management of pressure ulcers when compared to clinical judgement. The study by cochrane database provides insight into the meaningfulness of risk assessment in the prevention of management of pressure ulcers as against clinical judgment. Challenges pertaining to the issue Several challenges are there for prevention of sores and ulcers due to NIPPV. Some of them include lack of appropriate resources for monitoring and applying preventive efforts, lack of availability of good quality mask due to repeated use, lack of skin care protectant by the department, lack of manpower for providing adequate nursing and practicing hygiene and skin care, and nursing overburden. Other barriers include, lack of evidence based knowledge, lack of appropriate information and poor attitudes of the nursing staff. According to a study by Strand and Lindgren (2010), lack of time, severe illness of the patients, lack of access to equipment necessary for prevention, and lack of opportunities for knowledge. Moore and Price (2004) reported that haphazard and erratic practices were barriers for prevention of pressure ulcers and they mainly occurred due to lack of adequate staff and sufficient time. Conclusion There are several strategies to prevent facial nasal bridge pressure sores. Application of correct size of mask with a suitable dressing beneath the mask is one of the useful strategies. Other strategies include correct positioning of the mask, maintenance of skin care and integrity and frequent removal of the mask from the face. Proper assessment of skin integrity is warranted. As far as type of dressing is concerned, any skin dressing which serves as a suitable barrier is useful. While assessment tools like Braden Scale are frequently used to prevent and evaluate pressure ulcers in early stages, the Cochrane database argues that there is no evidence-base for such an application in practice since there are no definite and valid randomized controlled trials to prove the role of assessment tools as against clinical judgment. Thus, this research ended with unclear information as to whether assessment tools are useful in the prevention and early management of pressure ulcers. References Callaghan, S., Trapp, M. (1998). Evaluating two dressings for the prevention of nasal bridge pressure sores. Prof Nurse., 13(6), 361-4. Czervinske, M. (2004). AARC clinical practice guideline application of continuous positive airway pressure to neonates via nasal prongs, nasopharyngeal tube, or nasal mask—2004 revision and update. Respiratory Care, 49(9), 1100-1108. Evans, D., 2003. Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. 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