The Nursing Care for the Medical Device Related Pressure Injury Patient with a Mucosal Pressure Injury Due to an Endotracheal Tube: A Case Report

When the inpatient profile of intensive care units is evaluated, medical devices are used frequently for treatment and interventions in patients. For this reason, medical device-related pressure injuries (MDRPIs) are common in patients in intensive care units, except for pressure injury (PI) due to immobilization. Studies on the prevalence of MDRPIs and risk factors for their development revealed that the prevalence had been reported to vary between 1% and 86%.^1,2 MDRPIs have become an increasing concern among health care professionals.^3,4

MDRPIs develop when the skin or underlying tissues are subjected to constant pressure or friction from medical devices. PIs usually occur on the bony area or tissue exposed to pressure due to immobility and support surface.^3-5

MDRPIs can be caused by constant pressure or friction from the medical devices, immobility, sensory disturbances, humidity, nutritional deficiencies, micro-climatic balance of the skin, nutrition, comorbidities, and poor oxygenation.^5-8 MDRPIs often take on the shape of the device.^3,4 Essential components of diagnosis and treatment differ from typical PIs.^9-10 MDRPIs are more common in the mucosa than in skin and the bony area.^11,12 Furthermore, since mucosal tissue is histologically differentiated from skin tissue, the National Pressure Injury Advisory Panel (NPIAP) PI staging stated that MDRPIs cannot be staged because they are based on the skin and the underlying anatomical structures.^2,4,13 Due to the widespread use of medical devices for diagnostic and therapeutic purposes, the risk of developing MDRPIs is increasing, especially in intensive care units where medical devices are used more frequently.^1,14 A study by Van Gilder et al showed that 9.1% (n = 1631) of 86 932 PIs in patients in acute care were caused by a medical device.¹ According to another study, the most common areas of MDRPIs are the ear (20%), sacral/coccyx region (17%), heel (12%), and trochanters (10%).¹⁵

According to the NPIAP guidelines, pressure should be redistributed and shear force should be reduced in order to eliminate possible pressure sources related to the device as soon as possible.^13,16

Health professionals, especially nurses, are of critical importance in preventing all types of PIs, identifying patients at risk of development, and providing appropriate preventive care.^17,18 Nursing models and the nursing process are tools that provide a scientific and planned approach to nursing care. Various models developed by theorists provide a systematic and comprehensive collection of data from a healthy or sick individual and their family.^19,20 Standardized care models such as Gordon’s Functional Health Patterns (GFHP) provide comprehensive care by addressing the needs of individuals in 11 functional areas. Determining the nursing diagnosis is the basis for planning individual nursing care. By systematically collecting data about the patient, GFHP guides practitioners toward reaching the most accurate diagnosis.^20,21 The use of GFHP also enables the delivery of holistic nursing care to the patient. By using nursing care models, it is ensured that patients are systematically given holistic nursing care. As a result, it leads to positive outcomes in nursing care.^19,20

The patient is a 35-year-old male with a history of chronic obstructive pulmonary disease (COPD) for approximately 10 years. The patient has no other chronic disease other than COPD. The patient has no known food or drug allergies, and his COPD medical therapy was Salmeterol Fluticasone (GlaxoSmithKline) and Theophylline SR 100 mg (Nobel), each 2 puffs once daily. The patient was admitted to the emergency department showing signs of respiratory distress, wheezing, productive cough, high fever (39.5 °C), and myalgia. In the patient's examination, arterial blood pressure was measured as 152/95 mmHg, radial pulse rate was 98 per minute, respiration was 28 per minute, and body temperature was 39.1 °C. In the Glasgow Coma Scale (GCS) assessment performed to evaluate the patient's consciousness, the GCS score was determined to be 4 points (range, 0-15). In addition, vital signs were checked and monitoring was provided to the patient. Cardiac supportive drugs were infused for the increased cardiac load in the patient. 

A polymerase chain reaction test (PCR) was performed due to increasing dyspnea, cough, and high fever. The PCR test was positive, determining the SARS-CoV-2 virus (ie, COVID-19) in the patient. 

The patient was transferred to the internal medicine intensive care unit from the emergency room. As a result of radiologic examinations, thorax computed tomography revealed findings of peribronchial thickening and viral pneumonia. First, bronchodilator medication and oxygen therapy were started for the patient's COPD treatment. Despite the patient's high-flow oxygen therapy, due to increasing respiratory distress and decreasing oxygen saturation values (PO₂ = 65%), the team decided to intubate or start mechanical ventilation due to the deteriorating condition of the patient. He was intubated on the second day after admission, and mechanical ventilator treatment was started. Antibiotics and supplements like dexamethasone and azithromycin were given to treat the patient's pneumonia caused by COVID-19. A mucosal membrane MDRPI due to ET was observed at the lower lip edge on the fifteenth day after intubation. The size of the MDRPI was measured as 2 mm x 1 mm and observed to be a slightly hyperemic, partial tissue loss wound feature (Figure 1). 

The nursing process is used in nursing activities that provide nursing care with a certain systematic method and consists of successive stages in solving the individual's health problem.^22,23 The nursing process is goal-centered and can be applied in every field where the nurse serves, providing the best and qualified care to the patient.^22,24 The nursing care process was used to plan the nursing care to be given to the patient. 
 

It has been determined that for patient nursing care, nursing diagnoses were recognized according to GFHP, and nursing care was planned and performed in line with the diagnoses obtained. In GFHP, 11 functional area individual needs are systematized and provide a holistic approach to nursing care.^19,20 After determining the needs of the individual, the nursing diagnoses approved by the North American Nursing Diagnosis Association (NANDA) were determined. The patient’s care was planned in line with the classification of Nursing Interventions Classification (NIC) nursing interventions and NOC care outcomes according to the determined nursing diagnoses. In this case, professional, qualified nursing care was given by applying GFHP and planning effective and holistic evaluated care.

The "Prevention and Treatment of Pressure Ulcers/Wounds: Quick Reference Guide," published by the European Pressure Ulcer Advisory Panel (EPUAP) in 2019, was used for the nursing care of patients' PIs due to medical devices.¹³ The patient was given supportive treatment such as antibiotic therapy, nutritional support to treat worsening respiratory function, and intubation. In the hospital, the patient’s vital signs were monitored. After the supportive treatments and antibiotic treatment were started at the end of the fourth day of admission, an improvement in the patient’s general condition and an increase in the GCS score were observed.

Nurses play a crucial role in the early recognition, prevention, and implementation of protocols and in treating patients at risk for MDRPIs.^1,8 Nursing care is critical for the prevention and treatment of MDRPls.

Although the formation mechanism of PI owing to medical devices is similar to PIS resulting from immobilization, it was seen on the skin and mucosa rather than the bony area.^11,12 Because mucosal tissue has different histological structures from skin and bone tissues, and because most of them do not have adipose tissue, their tolerance to pressure is lower than other tissues.^4,5,7 The resultant PI generally conforms to the pattern or shape of the device. A mucosal membrane PI is found on mucous membranes with a history of a medical device in use at the location of the injury.^13,17 If the injury is in the skin, it should be staged using the staging system, but these injuries in the mucosal membrane cannot be staged due to the anatomy of the tissue. Therefore, evaluating with standard PI staging measurement tools is impossible.^13,16 Although all medical devices potentially cause PI, they usually take the shape of the device and develop around or below it.^3,8 MDRPIs are most common in the head, face, neck, and extremities.^9,16

The basic nursing interventions that should be done for the prevention of MDRPIs and the care of injuries are included in the "Prevention and Treatment of Pressure Ulcers/Wounds: Quick Reference Guide" published by EPUAP in 2019. In line with this guideline, the device should be selected in the appropriate size for the individual, and the skin should be protected and covered with protective dressings in high-risk areas. The skin under any medical device should be examined for signs of injury at least twice daily. Regular evaluation of the skin should be done once a day. Repositioning of the patient and device was recommended to prevent MDRPls.^13,16 In order to eliminate possible pressure sources related to the device as soon as possible, pressure should be redistributed and shear force should be reduced.^13,16,25,26

Due to the patient's injury being caused by the ET, it was first evaluated whether the ET was the appropriate size for the patient. A protective dressing was then placed on the area under the ET. By fixing the ET to the right and left rim of the mouth twice daily, the blood supply to the injured area was ensured. The tissue under the ET was observed twice a day for injury and recorded in the nursing observation form. In order to accelerate wound healing in the injured tissue, the injured area was cleaned by wiping with saline solution, and then a hydrocolloid dressing was applied. It was thought that the patient had been taking cortisone therapy for a long time, which causes the expected recovery time to prolong. On the fifth day after wound care started, the wound's hyperemic appearance was removed, and wound healing was observed.

After the patient's data were systematically evaluated in line with GFHP, nursing diagnoses per NANDA were determined. Nursing interventions were applied in line with the NIC, primarily by determining the diagnoses of "hyperthermia, risk of fluid volume imbalance, deterioration of skin integrity, deterioration in gas exchange, [and] risk of infection transmission.” As a result, most of the patient's care problems were resolved with the nursing care given to the patient in line with the GFHP.

¹Associate Professor, Yuksek Ihtisas University, Faculty of Health Sciences, Fundamentals of Nursing, Ankara, Turkey

²PhD Student, Karadeniz Technical University, Turkey

Demet Bal; Research Assistant; Karadeniz Technical University: Karadeniz Teknik Universitesi; Nursing Üniversite Mah. Farabi Cad. No:88; Trabzon, Ortahisar 61080; Turkey; +905312650224; demetk@windowslive.com

1. VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008-2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage. 2009;55(11):39-45.

2. Galetto SG da S, Nascimento ERP do, Hermida PMV, Malfussi LBH de. Medical Device-Related Pressure Injuries: an integrative literature review. Rev Bras Enferm. 2019;72(2):505-512. doi:10.1590/0034-7167-2018-0530

3. Young M. Medical device-related pressure ulcers: a clear case of iatrogenic harm. Br J Nurs Mark Allen Publ. 2018;27(15):S6-S13. doi:10.12968/bjon.2018.27.15.S6

4. Erbay Dalli O, Ceylan İ, Kelebek Girgin N. A Neglected Area: Medical Device Related Pressure Injuries. Turk Klin J Anesthesiol Reanim. 2019;17. doi:10.5336/anesthe.2019-71429

5. Jackson D, Sarki AM, Betteridge R, Brooke J. Medical device-related pressure ulcers: A systematic review and meta-analysis. Int J Nurs Stud. 2019;92:109-120. doi:10.1016/j.ijnurstu.2019.02.006

6. Owens L, Stamps H. Eliminating Medical Device-Related Pressure Injury From Blood Pressure Cuffs During Continuous Monitoring in the Perioperative Setting: A Novel Approach. J Perianesthesia Nurs Off J Am Soc PeriAnesthesia Nurses. 2018;33(4):444-447. doi:10.1016/j.jopan.2016.12.007

7. Tayyib N, Asiri MY, Danic S, et al. The Effectiveness of the SKINCARE Bundle in Preventing Medical-Device Related Pressure Injuries in Critical Care Units: A Clinical Trial. Adv Skin Wound Care. 2021;34(2):75-80. doi:10.1097/01.ASW.0000725184.13678.80

8. Brophy S, Moore Z, Patton D, O’Connor T, Avsar P. What is the incidence of medical device-related pressure injuries in adults within the acute hospital setting? A systematic review. J Tissue Viability. 2021;30(4):489-498. doi:10.1016/j.jtv.2021.03.002

9. Barakat-Johnson M, Barnett C, Wand T, White K. Medical device-related pressure injuries: An exploratory descriptive study in an acute tertiary hospital in Australia. J Tissue Viability. 2017;26(4):246-253. doi:10.1016/j.jtv.2017.09.008

10. Jackson D, Sarki AM, Betteridge R, Brooke J. Medical device-related pressure ulcers: A systematic review and meta-analysis. Int J Nurs Stud. 2019;92:109-120. doi:10.1016/j.ijnurstu.2019.02.006Coyer FM, Stotts NA, Blackman VS. A prospective window into medical device-related pressure ulcers in intensive care. Article in Swedish (Sweden). Int Wound J. 2014;11(6):656-664. doi:10.1111/iwj.12026

11. Kim JY, Lee YJ, Korean Association of Wound Ostomy Continence Nurses. Medical device-related pressure ulcer (MDRPU) in acute care hospitals and its perceived importance and prevention performance by clinical nurses. Int Wound J. 2019;16 Suppl 1:51-61. doi:10.1111/iwj.1302

12. European Pressure Ulcer Advisory Panel. Accessed May 15, 2022. Retrieved from: https://www.epuap.org/pu-guidelines/

13. Rashvand F, Shamekhi L, Rafiei H, Nosrataghaei M. Incidence and risk factors for medical device‐related pressure ulcers: The first report in this regard in Iran. Int Wound J. 2019;17(2):436-442. doi:10.1111/iwj.13290

14. Kayser SA, VanGilder CA, Ayello EA, Lachenbruch C. Prevalence and Analysis of Medical Device-Related Pressure Injuries: Results from the International Pressure Ulcer Prevalence Survey. Adv Skin Wound Care. 2018;31(6):276-285. doi:10.1097/01.ASW.0000532475.11971.aa

15. National Pressure Ulcer Advisory Panel. Accessed June 26, 2022. Retrieved from: https://www.npuap.org/resources/educationaland-clinical-resources/npuappressure-injury-stages/.

16. Avşar, Pınar K Ayişe. Turkish Adaptation and ValidityReliability Study of the Waterlow Pressure Ulcer Risk Assessment Scale. J Hacet Univ Fac Nurs. 2016;3(3):1-15.

17. Mallah Z, Nassar N, Kurdahi Badr L. The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: controlled before and after study. Appl Nurs Res ANR. 2015;28(2):106-113. doi:10.1016/j.apnr.2014.07.001

18. Pereira CDFD, Tourinho FSV, Ribeiro JLS, Medeiros SBM, Santos VEP. Functional health patterns: nursing diagnoses in public school-aged children and adolescents. Article in Portuguese (Brazil). Text Context Nursing, Florianopolis. Out-Dez 2013;22(4):1056-1063.

19. Carpenito-Moyet LJ. Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems. 5th ed. Lippincott Williams and Wilkins. 2008:814.

20. Staub-Müler M. Evaluation of the implementation of nursing diagnosis, interventions and outcomes. International Journal of Nursing Terminologies and Classification. 2009;20(1):9-15. doi: 10.1111/j.1744-618X.2008.01108.x.

21. Craven RF, Hirnle CJ. Fundamentals of nursing: human health and function. In: Henshawa CM. Fundamentals of Nursing: Human Health and Function. 7th ed. Wolter Kluwer Health/Lippincott. 2020:12-16.

22. Taylor C, Lillis C. Lemone P. Nursing process: foundation for practice. In: Lillis C. Fundamentals of Nursing: The Art &Science of Nursing Care. 4th ed. Philadelphia: Lippincott. 2001:189-198.

23. White L. Documentation & The Nursing Process. 1st ed. Delmar Cengage Learning. 2002:2-13.

24. Delmore BA, Ayello EA. CE: Pressure Injuries Caused by Medical Devices and Other Objects: A Clinical Update. Am J Nurs. 2017;117(12):36-45. doi:10.1097/01.NAJ.0000527460.93222.31

25. Haesler E. Evidence Summary: Pressure Injuries: Preventing medical device related pressure injuries. Wound Pract Res. 2017;25(4):214-216.