Improving pressure ulcer care in intensive care units: Evaluating the impact of bundled care and silver nanoparticle dressings

Table 1 Bundled care in the management of pressure ulcers in critically Ill adults in intensive care units

Bundled care	Contents
1. Multidisciplinary collaboration	Ensure collaboration among healthcare professionals, including physicians, nurses, physical therapists, dietitians, and other specialists, to develop and execute a comprehensive care plan
	Hold regular interdisciplinary meetings to share information, coordinate treatment measures, and provide a unified approach to care
	Nurses conducts a thorough skin inspection during each shift and recording relevant information
2. Assessment	Conduct a thorough pressure ulcer assessment, including a detailed description of the wound's depth, size, shape, edge condition, and characteristics of the wound base
	Evaluate the skin surrounding the wound for signs of inflammation, redness, or swelling
3. Wound cleansing	Use a gentle saline solution or specialized wound cleansing solution to clean the wound with gauze or sterile cotton balls, avoiding the introduction of new bacteria
	Remove necrotic tissue, exudate, and debris to ensure a clean wound surface
4. Maintain moisture	Use the dressing to maintain a moist wound environment, which accelerates healing and supports new tissue growth
	Change the dressing as needed, typically when the dressing changes color from dark green to light green, indicating over 70% of the silver has been released
5. Nutritional support	Dietitians closely monitor the nutritional status of patients and design high-protein dietary plans to support wound healing
	Ensure the patient receives adequate protein and vitamin intake to support wound healing
	Provide oral nutritional supplements or enteral nutrition support through a feeding tube, depending on the patient's oral intake capacity
6. Pain management	Offer effective pain management, including medication, to alleviate wound discomfort
	Use non-pharmacological methods such as heat therapy, cold compresses, or relaxation techniques to reduce discomfort and pain
7. Prevent further deterioration	Ensure regular patient repositioning t least every 2 hours to prevent prolonged pressure on the same area
	Use specialized mattresses, cushions, and care pads to reduce pressure and provide appropriate support
8. Education	Provide comprehensive education to both the patient and family members, including wound monitoring, recognizing signs of infection, and proper wound care methods
	Emphasize the importance of pressure ulcer prevention, including pressure distribution and turning techniques
9. Data monitoring	Continuously monitor wound progress and any changes, documenting observations
	Reassess the pressure ulcer's status regularly to track healing progress

Table 2 Assigning scores to parameters in the pressure ulcer scale for healing tool

Parameter	Description	Score
Surface area	Determined by multiplying the greatest length by the greatest width	0-10
	0 cm²	0
	< 0.3 cm²	1
	0.3-0.6 cm²	2
	0.7-1.0 cm²	3
	1.1-2.0 cm²	4
	2.1-3.0 cm²	5
	3.1-4.0 cm²	6
	4.1-8.0 cm²	7
	8.1-12.0 cm²	8
	12.1-24.0 cm²	9
	> 24.0 cm²	10
Exudate (drainage)	Assessed at dressing removal before applying a topical agent	0-3
	None	0
	Light	1
	Moderate	2
	Heavy	3
Tissue type		0-4
Closed/resurfaced	The wound is completely covered with epithelium/new skin	0
Epithelial tissue	New pink or shiny tissue/skin growing in from the edges or as islands on the ulcer surface (for superficial ulcers)	1
Granulation tissue	Pink or beefy red tissue with a shiny, moist, granular appearance	2
Slough	Yellow or white tissue adhering to the ulcer bed in strings or thick clumps, or is mucinous	3
Necrotic tissue/eschar	Black, brown, or tan tissue adhering firmly to the wound bed or ulcer edges, may be firmer or softer than surrounding skin	4
Total PUSH score	Obtained by summing the scores for the above three parameters	0-17

PUSH: Pressure ulcer scale for healing.

Table 3 Baseline characteristics of control and intervention groups

	Total (n = 98)	Control group (n = 49)	Intervention group (n = 49)	P value
Age (yr)		54 (35.5-68.5)	52 (36.5-69.5)	0.881
Gender
Male	61	29	32
Female	37	20	17	0.677
Stage
Stage I	38	20	18
Stage II	39	21	18
Stage III	12	6	6
Stage IV	2	1	1
Unstageable	7	1	6	0.419
Location
Coccyx	36	20	16
Buttocks	14	8	6
Trochanter	10	5	5
Scapila	8	4	4
Malleolus	8	4	4
Head	5	3	2
Heel	7	3	4
Elbow	10	2	8	0.700
Comorbid conditions
Sepsis	45	24	21	0.685
Myocardial infarction	1	1	0	1.000
Congestive heart failure	29	16	13	0.659
Cerebral vascular disease	2	0	2	0.495
Chronic pulmonary disease	14	8	6	0.774
Diabetes with complication	4	2	2	1.000
Diabetes without complications	20	9	11	0.803
Total braden at ICU admit		14 (10-20)	13 (10.5-18.5)	0.565

ICU: Intensive care unit.

Table 4 Comparison of pressure ulcer scale for healing score before and after intervention in two groups

Time points	Control group (n = 49)				Intervention group (n = 49)
	Surface area	Exudate (drainage)	Tissue type	Total scores	Surface area	Exudate (drainage)	Tissue type	Total scores
Day 0	7 (4-9)	1 (0-2)	2 (1-2)	9 (5-13)	6 (3-8)	1 (0-2)	1 (1-2)	10 (5-11.5)
Day 3	7 (4-8.5)a	1 (0-2)	1 (1-2)	9 (5-12.5)a	5 (3-7.5)a	1 (0-1)a	1 (1-2)a	8 (4-10.5)a
Day 6	7 (4-8)a	1 (0-2)a	1 (1-2)	9 (5-12)a,b	5 (2.5-7)a,b	1 (0-1)a,b	1 (1-2)a	8 (4-9.5)a,b
Day 9	7 (4-8)a	1 (0-2)a	1 (1-2)a	9 (5-12)a,b	4 (2-6)a,b,c	1 (0-1)a,b	1 (1-2)a	6 (3-9)a,b,c
Day 12	7 (4-8)a	1 (0-2)a	1 (1-2)a	9 (5-12)a,b,c	4 (2-6)a,b,c,d	0 (0-1)a,b,c	1 (1-2)a,b,c,d	6 (3-8)a,b,c,d

^aSignificant differences compared to day 0.

^bDenote significant differences compared to day 3.

^cSignificant differences compared to day 6.

^dSignify significant differences compared to day 9.