Download preventing pressure ulcers

PREVENTING
PRESSURE ULCERS
Contents
Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Risk Assessment Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Braden Scale for Predicting
Pressure Sore Risk© . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Norton Plus Scale . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Practical Applications of the Assessment Tools . . . . . . . 9
Friction and Shear . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Pressure Reduction/Prevention
versus Pressure Relief . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Prevention Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Therapeutic Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Support Surface Selection Guide . . . . . . . . . . . . . . . . . 27
Off-Loading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Positioning Measures . . . . . . . . . . . . . . . . . . . . . . . . . . 32
The Seated Dependent Patient . . . . . . . . . . . . . . . . . . . 32
Operating Room Pressure Ulcer Prevention . . . . . . . . 32
Pressure Ulcer Risk - Common Pressure Points . . . . . . 35
1
Risk Assessment
Prevention of pressure ulcers begins with a complete and
thorough assessment. Conditions such as diabetes and
hypertension can be key factors in the development of
pressure ulcers. A patient’s medications and particular
lab values should also be evaluated. Understanding the
factors will help you identify potential risks before a
pressure ulcer can develop.
Make sure to communicate and document the risk assessment
score for all of your patients and design a plan of care (POC)
to address individual needs. Allow for plan adjustments
because circumstances can always change. Most importantly,
embrace this valuable opportunity to help improve the
physical condition and safety of all your patients.
Risk Assessment Tools
Risk assessment tools can help you identify patients at risk of
developing pressure ulcers and improve care. The Braden Scale
for Predicting Pressure Sore Risk and the Norton Plus Risk
Assessment Scale contain subscales to help you identify the
areas of greatest risk. Patients are scored on the subscales,
which include sensory perception, moisture, activity,
mobility, nutrition and friction/shear.
The Braden Scale for Predicting Pressure Sore Risk
The Braden Scale was developed by Barbara Braden and Nancy
Bergstrom in 1988 as a method for consistently identifying
pressure ulcer risk. The scale is still widely used today.
Each subscale is rated numerically, tallied and recorded.
The risk score can range from a low of 6 to a high of 23.
Lower scores signify greater risk:
Mild risk =
Moderate risk =
High risk =
Very high risk =
15 to 18
13 to 14
10 to 12
<9
2
Sensory Perception
Sensory perception refers to the ability to meaningfully
respond to pressure-related discomfort. Patients unable to
feel pain or discomfort are at greater risk for pressure ulcers. In
these cases, consider using pressure-reducing devices containing air, foam or gel on patients’ beds, chairs and other surfaces.
Moisture
Exposure to moisture from perspiration, urine, stool, wound
drainage or leaking tubes can lead to skin breakdown. If a
patient is incontinent, be sure to cleanse their skin at the time
of soiling using a product designed to remove urine, stool and
other contaminants. Avoid soaps and harsh chemicals, which
can cause dryness and affect the skin’s pH balance.
Make sure the skin remains protected by applying a moisture
barrier after the skin is cleansed. Consider using disposable
containment devices made with special features such as
polymers, which have been shown to dry faster and hold
more liquid.
One clinician used
pictures of puppies
with different
colored collars as
bedside reminders
(PUP = Pressure
Ulcer Prevention).
Blue collars were
for high risk, orange
for damaged skin,
red for antifungal
treatment and
green for when
there is little risk
of developing a
pressure ulcer.
3
Activity
The patients activity level affects their chances of developing
pressure ulcers. The less active a patient is, the more protection
he or she needs from pressure, friction and shear.
Mobility
Immobility leads to unrelieved pressure, which results in
decreased blood supply to tissue. That is why immobile
patients need to be repositioned frequently, usually at least
every two hours. It is helpful to post a turning schedule to
remind staff. One clinician used pictures of puppies with
different colored collars as bedside reminders (PUP = Pressure
Ulcer Prevention). Blue collars were for high risk, orange for
damaged skin, red for antifungal treatment and green for
when there is little risk of developing a pressure ulcer.
Place patients on their side at a 30 degree angle (or less)
to avoid direct pressure on the hip bone and, whenever
possible, keep the head of the bed positioned below 30
degrees (to relieve pressure on the tail bone and help prevent
shear). Pillows, wedges and other devices can either cause or
relieve pressure. When placed between bony areas like the
knees and ankles, they help reduce pressure. But when placed
under the heels, they can be a pressure source. Accordingly,
be sure that they are under the legs if the goal is to relieve
heel pressure.
Nutrition
Nutrition refers to a patient’s standard food intake.
Encourage patients to eat and be sure to record the
amount of food eaten at each meal. Help to cut the
patient’s food, open containers, make sure food trays
are within reach and offer assistance when needed.
Consider whether nutritional supplements are required to
help patients meet their caloric and nutrient needs, or if
tube feeding or intravenous methods are necessary.
Consult a dietitian if you have any questions.
Friction and Shear
Friction is tissue damage that occurs when skin slides on a
surface. Shear is deep tissue injury that occurs when skin
sticks to a surface and the small blood vessels tear.
To prevent friction and shear, use appropriate lifting devices
to move patients. You can use a trapeze if they have upper
body strength to help with movement (remind the patient
to bend their knees to prevent sliding). Use skin lubricants,
a liquid skin barrier or powder to protect the skin when
patients are moved. Lubricants should particularly be
used on heels, buttocks, elbows and shoulder blades.
4
An example of the Braden Scale For Predicting Pressure
Sore Risk is shown below.
© Copyright Barbara Braden and Nancy Bergstrom, 1988.
All rights reserved. Reprinted with permission.
5
The Norton Plus Scale
The Norton and Norton Plus Scales were developed by Doreen
Norton, Rhoda McLaren and A.N. Exton-Smith as tools to
determine risk of pressure ulcers. The 1960 original and
modified versions are widely used today.
The Norton Plus Pressure Ulcer Scale has two sections.
Section One — Score/Description
Section one of the scale rates physical condition, mental state,
activity level, patient mobility and incontinence using a scale
of one to four. Total scores range from five to 20; the lower
the score, the higher the risk of pressure-related breakdown.
This number is tallied and recorded.
Physical Condition
A patient’s physical condition will obviously impact the
risk for developing a pressure ulcer. Patients in good
physical health who are able to move around and
reposition in bed or in a chair will usually have a lower risk
for pressure ulcers.
Mental State
How is the patient’s mental state? Is he or she alert,
apathetic or confused? The patient’s mental state may
determine how well the patient can take care of him
or herself.
Activity
The patients activity level affects their chances of
developing pressure ulcers. The less active a patient is,
the more protection he or she needs from
pressure, friction and shear.
Mobility
Does the patient have full or limited mobility? As we
know, immobility leads to unrelieved pressure, which
results in decreased blood supply to tissue. Immobile
patients need to be repositioned frequently, usually
at least every two hours.
6
Incontinence
Moisture from urine or stool can lead to skin breakdown.
If a patient suffers from incontinence, be sure to cleanse
their skin when it is soiled. Avoid soaps and harsh
chemicals, which can cause dryness and affect the
skin’s pH balance.
Make sure the skin remains protected by applying a
moisture barrier after the skin is cleansed. Consider using
disposable containment devices made with special features
like polymers, which have been shown to dry faster and
hold the liquid away from the skin.
Section Two — Deductions
Section two of the scale rates the diagnosis of diabetes,
hypertension, hematocrit, hemoglobin, albumin level,
febrile >99.6, five or more medications, and changes in
mental status to confused or lethargic within 24 hours.
If any of these are present, a check mark is added to the
Norton Plus Scale. These entries are thought to affect wound
healing and must be considered in the overall plan of care.
The total is determinined as follows:
Total Norton Scale
- Total Number of Check Marks
= Total Norton Plus Score
No to low risk = 16 to 20
Moderate risk = 13 to 15
High risk = 5 to 12
7
A sample of the Norton Plus Pressure Ulcer Scale is shown below.
Worth
remembering ...
Total Norton Scale
- Total Number of
Check Marks
= Total Norton
Plus Score
8
Practical Applications of the Assessment Tools
It is important to note that when completing either of these
tools, the score is dependent upon the clinician’s knowledge
of the patient. If a poor history is taken, the information
gleaned from the tool will not be accurate. A solution to
this is to not just consider the score but to consider the
patient independent of the score. The prevention program
should always be at a higher level. There is never a problem
with implementing too much prevention programming.
The purpose of the following exercise is to read the
scenarios, based on the information provided, and review
the suggetsed Braden and Norton Plus Scales to test your skills.
You can also use these scenarios with other staff members to
help them improve their skills in predicting pressure ulcer risk.
Exercise #1
Jackson is a 37-year-old male who was in a motor vehicle
accident. He fractured his left femur and sustained injuries
to his L3 and L4 vertebrae, resulting in paraplegia. Following
surgery, a cast was placed on his body up to the groin. He
also sustained bilateral hip fractures with pins and an
abductor pillow in place. Jackson has a Foley catheter and
is incontinent of bowel. He is on a low air loss, alternating
air, turning mattress replacement. His medications include
antihypertensive, vitamins, pain medication and stool
softeners. Jackson is oriented times 3 and can actively
verbalize his needs. He is on IV fluids and a clear liquid
diet. He is depressed and concerned regarding his job
and the ability to care for his family.
He has a past medical history of hypertension, which
was controlled with Norvasc®. He had a recent planned
50-pound weight loss. Prior to his injury, he exercised
three times a week with cardio and weights. He is an
executive with a sales company.
Jackson is often diaphoretic and complains of body
temperature fluctuations from feeling hot to feeling cold.
His hematocrit is WNL, hemoglobin is WNL, and albumin
is 3.3 g/dL.
9
See below for suggestions on completing the Braden and
Norton Plus Scales
Braden Scale For Predicting Pressure Sore Risk
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
=2
=1
=1
=2
=1
=1
Very limited
Constantly moist
Needs assistance
Very limited
Very Poor
Potential problem
Total Braden Scale
Level of Risk
=8
= Severe Risk
10
11
Norton Plus Pressure Ulcer Scale
Physical Condition
Mental State
Activity
Mobility
Incontinence
=3
=4
=1
=1
=1
Diagnosis of Diabetes
= No
Diagnosis of HTN
= Yes
Hematocrit
= WNL
Hemoglobin
= WNL
Albumin Level
= Yes
Febrile
= Yes/No
Five (or more) Medications
= No
Changes in Mental Status
= No
(to confused or lethargic within 24 hours)
Total Norton Score
= 10
Total Number of Check Marks
Total Norton Plus Score
Level of Risk
√
√
√
= 3
= 7
= High Risk
Exercise #1: Suggested Protocol for “Jackson”
Jackson is currently wound free and has no skin breakdown.
A physical or occupational therapist should be consulted to
evaluate his upper body strength, endurance and ambulatory
skills, as well as for appropriate wheelchair and seat cushion
placement. Jackson should be educated on transferring using
a slide board, repositioning and weight-shifting utilizing
adjunctive devices, which could also include a special watch
that would supply a timer with short intervals. The registered
dietician will evaluate Jackson so that when he progresses
from clear liquids; his preferences are addressed, including
the importance of fluid and fiber intake. Bowel care for
this level of injury includes adequate fluid intake and
a diet rich in fiber. Defecation is stimulated by deliberately
increasing abdominal pressure. Bladder care includes
indwelling catheterization or intermittent catheterization
depending upon physical, mental and emotional recovery.
Preventive protocols must be in place to help lower
the chance of urinary tract infections (UTIs).
12
Exercise #2
Mabel lives alone but has been cared for by her daughter for
the last 15 years. She depends on her daughter for assistance
with all activities of daily living (ADLs). Until now, Mabel has
been alone at night and has not posed a safety risk to herself.
With her Alzheimer’s progressing and “Sundowner Syndrome”
increasing, Mabel requires more care and supervision. As
a result, her daughter is looking into alternative living
arrangements.
Mabel walks slowly and deliberately with a walker. Once in
bed, however, she has significant upper body weakness and
is unable to reposition herself.
Mabel eats 100 percent of three meals per day but requires
significant prompting and frequent hands-on assistance. Each
meal often lasts two hours. She has been about five pounds
under her ideal body weight for the last 15 years. Her daughter
encourages her to drink 32 ounces of fluid throughout the day
in addition to the fluid provided with her meals. Mabel is not
on any fluid restriction. She drinks this additional fluid with
much prompting. Her skin is warm and dry and appears well
hydrated, with minimal dry skin.
She takes a multiple vitamin with minerals, Darvocet N®-100
PRN for pain, and 100 mcg of Levoxyl® per day. Her vital signs
are within normal limits. She is alert but confused as to the
time, date and place. Mabel’s past memory recall is fair. Her
daughter toilets her in advance of need, therefore she remains
dry during the day. Mabel is incontinent of urine and stool at
night, and wears a brief liner and mesh pants. If it was not for
the prompted voiding, Mabel would be incontinent of both
urine and stool.
Her hematocrit is 44 percent, hemoglobin is 16 g/dL, and
albumin is 4.1 g/dL.
Complete the Braden and Norton Plus Scales for our patient,
“Mabel,” and see the following pages for completed versions.
13
Braden Scale For Predicting Pressure Sore Risk
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
=2
=1
=3
=2
=2
=2
Very limited
Constantly moist
Needs assistance
Very limited
Adequate
Potential problem
Total Braden Scale
Level of Risk
= 12
= High Risk
14
15
Norton Plus Pressure Ulcer Scale
Physical Condition
Mental State
Activity
Mobility
Incontinence
=3
=2
=3
=3
=1
Diagnosis of Diabetes
= No
Diagnosis of HTN*
= No
Hematocrit
= WNL**
Hemoglobin
= WNL
Albumin Level
= WNL
Febrile
= No
Five (or more) Medications
= No
Changes in Mental Status
= No
(to confused or lethargic within 24 hours)
*hypertension (HTN)
**within normal limits (WNL)
Total Norton Score
Total Number of Check Marks
Total Norton Plus Score
Level of Risk
= 12
= None
= 12
= High Risk
Exercise #2: Suggested Protocol for “Mabel”
Mabel currently has no wound or skin issues. A physical or
occupational therapist should be consulted to evaluate her
upper body strength, endurance and ambulatory skills. She
should be in a feeding program that provides for maximal
prompting and assistance when necessary. A registered
dietician should evaluate Mabel regarding between-meal
snacks or nutritional supplements to help her gain weight.
Mabel may be an ideal candidate for a bowel and bladder
program, but she must be thoroughly evaluated. Due to
her cognitive function, it may be determined that therapy
will be of no benefit based on her medical diagnosis. Enroll
the patient in a therapeutic activity such as program cards,
crafts and music depending upon her ability. She should be
placed on an appropriate support surface, such as a
pressure reduction mattress replacement.
16
Exercise #3
Robert is a 40-year-old male who presented to the ER with
acute appendicitis. He is a general contractor and maintains a
very active lifestyle. Surgery was performed on an emergency
basis without surgical complications. Post-op, the patient was
admitted to a medical floor for observation. The patient was
alert and oriented x 3. On a soft, well-tolerated diet, he ate 100
percent of each meal. He was continent of bowel and bladder,
initially was on bed rest and utilized a urinal and bed pan. The
patient was instructed to use an incentive spirometer three
times a day (TID). The patient complained of surgical site pain
with guarding. He utilized a pillow to the lower abdominal
area to cough and breathe deeply. Within 12 hours of surgery
he was ambulating with one assist. He was able to reposition
in the bed without assistance slowly but required prompting.
Medications include Percocet® every 4 hours for pain and a
stool softener.
The patient’s past medical history is negative.
His hematocrit, hemoglobin, and albumin were all WNL.
Complete the Braden and Norton Plus Scales for our patient,
“Robert,” and see the following pages for completed versions.
17
Braden Scale For Predicting Pressure Sore Risk
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
=4
=4
=3
=4
=4
=3
No impairment
Rarely moist
Walks occasionally
No limitations
Excellent
No apparent problem
Total Braden Scale
Level of Risk
= 22
= Little or No Risk
18
19
Norton Plus Pressure Ulcer Scale
Physical Condition
Mental State
Activity
Mobility
Incontinence
=4
=4
=3
=4
=4
Diagnosis of Diabetes
= No
Diagnosis of HTN
= No
Hematocrit
= WNL
Hemoglobin
= WNL
Albumin Level
= WNL
Febrile
= No
Five (or more) Medications
= No
Changes in Mental Status
= No
(to confused or lethargic within 24 hours)
Total Norton Score
Total Number of Check Marks
Total Norton Plus Score
Level of Risk
= 19
= 0
= 19
= None
Exercise #3: Suggested Protocol for “Robert”
According to both the Braden and Norton Plus Scale,
Robert is not at risk for the development of pressure ulcers
or other skin breakdown. Prior to the episode with acute
appendicitis he had no health concerns. Due to Robert
initially requiring prompting with repositioning and his
need to guard the surgical site with a pillow during
coughing, deep breathing and repositioning, the staff
made the decision to put him on a pressure reduction
mattress replacement to ensure optimal skin integrity.
20
Friction and Shear
Two forces that lead to skin breakdown are friction and shear.
Friction injuries occur when the skin moves across a coarse
surface such as bed linen. Most friction injuries can be avoided
by using appropriate techniques when moving patients, so
that their skin is never dragged across the linen. Voluntary and
involuntary movement by an individual can lead to friction
injuries, especially to elbows and heels. Shear injury occurs
when the skin remains stationary and the underlying tissue
shifts; the shift diminishes blood supply to the skin and soon
results in ischemia and tissue damage. Most shear injuries can
be eliminated by proper positioning.
As a rule, skin injury due to friction and shear forces should be
minimized through proper positioning, transferring and turning techniques. When needed, friction injuries may be reduced
by the use of lubricants, protective films, protective dressings
and protective padding.
Pressure Reduction/Prevention
versus Pressure Relief
TIPS!
Think of pressure
“reduction”
surfaces in terms
of prevention, and
think of pressure
“relief” surfaces in
terms of patients
who already have
a pressure ulcer.
21
Support surfaces can affect five extrinsic risk factors that
can be detrimental to the skin and soft tissue: pressure, shear,
friction, heat and moisture. “Pressure relief” and
“pressure reduction” have described many therapies, but
most recently the terms are used to represent the difference
between a therapeutic support surface and preventive surface.
The National Pressure Ulcer Advisory Panel (NPUAP) released
the final version of support surface terms and definitions in
August 2006 as part of their Support Surface Standards Initiative. This document clarifies the terms closely associated with
pressure, skin and support surfaces. The most important thing
for you to remember is that there is a new phrase to replace
pressure reduction and pressure relief: pressure redistribution. We all know that pressure is defined as “the force
exerted over an area.” To reduce pressure, you can spread
the pressure over a larger area or move the pressure
completely to another part of the body.
Suggestions for decreasing pressure are:
•
•
•
•
•
•
•
•
Bed-restricted patients should be repositioned
systematically; the standard is every 2 hours. A written
schedule for turning and repositioning may be helpful
to prompt the caregiver.
Positioning devices should be used to protect bony
prominences from direct contact with one another.
For example, you can provide heel pressure relief by
placing a pillow under the calf to keep weight off of
the heels. Avoid positioning patients directly on the
trochanter when in the side-lying position.
Position the head of bed at the lowest degree of
elevation consistent with medical conditions and
other restrictions. Also, the amount of time the head
of the bed is elevated should be limited.
Use lift sheets or devices to move patients in bed to
avoid dragging the skin over bed linens.
Chair-bound patients should avoid uninterrupted
sitting and should be repositioned to shift points that
are under pressure at least every hour. Alternatively,
they can be placed back in bed if it is consistent with
the overall patient care goals.
If patients are able they should be taught to shift
their weight every 15 minutes.
Pressure reducing devices for chairs that are high
density foam, air or gel should be utilized.
Do not use donut-type devices.
Prevention Devices
DID YOU KNOW
Pressure-reducing
surfaces are for
the treatment of
partial thickness
wounds and
stage I and II
pressure ulcers.
Prevention devices, also called pressure-reducing support
surfaces, are intended to be used for the treatment of partial
thickness wounds through stage II pressure ulcers, as well as
for prevention. They can be used for comfort and pain management. The historical term, “pressure-reducing,” refers to
decreasing the interface pressure to less than a regular hospital
mattress, but not below 32 mmHg.
There are two types of prevention devices. The first is an
overlay. Mattress overlays are placed on top of an existing
mattress. They can be filled with air (either powered by
electricity or filled with static air), foam, gel, water or a
combination thereof. Consider some of the advantages
and disadvantages of an overlay:
22
Type of
overlay
Air filled
Advantages
•
•
Disadvantages
Durability
Ease of repair and
cleaning
Lightweight
The ability to adjust
the air with certain
types of “zoned”
products
•
•
•
•
•
Cost-effective
Lightweight and
portable
Low-maintenance
Able to customize
Gel filled
•
•
•
Minimal maintenance
Multiple patient use
Easy-to-clean
•
•
•
Can be expensive
Heavy
Lack of air flow, which
can contribute to
perspiration
Water filled
•
•
•
Commonly available
Easy-to-clean
Significantly lower
pressure than a regular
mattress
Can maintain temperature with appropriate
heating
•
•
Heavy
Unable to raise the
head of the bed
Can produce
“hammocking” of
the bed
If lacking a heater, the
water may become
too cold
Potential for puncture
•
•
Foam filled
•
•
•
•
•
•
•
•
•
•
Need for electricity
(if powered)
Potential for puncture
Continuous monitoring is required to ensure proper inflation
Limited life span
Disposal concerns
(recycle?)
Patient weight limit
Single patient use
The other type of prevention device is a mattress replacement.
Most are made of high quality foam or other material and actually replace the inner-spring mattress directly on the bed
frame. They provide pressure reduction that is not available
with a standard hospital mattress.
23
When evaluating foam mattresses several factors are important.
1.
The base height of the mattress should be at least
five inches.
2.
The density of the foam, which is the ability of the
foam to support the patient’s weight, should be
approximately 1.5 pounds per cubic foot.
3.
The ability of the foam to conform to or redistribute
the body’s weight is called the indentation load
deflection (IDL). The IDL measures the amount
of pressure required to decrease the foam by 25
percent, for instance, from 5 inches to 3.75 inches.
The recommended IDL is between 25 and 35 pounds.
Mattress replacements are covered with a durable, waterproof
covering that is often bacteriostatic. You should always consult
the manufacturer’s guidelines in regard to the maximum
weight that can be placed on the surface. Consider bariatric
surfaces, if appropriate. The manufacturer will also have a warranty that covers the life of the mattress replacement. Be sure
to understand the requirements regarding weight limits and
proper care. Often a mattress replacement needs to be turned
and rotated at specific intervals while other mattresses should
not be turned at all, depending upon their construction.
Type of
surface
Mattress
Replacement
Advantages
•
•
Low maintenance
Multiple patient use
Disadvantages
•
•
•
High initial expense
Life expectancy of
the product
Disposal concerns
(recycle?)
Understand that replacing the support surfaces for an entire
facility can be a major capital expense; consequently, many
facilities choose to replace them over time. Some facilities
replace all their mattresses with preventive mattress replacements, offering all patients prevention from the time of admission. This can help prevent problems before they occur.
24
Therapeutic Devices
Beyond prevention, the next step in support surfaces is the
therapeutic device category. Formerly termed “pressurerelieving,” these surfaces are utilized to redistribute pressure
or reduce pressure against the skin and soft tissue. Even
though this number is not finite, 32 mmHg has been used
as the average of all capillary closing pressures. The original
study was determined using healthy male volunteers. Of
course, the actual number of patients who experience
capillary closing will vary.
These surfaces may be used on patients with full thickness
wounds, burns, and pressure ulcers through stage IV, including
muscle-skin grafts and flaps. They are often used to regulate
moisture and heat in cases of low air-loss support surfaces.
This category includes mattress overlays, mattress replacements and full-bed systems. The therapeutic surfaces can also
be further categorized as nonpowered (static); various types of
powered; low air-loss; air-fluidized or high air-loss; alternating
pressure; lateral rotation (kinetic); and hybrid systems that
offer a combination of at least two of these categories.
Bariatric versions of these surfaces are also available.
Nonpowered Systems
Nonpowered systems are made of either air or gel-filled overlays or mattresses. They do not require electricity and are often
a good alternative for patients with therapeutic needs and
budget restraints. Air-filled static devices may offer zoned
and adjustable surfaces that meet the needs of the patient.
This “zoned” approach decreases the chance of bottoming
out, which is commonly seen with the single, air-filled
bladder devices that are usually intended for prevention.
Powered Systems
Powered systems include the following:
Low Air-Loss Systems – These systems are designed to allow
air to flow across the entire surface around the patient,
thus helping to improve moisture and temperature control.
A pump supplies a predetermined amount of air to flow
throughout the multiple bladders to produce the low air-loss
affect. Often, the pump can be adjusted as the patient requires
25
more or less air flow. These surfaces can either be overlays,
mattress replacements or entire bed systems.
Air Fluidized (High Air-Loss) Systems – Filtered air is circulated
through silicone-coated beads, creating the effect of fluid,
allowing the patient to “float” on the surface. Approximately
one - third of the patient’s body is actually above the surface
and the remainder is immersed in the bed. Air fluidized
surfaces are used to treat patients with burns, full thickness
wounds and pressure ulcers through stage IV, severe pain
control and to treat hypothermia. Caution should be taken
when treating patients with pulmonary disease or unstable
spinal conditions. The choice of topical dressings must be
considered because these beds have a drying effect. If not
properly addressed, they can desiccate the wound bed. Some
of the disadvantages of this bed are that it is very heavy and
it may make the entire room warm. Because of the frame of
the bed, there is a weight or size issue and alternatives must
be arranged for the obese patient. Nursing care of the patient
may be difficult due to the height of the bed (usually caregivers use a step), patient transfer may be impossible, and
since the head of the bed cannot be raised, foams or other
devices are used to achieve position changes.
Alternating Pressure – Alternating pressure surfaces are surfaces
that cycle air to prevent constant pressure against the skin by
creating both low and high pressure areas. These are dynamic
systems of both pumps and blowers that cycle air at regular
intervals to provide deflation and inflation. The pressure
points are constantly changing and create gradients that are
thought to enhance blood flow. The combination of the air
chamber height, the air flow (including both amount and
frequency), and the proximity of the chambers to each other
all contribute to effective pressure reduction.
Lateral Rotation (Kinetic) – These surfaces are specifically
designed for the immobile patient to provide passive motion,
usually rotating from side to side. Because of the constant
movement, the kinetic therapy has the ability to help mobilize
pulmonary secretions, prevent urinary stasis and affect other
body systems. By using alternating pressure points through
the lateral movement of the bed, the surface helps decrease
pressure yet has no effect on the forces of friction and shear.
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Hybrid Systems
There are surfaces that combine several therapies into one.
An example of a hybrid system is a lateral rotation system
that also offers the benefits of low air-loss. For example, specific bariatric surfaces for the obese patient offer a special bed
frame that is usually reinforced and wider, often with a built-in
scale and a “chair” feature that allows the patient to change
positions without actually getting out of bed.
Other important matters to consider when using support
surfaces include turning and repositioning the patient.
Despite support surface use, patients still need to be
turned and repositioned per your facility’s protocol, usually
a minimum of every two hours, no matter how effective the
surface. Range of motion and prevention of contractures
and other problems is not accomplished by any surface;
consequently, good nursing care must prevail. A minimum
of linen use is recommended with every support surface.
More benefits will be received by the patient whey they
are closer to the therapy. Less linen and fewer incontinence
pads are always best.
Support Surface Selection Guide
Use the following selection guide to help you identify the
products that are most appropriate for your patients.
Cost
($-$$$$$)
27
Ease of Use
Pressure
Redistribution
1- 5
1- 5
Easy - complex Best - worst
Maintenance
1- 5
Low - high
Life
Expectancy
1- 5
Long - short
Portability
1 - 5
Easy - difficult
Foam Overlay
$
1
1
1
5
1
AP Pump & Pad
$
1
1
2
4
1
Gel Foam
Overlay
$$
1
1
1
4
3
Air Overlay
(waffle)
$$
2
2
2
4
1
Pressure
Reducing Foam
Mattress
$$$
1
1
1
2
2
Low Air-Loss
Mattress
$$$$
3
3
4
2
3
Alternating
Pressure
Mattress
$$$$
3
3
4
2
3
Air Fluidized Bed
$$$$$
4
4
5
2
5
Off-Loading
What areas must we concern ourselves with when it comes
to relieving pressure, or off-loading? The areas of most concern are the heels, ankles and elbows. Consider pressure reduction along the continuum of care. An estimated 15 percent of
all pressure ulcers occur on the heels and ankles. Pressure-reducing devices made from foam and air are excellent adjunctive devices to off-load and protect vulnerable lower
extremities.
Devices used in seating areas such as a shower chair or bench
and the transfer or “sliding” board are available in skinsparing, pressure-relieving varieties.
Positioning Measures
Recommended prevention measures include positioning the
patient off of ulcers and placing pillows, foam wedges or
cushioning devices between the legs or ankles and other bony
prominences. The 30 degree lateral position is suggested for
side-lying patients. Do not place a patient at a 90 degree angle
directly on their greater trochanter, or hip bone. Positioning
the patient on the fleshy portion of the buttocks is recommended because it provides more surface area to distribute
the patient’s weight. A foam positioning wedge can assist
the caregiver to position the patient appropriately while
addressing pressure relief.
The Seated Dependent Patient
DID YOU KNOW
Patients with
muscle wasting
have a higher risk
of developing
pressure ulcers.
Individuals who are chair bound should reposition themselves
every 15 minutes by doing a push-up in the chair, rocking
from side to side or bending at the waist to relieve pressure.
If the individual cannot do a weight shift, provide assistance
or help move the patient to bed for a short period of time.
Chair bound individuals with pressure ulcers on their sitting
surfaces should limit the time they sit in a chair. Under this
circumstance, always use a gel or air cushion to provide
pressure relief.
Many patients use wheelchairs or sit in geriatric chairs most of
the day. One of the first steps is to acknowledge the situation
and ask yourself a simple question, “Is a referral to a physical
28
or occupational therapist necessary for a seating evaluation?”
This can help facilitate the selection of the correct rehabilitation equipment, including the right wheelchair and cushion.
Most seated, dependent individuals have muscle wasting in
their lower extremities. This situation places them at an even
higher risk for pressure ulcers since they have less tissue to distribute their weight upon.
Every patient that sits the majority of the time or requires a
wheelchair for movement needs a therapeutic surface for their
chair. Cushions can promote comfort, optimize blood flow,
provide stability, protect the skin, equalize pressure, optimize
function, and prevent and help heal pressure ulcers. Cushions
are made of various combinations of gel, air and foam materials. They are used to distribute pressure and minimize shear
and friction in addition to a number of other applications. Gel
(the jelly type, not the hard static type) and air cushions have
been shown to be the most effective. Make sure the foam cushions your facility uses are thick enough so the patient does not
bottom out, or hit the bottom of the cushion. For the cushion
to be effective, the patient must “float” in the cushion and be
able to sink in. Also, cushions do not last forever. Foam breaks
down, air cushions get holes in them and gel cushions can
leak. Be sure to check the repair of all cushions on a regular
basis and replace them as needed.
Because every seated, dependent patient should be evaluated
for a support surface, you must be aware of the options available to be able to choose the correct cushion for your patient.
1. Which wheelchair cushion design is best for my patient?
29
Type of Cushion
What it does
Flat
Sometimes referred to as a zero
elevation cushion, the thickness
is consistent across the entire
cushion. This cushion can be
used for comfort or pressure
redistribution.
Type of Cushion
What it does
Contour
Sometimes referred to as a
saddle cushion, it emphasizes
proper positioning and leg
alignment while reducing hip
rotation. This cushion provides
pressure redistribution and
comfort by increasing the
seating area.
Wedge
Thicker in the front and angling
down to a thinner back, this
cushion provides support,
stability and pressure redistribution for patients that tend to
slide forward
Anti-Thrust
This cushion has a one inch
shelf in the middle to reduce
thrusting and sliding forward.
It helps prevent sacral sitting
while the low profile front
minimizes leg elevation.
Pommel
Abducts legs to reduce skin
shear and pressure as well as
prevents hip rotation. This can
be a flat or wedge cushion.
Back
Provides comfort, support and
cushioning to the back and
spine. This cushion helps
redistribute pressure while
eliminating the hammock
effect of a sling back.
30
2. What level of pressure redistribution are you looking for?
Type of Redistribution
What it does
Basic Pressure
Redistribution
Adds comfort and reduces pain for lower-risk patients.
Moderate Pressure
Redistribution
Helps redistribute pressure for those at risk of pressure
ulcers. It may also help with positioning needs.
Advanced Pressure
Redistribution
Will address positioning needs and provide significant
pressure redistribution for the highest-risk patients or
those with pressure ulcers. It may be adjustable to meet
individual patient needs.
3. What type of cushion material are you looking for?
31
Cushion Material
What it does
Foam Cushion
Made of the most economical material, this cushion is
typically used for comfort through moderate pressure
redistribution. Different density foams can be used to
address patient comfort, including more expensive visco
elastic memory foams. Different cut-patterns are often
used to prevent shear and help reduce pressure.
Gel and Foam Cushion
Typically provides moderate to advanced pressure redistribution. The most common design is gel sacks placed
between higher quality foams. Gel sacks separated into
quadrants perform best by keeping the gel focused under
problem areas to reduce pressure. Designed to reduce shear
and heat.
Air Cell Cushion
Typically provides the most advanced pressure redistribution. These cushions are adjustable to meet the individual
needs of each patient. Redistributes pressure very well by
distributing weight evenly. Tracks patient movements and
adjusts to the patient’s body contours, eliminating
pressure points.
All support surfaces should be chosen based on the patient’s
and the facility’s needs. Consider the following characteristics
when choosing a support surface:
•
•
•
•
•
•
•
•
•
Ease of use
Patient comfort
Positive clinical outcomes
Cost-effectiveness
Distribution of pressure
Versatility
Infection control compliance
Safety issues
Durability
Operating Room Pressure Ulcer Prevention
According to the Preventing 5 Million Lives From Harm
Campaign, “Because surgical patients who are under
anesthesia for extended periods of time often have an
increased risk of developing pressure ulcers, all surgical
patients (pre-operative, intra-operative, post-anesthesia)
should receive a skin assessment and a risk assessment.
Caregivers should then implement prevention strategies
such as ensuring repositioning and placing patients on
appropriate redistribution surfaces for all surgical patients
who are identified as being at risk.”
There are several important issues to remember:
•
•
•
•
•
All O.R. patients should receive a skin and
risk assessment.
Patient positioning is critical.
Padded positioners should be used if possible,
especially if a patient will remain in one position
for a long period of time.
Pooling of fluids on the skin should be
eliminated if possible.
The patient’s skin should be cleaned and dried
of all fluids before leaving the O.R.
32
Three key causes of pressure ulcers in the O.R. are:
1. Immobility during the surgical procedure
2. Prolonged pressure
3. Diminished tissue tolerance
A nurse’s ability to identify patients at risk for skin breakdown
is the first line of defense in preventing pressure ulcer development. Identifying risk factors allow practitioners to direct their
actions toward prevention. Important prevention factors in
the perioperative environment are the early identification of
patients at risk and implementation of preventive measures.
The type of surgery should be considered when determining
the level of risk for pressure ulcers.
Significant Predictors of Perioperative Pressure Ulcers
3
q
3
q
3
q
q
3
q
3
q
3
q
3
q
3
q
3
q
3
q
3
q
3
q
3
q
3
q
3
33
More than 55 years old
Diagnosis of diabetes, vascular or respiratory disease
Poor nutrition
Anemia
Low albumin, hematocrit or hemoglobin levels
Dehydration
Low arterial pressure
Hypothermia
A current pressure ulcer
Low body fat (because patients with less body fat
are less likely to maintain body temperature and
have less padding over bony prominences)
Medications such as corticosteroids and
vasoconstrictors
A Braden Scale score of less than 20
A surgical procedure that lasts more than 3 hours,
especially cardiovascular surgery
Poor anesthesia assessment status
Epidural anesthesia (which has a greater risk
than general anesthesia)
Important factors in reducing the incidence of pressure
ulcers in the O.R. include placing a forced-air warming
blanket over the patient, away from pressure areas. In
addition, a good supportive mattress that distributes pressure
without bottoming out is important. Foam mattresses break
down over time, which results in decreased support in the
areas where an inactive patient has the most pressure. There
is no conclusive research regarding the use of alternating air
mattresses or gel overlays; however, research speculates that
they might be better in reducing the incidence of pressure
ulcers when compared to a standard hospital mattress.
Best practice supports the use of small foam pads and
pillows to support the body. Padding for common pressure
ulcer locations requires great care, with a special focus on
bony prominences that come into contact with a surface.
Education regarding risk factors for pressure ulcer development, proper body alignment, reducing pressure, not allowing
liquids to pool, decreasing friction and shear, and performing
a skin assessment are crucial for your staff.
The human cost of pressure ulcer development includes
extreme pain, disfigurement or scarring, additional
treatment and surgery, longer hospital stays, increased
cost and increased morbidity or even death. The suffering
and cost can be prevented by determining the risk factors
and applying preventive measures to avoid the development
of pressure ulcers.
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Pressure Ulcer Risk - Common Pressure Points
There are common pressure points where patients develop pressure
ulcers. A patient may change positions, which adds new risk for the
development of pressure ulcers. Be sure to assess your patient with
each position change, and evaluate them for risk of skin breakdown.
Prone Position
Side-lying Position
Supine Position
35
Sitting Position
Wheelchair Position
36
Foot
Plantar View of the Foot
37
References:
Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of pressure ulcers.
Clinical practice guideline No.15. Rockville, MD: US Dept of Health and
Human Services, Agency for Health Care Policy and Research, AHCPR
publication; 1994 95-06522.
Braden Scale for Predicting Pressure Sore Risk. Copyright. Barbara Braden and
Nancy Bergstrom, 1988. Reprinted with permission.
Bryant R. Acute & Chronic Wounds. 2nd Ed. St. Louis, Mo: Mosby, Inc.; 2000.
Corbett L, Dubuc D, Milne C. Wound, Ostomy, and Continence Nursing Secrets.
Philadelphia, Pa: Hanley & Belfus, Inc.; 2003.
Fleck CA, Sprigle S. Support Surfaces: tissue integrity, terms, principles and
choice. In: Krasner D, Rodeheaver G, Sibbald G, eds. Chronic Wound Care: A
Clinical Source Book for Healthcare Professionals. 4th Edition. Malvern, Pa.:
Health Management Publications, Inc. 2007:629-640.
Institute for Healthcare Improvement. 5 Million Lives Campaign. Getting
Started Kit: Prevent Pressure Ulcers How-to Guide. Cambridge, Mass: IHI;
2007: 13.
National Pressure Ulcer Advisory Panel. Available at: www.npuap.org. Accessed
January 10, 2007.
Norton D, McLaren R, Exton-Smith AN. An Investigation of Geriatric Nursing
Problems in Hospital: Norton Plus Pressure Ulcer Scale. London, England:
Edinburg, Churchill, Livingstone; 1975: 225.
Schultz A. Predicting and preventing pressure ulcers in surgical patients.
AORN. 2005;5:985-8, 990-2, 994-6 passim.
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