PREVENTING PRESSURE ULCERS

Transcription

1 Contents PREVENTING PRESSURE ULCERS Risk Assessment Risk Assessment Tools The Braden Scale for Predicting Pressure Sore Risk The Norton Plus Scale Practical Applications of the Assessment Tools Friction and Shear Pressure Reduction/Prevention versus Pressure Relief Prevention Devices Therapeutic Devices Support Surface Selection Guide Off-Loading Positioning Measures The Seated Dependent Patient Operating Room Pressure Ulcer Prevention Pressure Ulcer Risk - Common Pressure Points

2 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 = 15 to 18 Moderate risk = 13 to 14 High risk = 10 to 12 Very high risk = <9 2

3 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. 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. 3

4 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

5 An example of the Braden Scale For Predicting Pressure Sore Risk is shown below. Copyright Barbara Braden and Nancy Bergstrom, All rights reserved. Reprinted with permission. 5

6 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

7 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

8 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

9 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

10 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 Very limited = 1 Constantly moist = 1 Needs assistance = 2 Very limited = 1 Very Poor = 1 Potential problem Total Braden Scale = 8 Level of Risk = Severe Risk 10

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12 Norton Plus Pressure Ulcer Scale Physical Condition = 3 Mental State = 4 Activity = 1 Mobility = 1 Incontinence = 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 = 3 Total Norton Plus Score = 7 Level of Risk = 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

13 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

14 Braden Scale For Predicting Pressure Sore Risk Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear = 2 Very limited = 1 Constantly moist = 3 Needs assistance = 2 Very limited = 2 Adequate = 2 Potential problem Total Braden Scale = 12 Level of Risk = High Risk 14

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16 Norton Plus Pressure Ulcer Scale Physical Condition = 3 Mental State = 2 Activity = 3 Mobility = 3 Incontinence = 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 = 12 Total Number of Check Marks = None Total Norton Plus Score = 12 Level of Risk = 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

17 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

18 Braden Scale For Predicting Pressure Sore Risk Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear = 4 No impairment = 4 Rarely moist = 3 Walks occasionally = 4 No limitations = 4 Excellent = 3 No apparent problem Total Braden Scale = 22 Level of Risk = Little or No Risk 18

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20 Norton Plus Pressure Ulcer Scale Physical Condition = 4 Mental State = 4 Activity = 3 Mobility = 4 Incontinence = 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 = 19 Total Number of Check Marks = 0 Total Norton Plus Score = 19 Level of Risk = 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

21 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. 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. 21

22 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

23 Type of overlay Air filled Foam filled Advantages 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 Disadvantages 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 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 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

24 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

25 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

26 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. 26

27 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 Ease of Use Pressure Redistribution Maintenance Life Expectancy Portability ($-$$$$$) 1-5 Easy - complex 1-5 Best - worst 1-5 Low - high 1-5 Long - short 1-5 Easy - difficult Foam Overlay $ AP Pump & Pad $ Gel Foam Overlay $$ Air Overlay (waffle) $$ Pressure Reducing Foam Mattress $$$ Low Air-Loss Mattress $$$$ Alternating Pressure Mattress $$$$ Air Fluidized Bed $$$$$

28 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. DID YOU KNOW Patients with muscle wasting have a higher risk of developing pressure ulcers. The Seated Dependent Patient 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

29 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? 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. 29

30 Type of Cushion What it does Contour Wedge 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. 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

31 2. What level of pressure redistribution are you looking for? Type of Redistribution Basic Pressure Redistribution Moderate Pressure Redistribution Advanced Pressure Redistribution What it does Adds comfort and reduces pain for lower-risk patients. Helps redistribute pressure for those at risk of pressure ulcers. It may also help with positioning needs. 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? Cushion Material Foam Cushion Gel and Foam Cushion Air Cell Cushion What it does 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. 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. 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. 31

32 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

33 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 q3 More than 55 years old q3 Diagnosis of diabetes, vascular or respiratory disease q3 Poor nutrition q3 Anemia q3 Low albumin, hematocrit or hemoglobin levels q3 Dehydration q3 Low arterial pressure q3 Hypothermia q3 A current pressure ulcer q 3 Low body fat (because patients with less body fat are less likely to maintain body temperature and have less padding over bony prominences) q Medications such as corticosteroids and 3 vasoconstrictors q A Braden Scale score of less than 20 3 q A surgical procedure that lasts more than 3 hours, 3 especially cardiovascular surgery q Poor anesthesia assessment status q3 Epidural anesthesia (which has a greater risk 3 than general anesthesia) 33

34 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. 34

35 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

36 Sitting Position Wheelchair Position 36

37 Foot Plantar View of the Foot 37

38 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; Braden Scale for Predicting Pressure Sore Risk. Copyright. Barbara Braden and Nancy Bergstrom, Reprinted with permission. Bryant R. Acute & Chronic Wounds. 2nd Ed. St. Louis, Mo: Mosby, Inc.; Corbett L, Dubuc D, Milne C. Wound, Ostomy, and Continence Nursing Secrets. Philadelphia, Pa: Hanley & Belfus, Inc.; 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. 4 th Edition. Malvern, Pa.: Health Management Publications, Inc. 2007: 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: Accessed January 10, 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, passim. 38