PRESSURE DETECTIVES

Seating Surfaces

H Raymond Bingham, DPT, MBA, CWSEastern Idaho Regional Medical CenterIdaho Falls, ID

WHAT IS A PRESSURE ULCER?

According to the National Pressure Ulcer Advisory Panel (NPUAP): A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with SHEAR.

WHO IS AT RISK? According to the NPUAP:

Consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.

Soooo . . . . . Most residents of SNF’s/ALF’s qualify as either bed-bound, chair-bound OR “those whose ability to reposition is impaired”

WHAT ARE THE RISK FACTORS? (CLUES!!!) Pressure Shear Skin Microclimate

Heat Humidity

Friction Immobility Device-Related Pressure

PRESSURE

Google Definition The continuous physical force exerted on or

against an object by something in contact with it. Prolonged pressure impairs blood flow leading

to areas of tissue ischemia => cell death Larger surfaces redistribute pressure better

than smaller surfaces Immersion in the surface without bottoming

out reduces pressure

SHEAR

According to the NPUAP: Shear is a normal mechanic force with

physiological effects. The deformation of the tissues alters

the tissues physiology and increases the risk for pressure ulcer.

Some studies suggest that shear may play more critical role than pressure in ulcer formation.

SKIN MICROCLIMATE

Humidity (Moisture) Includes Incontinence, Sweating, &

External Sources (spilled milk, juice, soup, etc.)

Moistures affects skin by: ↓ the skin’s stiffness ↓ the skins strength ↑ Friction at the skin surface ↑ Adherence to surfaces => ↑ SHEAR

SKIN MICROCLIMATE

Heat Increased temp => Increased metabolic

rate Increases demand on cells for nutrients, O2, etc.

which are in short supply when under pressure Increased temp => Increased Sweating,

leads to increased moisture Encourage patients to wear the least

amount of layers they are comfortable with.

If pt must wear Incontinent Briefs Least bulky that works & breathable if able

FRICTION

Google Definition The resistance that one surface or object

encounters when moving over another. Increased friction will increase the

shear and magnify the pressure on the bony prominences

IMMOBILITY

Patients who lack mobility or who have altered mobility will be at higher risk for pressure ulcers as they will not be able to provide adequate pressure redistribution with assistance

Use Therapy to improve mobility. If therapy is not available/indicated, then

use restorative aides, activity directors, etc.

DEVICE-RELATED PRESSURE

If pt gets pressure ulcer while on pressure redistribution surface, need to assess the surface Flat ROHO example

If pt gets pressure ulcer in an odd place or with an odd appearance, check pt’s environment for sources of device-related pressure

RECOMMENDATIONS

Per NPUAP Reposition chair-bound pt’s at least every

hour Teach pt to do pressure relief activity every

15 minutes for pt’s who are able.

RECOMMENDATIONS

Educate Caregivers/Pt’s/Family Importance of pressure redistribution

surfaces Importance of pressure relief every 15

mins sitting Importance of maintaining posture during

sitting Limit sitting time to 1 hour, 3X/day max for

at risk or those with minor (Stage I or II) ulcers

Avoid pressure on Stage III or IV ulcers as much as possible

RECOMMENDATIONS

Use Therapies (Physical & Occupational) Use for Rehab to improve pt’s strength to

increase ability to reposition self in seating surfaces general posture

Many therapists have obtained specialized skills in assessing and recommending seating surfaces

Therapists will have good ideas on how to alter existing surfaces or postures to improve pressure redistribution

RECOMMENDATIONS

Obtain Specialized Seating Surfaces Foam Gel Air Combination

NO!!!! Donut-type Devices NO!!!! Sheepskin Devices NO!!! Egg Crate Devices

FOAM SURFACES

Use of viscoelastic foam for pressure redistribution

GEL SURFACES

Use of Viscoelastic gel for pressure redistribution

AIR SURFACES

Use of air-filled bladders to provide pressure redistribution

COMBINATION SURFACES

Combine the positives of one surface with the positives of another surface to achieve pressure redistribution

SPECIALTY CUSHIONS

Cushions for special populations or situations

ITEMS TO REMEMBER ON SEATING SURFACES

Purpose of seating surfaces is to REDISTRIBUTE pressure off bony prominences

If surfaces is too rigid, the surface will actually magnify the pressure on the bony prominences

If surface is too soft the bony prominences will rest on the base surfaces leading to increased pressure

ITEMS TO REMEMBER ON SEATING SURFACES

Select cushions based on individual patient characteristics

Patients bodies change over time and their cushion requirements will change too

Donuts, Sheepskin, and Egg Crates are NOT pressure redistribution surfaces

May use pillows/foam to achieve position change on pressure redistribution surface

A FEW TAKE HOME ITEMS

Make connections with a seating specialist (be it a P.T., O.T. or a vendor)

A wheelchair cushion is less expensive than treating a pressure ulcer (Prevention costs less than Treatment)

Do what’s best for your patients