SUPPORT SURFACES AND POSITIONING Support... · 2016-01-13 · • Avoid positioning directly on medical devices • Avoid positioning on bony prominences with existing pressure ulcers
Disclaimer The information presented herein is provided for educational and informational purposes only and to promote the safe-and-effective use of the wound care products provided. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.
According to the NPUAP, many pressure ulcers are preventable and all are treatable…even if healing is not the goal, such as in palliative care—yet the fact is that residents and patients continue to have decrease in their quality of life due to pressure ulcers and sometimes die of pressure-ulcer related complications. One way you can make a difference in your patient’s care is by learning how support surfaces, such as mattress overlays, mattress replacements, and specialized beds, relieve or redistribute pressure on skin and prevent pressure ulcers from forming or worsening in addition to reviewing positioning strategies for prevention and treatment of pressure ulcers. Our objectives for today are to: Describe accepted positions to properly redistribute pressure, and to Recognize the different groupings of support surfaces, their intended use & possible effects on wound dressing selection
There are three major components that contribute to pressure ulcer development: pressure duration and pressure intensity, for which you can intervene, and tissue tolerance which is individualized to each person. Tissue Tolerance is the ability of both the skin and its underlying supporting structures to endure pressure without adverse consequences. A wide range of factors affects tissue tolerance. These are generally organized into two major groups: Extrinsic (primary or management related factors) and Intrinsic (secondary or patient-condition related factors) Repositioning the resident’s body at regular intervals reduces the duration of pressure. Using appropriate support surfaces reduces the intensity of the pressure. You need to use both support surfaces and repositioning to take load off body pressure points. These actions will decrease the chances of someone with limited mobility in acquiring pressure ulcers.
MANAGING TISSUE LOADS • Support surfaces: one of the major ways to manage
pressure, friction, and shear – Used on beds, chairs, exam tables, OR tables
• Should be combined with other interventions – Positioning devices – Pressure relief for the heels – Side lying positions – Bed positioning – Chair positioning – Lifting devices – Positioning schedule
Support surfaces are one of the major ways to manage pressure, friction, and shear on tissues. We see them used on beds and chairs, and we are starting to see them used more and more on exam tables and OR tables (the foam kind, not the dynamic alternating air kind… Can you imagine performing surgery on a patient that is on an alternating mattress?!? ) And as I mentioned before, you also should incorporate repositioning techniques and other interventions such as pillows, foam wedges, lifting devices… Pillows or foam wedges can be used to separate bony prominences from direct contact with one another as well as to raise the heels off of the bed. Pillows and foam wedges can also be used when side-lying avoid positioning directly on trochanter. You should always maintain head of bed at the lowest degree of elevation consistent with medical conditions and other restrictions and limit amount of time head of bed is elevated. With more elevation of the head of the bed, the body can slide down the mattress, developing shearing forces within the tissues and increase the potential for sacral dressings to dislodge. Use lifting devices, trapeze or bed linen, to move- not drag- pts in bed who cannot assist during transfers or position changes. The friction or dragging that occurs without lifting is detrimental to the skin and again can dislodge dressings. Other interventions: Critical to address nutrition and moisture!!! Also, underlying disease processes.
Here we have illustrated some of the most common pressure points at risk for breakdown in the different positions. In each of these positions, repositioning should be undertaken to reduce the duration and magnitude of pressure over these vulnerable areas of the body. The use of repositioning as a prevention strategy must take into consideration the condition of the resident and the support surface in use.
REPOSITIONING FREQUENCY
Frequency of repositioning: influenced by several variables
The NPUAP discusses repositioning in depth and includes the following recommendations in the Pressure Ulcer Prevention and Treatment Guidelines: Frequency of repositioning is influenced by variables concerning the individual and the support surface in use. Repositioning frequency will be determined by the individual’s tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessments of the individual’s skin condition.
REPOSITIONING TECHNIQUES • Avoid pressure / shear forces • Use transfer aids • Lift—don’t drag • Avoid positioning directly on medical devices • Avoid positioning on bony prominences with
existing pressure ulcers or non-blanchable erythema • Continue to turn and reposition
regardless of support surface used • Do not use ring- or donut-shaped
Here are some repositioning techniques to consider: Avoid subjecting the skin to pressure and shear forces. Use transfer aids to reduce friction and shear. Lift—don’t drag—the individual while repositioning. Avoid positioning the resident directly onto medical devices, such as tubes or drainage systems. Avoid positioning the resident on bony prominences with existing pressure ulcer or non-blanchable erythema. Continue to turn and reposition the individual regardless of the support surface in use. Do not use ring- or donut-shaped devices. Do not apply heating devices.
REPOSITIONING TECHNIQUES
• Use 30-degree tilted side-lying position – alternately; right, back, left side
• Prone if individual can tolerate; – medical condition allows
Repositioning should be undertaken using the 30-degree tilted side-lying position (alternately, right side, back, left side) or the prone position if the individual can tolerate this and his/her medical condition allows. Avoid postures that increase pressure, such as the 90-degree side-lying position, or the semi-recumbent position.
REPOSITIONING TECHNIQUES • Sitting in bed
– Avoid head-of-bed elevation – Avoid slouched position
• places pressure and shear on the sacrum and coccyx
• Limit head-of-bed elevation to 30 degrees – resident on bed-rest – unless contraindicated by
If sitting in bed is necessary, avoid head-of-bed elevation or a slouched position that places pressure and shear on the sacrum and coccyx. Limit head-of-bed elevation to 30 degrees for a resident on bed-rest, unless contraindicated by medical condition. Encourage residents to sleep in a 30 to 40-degree side-lying position or flat in bed if not contraindicated.
SEATED CONSIDERATIONS • Select posture acceptable for the
resident • Posture that minimizes
pressures and shear • Place the feet on
footstool or wheelchair footrest when feet do NOT reach the floor
• Limit time spent in chair without pressure relief
In repositioning the seated resident, you always want to position the resident so as to maintain his/her full range of activities. Some things to consider include: Selecting a posture that is acceptable for the resident and minimizes the pressures and shear exerted on the skin and soft tissues. Placing the feet of the individual on a footstool or footrest when feet do not reach the floor. Limiting the time a resident spends seated in a chair without pressure relief. In looking at this photograph, can you tell me what all is wrong with this little girl’s positioning?
HEEL CONSIDERATIONS
• Relieve pressure under heel(s) with Stage I or II PUs
• Legs on pillow to “float heels” off bed or use pressure-reducing devices with heel suspension
• Stage III or IV PU place the leg in device that elevates heel from surface of bed, completely offloading the heel
Then there are some important considerations for the heels related to repositioning. The NPUAP recommends you relieve pressure under the heel(s) with Stage I or II pressure ulcers by placing legs on a pillow to float heels off the bed or by using pressure-reducing devices with heel suspension. When using a device, be sure to apply the device according to the manufacturer’s instructions. You also need to ensure that the device is not too tight and does not create additional pressure damage. Check device placement more frequently in residents with neuropathy, peripheral arterial disease, lower-extremity edema; or who are likely to develop edema. Also be sure to remove the device periodically to assess skin integrity.
Then you must document. You need to record repositioning regimes, specifying frequency and position adopted, and you should also include an evaluation of the outcome of the repositioning regime.
And don’t forget about education and training! The NPUAP Pressure Ulcer Prevention and Treatment guideline discusses the importance of Education regarding the role of repositioning in pressure ulcer prevention and treatment and that education should be offered to all persons involved in the care of residents, including the resident and his/her family. Training in the correct methods of repositioning and use of equipment should also be offered to all persons involved in the care of residents at risk of pressure ulcer development, including the resident and his/her family.
It’s more than just a bed! Per the NPUAP, a support surface is a specialized device for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions, e.g., any mattresses, integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay.
PRESSURE REDISTRIBUTION • The ability of support surface to distribute load over
Support surfaces include the concept of pressure redistribution which is the ability of a support surface to distribute a load over the contact areas of the human body. This term replaces prior terminology of pressure reduction and pressure relief surfaces.
HOW SUPPORT SURFACES WORK • Immersion and envelopment reduce tissue stress • Increasing the contact area between the support
surface and individual’s body • Allowing for pressure redistribution
To be effective, support surfaces must mold to the body to maximize contact, then redistribute the resident’s weight as uniformly as possible. Support surfaces also use the principle of deformation: They must be capable of deforming enough to permit prominent areas of the body to sink into the support. Finally, they must be able to transmit pressure forces from one body area to another. This is all done through two primary therapeutic functions of immersion and envelopment.
HOW SUPPORT SURFACES WORK
• IMMERSION - ability of support surface to allow body sink into it
The ideal characteristics of a support surface are as illustrated in this picture. Obviously not every support surface has each of these characteristics- remember these are the ideal. However, you should choose surfaces that meet the needs of your residents and the facility. If the next three slides are hidden, state this here: (The NPUAP actually has a fantastic resource online called their S3I (Support Surface Standards Initiative). To access that document, all you have to do is go to www.npuap.org, select Research on the left, and then select S3I. From there, all you have to do is select S3I Terms and Definitions and then you will have a fantastic, 10 page pdf file were you will find all of the most up-to-date terms and definitions related to support surfaces. So rather than going over the physical concepts, components, features, and categories of support surfaces, I am directing you to this website.)
The NPUAP actually has a fantastic resource online called their Support Surface Standards Initiative (S3I). To access that document, all you have to do is go to www.npuap.org, select Research on the left, and then select Support Surface Standards Initiative (S3I). This information is also in the new National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel’s Pressure Ulcer Prevention and Treatment Guideline which was published and released in November of 2009. You can purchase a copy of the guideline for your facility at the NPUAP.org website.
From there, all you have to do is select S3I Terms and Definitions and then you will have a fantastic, 10 page pdf file were you will find all of the most up-to-date terms and definitions related to support surfaces.
So rather than going over the physical concepts, components, features, and categories of support surfaces here, I am going to direct you to this document on the NPUAP’s website.
The Centers for Medicare and Medicaid Services divides support surfaces into three groups: Group 1 – non-powered mattresses and overlays Group 2 – powered mattresses and overlays Group 3 – air-fluidized beds or high air loss systems
Group 1 surfaces do not require electricity and include static air, foam, gel, and water mattresses or overlays. These surfaces are intended for pressure ulcer prevention in individuals who have been recognized at be at risk for pressure ulcer development.
GROUP 2 • Indicated for Stage III or IV PUs • Muscle flap repair of a PU • Multiple Stage II PUs
Group 2 surfaces include dynamic powered surfaces and advanced non-powered surfaces – including your dynamic air overlays and low-air-loss systems. These surfaces are indicated for patients with Stage III or IV pressure ulcers on the trunk or pelvis, muscle flap repair of a pressure ulcer within the last 60 days, or multiple Stage II pressure ulcers that haven’t improved on a Group 1 surface in the last month, even with comprehensive care.
GROUP 3 • Indicated for Stage III or IV PUs that have not
Group 3 consists of air-fluidized beds, a high-air-loss system with ceramic silicone beads that become fluidized as warm pressurized air is forced up through the beads. This gives the beads the characteristics of fluid, allowing the patient’s or resident’s body to float on the surface and minimizing pressure, shear, and moisture. These have the capability to control large amounts of bodily fluids. They are not recommended for mobile residents, residents with pulmonary disease, or residents with an unstable spine. Continuous circulation of warm dry air may dehydrate the patient or desiccate the wound bed affecting your dressing selections. A Group 3 surface is indicated for patient’s or resident’s with Stage III or Stage IV pressure ulcers that haven’t improved on a Group 2 surface over the last month, even with comprehensive care.
Pressure Redistribution
Skin Moisture Control
Skin Temperature Control
CHARACTERISTICS TO CONSIDER WHEN CHOOSING A SUPPORT SURFACE
When you are evaluating support surfaces for resident use, here are some characteristics to consider when choosing a support surface: Pressure Redistribution. The surface should support the resident’s body weight without harming his/her skin. Skin moisture control. The surface should keep the resident’s skin dry. Skin temperature control. The surface shouldn’t make him/her sweat. Increased perspiration can affect how adhesives on dressings perform causing the dressing adherence to fail.
Friction Infection Control Flammability
CHARACTERISTICS TO CONSIDER WHEN CHOOSING A SUPPORT SURFACE
Other characteristics to consider include: Friction. The surface should let the resident transfer but not slide off. Infection control. The surface should not promote bacterial growth. Flammability. The surface should not ignite if someone drops a lighted cigarette on it.
If you do not know the equipment and have no experience with it then it is important you refer to the operation manual. Check if sheets or chucks impact the functioning of the equipment or if specialized category of products may be used. Check for the product service requirements. The owner’s manual should describe how to clean and maintain the surface. Review the life expectancy of the equipment. The manual should indicate how long the surface is expected to last, so it can be replaced before problems arise. And be aware of fail safety. The manual should tell you what to do should the surface becomes unusable.
SUPPORT SURFACE SELECTION • PLEASE NOTE: Selection of support surfaces is
complex and cannot be determined solely on the basis of the category/stage of the ulcer.
• NPUAP/EPUAP suggestions:
– Consider higher-specification foam or similar non-powered pressure-redistribution support surfaces for Stage I or II PUs.
– Position the individual off of the area(s) of suspected deep tissue injury with intact skin, Stage III, IV, and unstageable PUs.
The NPUAP/EPUAP Pressure Ulcer Prevention and Treatment Guidelines reminds us that selection of support surfaces is complex and cannot be determined solely on the basis of the category/stage of the ulcer. However, here are some NPUAP/EPUAP suggestions: Consider using higher-specification foam or similar non-powered pressure-redistribution support surfaces for Stage I or II pressure ulcers. Position the individual off of the area(s) of suspected deep tissue injury with intact skin, Stage III, IV, and unstageable pressure ulcers. If pressure over the area cannot be relieved by repositioning or if there are pressure ulcers on multiple turning surfaces, evaluate the individual and provide a support surface properly matched to his/her needs, considering pressure redistribution, shear reduction, and microclimate control. Keep the individual off of the area as much as possible.
SUPPORT SURFACE SELECTION • NPUAP/EPUAP suggestions:
– Beds with air-fluidized features produced better healing outcomes for Stage III and IV PUs than standard beds
– Beds with low-air-loss features resulted in better healing outcomes for Stage III and IV PUs than foam mattresses
– Mattresses and overlays with alternating-pressure features are recommended and used by clinicians for both prevention and treatment
The NPUAP/EPUAP has some recommendations related to support surface selection. For instance: Beds with air-fluidized features produced better healing outcomes for Stage III and IV pressure ulcers than standard beds. Beds with low-air-loss features resulted in better healing outcomes for Stage III and IV pressure ulcers than foam mattresses. Mattresses and overlays with alternating-pressure features are recommended and used by clinicians for both prevention and treatment; however, no published studies demonstrating better healing outcomes for Stage III or IV pressure ulcers in comparison to other types of support surfaces were identified.
SUPPORT SURFACE SELECTION • NPUAP/EPUAP suggestions while in chair:
– Use a pressure-redistribution cushion in the chair for individuals with Stage I or II PrUs
– Minimize seating time and consult a seating specialist if PrUs worsen on the seating surface selected
– Avoid seating an individual with an ischial ulcer in a fully erect posture (in chair or bed)
– If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to 3 x day in periods of 60 min or less
Then there are the NPUAP/EPUAP suggestions while the resident/patient is in a chair: Use a pressure-redistribution cushion in the chair for individuals with Stage I or II PUs. Minimize seating time and consult a seating specialist if PUs worsen on the seating surface selected. Avoid seating an individual with an ischial ulcer in a fully erect posture (in chair or bed). If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to 3 x day in periods of 60 min or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer. The NPUAP/EPUAP Pressure Ulcer Prevention & Treatment Clinical Practice Guidelines also include repositioning and support surface recommendations that address the special needs of critically ill, spinal-cord-injured, and bariatric individuals.
IN SUMMARY • Prevention in individuals at risk should be provided
on a continuous basis during the time that they are at risk
• Do not base selection of a support surface solely on perceived level of risk for PU development or the category/stage of any existing pressure ulcer
• Select support surface that meets resident’s needs for pressure redistribution, shear reduction, and microclimate control
• Examine appropriateness and functionality of support surfaces on every encounter with resident
In Summary: Prevention in individuals at risk should be provided on a continuous basis during the time that they are at risk. Do not base the selection of a support surface solely on the perceived level of risk for PU development or the category/stage of any existing PU. Select a support surface that meets the resident’s needs for pressure redistribution, shear reduction, and microclimate control. Examine the appropriateness and functionality of the support surfaces on every encounter with the resident. (How many times have you gone into a residents room and noticed that their low-air-loss mattress was set on max inflation or, better yet, unplugged altogether?)
PRESSURE ULCER MANAGEMENT
Comprehensive Care • Nutritional Planning • Managing Incontinence or
Moisture • Good Local Wound Care • Repositioning • Assessing skin and
Support surfaces are no substitute for careful nursing care and educating the resident and family about wound care. Comprehensive care includes a nutrition plan to optimize wound healing, managing incontinence or moisture, utilizing good local wound care with safe and effective use of the appropriate dressings that match the condition of the wound and the resident’s individual needs, repositioning your resident based on an individualized repositioning schedule that reflects that individuals level of immobility and tissue tolerance, and assessing the patient’s or resident’s skin and areas pressure points for potential problems each time you turn the resident.
And Finally • Not a comprehensive educational activity on
support surfaces and repositioning • It is a overview • NPUAP/EPUAP Pressure Ulcer Prevention and
Treatment Guidelines and Support Surface Standards Initiative (S3I) for more detailed information and education
• Always, always read and follow the manufacturers instructions and recommendations for use of support surfaces and other devices used with your residents and patients
And Finally: This presentation is not a comprehensive educational activity on support surfaces and repositioning It is a overview Please see the NPUAP/EPUAP Pressure Ulcer Prevention and Treatment Guidelines and the Support Surface Standards Initiative (S3I) for more detailed information and education And always, always read and follow the manufacturers instructions and recommendations for use of support surfaces and other devices for use with your residents and patients. Thank you for your attention
Review Questions 1. The 3 main components contributing to pressure ulcer
development are pressure _________, pressure ________, and tissue ___________.
2. Scheduled repositioning is not necessary on a Group 2 Support Surface. True or False
3. Pressure redistribution refers to: A. The ability of the support surface to distribute a load over contact areas of the body. B. The ability of the patient to shift his/her weight. C. The ability of the support surface to prevent pressure ulcer development. D. The ability of the support surface to support the weight of the patient.
• European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009.
• National Pressure Ulcer Advisory Panel; Support Surface Standards Initiative; Terms and Definitions Related to Support Surfaces, Ver. 01/29/2007.
