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Preventing Pressure Ulcers Repositioning and Microturns Denise Nix MS RN CWOCN MHA SAFE SKIN Consultant

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Preventing Pressure Ulcers

Repositioning and Microturns

Denise Nix MS RN CWOCN

MHA SAFE SKIN Consultant

Objectives

• Understand the significance of this topic for Minnesota Hospitals

• Define “optimal positioning” for the bedbound patient • Discuss MHA Recommendations for alternative positioning

(only in the absence of optimal positioning) • Describe the history and literature related to weight

shifting and microturning • Present examples of techniques for alternative positioning • Provide relevant references for further exploration of the

topic

Significance

Almost 60% of stage 3, 4, and unstageable pressure ulcers in MN hospitals develop on the sacral, coccygeal, buttocks region

Sacrum, Buttocks, Coccyx

Medical Devices

Other

AHE reports revealed:

o 52% - condition prohibited turning

o 22% - patient refused positioning

Hospitals reporting success:

o Nurse-MD communication about positioning issues

o Bed ahead programs

o Frequent tailbone offloads of some kind

o Frequent reevaluation, reeducation and turning trials

Significance

If a patient is not able to be adequately or

routinely repositioned:

owritten confirmation that patient

cannot be repositioned from the

physician with daily re-evaluation

o Immediate evaluation for the most

appropriate surface to redistribute

pressure

o at least hourly mini shifts off the

tailbone

MHA SAFE SKIN Recommendations

Optimal Positioning

Tissues of the body are not meant to be stationary

The average healthy person repositions him/herself every 6 to 11.6 minutes

Keane FX . The minimum physiological movement required for a man supported

on a soft surface. Paraplegia. 16, 383-9. 1978.

Optimal Positioning

• Hospital bedbound patients

• 30 degrees side lying turns

• Every 2 hours

Wound , Ostomy and Continence Nurses (WOCN) Society : Guideline for

prevention and management of pressure ulcers , Glenview , IL , 2010 , Author.

Optimal Positioning

• HOB 30 degrees or less

• Float heels

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel

(EPUAP) : Prevention and treatment of pressure ulcers: Washington DC , 2009

In the Absence of Optimal Positioning:

Courtesy Mayo Clinic

History Behind Weight Shifts

Panel on the Prediction and Prevention of Pressure Ulcers in Adults: Clinical Practice Guideline No. 3 Rockville, MD: Agency for Health Care Policy and Research; 1992. AHCPR Publication No 92-0047.

Wound , Ostomy and Continence Nurses (WOCN) Society : Guideline for prevention and management of pressure ulcers , Glenview , IL , 2010 , Author.

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) : Prevention and treatment of pressure ulcers: Washington DC , 2009

Pressure Mapping

Pressure Mapping-Weight Shifts

Ischial Tuberosities (Sitting Bones) Sitting on Chair with Cushion

Ischial Tuberosities (Sitting Bones) Same Patient Leaning to Side

Lorraine

Pressure Mapping-MiniTurn

Supine Position Pressure Redistribution Mattress

HOB 30 Degrees

Same Patient –Miniturn Same Mattress

HOB 30 Degrees

15

Critical Care

Critical Care 63%

Other 37%

Hemodynamic Instability

“Hemodynamic Instability” may be used inappropriately to describe critically ill patients

Repositioning may be withheld due to fear of affecting systemic perfusion, ICP or oxygenation.

It is passed on from shift to shift without verification nor inclination of when to resume or trial positioning

Winkelman C, Peereboom K. Staff-perceived barriers and facilitators. Crit Care Nurse. 2010;30:13–16

Choi J, Tasota FJ, Hoffman LA. Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of literature. Biol Res Nurs. 2008;10(1):21–33

ICP Monitoring

Most neurosurgery patients with intracranial pressure monitoring can be turned safely beginning in the

immediate postoperative period

Jones B. The effects of patient repositioning on intracranial pressure. Aust J Adv Nurs.

1994;12(2):32–39.

O'Connor ED, Walsham J. Should we mobilise [sic] critically ill patients? A review. Crit Care Resusc. 2009;11(4):290–300.

Gravitational Equilibrium

Process

Failure to turn for prolonged periods

Hemodynamically calibrates to a supine position

Creates maladaption to position changes

Orthostatic response with rapid movement

Management

SLOW movement followed by 5- to 10-minute recovery periods

CLRT (turning beds) does not count as patient turning for pressure ulcer prevention

Vollman K. Introduction to progressive mobility. Crit Care Nurse. 2010;30:3–5

SVO2 and Heart Rate

Monitored changes in SvO2 and heart rate following lateral turns in ICU patients

Changes found to be transient

Most patients returned to baseline within 5 minutes

Winslow EH, Clark AP, White KM, Tyler DO. Effects of a lateral turn on mixed venous oxygen saturation and heart rate in critically ill adults. Heart Lung. 1990; 19:557–561

Respiratory Instability

Sometimes repositioning is the actual treatment for the respiratory instability:

• Atelectasis

• Shunting in the context of a collapsed lung

• Differences in lung compliance.

Brindle CT Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability: A Literature Review and Consensus Recommendations J Wound Ostomy Continence Nurs. 2013;40(3):254-267

Turning Trials

Insufficient evidence to determine which patients are severe enough to preclude turning trials

Turning, repositioning, and mobilizing the intensive care patient requires multidisciplinary collaboration

Chulay M, Brown J, Summer W. Effect of postoperative immobilization after coronary artery bypass surgery. Crit Care Med. 1982;10(3):176–179.

Brindle CT Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability: A Literature Review and Consensus Recommendations J Wound Ostomy Continence Nurs. 2013;40(3):254-267

Author Examples -Too Unstable To Turn (Use Weight Shifts, Passive ROM, Mini-turns Instead)

Discuss With MD and Reassess Each Shift:

Active uncontrolled bleeding (ex: Open chest graft failure)

Massive Transfusion protocols

No fluid/blood going in= no blood pressure (does NOT include minor fluid boluses for correction)

Sudden desaturation from patient’s baseline that doesn’t RECOVER

Sudden change in MAP that does not RECOVER (and can’t be corrected with vasopressive agents)

King LT Airway

Brindle CT Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability: A Literature Review and Consensus Recommendations J Wound Ostomy Continence Nurs. 2013;40(3):254-267

Techniques

SLOWLY move to 10 degrees-allow recovery period- move to 20 degrees-allow recovery period etc

Using a turn/lift sheet to tilt off tailbone

Lift head or extremity off bed surface for 1-2 minutes at a time

Utilize the lost art of passive range of motion

Communicate, Trouble Shoot, Communicate!!

Brindle CT Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability: A Literature Review and Consensus Recommendations J Wound Ostomy Continence Nurs. 2013;40(3):254-267

References (Micro/Minor/Mini) Shifts or Turns

Brindle CT Outliers to the Braden Scale Identifying high ICU patients and the results of prophylactic

dressing use WCET Journal Volume 30 Number 1 – January/March 2010.

Brindle CT Turning and Repositioning theCritically Ill Patient WithHemodynamic Instability: A Literature Review and Consensus Recommendations J Wound Ostomy Continence Nurs. 2013;40(3):254-267.

Bryant, R. Nix D. Developing and Maintaining a Pressure Ulcer Program. In Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 4th Edition. St. Louis, Mosby, January, 2012.

Institute for Clinical Systems Improvement (ICSI): Health Care Protocol :Pressure Ulcer Prevention and Treatment Protocol 3rd Edition January, 2012 Available at www.icsi,org

Keane FX (1978) The minimum physiological movement required for a man supported on a soft surface. Paraplegia. 16, 383-9.

Knox, D.M., Anderson, T.M., & Anderson, P.S. (1994). Effects of different turn intervals on skin of healthy older adults. Advances in Wound Care, 7(1), 48–52, 54–56.

Oertwich PA, Kindschuh AM, Bergstrom N. The effects of small shifts in body weight on blood flow and interface pressure. Res Nurs Health. 1995 Dec;18(6):481-8.

Paralyzed Veterans of America (PVA). (2000). Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury:. A Clinical Practice Guideline for Health-Care Professionals. Washington, D.C.: Author

Pressure Redistribution: Seating, positioning, and support surfaces. Matching Support to Patient Needs. IN Baranoski S. Wound care essentials:practice principles. Second Edition 2008.

Wound , Ostomy and Continence Nurses (WOCN) Society : Guideline for prevention and management of pressure ulcers , Glenview , IL , 2010 , Author.

Young T. The 30 degree tilt position vs the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: a randomized controlled trial. J Tissue Viability. 2004 Jul;14(3):88, 90, 92-6.

References Positioning & Hemodynamic Unstablity

Winkelman C , Peereboom K . Staff-perceived barriers and facilitators. Crit Care Nurse. 2010 ; 30 : 13-16 .

De Jonghe B , Lacherade JC , Shashar T , Outin H . Intensive care unit–acquired weakness: risk factors and prevention . Crit Care Med. 2009 ; 37 ( 10 ): s309-s315 .

Bailey P , Thomsen GE , Spuhler VJ , et al. Early activity is feasible and safe in respiratory failure patients . Crit Care Med . 2007 ; 35 ( 1 ): 139-145 .

Morris PE , Goad A , Thompson C , et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure . Crit Care Med . 2008 ; 36 ( 8 ): 2238 2243 .

Choi J , Tasota FJ , Hoffman LA . Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of literature . Biol Res Nurs. 2008 ; 10 ( 1 ): 21-33 .

Winslow EH , Clark AP , White KM , Tyler DO . Effects of a lateral turn on mixed venous oxygen saturation and heart rate in critically ill adults . Heart Lung. 1990 ; 19 : 557-561 .

Vollman K . Introduction to progressive mobility . Crit Care Nurse . 2010 ; 30 : 3-5 .

Coupe M , Fortrat JO , Larina I , Gauquelin-Koch G , Gharib C , Custaud MA . Cardiovascular deconditioning: from autonomic nervous system to microvascular functions . Respir Physiol Neurobiol. 2009 ; 169s : s10-s12 .

Offner PJ , Haepel JB , Moore EE , Bliff WL , Franciose RJ , Burch JM . Complications of prone ventilation in patients with multisystem trauma with fulminant acute respiratory distress syndrome . J Trauma . 2000 ; 48 ( 2 ): 224-228 .

References: Pressure Mapping, “Capillary Closing”, and Interface Tissue Measurement

Le KM et al : An in-depth look at pressure sores using monolithic silicon pressure sensors,

Plast Reconstr Surg 74 ( 6 ): 745 , 1984 .

Nix D, Mackey Diane. Support Surfaces. In Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 4th Edition. St. Louis, Mosby, January, 2012.

Reger SI et al : Correlation of transducer systems for monitoring tissue interface pressures , J Clin Eng 13 ( 5 ): 365 - 371 , 1988 .

Stinson M, Porter A, Eakin P. Measuring interface pressure: a laboratory-based investigation into the effects of repositioning and sitting. Am J Occup Ther. 2002;56(2):185-190.

Stinson MD, Porter-Armstrong A, Eakin P. Seat interface pressure: a pilot study of the relationship to gender, body mass index, and seating position. Arch Phys Med Rehabil. 2003;84(3):405-409.

Stinson MD, Porter-Armstrong AP, Eakin PA. Pressure mapping systems: reliability of pressure map interpretation. Clin Rehabil. 2003;17(5):504-511.

Wound, Ostomy and Continence Nurses (WOCN) Society : Guideline for prevention and management of pressure ulcers , Glenview, IL , 2003 , Author .

Thank You!!

Denise Nix