Right Patient, Right Surface, Right Time

Objectives• Explain and define a support surface algorithm

• Navigate the support surface selection process utilizing an algorithm

• Discuss the questions needed to gather data to utilize a support surface algorithm

• Review how a support surface algorithm is used to select the right support surface, for the right patient at the right point of care

NPUAP/EPUAP/Pan Pacific GuidelinesS3i Standard Testing Research

Pressure Injury (Ulcer) Causes• Pressure Injury:

A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue

PressureIncrease contact area → greater immersion → reduce pressure

Stage 4 Pressure Injury

Shear

Stretching effect of tangential

force depends on coefficient of

friction and causes sliding of

tissue layers. (Deep Tissue

Injuries)

Deep Tissue Injury (DTI)

Stage 3 Pressure Injury with undermining

Microclimate Management (LAL)

• The ability of a body support surface to dissipate body heat and moisture makes an important contribution to comfort.

• Moisture and skin temperature influence tissue tolerance to pressure and can increase the risk of skin damage

Excessive Heat & Moisture

Microclimate Management (LAL) does not address incontinence, areas covered by briefs, wound drainage

(should be covered by a dressing) or infections

Interventions

Turning

Manual

Lateral Rotation: 18-20 degrees

Wound Turn: 30 degrees

Treatment or pulmonary: 45 + degrees

If every 4 hour turning is not working, what do you do?

Therapy to Consider: Pressure Redistribution

Support surfaces redistribute pressure off of high pressure areas

like the sacrum/coccyx and heels, and onto more load tolerant

areas like the calves and the back. They do this by either

conforming to the body or providing immersion to equalize

pressure, as shown above.

Immersion and Envelopment

Pressure Redistribution

FOAM + AIRAIRFOAM

Additional Therapies

•Alternating Pressure

•Lateral Rotation

Microclimate Management (LAL)

• Microclimate – the local tissue temperature and moisture (relative humidity) level at the body/support surface interface

• Microclimate Management: moisture vapor and heat penetrate the coverlet and is removed by the air delivery cover below

How to choose

the right surface for

the right patient at

the right time –

Algorithm/Decision Tree

WOCN Prevention

WOCN - Treatment

What is an Algorithm?

An algorithm is defined as a set of steps followed to solve a problem. A Support Surface Management algorithm helps the non-wound expert (based on patient assessment) choose the correct therapeutic support surface for prevention and treatment of pressure injuries (ulcers).

The questions on the algorithm are not all inclusive and as the note under the title states: an algorithm is a guide, not a substitute for clinical judgment, and does not replace a full patient assessment.

A therapeutic support surface is only one of many interventions. The patient still needs topical therapy, nutrition/hydration, repositioning, pain management, infection control, etc.

Top Five Assessment DataQuestions:

1. Are there existing pressure injuries (ulcers),

stages, how many, locations and how many

turning surfaces affected?

2. Does the patient have an issue with

excessive sweating?

3. What surface is the patient currently using,

patient’s ability to reposition, be

repositioned, and/or be up in chair?

4. Patient’s height and weight?

5. Is the patient a quadriplegic or paraplegic?

Justification1. The number and location of the pressure injuries

affects the ability to reposition the patient off the

injuries.

2. If the patient has a moisture issue (sweating),

microclimate management (LAL) is needed

3. The surface may need to be upgraded. Manual

repositioning may need to be more frequent (in

bed and chair)

4. The amount and distribution of weight effects the

amount of immersion and envelopment (pressure

redistribution)

5. Quads and Paraplegics are/want to be involved in

their care. Explain the features and benefits of the

surface

Microclimate management with alternating pressure

Microclimate management with lateral rotation (unless a fresh flap)

Pressure Redistribution with control unit. (lateral rotation or

alternating pressure)

Heel elevation

Self adjusting pressure redistribution (air and foam) Control unit for alternating

pressure/lateral rotation

Pressure redistribution

with therapeutic foam

Self adjusting pressure redistribution air and foam

Prevention: Risk Assessment – Waterlow, Braden, Norton, etc.

NPUAP/EPUAP Heel Recommendations

General Recommendations1.Inspect the skin of the heels regularly (SOE=C)* Repositioning for Preventing Heel Pressure Ulcers Ensure that the heels arefree of the surface of the bed (SOE=C)* Ideally, heels should be free of all pressure –sometimes referred to as “floating” the heels. Pressure can be relieved by elevating the lower leg and calf from the mattressby placing a pillow under the lower legs or by using a suspension device ……

1.1 Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of theleg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term useor for individuals who are not likely to keep their legs on pillows. (SOE=B)*The knee should be in a slight (5 to 10 degree) flexion. (SOE=C)*Avoid areas of high pressure, especially under the Achilles tendon (SOE=C)*Use foam cushion the full length of the calves to elevate heels. (SOE=B)* “Pillows placed under the full length of the calves toelevate heels are also appropriate for short‐term use in alert and cooperative individuals” *

Risk Factors For Heel Ulcers

• Diabetic neuropathy, stroke, nerve block after surgery, analgesia

• Peripheral vascular disease, vasopressive medications

• Hip fracture, total knee replacement

• Low serum albumin levels

• The calcaneus of the heel is prominent, extending into the mattress of the bed. Some patients have sharp posterior calcanei, thin soft-tissue padding and heavy feet making them at higher risk

• A 0.8 ankle brachial pressure index provides high sensitivity and adequate specificity to predict pressure ulcer development on the heel.

Additional Assessment Data• Patient’s medical

condition/diagnosis

• Patient’s age

• Incontinence

• Ability to reposition and OOB

• Fall risk level

• Pain level

• Fever

• Poor nutritional status

• Edema

• Bed frame size

• Diastolic < 60 mm/Hg

• Anemia

• Heel risk level

Patient and Caregiver Safety and Mobility

Patient Mobility Assessment

Moving Patients

“Out of Bed, Up in the Chair”Now What?

• Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development (SOE=B)

• Limit the amount of time an individual spends seated in a chair without pressure relief (SOE=B)

NPUAP Clinical Practice Guidelines (Prevention)

1. Anderson, C et al. Lateral rotation mattresses for wound healing. April 2004. Ostomy/Wound Management 50(4) 50-62

2. Bergstrom N, Bennett MA, Carlson DE, et al. Treatment of Pressure injury (ulcer)s. Clinical Practice Guideline, No. 15. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research.

3. AHCPR Publication No. 95-0652. December 1994.

4. National Pressure injury (ulcer) Advisory Panel, Support Surface Standards Initiative (S3I) 2012

5. Sussman Carrie, Bates-Jensen Barbara, Wound Care: A Collaborative Practice Manual, Third Edition, PA: Lippincott Williams & Wilkins: 2007. 2:26-39.

6. International Guideline: Prevention and Treatment of Pressure injury (ulcer)s: Clinical Practice Guideline. 2009, updated 2014. NPUAP/EPUAP/Pan Pacific

7. Identifying the Right Surface for the Right Patient at the Right Time: Generation and Content

8. Validation of an Algorithm for support Surface Selection. McNichol, L. et al JWOCN, Vol. 42/No. 1, 2015

9. Choosing a Support Surface to Prevent Pressure Ulcers. McNichol, L. et. al. American Nurse Today 11/2015, pp. 13-14

10. Creating a Pressure Ulcer Prevention Algorithm: Systematic Review and Face Validation. Rijswijk, L V. et. Al. Ostomy and Wound Management. 11/2013. pp. 28-40

REFERENCES