Week 13: Prevention & Off-Loading

ounce of prevention is worth

a pound of cure

Chronic wound incidence

5.7-6.5 million

Main comorbidities

• Diabetes

• Obesity

• Vascular disease

Average cost to heal wounds

$3,927

Locations most susceptible to pressure ulcers in supine

heels and sacrum

Toes are susceptible to pressure from

bedsheet

Sidelying locations susceptible to ulcer development

Ear

Elbow

Acromion (shoulder)

Greater trochanter

Top leg medial epicondyle

Bottom leg lateral epicondyle

Heel

Malleoli

Seated locations susceptible to ulcer development

Head

Angles of scapula

Sacrum

Ischial tuberosities

Heel

Toes

3 principles for positioning to prevent pressure ulcers

1. Spread out the pts weight over a larger surface area

2. Position so bony prominences are not in contact with support surface

3. Changes positions regularly

Position change fx while in bed

Minimum of every 2 hrs

Supine locations susceptible to ulcer development

Occiput

Scapula/shoulder

Elbows

Sacrum/buttocks

Heels

Toes

Position change fx while sitting in a chair

every 15 min

position the shoulder for positioning

ER

Why do we change positions?

So that the pressurized area can reprofuse with oxygen

basic seating principles for ulcer prevention

• Thighs horizontal to ground with knees and hips even

• Feet supported so knees are even with hips

• Back supported to keep normal curves

• Ear, shoulder, hip in alignment

• Support surface ends 1.5-2" behind popliteal fossa

Common seated position for ulcer prevention

90/90/90

or

95 hips / 85 knees / 90-95 ankles

Common supine position for ulcer prevention

knees/ hips flexed 25-30 deg

slight turn to take pressure off sacrum

float heels w/ support under entire calf

hip neutral rotation

dorsiflexion to 90 deg to prevent contracture

Common sidelying position to prevent ulcers

Turned to 30 deg

Upper leg position on pillows w/ slight hip/knee flexion

Upper arm 55 deg of abduction with 30 deg horizontal ADD

How do you maintain the 30 deg turn in sidelying?

Entire trunk and pelvis must be supported

Positioning purpose

Comfort

Redistributing a person's BW over large surface area

Contracture prevention

Keys to pressure ulcer prevention

Education

Positioning

Mobility

Nutrition

Managing incontinence

What should you perform every time when working with a pt in the hospital?

Skin inspection

if someone develops a pressure ulcer in the hospital

• the facility will not get paid to heal it

Turning schedule

Every 2 hrs in bed

Every 15 min in chair

Every hr if dependent on a support system

pressure in sitting vs supine

sitting is more in a smaller area when sitting vs supine

Floating heels

pillow is placed under ankle to allow the heel to hang over the pillow

Trapeze uses can assist with

pressure relief

Trapeze negatives

• people may want to take them home instead of learning how to properly use their legs

How do you identify at risk pts?

Braden scale

Braden scale

Pressure ulcer grading scale ranging from 6-23

Lower score Braden scale

Greater impairment and a higher risk for developing a pressure ulcer

Braden score <18

Pt at risk for developing pressure ucler

Braden score 15-18

mild risk

Braden score 13-14

moderate risk

Braden score <13

High risk

Footcare guidelines

1. Inspect feet daily

2. Do on walk barefoot

3. Do not soak feet

4. Moisturize feet but not b/w toes

5. Toenails cut straight across

6. Seek medical attention if callus forms

7. Control DM/stop smoking

why no moisturizer between the toes

fungal growth

calluses can cause

skin breakdown beneath the,

What should you educate a diabetic pt on?

Footcare guidelines

loss of sensation

diabetic nails should only be cut by a

podiatrist

Duration required to restore oxygen levels to unloaded levels

1-2min of complete relief

What should you recommend prior to surgery?

ABI

Support surface

anything we are sitting or lying on

Types of surfaces

Seat cushions

Mattresses

Mattress overlays

Mattress replacements

integrated bed systems

Factors to consider of the pts status

Body structure

BW

Continence

Risk of development

Dependency/mobility

Factors to consider of the pts needs

pressure redistribution

shear reduction

temperature control

moisture control

when getting a patient out of bed

Lift, don't drag

What happens to the temperature of an area that is pressurized?

Localized temperature increases

increased temperature causes

• metabolic demands of the tissue also increase

3º drop in skin temperature results in a

• 14% reduction in interface pressure

wicking quality

• Takes fluid off skin and redistributes to environment

• Important for incontinence

Devices and support surfaces NOT a substitute for

turning and pressure relief

Breakdown pressure

32 mm Hg

Pressure reducing technologies

lower tissue interface b/w 23-32mmHg

Pressure relieving technologies

lower tissue interface pressure to <23mmHg

Static support surfaces

used to prevent wounds from forming

static support surfaces are used

prophylactically

Static support surface types

Foam

Foam/air

Foam/water

Foam/gel

• mattress replacements or mattress overlays or cushions

Dynamic support surface types

motorized or nonmotorized

Motorized dynamic support system

Electric device that uses air or fluid flow to redistribute pressure more equally across the body

Dynamic support surfaces

electric devices that use currents of air or fluid to redistribute pressure across the body

Nonmotorized dynamic support surfaces

use valve system to redistribute pressure

Immersion

depth of penetration into a support surface

Pressure relief via immersion

air filled cushions that sink down and allow pt to immerse into them

Consideration for immersion techniques

make sure pt doesnt bottom out and hit a hard surface

Pressure relief via envelopment

support surface conforms to body's structure

Materials used in support surface technology

Gel

Foam

Fluid/air-filled bladders

Gel in support surface tech

able to conform in proportion to the load applied to it

Gel disadvantages

affected by temperature

gel cushions in a cold environment

cold and firm

gel cushions in a hot environment

soft and moisture retentive

Gel advantages

doesn't require much maintenance

Key to using foam

thick enough so person doesnt bottom out while sitting on it

With foams we need to ensure

it's not too stiff or dense to limit the ability to envelop or immerse a patient

Fluid/air-filled bladders

fluid moves in chambers in response to pts movement

Features of support surfaces

air fluidized

alternating pressure

lateral rotation

low air loss

Air-fluidized bed

contains collection of tiny beads with a mattress cover-beads are blown upward on warm air.

What population is air-fluidized bed used for?

large burns

large skin grafts

Low-air-loss bed

mattress placed directly on existing bed frame or as overly on other mattress, pressure redistribution and air flow to manage heat/moisture of skin

How does the low-air-loss bed decrease maceration?

Porus fabric for wicking

Blower to get heat/moisture out

Alternating pressure bed

supports the person on a series of compartments that fill with air and then deflate on a rotating basis

Lateral rotation bed

passively move Pt side to side

improve circulation

good for pulmonary Pt and spinal fractures

still need to adjust Pt position

Population common for lateral rotation/roto bed

spinal cord injury

Donut cutouts are not so good because

• the area around the cutout breaks down from higher pressure

NO ULCERS

Nutrition and fluid status

Observation of skin

Up and walking or assist with position changes

Lift, don't drag

Clean skin and continence care

Elevate heels

Risk Assessment

Support surfaces

SKIN

Surface selection

Keep turning

Incontinence management

Nutrition

How to prevent shear during transfers?

Lift, don't drag

• Avoid shear when raising HOB

• Can cause shear to sacral area and low back

policy for lifting patients

• 50lbs per clinician when moving people

floating the heels

• Pillow longitudinally, not sheepskin heel cups

Recumbent position

lying down in any position

Sitting position for <90 deg hip flexion

Cushion for stabilization

Open seat to back angle for accommodation

Sitting position for <90 deg knee flexion

Adjustable/elevating leg rests to accommodate for ROM

A cushion to prevent sliding

calf support

Sitting position for flexible scoliosis

build up the lower side

Cushion w/ pressure elimination at ischials

Pelvic obliquity

one side of the pelvis is lower than the other side, named by the lower side

fixed scoliosis

can't get pelvis level

Adjustable soliosis

able to get pelvis level

Sitting position for fixed scoliosis

build up higher side (bring support surface to meet higher side)

Sitting position for kyphosis

Tilt chair back so head and trunk align

Pillow/support under dowagers hump and head

Sitting position for below knee amputee

Stump board

cushion under legs