care REPOSITIONING AND PRESSURE WOUND PREVENTION IN THE SEATED INDIVIDUAL

Pressure wounds are common and costly, impacting negatively on health and social gain (Moore et al, 2011). Pressure wounds will only occur when individuals are exposed to prolonged externally applied mechanical forces (Bader, 1990). Therefore, pressure wounds mainly occur in those with mobility/activity difficulties, as these impact on the individual’s ability to alter their position, which relieves pressure over bony prominences.

The ability to reposition is often diminished in the very old, the malnourished and those with acute illness (Fisher et al, 2004; Lindgren et al, 2004; Robertson et al, 1990).

Those with spinal injury and musculoskeletal disorders are also at high risk of immobility. Changing population demographics and the expected rise in the number of elderly persons, suggest that pressure wound prevalence and incidence is set to increase (Moore and Cowman, 2011). Pressure wounds can be prevented by determining those who are most at risk and implementing effective prevention strategies (Moore et al, 2011). Repositioning is a powerful yet practical preventative measure that is within the domain, power and control of all healthcare professionals (Moore et al, 2011). This article focuses on repositioning as a component of pressure wound prevention in the acutely ill seated individual.

“The presence of a pressure wound impacts negatively on the individual’s quality of life and may contribute to increased mortality. Pressure wounds develop due to exposure to prolonged, unrelieved external mechanical forces. For the seated individual, the risk is greater than for those nursed in bed. This is due to the relatively small surface area which is absorbing the high pressures. Repositioning is advocated by international guidelines as being central to the prevention of pressure wounds.”

Adapted from Woundsinternational.com, Wounds UK, 2011, Vol 7, No 3

Impact of external mechanical forces on tissues

The exact mechanisms by which externally applied mechanical forces result in pressure wound development are not clearly understood (Bader, 1990; Bader and Oomens, 2006; Stekelenburg et al, 2008; Stekelenburg et al, 2006). However, it is postulated that there are four mechanisms within three functional units which lead to pressure wound development (Stekelenburg et al, 2008). The functional units are the capillaries, the interstitial spaces and the cells (Nixon et al, 2005). The mechanisms are:

• Local ischaemia

• Reperfusion injury

• Impaired interstitial fluid flow and lymphatic drainage

• Sustained deformity of cells (Bouten et al, 2003; Stekelenburg et al, 2006)

The external forces which probably cause the internal effects described above are:

• A vertical force (pressure deformation)

• A horizontal force (shear deformation)

• Microclimatic factors, as a build up of temperature and humidity

Defloor (1999) posits that there is a conceptual scheme for pressure wound development that includes four elements:

• Pressure

• Shearing force

• Tissue tolerance for pressure

• Tissue tolerance for oxygen

Planning pressure wound prevention in the acutely immobile individual involves deliberation of the following:

• Risk assessment

• Type of chair

• Duration of sitting

• Method of repositioning

• Use of pressure redistribution devices (Stockton et al, 2009).

Risk assessment

Pressure wounds occur due to prolonged unrelieved exposure to externally applied mechanical forces (Kosiak, 1959; EPUAP/NPUAP, 2009).

Those who are vulnerable to exposure to this pressure are the immobile, with the older person population demonstratng the highest propensity to mobility problems (Bergstrom et al, 1996; Casimiro et al, 2002; Goodridge et al, 1998; Moore, 2008). Therefore, it is logical that activity and mobility are the highest predictors of risk, as it is these factors that cause an individual to be exposed to pressure. If the individual does not demonstrate mobility or activity problems, other factors such as nutrition, incontinence and age are not relevant in terms of pressure wound risk, because the individual must firstly be exposed to prolonged, unrelieved external mechanical loading (Moore et al, 2011). Thus, it is postulated that there are a combination of factors interplaying which lead an individual to be susceptible to pressure wound development — pressure and shear, time and the individual (Defloor, 1999).

Pressure and shear must be present for a pressure wound to develop, with the effect of pressure and shear being time-dependent. The time it takes a pressure wound to develop will be influenced by the general condition of the individual (Moore and Cowman, 2011). As such, the authors argue that the risk assessment process should begin with an assessment of mobility and activity, followed by a more complete assessment should these impairments be identified. In this way, the process is simplified and focuses attention to the key causative factor, namely, pressure.

Type of chair

Stockton et al (2009) suggest that there are a number of important considerations when planning seating for a dependent individual. These relate to the chair itself and to the posture the individual adopts when seated. A backrest that is designed to follow the shape of the back increases the contact area and reduces pressure on seating and the risk of sliding forces (Stockton and Flynn, 2009).

The chair should be the right height, so that the patient can sit comfortably with their feet on the floor or on a foot rest, as appropriate (EPUAP/NPUAP, 2009). When the person is seated, their position in the chair should be checked to ensure that no aspects of the chair are pressing into the knees or thighs, which could cause a pressure wound to develop in these areas (Stockton et al, 2009). The chair also needs to be of the correct width to accommodate the patient, including the pressure-reducing device in use

(Stockton et al, 2009). If the chair is too narrow, this may cause excess pressure on the hips leading to an increased risk of pressure injuries. Alternatively, if the chair is too wide, this may cause instability or pelvic obliquity leading to increased pressure and shear forces (Sprigle et al, 2003). Furthermore, the movements of the patient will be restricted, which again increases pressure wound risk and a feeling of insecurity in the chair (Stockton et al, 2009).

There is no one position that is suitable for all persons. However, seating stability, ease of transfer and maintenance of functional ability are key influencing factors in posture selection for the seated individual (Stockton et al, 2009). The posture the patient adopts will influence the likelihood of pressure wound development. Therefore, bearing in mind that more regular repositioning reduces the incidence of pressure wounds (Moore et al, 2011), the position of the person should be checked often, by the individual responsible for the care of the patient. The EPUAP and NPUAP (2009) guidelines suggest that the posture adopted should ensure that exposure to pressure and shearing forces is minimised. Furthermore, the position should not adversely influence the individual’s ability to carry out their activities of daily living (EPUAP/NPUAP, 2009).

Duration of sitting

When seated, the risk of developing a pressure wound is increased due to the relatively small area of the body which is carrying the entire load (EPUAP/NPUAP, 2009). Therefore, it is recommended to reduce the duration of sitting to less than two hours at any one time (Stockton et al, 2009). However, some patients may only be able to tolerate sitting for shorter durations and a careful assessment of the patient and their response to sitting out should influence care planning. Specifically, the skin should be assessed for changes in integrity, including localised heat, oedema or hardness. Furthermore, the comfort of the patient should be noted (EPUAP/ NPUAP, 2009). Allowing the patient to rest in bed for periods throughout the day will relieve pressure and also reduce fatigue, thereby enhancing well-being (Bliss, 2004). The specific length of time the patient rests in bed during the day will be influenced by the individual needs of the patient, however, it is important to ensure that repositioning continues while in bed (Moore and Cowman, 2011).

Use of a pressure redistribution device in the chair

The underlying principles for use of specialised seating cushions are to redistribute pressure and to dissipate heat and humidity. All patients at risk of pressure wound development due to activity and mobility difficulties should have a suitable pressure redistributing cushion in use (EPUAP/ NPUAP, 2009). The first issue of concern in cushion selection relates to comfort: the cushion should be acceptable to the patient and should not impede activities of daily living (EPUAP and NPUAP 2009). Further considerations in cushion selection relate to the following individual patient factors:

• Highly localised stresses

• Heat accumulation

• Moisture accumulation

• Poor sitting posture and positioning

• Poor trunk stability

• Degree of sensation

• Regular relief of stresses by movement (Ferguson-Pell, 1992)

There is limited evidence to suggest which pressure redistribution cushion is most effective (McInnes et al, 2011). As patient factors play a key role in selecting the most appropriate system, it is wise to seek advice from a seating expert.

Pressure forces are strongly dependent on the cushion material features and how the pressure is redistributed by the cushion (Sprigle et al, 2003).

Seating materials have a redistributing effect in two ways: immersion (how far it is possible to sink into the material) and envelopment (capability of a support surface to deform around and encompass the contour of the human body) (Sprigle and Sonenblum, 2011). Different materials accommodate body loads in different manners. Foam and air are compressed, whereas fluids are displaced. However, compression and displacement are dependent on the size of the bladder (fluids and air) and the tension of the cover (Sprigle and Sonenblum, 2011).

Conclusion

Pressure wounds are common, costly and impact negatively on health and social gain. They occur in those who are exposed to unrelieved external mechanical forces, with activity and mobility factors being the highest predictors of pressure wound risk. The older population display the greatest propensity for pressure wound development due to problems with activity and mobility. Furthermore, those with spinal injury and musculoskeletal disorders, for example, are also at high risk of immobility.

Repositioning is a key component of pressure wound prevention strategies. It is important that this should be undertaken not only when the individual is in bed, but also during seating. All members of the multidisciplinary team have a role to play in pressure wound prevention, and the skills and expertise of the physiotherapist and occupational therapist may be of particular value.

During seating, the individual’s health and well-being and specific activities of daily living need consideration. Repositioning should not adversely impact on healthrelated quality of life, which should be balanced against the need for effective pressure relief. The chosen method of repositioning should be determined after an assessment of the individual needs of the person and monitored through accurate and ongoing assessment. All components of pressure wound prevention strategies need to be actively implemented to ensure a reduction in prevalence and incidence figures. In doing so, each healthcare provider will be actively participating in the guidance from the National Patient Safety UK ‘10 for 2010’ programme, by working towards preventing all preventable pressure

Key Points

• Risk assessment should be conducted to identify those with activity and mobility difficulties.

• Repositioning the immobile seated individual is central to the success of pressure wound prevention strategies.

• Assessment of the individual and their skin will help to determine their tolerance of the planned repositioning regimen.

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pressure care

Traditional Manual Methods Of Repositioning Versus Automated Repositioning

- WHICH IS BETTER?

A new study has investigated the clinical effectiveness of frequent repositioning – and the findings show that you can prevent ALL pressure wounds with frequent repositioning.

Frequent and automatic repositioning can be achieved with our automated 30-degree side positioning mattress, Turn All.

The traditional way to avoid the formation of pressure injuries involves a family member, caregiver, or institutional worker regularly turning and stabilising the patient (it is recommended that this be done every two hours) in a new position to relieve tissue compression and restore blood flow. This manual handling process has to be done around the clock and unfortunately has a significant number of disadvantages that include:

• The immobilised patient is woken up at night by the repositioning process

• Caregivers, family members or institutional staff may suffer serious back injuries from the manual handling involved

• Caregivers or family members must be present 24 hours a day and this can lead to severe insomnia and emotional stress

• In institutional settings, the need to frequently turn immobilised patients is expensive, because of the additional hours of staff time required to care for them

• The patient may be in a home environment where family members are physically incapable of regularly turning them

• If the support available at home is inadequate, it may be necessary to relocate patients to a long term institutional care setting, with the resulting loss of privacy, dignity and independence

How the Turn All™ System Works

Prior to starting the Turn All™ automated lateral repositioning system, ensure the patient is in a supine position, in the centre of the bed.

When the Turn All™ system commences operation, it gradually inflates one side evenly and quietly, lifting the outer edge of the mattress directly above to form a ‘wing’ that supports the entire length of the patient’s body, from ankle to shoulder.

At the same time the Turn All™ system partially inflates the air cells on the opposite side, to evenly lift that edge of the mattress above sufficiently to counteract any potential for the patient to slip and experience skin shear that could lead to pressure injuries. The support this feature provides also assists in reassuring and comforting the patient.

Any pressure transferred to the patient’s side, while being gradually turned, is evenly distributed along the entire length of his or her body.

When Turn All™ reverses the rotation, both sides gradually lower until the mattress is in a horizontal position again.

Turn All™ then automatically switches to the other side to complete the cycle.

Benefits for Patients

The features of the Turn All™ System provide a number of important benefits for immobilised bed users such as:

• The automated repositioning process allows for more frequent repositioning to address pathophysiological events associated with immobility. Also referred to as kinetic therapy, this bidirectional lateral turning not only provides pressure relief to prevent or treat pressure injuries, but it can also produce, for example, a dramatic reduction in the incidence of respiratory problems and urinary tract and bladder infections (9).

• Significantly better sleep quality, as the patient does not have to be turned manually at night and is not disturbed by the gentle and gradual rolling action of the Turn All™ system. This results in better mental clarity, improved health and a more satisfying lifestyle, free from dependence on caregivers at night (5).

• The possibility of living at home instead of in an institution

• Pain reduction - Even heavy patients are positioned gently

• Better blood circulation - Turn All™ can still laterally turn a patient when the torso is in an elevated position up to 30°. This is a significant benefit for people who receive tube feeding.

• Prevention or reduction of gastroesophageal reflux

• Assists the release of upper respiratory tract and oral secretions for improved respiration (6).(7).(8).

• Reduction in spasticity and abnormal muscle tone, improving comfort

• Improved bowel regularity

• No dehydration and subsequent electrolyte imbalance, as Turn All™ does not generate heat

• Side support system - As the Turn All™ system begins the lateral turning process, it also slightly lifts the mattress edge, on the opposite side, to counteract any risk of slipping and shear and provide additional support and reassurance for the patient.

Benefits for care givers

There are a number of significant benefits accruing to institutions as a result of investing in Turn All™. These include:

• Increased Productivity - Turn All™ significantly reduces the amount of time that nursing and auxiliary staff need to allocate to the manual turning of patients, allowing them to dedicate more time to other important clinical care functions

• Improved Standard of Pressure Care Treatment - the Turn All™ system is simple to operate and because of the way it gradually and gently laterally turns a patient from supine through 30° of side lying and back again, it is effective in the treatment and prevention of pressure injuries and other complications of immobility. In addition, because this process is automated, Turn All™ ensures a greater degree of consistency and reliability in the treatment of these patients

• Reduced Outlay on Specialised Equipment - Turn All™ is designed to function on any standard care bed with a removable mattress. Installation is simple and can be easily accomplished by a caregiver in just a few minutes

• Reduced Manual Handling Injuries and Associated Costs

- Turn All™ removes the need for staff to laterally turn patients (for pressure care treatment), eliminating a manual handling task known to cause a significant number of debilitating back, neck and shoulder injuries, along with the costs associated with absenteeism, workers’ compensation claims and the hire of replacement staff.

• Decreased Staff Turnover - with the introduction of Turn All™, healthcare facilities can expect a reduction in manual handling injuries and a commensurate rise in morale and improved staff retention, leading to lowered recruitment and training costs for new employees and less reliance on casual replacements

• Spinal cord injuries causing paraplegia and quadriplegia (with or without ventilator)

• Muscular dystrophy and multiple sclerosis

• Severe head injuries and stroke

• Severe respiratory ailments such as chronic obstructive pulmonary disease

• Immobility due to aging

• Cancer

• Guillain Barre Syndrome

• AIDS

• Coma

• Amputations

• Osteomyelitis

• Degenerative disc disease, postspinal fusion and laminectomy

• Rheumatoid Arthritis

• ALS

• Any other condition where turning assistance is required

(5). Quality of sleep in the medical department. Article in The British journal of clinical practice · July 1992.

Amos M YinnonShaare Zedek Medical Center. Gheona Altarescu Shaare Zedek Medical Center. Boaz Tadmor Rabin Medical Center.

(6). Staudinger et al (2010) patient receiving CLRT are less likely to contract ventilator associated pneumonia and other pulmonary complications and their readmission rates are lower that patient who did not receive the therapy.

(7). Swadener, L. (2010). Continuous lateral rotation therapy. American Association of Critical Care Nursing 30 (2), S5-S7.doi:10.4037/ccn2010766

(8). 36. Vollman KM (2004). The right position at the right time: mobility makes a difference. Intensive Crit Care Nurs,20:179-182

(9). Ahrens T, Kollef M, Stewart J, Shannon W (2004). Effect of Kinetic Therapy on Pulmonary Complications. American Journal of Critical Care, 13(5): 376-382

Bedridden people who do not turn or reposition often enough have a significant risk of developing pressure injuries (most often on the buttocks, sacrum, hips and heels - also known as decubitus), kidney, bladder or lung/respiratory infections and a range of other medical complications.

The Levabo Turn All™ lateral turning system has been developed to assist clinicians and carers in the acute, aged, community and home care settings. It is designed to streamline the delivery of consistent and effective pressure care for vulnerable immobile patients, with pre-existing pressure injuries, as well as providing protection for those at risk of developing them.

Fits On Most Beds

Designed to be positioned under a static or dynamic mattress, on a standard bed, with or without electric profiling.

Consistent And Controlled Turning

The system automatically rolls the patient into a sidelying position, gently and quietly, reducing the need for manual handling intervention from care givers.

Side Support Function

The Side Support function is a safety feature that reduces the risk of skin shear, while increasing the patient’s feeling of security, by slightly raising the edge of the mattress on the side they are being gradually and gently rolled towards.

manual handling