Cathy Thomas Hess is president and director of clinical operations for Wound Care Strategies, Inc., in Harrisburg, Pa.
Adapted from Hess CT. Managing tissue loads. Adv Skin Wound Care. 2008;21(3):144.
PRESSURE ULCERS remain the biggest challenge wound care practitioners face today. In most cases, pressure ulcers develop when soft tissue is compressed between a bony prominence (such as the sacrum) and an external surface (such as a mattress or the seat of a chair) for a prolonged period. Pressure—applied with great force for a short period or with less force over a longer period—disrupts blood supply to the capillary network, impeding blood flow to the surrounding tissues and depriving tissues of oxygen and nutrients. This leads to local ischemia, hypoxia, edema, inflammation, and, ultimately, cell death. The result is a pressure ulcer.
Shear, which separates the skin from underlying tissues, and friction, which abrades the top layer of the skin, also contribute to pressure ulcers. Contributing systemic factors include infection, malnutrition, edema, obesity, multisystem trauma, and certain circulatory and endocrine disorders.
Taking the pressure off
Support surfaces (also called tissue load management surfaces) are a major therapeutic means to managing pressure, friction, and shear on tissues. Support surfaces are available in various sizes and shapes for use on beds, chairs, examination tables, and OR tables. Used with proper topical skin and wound care, turning, and repositioning, the correct support surface enhances healing of pressure ulcers and helps prevent new ones.
The support surface isn't the only intervention you can use to prevent pressure ulcers. Effective turning and repositioning schedules are the best way to offset pressure in an immobile patient. On admission, healthcare providers should initiate proper policies and procedures, including the use of appropriate support surfaces to treat existing pressure ulcers and prevent new ones.
* Plans and scheduling. A written plan for the use of positioning devices and schedules are helpful for chair-bound and bedridden patients.
* Repositioning. At-risk patients in bed should be repositioned at least every 2 hours if consistent with overall patient goals. Use a written schedule for turning and repositioning the patient.
* Positioning devices. For patients in bed, use positioning devices such as pillows or foam wedges to keep bony prominences (such as knees or ankles) from contact with one another. Follow a written plan.
* Pressure relief for the heels. Immobile patients should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Don't use doughnut-type devices, which just localize pressure to other areas.
* Side-lying positions. When the patient is in the side-lying position, avoid positioning her directly on the trochanter.
* Bed positioning. Keep the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated.
* Lifting devices. Use lifting devices such as a trapeze or bed linen to move (rather than drag) patients in bed who can't help during transfers and position changes.
* Pressure-reducing devices for beds. Any patient at risk for developing pressure ulcers should be placed, when lying in bed, on a pressure-reducing device such as a foam, static air, alternating air, gel, or water mattress.
* Pressure from sitting. At-risk patients should avoid uninterrupted periods of sitting in a chair or wheelchair. Reposition the patient, shifting the points under pressure at least every hour, or put the patient back to bed if consistent with overall patient management goals. If the patient is capable, teach her to shift her weight every 15 minutes.
* Pressure-reducing devices for chairs. Use a pressure-reducing device, such as those made of foam, gel, air, or a combination, for chair-bound patients. Don't use doughnut-type devices.
* Postural alignment. When positioning chair-bound patients, consider postural alignment, weight distribution, balance, stability, and pressure relief. These steps help prevent or reduce pressure on the patient's skin.
Using these strategies in a comprehensive plan of care addresses the first line of defense for patients at risk for skin breakdown. The Wound, Ostomy and Continence Nurses Society (http://www.wocn.org) recently published additional strategies.
Pressure ulcers occur in patients in all healthcare settings. Effective interventions demand a multidisciplinary team approach that coordinates and meets the patient's needs.
© 2009 Lippincott Williams & Wilkins, Inc.