Pressure injury strategy - repositioning, support surfaces and beds
Part of an effective strategy to implement in the prevention and treatment of pressure injuries, should involve being pro-active in three main areas, namely repositioning, support surfaces and beds. Careful consideration in these three areas is vital and should be a part of your individualised pressure management plan.
Repositioning:
1. Reposition all individuals at risk of, or with existing pressure injuries
Repositioning of an individual is undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body and to contribute to comfort, hygiene, dignity, and functional ability.
2. Conduct regular evaluation of organisational performance in pressure injury prevention and treatment and provide feedback to the stakeholders.
Regular repositioning is not possible for some individuals because of their medical condition, and an alternative prevention strategy such as providing a high specification mattress or bed may need to be considered.
Additional Recommendations for Individuals with Existing Pressure Injuries
1. Do not position an individual directly on a pressure injury.
2. Continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual’s response. No support surface provides complete pressure relief.
3. Inspect the skin for additional damage each time the individual is turned or repositioned. Do not turn the individual onto a body surface that is damaged or still reddened from a previous episode of pressure loading, especially if the area does not blanch.
Repositioning for the Prevention of Heel Pressure Injuries
1. Ensure the heels are free of the surface of the bed. Ideally, heels should be free of all pressure:
Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of a leg along the calf without placing pressure on the Achilles tendon.
Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on pillows.
2. The knee should be in slight flexion (5° - 10°)
3. Avoid areas of high pressure, especially under the Achilles tendon. (5° - 10°)
Use a foam cushion under the full length of the calves to elevate the heels.
Pillows or foam cushions used for heel elevation should extend the length of the calf to avoid areas of high pressure, particularly under the Achilles tendon.
When using an aid in the prevention of heel pressure injuries, it is important to consider the affects that the aid may have on other areas of the leg – if it is causing increased pressure in another area, this can block blood flow and increase the risk of DVT development.
Cubro has products that support ‘floating heels’ which is recommended in the prevention and treatment of pressure injury development on the heel. It is recommended that products are designed specifically for this purpose when it is required for long term use as opposed to the ongoing use of pillows.
Conclusions
Once again, recommendations look at specifically designed pressure injury reduction programmes for individuals based on ongoing assessment of risk. It is important to regularly review where pressure is present in an individual and look at repositioning programmes and products that alleviate this pressure. It is also important to consider any changes in the medical or physical condition of an individual to work to accommodate this. Repositioning programmes consider client self-repositioning, active-assisted repositioning and products that support pressure redistribution.
Support Surfaces:
Aims
- Maintain skin integrity;
- Minimise peak pressures and pressure gradients;
- Reduce shear and friction forces;
- Accommodate orthopaedic deformities;
- Maintain/enhance function;
- Aid healing of existing pressure injury;
- Microclimate control;
- Envelopment – the ability of the support surface to conform (or fit, or mould around irregularities in the body);
- Comfort.
When selecting a support surface
Select a support surface that meets the individual’s needs. Consider the individual’s need for pressure redistribution based on the following factors:
- Level of immobility and inactivity;
- Need for microclimate control and shear reduction;
- Size and weight of the individual;
- Risk for development of new pressure injuries; and
- Number, severity, and location of existing pressure injurie(s).
Mattress and Bed Support Surfaces for Pressure Injury Prevention
Pressure redistributing support surfaces are designed to either increase the body surface area that comes in contact with the support surface (to reduce interface pressure), or to sequentially alter the parts of the body that bear load, thus reducing the duration of loading at any given anatomical site.
1. Use a high specification reactive foam mattress rather than a non-high specification reactive foam mattress for all individuals assessed as being at risk for pressure injuries.
Review the characteristics of foam mattresses used in the facility for pressure injury prevention to ensure they are high specification. Consider using other reactive support surfaces for individuals assessed as being at risk for pressure injury development.
2. Use an active support surface (overlay or mattress) for individuals at higher risk of pressure injury development when frequent manual repositioning is not possible. Selection of an alternating pressure mattress/overlay should consider pressure injury risk, comfort of the individual, and effectiveness determined through regular skin assessments.
Microclimate control:
1. Consider the need for additional features such as the ability to control moisture and temperature when selecting a support surface.
The use of specialised surfaces that come into contact with the skin may be able to alter the microclimate by changing the rate of evaporation of moisture and the rate at which heat dissipates from the skin.
A healthy microclimate considers temperature control, humidity and moisture loss or gain. With an increase in humidity and temperature, the skin becomes weaker and less stiff. Excessively dry skin becomes more brittle and liable to break.
Conclusions:
Understanding the specific specifications of a mattress that you provide is a very important part of a pressure injury prevention and treatment programme. Each individual requires different support surface properties, taking into consideration their differing levels of tissue tolerance, individual risk factors, and if they have current pressure area(s). There is a range of different pressure relieving foam mattresses from low specification foam to high specification foam – a standard low specification foam will not meet all requirements in these recommendations. For very high-level pressure care, a support surface that provides enhanced pressure redistribution, shear reduction, and microclimate control is essential.
When considering a support surface for a client’s individual requirements, it is important to consider pressure injury risk factors, body temperature, body mass, transfers/ mobility, moisture and comfort.
Beds:
In conjunction with an appropriate mattress, considering pressure management with a bed is also an important part of pressure injury prevention.
Considerations need to be made for the following areas:
- Profiling.
- Mattress compensation.
- Lying surface.
Profiling:
A profiling bed allows for pressure redistribution and repositioning.
Profiling beds with 4 section electric back and leg sections and with automatic triple action knee break, provide optimal profiling support.
1. Use a 30° tilted side-lying position (alternately, right side, back, left side) or the prone position, if the individual can tolerate this.
1.1 Avoid lying postures that increase pressure, such as the 90° side-lying position, or the semi-recumbent position. (alternately, right side, back, left side) or the prone position, if the individual can tolerate this.
2. Limit head-of-bed elevation to 30° for an individual on bedrest unless contraindicated by medical condition or feeding and digestive considerations..
2.1. If sitting in bed is necessary, avoid head-of-bed elevation or a slouched position that places pressure and shear on the sacrum and coccyx. . .
Sitting time should be limited according to the individual’s skin tolerance and medical status. Flexing the knees and positioning with pillows under the arms may prevent some sliding and slouching when the head of the bed is elevated.
Trendelenburg and reverse Trendelenburg is also a feature incorporated into some profiling beds. This allows either the feet to be raised higher than the head or vice versa. These positions are used for a variety of medical conditions (including use in postural drainage) however they must be used under a clinical management plan.
Mattress Compensation:
Mattress compensation needs to be included in the structure of the bed. This protects the individual from compression when adjusting the back section and leg section at the same time. Sliding towards the end board, resulting in shear, is also needing to be minimised.
Lying surface:
The lying surface in a bed also needs the ability to conform to an individual’s body shape, lying position and posture. The goal of a bed with a slatted bed frame is that the curved slats provide a somewhat elastic base that is designed to adapt to different individuals and sleeping profiles. Heavier parts of the body sink deeper into the bed supporting unique contours of the body in order to create a natural anatomical positon without creating pressure points. This supports the mattress with effective envelopment of an individual. A slatted base also allows for proper ventilation and air circulation, reducing the chance of mould and mildew and consequently, supporting a healthy sleep environment.
Conclusions:
It is advisable to match the pressure care requirements of an individual to both a mattress and a bed when considering the most appropriate management plan. Consider the amount of profiling each bed allows for, as more ability to profile provides increased pressure redistribution and repositioning ability. Mattress compensation within a bed protects the skin integrity of an individual and use of a frame that conforms to the body’s shape, lying position and posture, increases envelopment properties and supports natural anatomical positioning.
How Cubro can help:
Cubro can supply a range of mattresses and beds individualised to your client’s pressure risk requirements. Our mattresses range from standard low specification foam mattresses to a range of high specification foam mattresses. We also supply dynamic alternating air mattresses which meet the requirement for active pressure relief for those individuals with high pressure management requirements.
- For products to assist in pressure injury prevention and treatment please call Sharon Woodward on 0800 656 527.
- Please follow Cubro’s LinkedIn page for regular updates on this topic and other associated articles. Visit cubro.co.nz to view our product range.
