SUPPORT SURFACES

Vohra Wound Care Certification Course

Disclaimer:
This presentation is for informational purposes only. Every patient and medical situation is unique, and medical decisions should be
based on standard of care and medical practices. Views expressed in this presentation are the sole opinion of the presenter.

Learning Objectives
• Understand the concepts of pressure redistribution, repositioning, and offloading
• Know the mechanical forces involved in the development of pressure wounds
• Identify various categories of support surfaces
• Learn to correctly choose support surfaces based on the patient’s needs

Risk Factors for Pressure Ulcers

Pressure-induced injury is a complex process that is caused by internal and external factors. Pressure on the skin
that exceeds pressure within the arterioles prevents tissue perfusion (oxygen, nutrients, etc.). Cellular wastes
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accumulate, which become toxic (e.g. free radicals). This usually occurs where tissue presses on bony
prominences.
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Researchers have identified over 100 risk factors for pressure ulcers and soft tissue injuries. Some influence a
person’s susceptibility to developing one of these wounds, while others contribute to the size and severity of the
lesion.
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Major risk factors for pressure ulcers include
• Skin integrity – Skin provides an important natural barrier to injury
• Moisture control – Moisture can lead to dermatitis and foster microorganisms
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• Tissue perfusion – Tissue healing requires adequate tissue perfusion
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• Repositioning – Immobility strongly predisposes to pressure-induced injury
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• Mechanical Load – Degree of pressure and time correlate with injury
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• Friction and Shear Forces – These forces aggravate the effect of pressure.
Malnutrition and sensory loss are other important risk factors.

Age-related skin changes contribute to pressure ulcer formation

• Flattening of the epidermal/dermal junction
• Dehydration
• Decreased tissue elasticity and metabolism
• Reduced vascularization
• Disorganization and loss of collagen fibers
• Reduced vascularization

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Support Surfaces Vohra Post-Acute Physicians
Choosing the Correct Support Surfaces
Since pressure over a discrete area is the primary requirement for pressure ulcers, supportive surfaces that
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reduce discrete areas of sustained pressure are important for pressure ulcer prevention.

Factors to consider when choosing appropriate support surfaces

Key Characteristics of Support Surfaces

• Pressure redistribution – Decreases magnitude and shear on bony prominences
• Immersion – Degree with which an object embeds itself into a substance
• Envelopment – Degree to which a surface conforms to accommodate irregularities in an object
• Pressure gradient – Objects move from an area of high pressure to low pressure
• Low shear and friction forces – Gravity pulls a body down a bed, resisted by friction

Temperature and Moisture

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• Increased body temperature increases metabolism and oxygen use
o Increase of 1.0°C (1.8°F) = 10% increase in metabolism

• Moisture (perspiration, urine, feces, fistula, wound drainage) may lead to tissue maceration

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Support Surfaces Vohra Post-Acute Physicians
Mattresses and Bed Surfaces
Features of a mattress/bed surface that may prevent or reduce pressure ulcers include:
• Alternating pressure
• Lateral rotation
• Elevation of head and feet
Low Air Loss Mattress
Types of Bed Surfaces
• Regular bed
• Foam mattress
o Reduces pressure
• Low air loss
o Increased air flow manages heat and humidity
o Weight adjusted
o Lost air replaced by a pump
• Air fluidized
o Air forced through silicon beads
Low air loss mattress may be indicated in
• Multiple unresolved stage II pressure ulcers on trunk or pelvis with one month appropriate treatment
• Recent flap or skin graft for a pressure ulcer on trunk or pelvis and was on a group 2 or 3 surface prior to
discharge from hospital or nursing facility
• Significant Stage III or IV pressure ulcer on trunk or pelvis
Sitting Cushions
Prolong sitting can also lead to pressure ulcers in non-bedridden patients
• Foam cushion Roho Cushion
o Can be contoured to aid immersion
• Gel cushion
o Viscoelastic substance that increases envelopment
• Roho cushion
o Individual air filled cells
o Pressures shift depending on load

Lower Extremity Devices

Consider three factors
1. Ambulation – Is the patient walking?
2. Risk Area Location – Heel of the foot?
3. Factors Affecting Risk – Does the patient have postural or gait disturbances, external foot rotation?
Types of devices
• Multipodus boot (for walkers)
• EZ boot (best for walking, less so for bed)
• Foams boots (OK for non-ambulatory patients)
• Foam block (good for chronic external foot rotation)
• Air boot (washable, foam is not)

Pressure ulcer prevention and treatment should be individualized. Follow the patient’s specific
needs when choosing support surfaces from the many options available. Remember to reevaluate
often, as patient needs change.

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Support Surfaces Vohra Post-Acute Physicians
Recommended Reading
Exton-Smith AN, Sherwin RW. The prevention of pressure sores. Significance of spontaneous bodily movements.
Lancet. Nov 18 1961;2(7212):1124-1126.
Lyder CH. Pressure ulcer prevention and management. Jama. Jan 08 2003;289(2):223-226.
Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. Jama. Aug 23 2006;296(8):974-
984

References
1. Smart H. Deep tissue injury: what is it really? Adv Skin Wound Care. Feb 2013;26(2):56-58.
2. Lyder CH. Pressure ulcer prevention and management. Jama. Jan 08 2003;289(2):223-226.
3. Coleman S, Nixon J, Keen J, et al. A new pressure ulcer conceptual framework. J Adv Nurs. Oct
2014;70(10):2222-2234.
4. Whitney JD. The influence of tissue oxygen and perfusion on wound healing. AACN Clin Issues Crit Care Nurs.
Nov 1990;1(3):578-584.
5. Exton-Smith AN, Sherwin RW. The prevention of pressure sores. Significance of spontaneous bodily movements.
Lancet. Nov 18 1961;2(7212):1124-1126.
6. Gefen A. Reswick and Rogers pressure-time curve for pressure ulcer risk. Part 2. Nurs Stand. Jul 22-28
2009;23(46):40-44.
7. Reuler JB, Cooney TG. The pressure sore: pathophysiology and principles of management. Ann Intern Med. May
1981;94(5):661-666.
8. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. Jama. Aug 23 2006;296(8):974-
984.
9. Baracos VE, Whitmore WT, Gale R. The metabolic cost of fever. Can J Physiol Pharmacol. Jun 1987;65(6):1248-
1254.

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Support Surfaces Vohra Post-Acute Physicians