SEATING, POSITIONING AND SUPPORT SURFACES Lecture by : DR. PREM LATA Scanned with CamScannerPOSITIONING In addition to the NPUAP-EPUAP Guidelines for repositioning, a number of recommendations exist with regard to positioning for management of tissue loads. The following positions are commonly used to reposition patients on horizontal surfaces: + A prone position with rotation of 30 degrees to the right or left + A supine position with 30 degrees of rotation to the right or left + A supine position with slight right or left sacral relief + A supine position with the head of the bed elevated 30 degrees or less and the feet blocked. + A supine position with the head of the bed elevated 30 degrees or less and the knees flexed with the bed. Scanned with CamScannerIn all of these positions, the heels must be elevated with pillows or other devices. + Note the use of pillows and towels to separate and protect bony prominences. Additional positioning technique includes blocking the feet and knees in a flexed position to prevent shear forces created when the patient slides down in bed. For instance, foam wedges or pillows, used to position the patient on his or her side, can be altered slightly every 15 minutes. Scanned with CamScannerSEATING, POSITIONING AND SUPPORT SURFACES + Multiple intervention strategies are needed to prevent and treat pressure ulcers Managing loads on the skin and associated soft tissue is one of these strategie comprehensive care plan should include pressure redistribution strategies for individuals both while in bed and when seated. + Properly chosen support surfaces; adequate periodic pressure redistribution: protection of especially vulnerable bony prominences, such as the heels. sacrum. and coceyx: and consideration of special patient needs are all essential components of the care plan. - + Tum and position bed-bound clients every 2 hours if consistent with overall care goals. Use a 30-degree lateral side lying position: do not place client directly on their trochanter. Protect high-risk areas such as elbows. heels. sacrum. back of head from friction injury. Scanned with CamScanner¢ Akey study found that when sitting naturally for 1-2 hours, only a small amount could lead to the development of a pressure injury, as body weight in this position is redistributed over a smaller area, resulting in high pressure in the buttocks. * Choosing the right seating and surface influences pressure injury. The chair should be the correct width so the person fits comfortably into the chair. + Instability while seated can lead to sliding. Seating Matters have further demonstrated through the use of their chairs. Scanned with CamScannerBack =4% Bw Anns =2% By Butteckstnighs =75% Biv i Feet =18% Byy ischial tuneresities|) Scanned with CamScannerREPOSITIONING FOR PREVENTION OF PRESSURE (ULCER Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body Strength of evidence Repositioning frequency will be determined by the individual’s tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, the support surface used, and assessments of the individual’s skin condition. Repositioning should be undertaken using the 30-degree tilted side-lying position (alternately, right side, back, left side) or the prone position if the individual can tolerate this and her/ his medical condition allows. Avoid postures that increase pressure, such as the 90- degree side-lying position or the semi-recumbent position. If sitting in bed is necessary, avoid head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. Position the individual so as to maintain his/her full range of activities. Scanned with CamScanner* A support surface is a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and other therapeutic functions * Types of surfaces include mattresses, integrated bed systems, mattress replacements, mattress overlays, and seat cushions. * Support surfaces redistribute the body’s weight and protect the skin’s tissue while providing for proper body alignment, comfort and, as part of a seating system, postural control during functional movement. Scanned with CamScannerSupport Surface Performance Parameters Nine parameters must be considered when evaluating the characteristics of a support surface for the patient with a wound: Redistribution of pressure Moisture control Temperature control Friction control (between patient and product) Infection control Flammability Life expectancy Fail safety Product reputation Scanned with CamScannerPressure Redistribution + Pressure redistribution is the ability of a support surface to distribute load over the contact areas of the human body. + The redistribution of pressure reduces the magnitude of pressure and shear forces, both of which can cause excessive tissue distortion and damage soft tissue. + Pressure (stress) is defined as force per unit area; the pressure distribution is influenced by mechanical and physical characteristics of the support surface, mechanical properties of the body’s tissue, and weight distribution (posture). Scanned with CamScanner1.Immersion ¢ The fundamental strategy for reducing pressure near a bony prominence is to allow the prominence to be immersed into the support surface. ¢ For example, when a person is sitting on a relatively hard cushion, a disproportionately large portion of his or her body weight is born by the tissue beneath the ischial tuberosities. ¢ Ona softer surface, the ischial tuberosities and buttocks may immerse more deeply, even to the level of the greater trochanters. Scanned with CamScanner». Envelopment Envelopment is the ability of a support surface to conform to or mold around irregularities in the body. Good envelopment implies that the surface conforms to the body without a substantial increase in pressure. Examples of irregularities are bedding, or seat covers, and protrusions of bony prominences. A fluid support medium would envelop perfectly Scanned with CamScannerShear and Friction Reduction The term shear can be used to reference shear stress or shear strain, and that can be a source of confusion. Shear stress refers to forces applied tangentially over an area of tissue that induce deformation. Shear strain is a part of the overall tissue deformation that occurs on all supporting surfaces. For example, when the head of a bed is raised or lowered, if the skin over the sacrum does not slide along the surface of the bed, or the bed does not absorb the resulting shear force by deforming in the horizontal direction, the effect will be a shearing of the soft tissue between the sacrum and the support surface. Scanned with CamScannerSliding tendency due to gravity / Forces resisting the sliding tendency Friction and shear forces. This illustration shows the friction and shear forces acting on a person ying in bed, Scanned with CamScannerTemperature Control One of the extrinsic factors in pressure ulcer development, temperature, has not been definitively investigated. However, some clinical trials have shown that the application of repetitive surface loading alone induces an elevated skin temperature of 41°F or greater. In addition, peak skin temperatures have been found to be proportional to the magnitude and duration of the applied pressure. Any increase in temperature in combination with pressure is believed to increase the susceptibility of the tissue to injury either from ischemia or reperfusion injury when the pressure is relieved. Scanned with CamScannerNioistur Control Moisture is another key extrinsic factor in pressure ulcer development. The sources of skin moisture that may predispose the skin to breakdown include perspiration, urine, feces, and fistula or wound drainage. Excessive moisture may lead to maceration of the skin. However, good moisture management also provides the following benefits: increases wound healing rates (up to 50% faster in most cases) lowers the risk of infection and minimizes the need for antibiotics. Facilitates angiogenesis. Scanned with CamScannerMaterials and Components Used in Support Surface Systems The components and materials described here are the most commonly used in support surface systems and may be used alone or in combination. They include foam, gel pads, fluid-filled bladders, viscous fluid, and elastomers. + Foam + Elastic Foam + Viscoelastic Foam + Elastomers + Fluid-Filled Bladders and Compartments Scanned with CamScannerFoam + Foam may be elastic or viscoelastic and may be comprised of open or closed cells. + Open-cell foam is defined as a permeable structure in which the cells are interconnected and allows air or fluids to pass between them. * Closed-cell foam is a non-permeable structure comprised of isolated cells that are not connected. Scanned with CamScannerElastic Foam ¢ Elastic foam is a type of porous polymer material that conforms in proportion to the applied load. * Consequently, greater loads result in predictably greater deformations, and vice versa. ¢ Elastic foam is resilient, meaning that it returns to its nominal shape or thickness once load is removed. Scanned with CamScannerScanned with CamScannerCutout 1) Segmented Scanned with CamScannerViscoelastic Foam + Viscoelastic foam is a special type of open cell foam that compresses under load like elastic foam but has other unique qualities. + Viscoelastic foam is sometimes referred to as “memory foam” because it contours to the body and its elastic response diminishes over time. + Viscoelastic foam comes in a variety of stiffness so it can allow immersion similar to a similar elastic foam. Scanned with CamScannerScanned with CamScannerElastomers + Soft elastomers are rubber-like materials and are sometimes referred to as solid gels. For use in support surfaces, elastomers are often used on top of other materials because they tend to be heavy. + Elastomers have a high heat capacity and conductivity. + This is evidenced by the many elastomeric products designed to be heated or frozen to provide relief to a sore body part. When used as a support surface, an elastomer will absorb body heat so the interface temperature will not rise as quickly: . + This allows elastomers to feel cooler once they are sat upon. Scanned with CamScannerFluid-Filled Bladders and Compartments * Fluid-filled products may consist of small or large chambers filled with air, water, or other viscous fluid materials, such as silicon elastomer, silicon, or polyvinyl. Scanned with CamScannerScanned with CamScannerFeatures of Support Surfaces ¢ Air-Fluidized * Low-Air-Loss ¢ Lateral Rotation Scanned with CamScannerAir-Fluidized + A support surface with an air-fluidized feature provides pressure redistribution via a fluid-like medium created by forcing air through beds as characterized by immersion and envelopment. * These beds were originally developed in the late 1960s for use with burn patients. + Air-fluidized beds use fluid technology to decrease pressure through the principle of immersion while simultaneously reducing shear. Scanned with CamScannerScanned with CamScannerLow-Air-Loss ¢ Low-air-loss is a feature of a support surface that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin: * Low-air-loss systems use a series of connected, air-filled cushions or compartments, which are inflated to specific pressures to provide loading resistance based on the patient’s height, weight, and distribution of body weight. ¢ An air pump circulates a continuous flow of air through the device, replacing air lost through the surface’s pores. Scanned with CamScanner7 te, bangs from the back of Scanned with CamScanner