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PURPOSE: To enhance the learner's competence with knowledge of forces that affect skin breakdown and available bed surface support selections to help reduce the incidence of pressure ulcers (PrUs).
TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.
OBJECTIVES: After participating in this educational activity, the participant should be better able to:
1. Compare and contrast use of active and reactive support surfaces.
2. Relate pressure, friction, and shear forces to use of active and reactive support surfaces in prevention of PrUs.
3. Apply the principles learned from this activity in determining appropriate support surface selections for patients with various clinical scenarios.
ABSTRACT: The prevention and management of pressure ulcers, including support surface selection, are a primary focus of healthcare providers. This article discusses the forces contributing to pressure ulcer formation and explores choosing therapeutic support surface features based on the patient's clinical needs and on using the evidence-informed support surface algorithm and decision trees.
Therapeutic support surfaces are a critical component of a pressure ulcer (PrU) prevention or management plan. In the United States, the overall prevalence of PrUs is 12.3%, with 10% of these ulcers described as device related.1 In Canada, 26% of patients in the healthcare system have a PrU, with 70%of the ulcers being potentially preventable.2 Considering these statistics, the prevention and management of PrUs including support surface selection for pressure redistribution should be a primary focus of healthcare providers.
Cost is usually a consideration, but the most expensive surface is not always a "better" surface. No single support surface is best for all patients under all circumstances. The best surface for an individual needs to be based on a patient assessment, understanding of the forces acting on that patient, the needs of the care provider, and the location of the patient.3 Ultimately, the features of the support surface must match the identified needs of the patient.
In this article, the discussion is limited to the use of flat support surfaces for the recumbent position, including integrated bed systems, mattress replacements, and mattress overlays. By reading this article, clinicians will be better able to interpret terms associated with support surfaces, determine when to refer to other members of the interdisciplinary team, and apply algorithm use for support surface selection.
The National Pressure Ulcer Advisory Panel (NPUAP) established a common definition for support surfaces through a consensus process involving interprofessional volunteers.4A support surface is defined as: "A specialized device for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions (ie, any mattresses, integrated bed system, mattress replacement, overlay, or seat cushion or seat cushion overlay)."4 In the past, terms including pressure relief, pressure reduction, static, dynamic, prevention surface, or treatment surface have been used to describe these therapeutic support surfaces. The terms did not have a consistent, reliable definition, making the discussion and comparison of different surfaces or study results difficult.
Two distinct types of support surfaces have now been defined: reactive support surfaces and active support surfaces.4 Areactive support surface is "a powered or nonpowered support surface with the capability to change its load distribution properties only in response to applied load."4 See Table 1.
Examples of reactive support surfaces include a memory foam replacement mattress, a static air overlay (goes on top of the patient's current mattress), or a low-air-loss mattress. Note that, although powered, low-air loss is considered a reactive support surface. Low-air loss is defined as "a feature of a support surface that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin."4
An active support surface is "a powered surface with the capability to change its load distribution properties, with or without applied load."4 See Table 2.
In other words, this type of surface changes the pressure against the patient's skin regardless of whether the patient moves in the surface. Examples of active support surfaces include an alternating pressure mattress or a lateral rotation mattress.
Alternating pressure is "a feature of a support surface that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters."4
From a clinical perspective, there is little guidance as to the appropriate settings for an alternating air surface's parameters. Some laboratory evidence suggests that slower rates of change are better than faster rates of change5 and that repeated loading and unloading of tissue may decrease functional capillary density.6 In a review of the literature on alternating air, Vanderwee et al7 concluded that, although these surfaces are likely better than standard hospital mattresses, more study is required. It is also important to note that technical problems occur with these surfaces due in large part to incorrect use.7
Lateral rotation is defined as "a feature of a support surface that provides rotation about a longitudinal axis as characterized by degree of patient turn, duration, and frequency."4 Caution is required when considering this type of surface as caregivers may believe that because the mattress turns the patient, less hands-on care and repositioning by care providers are needed.
The goal of using a support surface is to reduce the forces of pressure, friction, and shear against the patient's body Table 3. Pressure is defined as "the force per unit area exerted perpendicular to the plane of interest."4
Decreasing peak interface pressure has been associated with decreased risk of PrUs.8 An absolute threshold for how much interface pressure can be tolerated has not been determined; however, it likely varies between individuals and may vary depending on body mass index and systolic blood pressure.
Friction is defined as "the resistance to motion in a parallel direction relative to the common boundary of 2 surfaces."4
Friction occurs when the patient slides across the mattress surface. This force often causes more superficial injuries, especially when combined with local excess moisture leading to skin maceration (eg, Stage II PrUs that probably have very little to do with pressure).9
Shear is defined as "the force per unit area exerted parallel to the plane of interest."4 This force often occurs when the head of the bed is elevated, and the patient slides down in bed. Friction tends to hold the skin in place against the mattress surface, and the skeletal structure slides internally against the skin. The combination of pressure and shear is often responsible for deeper Stages III and IV PrUs.9 Shear has been shown to double the impact of pressure.10
The Support Surface Cochrane Review provides some insight into the selection of support surfaces: "Foam alternatives to the standard hospital mattress can reduce the incidence of PrUs in people at risk. The relative merits of alternating and constant low pressure devices are unclear."11 The NPUAP/European Pressure Ulcer Advisory Panel pressure ulcer guidelines12 provide more clinical guidance:
* 2.1 Use higher-specification foam mattresses rather than standard hospital foam mattresses for individuals assessed as being at risk for PrU development.12
* 2.3 Use an active support surface (overlay or mattress) for patients at higher risk of PrU development where frequent manual repositioning is not possible.12
These guidelines in addition to the Registered Nurses Association of Ontario guidelines3 also promote maximizing mobility, and encourage turning/repositioning where possible.3,12
With the evidence-based practice background (scientific evidence, expert knowledge, and patient preference), clinicians still require a user-friendly guide to translate this information into practice to potentially improve patient care outcomes. The Support Surface Selection Tool was first developed in 2008 to respond to this need.13 This tool stratified the types of support surfaces (active support surfaces and reactive support surfaces) based on the risk of the patient developing PrUs or the number of ulcers the patient has and his/her mobility status. In the original publication, mobility status was determined using the Functional Independence Measure (FIM) score.14 The FIM score is a measure of disability and is scored on how much assistance the patient requires to perform the activity.14 In this way, it corresponds to the burden of care.14 Feedback from clinicians indicated that FIM was not a well-known tool, so the mobility indicator was changed to a description. Additional feedback indicated that although the tool was helpful, further assistance was required to select the additional features. As a result, 2 decision trees were created to help with the selection of specific features of active and reactive support surfaces.
As illustrated in Figure 1, a validated risk assessment tool should be utilized to determine the type of support surface required for an individual patient (ie, the columns across the top of the chart in Figure 1). If the patient currently has PrUs, choose the description in the first row that best fits the patient's clinical status. Note that the heels are excluded from this clinical description as heels are best managed independently from the bed surface.3,12
Next, determine the patient's usual degree of mobility in bed by selecting the appropriate row listed down the side of the chart. Where the column of "risk" intersects with the row of "mobility," a specific type of support surface is recommended-either a reactive support surface or an active support surface. If a reactive support surface is recommended, go to the reactive support surface decision tree Figure 2. If an active support surface is recommended, go to the active support surface decision tree (Figure 3). Follow the decision tree to identify other specific features that may benefit the specific patient. Recognize that this algorithm is not designed to replace clinical judgment, but is designed to assist the clinician to choose features for his/her patient based on a comprehensive assessment of each individual patient. Specific examples of support surfaces can be added into the last box of the decision tree based on the surfaces available in the clinician's setting. For clients with complex needs, or where the surface does not appear to be adequately managing pressure, friction, or shear forces, a referral should be made to the interprofessional team member with an expertise in support surface selection.
The clinician is asked to recommend a support surface bed for Mrs C., a patient who lives in a long-term-care facility. She has a Stage III PrU over her sacrum and can reposition herself independently in bed. The patient is also able to do a standing pivot transfer to her wheelchair with minimal assistance. Using this model, Mrs C. fits into the second column of Figure 4 with 1 PrU. Upon assessment, the clinician observes that she is independent with her in-bed mobility and changes her bed position at night. As a result, she would fit into the last row of the table Figure 4 Where the row and column intersect, a reactive support surface is suggested. The next step is to look at the reactive support surface decision tree Figure 5.
The first issue is whether she needs a powered surface. With most powered surfaces, the controls to set the mattress are at the foot of the bed. Because Mrs C. requires minimal assistance with her transfer (independently or with a family member), it is important that the mattress surface is always ready for her. For this reason, a nonpowered surface is recommended. The next decision is whether to have an overlay for her current mattress or replace the current mattress. Mattress replacements may be more expensive and require that the old mattress is stored. Overlays may raise the floor to mattress height and may shift on the bed surface. As this can impact transfers, a mattress replacement is recommended.
The next decision is whether a multizoned surface is required. A multizoned mattress has different sections to correspond with body segments. Although it is recommended that heels are managed independently of the surface, it is unlikely that this patient will be able to apply a heel boot when in bed and may forget to remove it before transfer. As a result, a multizoned mattress is recommended. To summarize, this algorithm (Figures 4 and 5) suggests a nonpowered multizoned reactive mattress replacement.
In addition to the factors discussed, the use of incontinence pads should be minimized because incontinence pads have been shown to increase peak pressure by 20% to 25%.15 An incontinence management plan needs to be in place as moisture increases the risk of skin breakdown.15
The weight capacity of specific mattresses needs to be identified. If the patient's weight is above that of the mattress's capacity, a bariatric therapeutic support surface may be required. Many support surface companies have bariatric models; however, these often require bariatric bed frames.
Entrapment is also a risk. In Canada, "between 1980 and 2008, there were 67 life-threatening entrapments related to side-rail use. Thirty-six of these entrapments (54%) lead to death."16 In the United States, 23% of entrapments resulted in injury.17 And, 65% of the 111 reported entrapment incidents in the United States between 1985 and 1995 resulted in death.17
Replacement mattresses can be placed on almost any bed frame; however, the dimensions of the support surface and bed frame must be considered to ensure that this combination meets local legislative standards. For example, there may be a requirement that the distance between the mattress and bed rail not exceed a certain distance. Another consideration is that, as the patient moves to the edge of the support surface, some surfaces tend to collapse. This may lead to a fall from the bed or to the patient being trapped against the bed rail if one is in place. For this reason, surfaces with a transfer border or perimeter are preferred over those that do not.
The selection of a therapeutic support surface is an integral part of the pressure prevention and management plan of patients, but does not replace good patient care. Turning and repositioning are still required despite having a therapeutic support surface. Support surfaces can help to reduce the forces of pressure, friction, and shear against the patient. With the multitude of surfaces available and the varied costs, it is important to choose the support surface with the features that best match the patient's individual needs, do not restrict his/her mobility, and are easy for caregivers to use. The Support Surface Selection Tool presented in this article facilitates the linkage of patient and clinician needs with specific therapeutic support surface features.
After reading this article, clinicians should be able to interpret terms associated with support surfaces, determine when to refer to other members of the interdisciplinary team, and apply algorithm use for support surface selection.
1. VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008-2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage 2009;55(11):39-45. [Context Link]
2. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage 2004;50(10):22-38. [Context Link]
3. Registered Nurses' Association of Ontario. Assessment and Management of Stage I to IV Pressure Ulcers (Revised). Toronto, ON, Canada: Registered Nurses' Association of Ontario; 2007. [Context Link]
4. National Pressure Ulcer Advisory Panel. Support Surface Standards Initiative: Terms and Definitions Version 01/29/2007. http://www.npuap.org/NPUAP_S3I_TD.pdf. Last accessed April 19, 2011. [Context Link]
5. Mayrovitz HN, Sims N, Taylor MC, Dribin L. Effects of support surface relief pressures on heel skin blood perfusion. Adv Skin Wound Care 2003;16:141-5. [Context Link]
6. Tsuji S, Ichioka S, Sekiya N, Nakatsuka T. Analysis of ischemia-reperfusion injury in a microcirculatory model of pressure ulcers. Wound Rep Reg 2005;13(2):209-15. [Context Link]
7. Vanderwee K, Grypdonck M, Defloor T. Alternating pressure air mattresses as prevention for pressure ulcers: a literature review. Int J Nurs Stud 2008;45:784-801. [Context Link]
8. Brienza D, Karg PE, Geyer MJ, Kelsey S, Trefler E. The relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users. Arch Phys Med Rehabil 2001;82:529-33. [Context Link]
9. Krasner DL, Sibbald RG, Woo KY, et al. Shifting the Original Paradigm (STOP): Pressure Ulcer Staging Consensus Statements and the Superficial Skin Changes and Deep Pressure Ulcer Theory. 2011 STOP Panel Members. http://www.gaymar.com/wcsstore/ExtendedSitesCatalogAssetStore/pdf/STOP%20Press%2. Last accessed April 19, 2011. [Context Link]
10. Ohura T, Takahashi M, Ohura N. Influence of external forces (pressure and shear force) on superficial layer and subcutis of porcine skin and effects of dressing materials: Are dressing materials beneficial for reducing pressure and shear force in tissues? Wound Rep Reg 2008;16:102-7. [Context Link]
11. McInnes E, Bell-Syer SE, Dumville JC, Legood R Cullum NA. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev 2008;4:CD001735. [Context Link]
12. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. [Context Link]
13. Norton L, Coutts P, Sibbald RG. A model for support surface selection as a part of pressure ulcer prevention and management: a preliminary study. WCET Journal 2008;28(3):25-9. [Context Link]
14. McGill University. In-depth Review of FIM. http://www.medicine.mcgill.ca/strokengine-assess/module_fim_indepth-en.html. Last accessed April 19, 2011. [Context Link]
15. Fader M, Bain D, Cottenden A. Effects of absorbent incontinence pads on pressure management mattresses. J Adv Nurs 2004;48:569-74. [Context Link]
16. Health Canada. Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching Reliability, and Other Hazards. Health Canada. March 2008. http://www.hc-sc.gc.ca/dhp-mps/md-im/applic-demande/guide-ld/md_gd_beds_im_ld_li. Last accessed April 19, 2011. [Context Link]
17. Todd JF, Ruhl CE, Gross TP. Injury and death associated with hospital bed side-rails: reports to the US Food and Drug Administration from 1985 to 1995. Am J Public Health 1997;87:1675-7. [Context Link]
For more than 62 additional continuing education articles related to Skin and Wound Care topics, go to http://NursingCenter.com/CE.
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