Support Surfaces: Support Surface and Pressure Injury Prevention Definitions
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
So in our last class, we talked about the general principles of pressure injury prevention.
Speaker A:We talked about it from an agency wide perspective.
Speaker A:And then we talked about a specific pressure injury bundle for the individual patient.
Speaker A:And we said that in this class we would be talking in detail about use of support surfaces and your overall program for pressure injury prevention.
Speaker A:And that's where we're to now.
Speaker A:So again, this will be broken into two parts.
Speaker A:We're going to first look at use of support surfaces kind of from the big picture perspective.
Speaker A:What are the general categories, what are definitions that you need to know related to support surface technology?
Speaker A:And then we're going to look at it from the individual patient perspective.
Speaker A:So let's look at risk factors that can be addressed by support surfaces.
Speaker A:Support surfaces, as we've said, can play a major role in pressure injury prevention.
Speaker A:So first of all, they help to compensate for reduced mobility and activity.
Speaker A:And all support surfaces today are now designed to help compensate for the negative effects of immobility and inactivity.
Speaker A:There's two ways in which support surfaces can help to mitigate the negative impact of immobility.
Speaker A:Many of the surfaces that we use are designed to be extremely conformable and to allow the patient to sink into the device to evenly distribute pressure across the entire contact area, to eliminate peak pressure points and to therefore increase time tolerance.
Speaker A:So those are known as pressure redistribution surfaces.
Speaker A:We'll come back to that terminology.
Speaker A:The other approach is to use alternating pressure.
Speaker A:So these are devices, many of you are familiar with them.
Speaker A:They consist of a series of air chambers connected to a pump.
Speaker A:At any given point in time, half of the chambers are inflated, half are deflated, and then they cycle so that the inflated cells go down and the deflated cells inflate.
Speaker A:So you're constantly changing the pressure point.
Speaker A:And that is designed to protect the patient by constantly changing pressure points.
Speaker A:So it works on the time component of that time tolerance ratio.
Speaker A:So all surfaces designed to help compensate for immobility and inactivity, either through even pressure distribution or through alternating pressure.
Speaker A:You'll notice that almost all of the surfaces today have low shear, low friction surfaces.
Speaker A:They're very slick.
Speaker A:That helps to eliminate the risk or not eliminate, helps to reduce the risk for shear force.
Speaker A:So that's built into essentially all of the surfaces.
Speaker A:And then some of the surfaces available to you provide microclimate control, moisture control.
Speaker A:So either blow air against the skin or have another mechanism for pulling moisture away from the skin, keeping the skin cool and dry rather than hot and wet.
Speaker A:We know that cool, dry skin is much more resistant than hot, wet skin.
Speaker A:But there are many risk factors for pressure injury development that are not addressed by support surfaces.
Speaker A:So support surfaces do not feed the patient.
Speaker A:They do not compensate for nutritional compromise.
Speaker A:They cannot compensate for perfusion issues.
Speaker A:So if your patient is hypotensive, if they're on vasopressors, a high quality support surface can give some protection, but it certainly doesn't compensate for compromised perfusion, doesn't compensate for aging, unfortunately.
Speaker A:So, in other words, yes, there's a lot that a support surface does, but there's a lot in terms of risk that you cannot address with a support surface.
Speaker A:So a support surface is never, ever a standalone pressure injury prevention system.
Speaker A:It is one component of an effective pressure injury prevention program.
Speaker A:So sometimes you'll hear patients or family members or even staff nurses say, oh, he's on an airbed.
Speaker A:We don't have to turn him.
Speaker A:That is rarely true.
Speaker A:And remember, everyone should get turned if at all possible, for many reasons.
Speaker A:Skin protection, but also for pulmonary function, vascular function, et cetera, et cetera.
Speaker A:Now, one of the things that you'll do as a wound care nurse is you'll help staff make appropriate decisions about support surfaces for individual patients.
Speaker A:And you're going to base selection on a comprehensive assessment that includes the following things you're going to look at.
Speaker A:Well, when I look at this patient's Braden scale, where do they score?
Speaker A:Low?
Speaker A:So do they score low on immobility?
Speaker A:Do they score low on activity?
Speaker A:What about moisture?
Speaker A:So if they scored low on both mobility and moisture, then I have to have a surface that addresses the negative impact of inactivity and immobility.
Speaker A:But I also have to have a surface that provides some approach to moisture management.
Speaker A:But if I look at a patient and they score very low on mobility inactivity, but moisture was not an issue, I can simply focus on selecting the best surface to compensate for immobility, inactivity.
Speaker A:I also have to consider weight.
Speaker A:A number of our patients are morbidly obese and will need a bariatric support surface, even if their overall weight is only 300 to 350.
Speaker A:If their girth is so sufficient to make it difficult for them to turn in a standard bed, they need a bariatric surface.
Speaker A:I have to think about fall risk.
Speaker A:So some surfaces are designed to convert to a low bed and others are not.
Speaker A:So if I have a patient who's a fall risk, when I'm making a selection, I have to think, can I convert this to a low bed?
Speaker A:And then I have to think, does this patient have any comorbid conditions that would serve as contraindications to selected surfaces?
Speaker A:For example, if I have a patient with an unstable spine, they usually need to be on a pretty rigid surface.
Speaker A:They should not be on an air support surface.
Speaker A:They definitely should not be on alternating air.
Speaker A:So I have to be very aware of individual patient factors that might make a particular surface contraindicated.
Speaker A:And as we have already said multiple times, and you'll keep hearing this, we constantly monitor skin status.
Speaker A:And if I detect any deterioration in skin status with my existing prevention program, I've got to upgrade my prevention protocol.
Speaker A:And that might involve moving the patient from a foam surface to an air surface.
Speaker A:We've already said how important it is to keep heels off the bed, either using offloading boots or pillows, even if they are on a very high level air surface.
Speaker A:So unless you have a product where the manufacturer gives you data, very good data, that says the heels are protected with this product.
Speaker A:Otherwise, the rule of thumb is heels off the bed, regardless of surface.
Speaker A:What about turning?
Speaker A:The rule of thumb is everyone gets turned unless there are specific contraindications.
Speaker A:All the reasons for turning we have reviewed.
Speaker A:It's for skin protection, but it's for overall health as part of your progressive mobility program, as part of protecting your patient against multiple complications.
Speaker A:The only patients who should not be repositioned are patients who have an unstable spine until they get a fusion or something that stabilizes the spine and makes it safe to turn them.
Speaker A:You can elect not to reposition a patient if their end of life and if they elect comfort over skin protection.
Speaker A:So we know that turning can be very painful for our end of life patients.
Speaker A:Some patients will say, I'd rather be pain free, or they're probably not going to be pain free.
Speaker A:I'd rather have comfort maximize my comfort than protect my skin.
Speaker A:Other patients will elect to continue turning because they don't want to risk and break down.
Speaker A:So that's an individual patient family decision.
Speaker A:And we've talked in depth about using a limited, slow approach to repositioning for patients who have hemodynamic instability.
Speaker A:And we've talked about using the guideline, if hemodynamic parameters return to baseline within 10 minutes, the patient is considered to have tolerated the term.
Speaker A:Now, I want to go over some terms and definitions.
Speaker A:These have changed and you always want to be using current terminology when you're talking about wound care, when you're talking about support surfaces.
Speaker A:So pressure relief is defined as total offloading of that anatomic area.
Speaker A:If I talk about Pressure relief for the heels.
Speaker A:I'm not talking about cushioning the heels, I'm talking about getting the heels off the bed.
Speaker A:If I talk about offloading the sacrococcygeal area, I'm not talking about a very conformable air surface.
Speaker A:I'm talking about literally turning the patient off of that surface.
Speaker A:So pressure relief is all floating, means you have them totally off that site.
Speaker A:Pressure redistribution means that if you have chosen a surface that provides very even distribution of pressure across the entire contact surface.
Speaker A:So most of our support surfaces today are pressure redistribution surfaces.
Speaker A:All of your foam surfaces, many of your air surfaces, they're designed with a conformable cover that lets your patient sink in.
Speaker A:The core is designed to contour to that patient's body contours so that you get that even pressure distribution.
Speaker A:So pressure redistribution is a term you definitely need to know.
Speaker A:Now, when you talk about pressure redistribution, you'll also hear the term constant low pressure, and that refers to constant redistribution of the pressure.
Speaker A:You're not alternating pressure points, you're just evenly spreading the pressure across the entire contact surface.
Speaker A:So constant low pressure and pressure redistribution are essentially synonyms, and you'll see vendors using them interchangeably.
Speaker A:How do pressure redistribution constant low pressure systems work?
Speaker A:They work through two principles, immersion and envelopment.
Speaker A:So immersion is the degree to which the patient sinks into the surface.
Speaker A:So you think if you're sitting on a wooden surface, you get no immersion.
Speaker A:You literally are perched on top of that wooden surface, your weight is supported by your bony prominences.
Speaker A:But if you get a 4 inch foam cushion and you put it on top of that wooden surface, and now you're sitting on the foam, you sink into the foam.
Speaker A:That's immersion.
Speaker A:Now, envelopment refers to the degree to which that surface evenly conforms to your body contours.
Speaker A:So foam, your therapeutic foams, give pretty good conformability.
Speaker A:If you look at all the commercials on TV for your Tempur Pedic type foams, the sometimes referred to as high specification or viscoelastic foams, you'll see that they're designed to conform pretty evenly to an individual's contours.
Speaker A:And then they usually show on the commercial that if you change positions during sleep, that the surface will recontour to again match your contours and to give you on the commercials, comfort.
Speaker A:But from our concerns, to give you even pressure redistribution.
Speaker A:Now, air is extremely conformable and gives excellent envelopment because air is a gas.
Speaker A:So it is going to shift when you shift, when the patient shifts and it's going to give you that very even conformability.
Speaker A:So pressure redistribution, constant low pressure systems work by allowing the patient to sink into the device and by contouring to that patient's body.
Speaker A:When the patient shifts position, the foam, the air, possibly a gel, shift as well, and recontour to continually provide even pressure redistribution.
Speaker A:So the things you're going to see are the devices you're going to use most commonly that work via pressure redistribution, constant low pressure.
Speaker A:It's primarily your air surfaces and your therapeutic foam surfaces.
Speaker A:Alternating pressure, totally different approach.
Speaker A:We've already mentioned this.
Speaker A:So this is a surface with alternating air chambers.
Speaker A:The air chambers need to be at least 10 cm in depth, 10 cm or more, so that you get adequate support.
Speaker A:And they work by constantly changing the pressure points so they don't create low pressure, they just constantly change the pressure points.
Speaker A:So it's like, okay, I could sit on that wooden surface, but I'm going to constantly change my position.
Speaker A:So I'll sit first to the right, then to the left, then to the right, then to the left.
Speaker A:That's what alternating pressure does.
Speaker A:So totally different approaches to solving the same problem.
Speaker A:The issue is immobility.
Speaker A:So you can compensate either by evenly distributing the pressure or by constantly changing the pressure points.
Speaker A:You'll also hear the terms active and reactive.
Speaker A:So a reactive surface is one that changes in response to changes in patient position.
Speaker A:So that's the commercial on tv, that's your pressure redistribution surface.
Speaker A:If I'm supine, the surface contours to my body in the supine position.
Speaker A:When you come and you turn me to the right now all the pressure points have changed, the entire surface has changed.
Speaker A:But that foam, gel or air will recontour to continue to provide me even pressure redistribution.
Speaker A:So all of your pressure redistribution, constant low pressure surfaces are reactive.
Speaker A:They change in response to changes in the patient's position.
Speaker A:It could be gel, but most commonly it's foam or air.
Speaker A:An active surface is one that's pump driven and that changes pressure points on a routine basis, determined by a cycle that's predetermined and plugged into the pump.
Speaker A:An active surface does its own thing.
Speaker A:It's not reacting to the patient, it's simply changing based on the cycle.
Speaker A:You can take a patient off of an alternating pressure surface and it'll continue to cycle.
Speaker A:So an active surface changes based, changes pressure points based on a cycle.
Speaker A:A reactive surface changes and recontours based on changes in patient position, low air loss and air fluidized.
Speaker A:Low air loss is considered to be a Feature of some of your air support surfaces.
Speaker A:The way it works, if you look at the device on top, most of these surfaces have little micro perforations in the mattress cover.
Speaker A:And they're connected to a pump.
Speaker A:And the pump is constantly circulating air through the device.
Speaker A:And as it circulates air through the device, air blows out through those little micro perforations, blows against the skin, and helps to keep the skin cool and dry.
Speaker A:When you see the term low air loss, you're thinking moisture management, microclimate control.
Speaker A:And it does it through those microperforations and constant airflow.
Speaker A:Air fluidized are those tank beds, or sometimes called sand beds or bead beds.
Speaker A:So they involve a tank.
Speaker A:Look at the bottom.
Speaker A:That tank is filled with siliconized glass beads, with all these little glass beads that are coated with silicone, so they're very slippery.
Speaker A:Then you pump air through that, and it essentially puts those beads in a fluidized state that creates extremely even conformability.
Speaker A:So the patient's literally floating on this sand bed, and it provides the highest level immersion and envelopment.
Speaker A:And it also provides airflow because the sheet over that tank is air permeable.
Speaker A:So air is also blowing through the sheet against the skin air.
Speaker A:Fluidized surfaces provide pretty high volume airflow.
Speaker A:If you have a very vulnerable patient, it can actually contribute to dehydration of the patient.
Speaker A:It can definitely cause drying of your wound dressings, depending on the type you're using.
Speaker A:Another term is continuous lateral rotation therapy.
Speaker A:You've already heard us use this term a couple of times.
Speaker A:A surface that provides continuous lateral rotation therapy is designed to at least partially counteract the negative effects of immobility on pulmonary function.
Speaker A:So you'll frequently see these surfaces used for patients who have adult respiratory distress syndrome.
Speaker A:What they do is they constantly rotate the upper body so they're turning this way, turning this way, this way, this way.
Speaker A:Constant lateral rotation.
Speaker A:Now, some of them are now designed to rotate all the way from the trunk to the knees, and those would provide both pulmonary protection and skin protection.
Speaker A:So you have to know, do you have devices in your formulary that provide continuous lateral rotation therapy?
Speaker A:If so, are they designed specifically for pulmonary effects, meaning they rotate upper body and the lung fields but do not affect the trunk?
Speaker A:Or are they designed for both pulmonary effects and skin protection, in which case they rotate the entire body down to the knees?
Speaker A:So find out what you have, Find out what it does.
Speaker A:In general, continuous lateral rotation therapy services are designed primarily for pulmonary care.
Speaker A:Most of those patients still require routine repositioning for skin Protection.
Speaker A:But remember that if you have access to continuous lateral rotation therapy devices, they can be an important part of your early mobility program for your patients who are critically ill, hemodynamically unstable, because they do provide that very gradual turn that's almost always tolerated, even by your very critically ill patients.
Speaker A:We have a number of bariatric support surfaces now available to us, which is extremely beneficial if you have morbidly obese patients in your patient population.
Speaker A:They're indicated for patients who weigh more than 300 to £350 in general, but also for patients whose body habitus means that they have fairly wide girth.
Speaker A:That makes it very difficult for them to turn in a standard bed.
Speaker A:So, you know that, you know, we all vary tremendously in our build.
Speaker A:And you have some patients who may not weigh that much, but all their weight is concentrated in the trunk, and it's very difficult to reposition them.
Speaker A:Those patients will benefit from a bariatric surface.
Speaker A:Now, if you have patients on bariatric surfaces, you also want to think about the fact that you're probably going to need some repositioning devices.
Speaker A:You might need an overhead lift system so that you can effectively reposition these patients without putting them at risk, without putting the staff at risk, and without causing undue discomfort.
Speaker A:Now, when you look at all the surfaces out there, it can be overwhelming.
Speaker A:If you go to a wound care conference and you walk in the exhibit hall, it's like, oh, my God.
Speaker A:Because you'll see beds everywhere.
Speaker A:Like, how do I keep these all straight?
Speaker A:Because every booth you go to is like, well, that sounds perfect.
Speaker A:That's what we need.
Speaker A:No, I think maybe we need this.
Speaker A:Well, how do I sort through it?
Speaker A:So, first of all, you need to know there are three approaches to classification of support surfaces.
Speaker A:The most important one is by therapeutic effects.
Speaker A:But you can also look at surfaces in terms of their relationship to the mattress or the bed.
Speaker A:And you can look at surfaces by the construction material.
Speaker A:What are they made of?
Speaker A:What's the support medium?
Speaker A:And usually we're considering several of those all at the same time.
Speaker A:By far the most important consideration is what are the therapeutic effects?
Speaker A:What does this surface offer my patient?
Speaker A:How does it fit into my overall pressure?
Speaker A:Injury prevention protocol, Go back to.
Speaker A: f all therapeutic surfaces in: Speaker A:That's what they're designed to do.
Speaker A:As we've already said, there are two approaches, and you see them here.
Speaker A:So if you look at the illustration on top, that is a surface that works by Pressure redistribution, constant low pressure.
Speaker A:So when the patient's in the supine position, they sink into the mattress.
Speaker A:The air or the foam.
Speaker A:In this case air, but it could be foam contours to their surfaces.
Speaker A:You get very even pressure distribution across the entire contact area.
Speaker A:You eliminate those peak pressure points when you come and you turn the patient to the right.
Speaker A:The foam or the air reacts to the change in patient position recontours to match the patient's contour.
Speaker A:So again, you have that even pressure distribution across the entire contact area.
Speaker A:If you look at the one on bottom, works totally differently.
Speaker A:This is alternating pressure.
Speaker A:So it's constantly changing the pressure points.
Speaker A:The focus of alternating pressure is not to create very low pressure across the surface, it's to constantly change the pressure points.
Speaker A:So it's like constantly turning the patient.
Speaker A:Now, when you talk about conformable surfaces, these are your pressure redistribution, this is your constant low pressure.
Speaker A:I think we've just covered this, but we keep saying the same thing so that hopefully it all sinks in.
Speaker A:So when you provide that even contouring, even pressure distribution, then you eliminate peak pressures, you eliminate high pressure points that can result in pressure injury development.
Speaker A:Do we have any evidence that says one type of pressure redistribution surface is better than another?
Speaker A:In other words, do we have any data that says air is better than gel, gel is better than foam?
Speaker A:No, because those studies have not been done.
Speaker A:So it doesn't mean that air is not better, it just means we can't prove it at this point point in time.
Speaker A:However, anecdotal reports from multiple clinicians.
Speaker A:Multiple clinicians, I'm sorry, suggest that air surfaces may provide better protection than foam surfaces.
Speaker A:And from a science perspective, that makes sense.
Speaker A:Again, you go back to the fact that air is a gas.
Speaker A:You can't beat a gas when it comes to conformability.
Speaker A:Many clinicians, if they have a patient on a pressure redistribution foam surface and that patient begins to experience deterioration in skin status, we'll bump them up to an air pressure redistribution surface.
Speaker A:Makes sense from a science perspective.
Speaker A:Makes sense based on anecdotal reports.
Speaker A:At this point, we lack objective data to prove that.
Speaker A:We've talked about the fact alternating pressure works differently than constant low pressure.
Speaker A:So constant low pressure reduces pressure intensity, alternating pressure reduces pressure duration.
Speaker A:Does it make a difference?
Speaker A:So these are two approaches to managing the negative effects of immobility.
Speaker A:Is constant low pressure better than constant pressure changes?
Speaker A:Is alternating pressure better than constant low pressure?
Speaker A:Again, we have very little data.
Speaker A:There are a couple of very small studies that suggest that alternating pressure may be more Protective than pressure redistribution for patients who cannot be turned.
Speaker A:So if you have a patient who cannot be turned because of whatever reason, maybe they're extremely unstable hemodynamically and you have the choice to use either pressure redistribution or alternating pressure.
Speaker A:In that case, you would probably elect alternating pressure.
Speaker A:But remember, very limited data at this point, not enough data to make a definitive recommendation, just considerations.
Speaker A:For us as clinicians, we've talked about the fact that most surfaces today have a low friction cover which drives down friction and drives down shear.
Speaker A:It allows the patient to slide without getting significant deformation of the tissues, without creating that shear force where tissue layers are sliding against each other.
Speaker A:So again, if you slide, I want all tissue layers to slide together.
Speaker A:And that's what a slick surface promotes and microclimate control.
Speaker A:So we've talked about that.
Speaker A:That surfaces that provide active airflow.
Speaker A:Who needs that?
Speaker A:Patients who are diaphoretic primarily.
Speaker A:If you have a patient who has no moisture related issues, then you really do not need that feature.
Speaker A:One thing we have to convey to all of our caregivers, I think this is a common error in care, is that you'll go in and you'll have a patient on a pretty high level surface.
Speaker A:Maybe it's an air surface, maybe it does provide low air loss, that constant low volume of airflow against the skin.
Speaker A:But you find multiple layers between the patient and the mattress.
Speaker A:So they might have a flat sheet, a draw sheet and a couple of underpants.
Speaker A:How much air is going to get to their skin?
Speaker A:Not much.
Speaker A:So when you select a surface that provides microclimate control, that provides low air loss, you want to minimize layers between the surface and the patient.
Speaker A:Most settings you use maybe one underpad that's dry flow that allows air to pass through, or maybe one turn sheet to try to minimize layers between the patient and the surface.
Speaker A:If you're looking for microclimate control.
Speaker A:So I'm going to summarize this section and then we're going to move ahead in the next class and talk about individual patient consideration.
Speaker A:So we've talked big picture about the role of support surfaces in pressure injury prevention.
Speaker A:We've talked about you always have to select your surface based on assessment of your patient's risk factors.
Speaker A:Are you just compensating for the negative effects of immobility or are you also compensating for the negative effects of moisture?
Speaker A:You want to be very clear on the differences between constant low pressure pressure redistribution and alternating pressure.
Speaker A:Two very different approaches to compensating for the negative effects of immobility either evenly distribute the pressure and eliminate high peak pressures, high pressure points, or constantly change the area of the body that's being loaded.
Speaker A:So you need to know your terms.
Speaker A:You need to know them for clinical practice, and you need to know them for the certification exam.
