Managing mechanical forces
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Assess situations where pressure may be increased and modify as necessary. | Level of Evidence Not Assessed |
| 2 | Avoid use of a standard mattress for patients at risk of developing pressure ulcers. | Level of Evidence Not Assessed |
| 3 | Assess and modify situations where pressure may be increased; provide appropriate support surfaces. | Level of Evidence Not Assessed |
| Address Patient-Centered Concerns | ||
|---|---|---|
| 4 | Attempt to minimize pain through management of mechanical forces | Level of Evidence Not Assessed |
| Provide Local Wound Care | ||
|---|---|---|
| 5 | For patients restricted to bed, after a complete assessment, use an interdisciplinary approach to plan care, including repositioning schedules; appropriate devices to enable positioning, lifting and transfers without dragging; supports and devices to prevent contact between bony prominences and eliminate pressure on vulnerable areas, such as the heels; and the lowest appropriate elevation of the head of the bed. | Level of Evidence Not Assessed |
| 6 | For patients restricted to a chair, after a complete assessment, use an interdisciplinary approach to plan care, including appropriate positioning in the chair, repositioning schedules, pressure-reducing seating surfaces and chair adaptations for special needs. | Level of Evidence Not Assessed |
| 7 | Use appropriate moisture balance-dressings that minimize friction and shear | Level of Evidence Not Assessed |
| 8 | Minimize pressure in patients at risk of pressure ulcer development through immediate implementation of a positioning schedule. | Level of Evidence Not Assessed |
| 9 | Use the appropriate type of therapeutic support surface, based on patient risk and other factors, to reduce pressure over bony prominences. | Level of Evidence Not Assessed |
| 10 | Use appropriate supports and turning and positioning schedules to minimize pressure over bony prominences and other areas felt to be at risk of pressure ulcer development. | Level of Evidence Not Assessed |
| 11 | If the potential exists to increase mobility and activity levels, institute a rehabilitation program, consistent with goals of care. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 12 | Empower an interprofessional team to manage mechanical forces | Level of Evidence Not Assessed |
Background
The effective management of mechanical forces is critical to prevent pressure ulcers, and a variety of interventions may be necessary to prevent tissue damage from these forces. Typical interventions include the following:• Pressure reduction:
o Positioning schedules: Current recommendations support the use of turning schedules, but research has not determined optimal intervals. In the absence of strong evidence, the repositioning schedule for patients restricted to bed or a chair should be individualized, based on skin inspection and individual needs. High-risk and emaciated patients should generally be turned more frequently.
o Pressure-relieving mattresses: Standard hospital mattresses should not be used for patients at risk of pressure ulcers. Foam-based, low interface pressure mattresses and overlays are consistently more effective than standard mattresses in preventing pressure ulcers. Patients with a very high risk of pressure ulcers may benefit from a technologically advanced pressure-reducing system, such as an alternating-pressure mattress or overlay. The ability of a support surface to dissipate heat and moisture are also important considerations in selecting a mattress. Whatever type of mattress is used, high-risk patients should be assessed for tissue damage frequently and thoroughly.
o Chair positioning and seating surfaces: Pressures generated in the seated position are greater than those affecting supine patients. Effective chair positioning is important, as high interface pressure can develop with poor posture and with the use of inappropriate seating surfaces. Patients with a high risk of pressure ulcers should not sit for more than 2 hours and should use a pressure-reducing chair surface. Few studies have been conducted, but static air cushions appear to provide better pressure reduction than foam- or water-filled cushions. The chair should be tilted back slightly and arm rests and foot supports used, with the heels extending over the back edge of the foot rest. Wheelchair seat backs may also be associated with pressure ulcers; pressure-reducing seat backs and various supports may be required to prevent ulcers over the vertebral spine and spine of the scapula. A consultation with a physiotherapist or occupational therapist may assist with seating assessments and individual adaptations.
o Protection of bony prominences: Bony prominences, such as the heels, should be protected by placing pillows that end at the ankle under the legs. If this is ineffective, ankle-foot orthoses may be used to prevent heel pressure. Contact between bony prominences should be prevented by using pillows or supports, such as foam wedges.
o Intraoperative pressure relief: Use of pressure-relieving surfaces in the operating room can reduce the development of pressure ulcers in high-risk patients. The most effective type of surface has not been determined.
• Shear:
o Proper positioning, turning and transferring techniques: Use of proper techniques can prevent tissue damage by shearing forces. Improper techniques, such as dragging patients across beds and other surfaces, increase the risk of shear damage. Elevating the head of the bed above 30° can cause shearing forces as the skin and superficial fascia remain in the original position, while the deep fascia and skeleton slide down the bed. Improper positioning of a patient confined to a chair can cause shearing forces if the patients slides forward or down.
• Friction:
o Patient movements: Voluntary and involuntary movements can result in skin damage due to friction, especially on the elbows and heels.
o Improper positioning, turning and lifting techniques: In addition to shear, improper techniques can result in friction damage.
• Rehabilitation:
o Larger ulcers are associated with immobility and inactivity, and patients restricted to bed or a chair have a higher risk of pressure ulcer development. Prevention efforts can be enhanced through strengthening, active and passive range-of-motion exercise, proper positioning, exercise and ambulation.
References
| Essential Publications |
|---|
| 1 | Pressure-reducing surfaces in prevention of heel pressure ulcers |
Quality Indicator
|
Type: Systematic review |
| Nicosia G, Gliatta AE, Woodbury MG. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. Int.Wound.J., 2007, 4, 3, 197-207 | |||
| This paper is useful in determining the value of pressure relieving surfaces in the prevention of pressure ulcers. It demonstrates that pressure relieving surfaces are beneficial in the prevention of pressure ulcers on the heel. It also highlights the need for further research in this field | |||
| 2 | Cost-effectiveness of pressure-reducing support surfaces in the prevention of pressure ulcers |
Quality Indicator
|
Type: RCT |
| Nixon,J. Nelson,E.A. Cranny,G. Pressure relieving support surfaces: A randomized evaluation. Health Technol.Assess., 2006, 10, 22, 101 | |||
| This study is useful because it demonstrates that pressure relieving mattresses are preferable to pressure relieving overlays. Since this study was implemented using the UK health care system, however, it is not universally applicable. | |||