Presented By: Jennifer Birt, OT Reg(MB) Specialized Seating & Mobility Clinical Specialist
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1 Presented By: Jennifer Birt, OT Reg(MB) Specialized Seating & Mobility Clinical Specialist 2013
2 1. Define and understand the concept of practical pressure management and categorizing individuals at different levels of risk from a practical perspective 2. Identify a minimum of 6 factors that commonly contribute to pressure ulcer development from a 24 hour perspective 3. Identify a minimum of 4 assessment techniques that can be utilized when evaluating these pressure factors 4. List a minimum of 4 recommendations guided by best practice to resolve these pressure factors Jennifer Birt 2013
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9 Occipu t Scapulae Spinous Processes Elbow Sacrum Ischial Tuberosity Coccyx Greater Trochanter Epicondyle Malleolus & Heel Jennifer Birt 2013
10 General CPG s Winnipeg Regional Health Authority (WRHA) updated 2012 Registered Nurses of Ontario (RNAO) updated 2011 & 2007 National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel (NPUAP/EPUAP) 2009 Canadian Association of Wound Care (CAWC) updated 2006 SCI-Specific CPG s Rick Hansen Institute (RHI) 2013 Spinal Cord Injury Rehabilitation Evidence (SCIRE) updated 2009 New South Wales Agency for Clinical Innovation (NSW ACI) 2008 Paralyzed Veterans of America (PVA) 2000 Jennifer Birt 2013
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14 Applying pressure management best practices into the functional context of an individual s daily life and environment What makes OT s key clinicians in the role of practical pressure management? Holistic (24 hour) approach Activity analysis Practical Problem solving Adaptive approach Assistive device & equipment specialists P-E-O Model Jennifer Birt 2013
15 Cognitive Issues Jennifer Birt 2013
16 PURPOSE To provide a clinical evaluation tool, based on best practice, that offers a systematic way of evaluating pressure management from a practical perspective The PMAT provides a structural framework that investigates the causative factors that contribute to the functional aspects of pressure ulcer development from a 24 hour perspective Jennifer Birt 2013
17 Working knowledge of clinical practice guidelines for pressure ulcer prevention & treatment Working knowledge of pressure ulcer stages as well as additional signs & symptoms of pressure-related damage to skin Ability to reliably landmark and palpate key bony areas that are most susceptible to pressure-related damage in a variety of positions Working knowledge of proper support surface terminology and principles Awareness of pressure-posture relationship Understand team roles in addition to your own role Jennifer Birt 2013
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20 Client X REFERRAL TO OCCUPATIONAL THERAPY Diagnosis: Multiple Sclerosis Associated medical conditions: Pressure Issue identified: Other issues flagged: Purpose of Referral: Spasticity Incontinence Skin breakdown on buttocks Sliding in the wheelchair Postural deformities Needs a cushion Needs a seating assessment Jennifer Birt 2013
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32 FUNCTIONAL WOUND EVALUATION Visual inspection of skin over primary weight bearing surfaces Remove dressings whenever possible involve nursing Side lying in mocked sitting position Rule of thumb when evaluating wounds: What do you see? What do you feel? What do you smell? Understand signs of pressure, shear, friction, & microclimate Digital photos Jennifer Birt 2013
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35 POSITIONING EVALUATION Palpation to correlate ulcer with each position Evaluate whether pressure ulcer is weight bearing, partial weight bearing, or fully offloaded for: All positions, on All support surfaces 24 hour perspective Mock up modified and/or additional positions with client as alternative solutions Understand PRESSURE- POSTURE relationship Jennifer Birt 2013
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37 POSTURAL SCREEN IN SITTING PRESSURE-POSTURE relationship What happens in the wheelchair is a good indication of what will happen on other sitting surfaces Influence of gravity Bodies will go in 3 general directions under the influence of gravity: Anterior Posterior Lateral Jennifer Birt 2013
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39 REPOSITIONING EVALUATION Evaluation of repositioning movements in: Bed Wheelchair Other sitting surfaces Goal is to determine whether: Client is capable of the movement Movement is effective Palpate ulcer area during movement to decide: Effective offloading? Shear, friction or trauma during movement? Jennifer Birt 2013
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41 SUPPORT SURFACE EVLAUTION Visually inspect every support surface used over a 24 hour period Ensure equipment is: Set up properly In good condition Understand impact of support surface on: Stability Microclimate Shear & friction Function Support surface performance may change when position changes Correlate ulcer location to support surface features Jennifer Birt 2013
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43 MOBILITY, FRICTION & SHEAR EVALUATION Watch transfer and repositioning movements and screen for signs of: Trauma Shear & friction Palpate ulcer area during transfer and repositioning movements Mock up alternative methods of movement Confirm trauma, shear & friction are eliminated or minimized with alternative methods Jennifer Birt 2013
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45 COGNITIVE SCREEN Indirect evaluation gathered from Part 1 & 2 results Appropriate pressure management requires: Insight & awareness Problem solving Motivation Ability to retain information and apply new learning Sometimes people make BAD lifestyle choices and decisions Jennifer Birt 2013
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48 TOP 10 TIPS FOR PROVIDING PRACTICAL RECOMMENDATIONS 1 Initiate consult to physician for unresolved medical concerns 2 Initiate cross referrals as indicated & at transition points in care 3 Clarify & collaborate regarding bedrest vs. sitting orders 4 Prioritize repositioning schedules & support surface use based on bedrest vs. sitting orders 5 Prioritize what to do for the interim vs. long-term 6 Prioritize interventions for essential functional tasks: eating, sleeping, toileting & bathing 7 Think outside the box for practical solutions to these core tasks Frame recommendations to create clear expectations & accountability Provide clients with the opportunity to choose whether or not they will follow recommendations Be clear on trade-offs & consequences if clients choose not to follow recommendations Jennifer Birt 2013
49 RECOMMENDATIONS 1 Pressure ulcer should be offloaded 100% of the time to help determine capacity to heal 2 Recommend medical re-evaluation for: (a) Ruling out need for surgical intervention (b) Spasticity management 3 Recommend a period of bedrest for 4-6 weeks if appropriate therapeutic sleep surface and repositioning schedule can be implemented to allow for full offloading 4 Upgrade to a low air loss mattress 5 Alternate client s position in bed between right and left side-lying; rotate 30 degrees over from supine and use a wedge to maintain this angle, and place pillows between knees and feet 6 Due to low tolerance in side-lying positions, initiate a turning schedule every hour to start and gradually build to 2 hours as tolerance increases Jennifer Birt 2013
50 RECOMMENDATIONS 7 Check skin after each turn in bed to evaluate tissue tolerance over weight bearing areas gradually increase turn intervals by 1 hour each week based on tissue response 8 Consult Home Care about increasing frequency of services to facilitate bed rest and turning schedule during the day 9 Use a slider sheet for repositioning in bed and remove after repositioning occurs 10 Use an alarm clock overnight to implement turning schedule and consult to Home Care to problem-solve day time turns 11 Evaluate client in side-lying with the head of the bed raised to 30 degrees as an alternative position to eat meals while on bed rest; place a wedge under knees in this position to minimize sliding and do not stay in this position any longer than 1 hour Jennifer Birt 2013
51 RECOMMENDATIONS 12 Consult to nursing about alternative solutions for bladder management catheter good or bad idea? Consult to Home Care about increasing frequency of brief changes 13 Eliminate use of soaker pads on sleep surface especially if briefs cannot be discontinued 14 Consult to nursing about bowel management for bed rest 15 Provide education to client s husband about performing skin checks and proper methods for assisting with bed mobility & bed positioning 16 Consult to dietitian re: intake requirements; additional consult to Home Care to assist with meal provision during the day 17 If client demonstrates wound healing after 4-6 weeks and no further medical interventions are required, re-initiate seating consult and re-evaluate mobility & function on sitting surfaces Jennifer Birt 2013
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53 Ontario Neurotrauma Foundation (ONF): (can download Canadian Best Practice Guidelines for SCI Pressure Ulcer Prevention & Treatment) Winnipeg Regional Health Authority (WRHA): ( for health professionals evidence informed practice tools wound care pressure ulcer Registered Nurses of Ontario (RNAO): International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International, National Pressure Ulcer Advisory Panel (NPUAP): Spinal Cord Injury Rehabilitation Evidence (SCIRE): New South Wales Agency for Clinical Innovation (Spinal seating online education program, module 8): Canadian Association of Wound Care (CAWC): Wound Care Canada (Official publication of CAWC): Paralyzed Veterans of America (PVA): Jennifer Birt 2013
54 1. Define and understand the concept of practical pressure management and categorizing individuals at different levels of risk from a practical perspective 2. Identify a minimum of 6 factors that commonly contribute to pressure ulcer development from a 24 hour perspective 3. Identify a minimum of 4 assessment techniques that can be utilized when evaluating these pressure factors 4. List a minimum of 4 recommendations guided by best practice to resolve these pressure factors Jennifer Birt 2013
55 Jennifer Birt, OT Reg(MB) Specialized Seating and Mobility Clinical Specialist (p) (f)
Presented by: Jennifer Birt, OT Reg(MB) Specialized Seating and Mobility Clinical Specialist Rehabilitation Day Program
Pressure Management Assessment Tool (PMAT): Development and Implementation of a Comprehensive Clinical Evaluation for Managing Pressure from a 24 Hour Perspective Presented by: Jennifer Birt, OT Reg(MB)
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