The Seated Patient 15 th Biennial Conference New Orleans

Transcription

1 The Seated Patient 15 th Biennial Conference New Orleans Track 1 March 11, 2017 Christine Berke MSN APRN-NP CWOCN-AP Nebraska Medicine cberke@nebraskamed.com 2017 National Pressure Ulcer Advisory Panel Objectives 1. Discuss the mechanisms of pressure injury in the seated patient: tissue deformation, shear, friction and microclimate. 2. Identify the potential impact of support surfaces and related devices on shear, tissue deformation, and microclimate in the seated patient. 1

2 Disclosures I have none. Progressive Mobility A series of planned movements in a sequential manner beginning at a patient s current mobility status with a goal of returning to his/her baseline¹ Safely mobilizing critically ill patients Avoid negative outcomes of immobility Respiratory Cardiovascular Skin Musculoskeletal Multiple protocols/algorithms²ˉ⁵ 2

3 Repositioning vs. Mobilization Repositioning: a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort (NPUAP⁶, p.91) Mobilization: assisting or encouraging a person to move or shift into a new position. (NPUAP⁶, p.91) 2 Guiding Principles: Can they feel pain? Can they physically move? Population and Risk All individuals need to be repositioned and mobilized. Average healthy adults change position/posture 3-12x/hour⁷. Risk Factors:⁶ Age Weight Nutrition Skin condition/moisture Presence of scars Medications Impaired Perfusion Vulnerable populations:⁹ Critically ill Elderly Immobile Spinal Cord Injury Neurologically Impaired 3

4 Bedside chair positioning⁶ ⁹ Type of chair (w/c, recliner, chair) Posture Foot support Back support, recline and tilt Seat depth, width, height Arm support Activity while sitting Stability for sitting Self support Confidence Time Cushion in the chair? Blank for photos 4

5 Seat Cushions No standardization of types Air, foam, gel, water, combination Contoured, dynamic vs. static NPUAP Support Surface Initiative Principles: Immersion, envelopment, avoid bottoming out, stability Pressure mapping limitations New cushion (deterioration, wear/tear) Snap shot for a day (activity, body changes) Interface pressures vs. deep tissue deformation Needs to be individualized Replacement (allowed vs. cost) Wheelchair bound versus minimally ambulatory Clothing, slings, blankets, pillows, pads, devices 5

6 General Recommendations⁶ Foci of control with seating: Pressure, shear, temperature, moisture Individualize selection and periodic reevaluation of seating support surface Stretchable/breathable cushion cover Temperature, moisture management Inspect equipment routinely for wear/tear Teach patient/caregiver Maintenance, replacement, proper use Refer to seating specialist Special considerations Weight (extremes) Existing pressure injury Goals for care Previous pressure injury scar History of surgery (flap, excision) Other Co-morbid conditions Perfusion, systemic disease (CKD, HF, DM, immunity) Neuromuscular degeneration Spinal cord injury Stroke Multiple sclerosis Amyotrophic Lateral Sclerosis 6

7 Patient with Spinal Cord Injury Wheelchair most common assistive device in the world (WHO Guidelines for manual w/c 2008) Body is loaded onto a smaller surface area⁶ ¹⁴ Stability while seated allows activity⁶ ⁸ Transfer techniques to avoid trauma⁸ ¹⁴ Frequency & timing of offloading NPUAP recommends every 15 minutes⁶ Less than ½ perform recommended⁷ Microchanges¹⁴ Deep tissue deformations (w/c position & posture) Muscle tone, spasticity vs flaccidity Macrochanges¹⁴ Change in body weight, fat mass/distribution, bone shape, muscle atrophy, skin, tissue perfusion Self repositioning⁶ ⁸ ¹⁴ Lift off or push ups arm strength critical, stability Important to ease back down slowly Roll side to side Armrests important, stability, trunk control Forward lean Trunk control, incontinence respiratory Standing Minimize friction when rising sit/stand 7

8 Tilt in Space Function 8

9 References 1. Vollman KM. Introduction to Progressive Mobility. Critical Care Nurse; 30(2),S3-S5. 2. Vollman KM. Understanding Critically Ill patients Hemodynamic Response to Mobilization: Using the evidence to make it safe and feasible. Critical Care Nurse; 36(1), Timmerman RA. A Mobility Protocol for Critically Ill Adults. Dimensions of Critical Care Nursing; 26(5),pp Perme C, Chandrashekar R. Early Mobility and Walking Program for patients in Intensive Care Units: Creating a Standard of Care. American Journal of Critical-Care Nurses; 18(3), Accessed on-line December 14, 5. Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): A multicenter collaborative. Intensive and Critical Care Nursing; (2012)28, National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; Stinson M, Gillan C, Porter-Armstrong A. A Literature Review of Pressure Ulcer Prevention: Weight shift activity, cost of pressure care and role of the occupational therapist. British Journal of Occupational Therapy; 76(4), Stockton L, Flynn M. Sitting Pressure ulcer 1: risk factors, self-repositioning and other interventions. Nursing Times; 105(24). Accessed on line otherinterventions. References 9. Dealey C, Brindle CT, Black J, Alves P, Santamaria N, Call E, Clark M. International Wound Journal; (2015)12, Gil-Agudo A, De la Pena-Gonzalez A, Del Ama-Espinosa A, Perez-Rizo E, Diaz- Dominguez E, Sanchez-Ramos A. Comparative study of pressure distribution at the user-cushion interface with different cushions in a population with spinal cord injury. Clinical Biomechanics; (2009)24, Moore Z, van Etten M. Ten top tips: seating and pressure ulcer prevention. Wound International (2015); 6(2), Levy A, Kopplin K, Gefen A. An air-cell-based cushion for pressure ulcer protection remarkably reduces tissue stresses in the seated buttocks with respect to foams: Finite element studies. Journal of Tissue Viability (2014) 23, Levy A, Kopplin K, Gefen A. A computer modeling study to evaluated the potential effect of air cell-based cushions on the tissues of bariatric and diabetic patients. Ostomy Wound Management 2016; 62(1), Gefen A. Tissue changes in patients following spinal cord injury and implications for wheelchair cushions and tissue loading: A literature review. Ostomy Wound Management 2014; 60(2): Burns S, Betz KL. Seating Pressure with conventional and dynamic wheelchair cushions in tetraplegia. Arch Phys Med Rehabil; 1999; 80:

10 Thank You for your time & attention 10