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 www.npuap.org 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
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
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
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
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
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
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
Tilt in Space Function 8
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Thank You for your time & attention 10