Pressure Ulcer Prevention and Management

Introduction

When prescribing a riser recliner or specialist seating system, it is important to consider the service user’s pressure ulcer prevention and management needs. Many factors contribute to the risk of pressure ulcers developing for example: bony prominences, immobility, poor skin integrity, continence issues, poor diet, poor circulation and many more.

Specialist fabrics and pressure cushions can contribute to pressure care and assist in prevention, and in some cases management of pressure ulcers.

Pressure risks

The risk of pressure ulcers developing is present for every service user. It is therefore essential to consider pressure needs when assessing for and providing seating. Increased pressure occurs over a body surface area which is relatively small in comparison to the load taken through that area. Some factors place particular service users at a higher risk than others:

Mobility and motor function

Where a person has limited mobility and motor function, they cannot support their body segments symmetrically, which leads to uneven loading though body parts. It can lead to the development of postural deformities such as scoliosis and kyphosis, which will impact on the position of the spine and pelvis on the seating surface. Poorly supported posture can lead to the service user being unable to maintain an upright position against gravity, resulting in uneven loading, sliding and shear. Shear forces are caused by forces moving in opposite direction and the surface area in between being sheared between those forces. This occurs when a person slides down in their chair (Pope 2007).

Sensation

Where a person has sensory changes or loss, they are at increased risk of developing pressure ulcers as they have no internal feedback mechanism to encourage them to move. When sitting in the same position for a period of time, pain, pressure and touch receptors are activated and the person can move to relieve the pressure. Where there is loss of sensation, this sensory motor feedback is lost (Sandoz 2012). The same is true for those who have diminished cognition and may not be able to recognise or report discomfort from long periods of sitting.

Weight, nutrition and hydration

Low body weight and soft tissue mass can result in bony prominences. A high load through these bony prominences can increase risk of pressure damage to the skin over these areas (Kottner et al 2011). This is essentially because the padding between the bone and supporting surface is minimal. If there is low body weight it could indicate a poor nutritional and hydration intake, which can contribute to pressure damage. Increased weight and obesity can make seeing and treating the pressure areas difficult (Sandoz 2012).

Continence

If a person has continence issues or difficulty maintaining body temperature, areas in contact with the seating surface can become hot and moist. These conditions can cause damage to the skin, further weakening the skin’s ability to maintain integrity (Sandoz 2012).

The combined effect of a number of risk factors will have more of an impact on pressure ulcer prevention and management, and careful assessment needs to take place. There are a number of assessment tools that can be used to measure the risk of pressure, such as the Braden Scale and Waterlow Score (Sandoz 2012).

To reduce this risk and meet the needs of many users, the Configura range of chairs come with a high-risk pressure prevention cushion built in as standard. This will provide enough prevention for some users, however will not be adequate for very high-risk users.

Where the need for higher pressure prevention or pressure management is required, the cushion can be easily removed and replaced with a more appropriate cushion for that service user.

Consideration as to whether the cushion is required to prevent pressure damage or is part of a pressure ulcer management programme is essential and will impact on the decision of the type of cushion required.

Choosing the right cushion can be very challenging and it is recommended that advice from an appropriately trained clinician, such as a District Nurse or Tissue Viability Nurse is sought.

Many cushions have been linked to different levels of need in terms of pressure management i.e. low risk, medium risk and high risk. Some cushions have linked usage to pressure risk assessment scores to help with appropriate selection. It is important to take all factors into consideration when choosing a cushion, not just the risk assessment score. For example, someone with a progressive condition may score low on a pressure risk assessment tool such as the Braden Scale or Waterlow Score when completed, indicating a low-level cushion is required. The measurement score is only a snap shot in time and doesn’t take into consideration future needs. In rapidly progressive conditions such as Motor Neurone Disease (MND), anticipatory prescribing is preferable to minimise multiple ordering of equipment and to meet the ongoing needs in the most clinically and cost-effective way (MNDA 2021). So, the low score on the measurement tools gives a misleading impression of pressure management needs.

There are two main categories of pressure cushions; static cushions and dynamic cushions.

There is a large range of pressure cushions using different technology to provide the pressure care – gel, foams with gel, air cells and combinations of all. These cushions do not change the supportive surface when the user is sitting on them, which makes them “static.” They may need some maintenance to reset them, such as adding in more air to cells, but they do not change when being used. These cushions are primarily used in helping the prevention of pressure damage.

Dynamic cushions tend to be used as part of an intervention plan for managing existing pressure ulcers. They include powered alternating cushions where air is pumped in and the air cells inflate and deflate over pre-determined cycles, as the user sits on them. They are designed to relieve pressure. These cushions need a power source, requiring to be plugged into the mains or a battery pack. The Configura chairs can accommodate the wiring and pipes (to pump), but this does however limit how much the chair can be moved within a room.

The Configura range can accommodate both static and dynamic cushions within the seating of the chair. This avoids having to position a cushion on top of the seat cushion which can result in the seat height being too high and the armrests being too low in relation to the seated position. The cushion is unstable if not secured to the seat and is likely to move around, which can increase the risk of falls from the chair and result in difficulty with transfers.

Additional information can be found in our Configura Range Cushion Guide and Choosing an Accora Mattress or Cushion information sheet.

The fabric choice of support surfaces also plays an important role in helping to prevent and manage pressure ulcers. Vapour permeable, four way stretch fabric is used on all the leg rests and seat bases of our Configura range of chairs. This fabric is breathable to better support the skin’s microclimate and allows the body to immerse into the cushion, resulting in better pressure distribution. This results in a reduction of the risk of pressure building up in concentrated areas.

Our more complex range of Configura chairs has vapour permeable fabric on the backrest, armrests, and inside of the seat, helping reduce pressure build up on other body parts that come into contact with the chair, for those at higher risk of pressure damage.

For more information on assessing for pressure ulcer prevention and management or to book seating assessment, contact our team on
01223 206 100 or via info@accora.care

Kottner J, Gefen A, Lahmann N (2011) Weight and pressure ulcer occurrence: a secondary data analysis. Int J Nurs Stud 48 (11): 2608-20

MND Association Wheelchair Pathway 2021, https://www.mndassociation.org/app/uploads/2021/01/Wheelchair-pathway.pdf

Sandoz H 2012, No Pressure – A study guide. Anthony Kerr, MA Healthcare Ltd. London