Positioning, Ergonomics and Pressure Sores Flashcards
Septicemia
A serious bloodstream infection. Occurs when a bacterial infection elsewhere in the body, such as the skin, enters the bloodstream. This is dangerous because the bacteria and their toxins can be carried through to entire body.
Reasons older populations develop skin problems
- Reduced sensitivity of immune system
- Reduced sebum secretion (dry, itchy skin)
- Less melanin production (sensitive to sun)
- Delayed wound healing
- Sensory receptors diminish in capacity
- Skin weakens, collagen loss, decreased elasticity
- Reduced efficiency of sweat glands/dermal blood supply
- Vascularity decreases in subcutaneous tissue (less pressure stops blood flow)
Substances that have negative affects when applied on older skin
- Alkaline soaps (reduces skin thickness; alters pH)
- Alcohol and Acetone (dehydrate skin)
- Starches (reduce protective barrier)
Areas where most pressure ulcers occur
Over major weight-bearing body parts such as sacrum, heels and ischial tuberosities (sit bones).
Classification of Pressure Ulcers
Grade 1: Non-blanchable erythema of intact skin; discoloration; warmth; edema; hardness
Grade 2: Partial-thickness skin loss; superficial ulcer; abrasion/blister
Grade 3: Full-thickness skin loss; may extend down to—not through—underlying fascia
Grade 4: Extensive destruction; tissue necrosis; damage to muscle/bone/supporting structures; with/without full-thickness skin loss
Tissue Tolerance
Amount of pressure an individual can withstand before capillary occlusion. Reduced by: • Low blood pressure • Malnutrition • Sustained pressure • Patient immobility
Risk Factors for Pressure Ulcers
- Older age
- Incontinence
- Poor skin hygiene
- Immobility
- Impaired nutrition/hydration
- Altered consciousness
- Sensory impairment
- Comorbidity
- Acute/Long-term/Terminal illness
- Previous pressure damage
Problems that occur when sitting/lying without moving much
(in order of severity):
• Pressure sores
• Skin breakdown
• Decubitus ulcers
of Deaths in US Yearly Related to Hospital-Acquired Pressure Uclers?
60,000 yearly
Mortality rate 2-6x higher than those without pressure ulcers
% of New Nursing Home Pts with Pressure Sore
11-56%
Role of OT in Pressure Sores
- Decide if Pt is at risk
- Come up with solutions to prevent breakdown in advance
- If already breakdown, come up with solutions to heal
- Allow for most functional performance of ADLs
Schematic for OT Prevention/tx of Pressure Ulcers
1) Risk assessment and Skin assessment
2) Record the assessment
3) Develop a care plan
4) OT intervention (education, positioning, moisture, nutrition, etc.)
5) Reassessment
* * Return to Step 1
Risk Assessment – Person
- Previous skin breakdown
- Sensory impairment
- Decreased consciousness (meds?)
- Cognition (self-advocating?)
- Pain (meds?)
- Psycho-emotional status
- Mobility
- Skeletal deformity (protrusions? Scoliosis?)
- Posture
- Nutrition/Hydration
- Incontinence
- Positioning preference (sleeping position?)
- Age
Risk Assessment – Environment
- Pressure*
- Shear*
- Friction*
- Moisture
- Socio-economic status
- Support surfaces over 24-hr period
*Biggest risk factors
Risk Assessment – Skin
- Persistent erythema (redness)
- Non-blanching redness
- Blisters
- Localized heat/coolness
- Localized induration (hardening)
- Localized edema
- Purplish/bluish localized area (bruise)
- Skin breakdown
**On darker skin, may not see all signs; look for discoloration, temp, raised areas
Bony Prominences most likely to have skin breakdown
- Sacrum
- Ischium
- Iliac crest
- Rib Cage
- Elbows
- Trochanters
- Knees
- Heels
- Toes
- T1 vertebra
- Back of head
Scales to Predict Pressure Ulcer Risk
Norton Scale – 1962 – scores 5-20, with 14 indicating risk
**Braden Scale – 1980s – replaced Norton Scale and is still most widely-used; Score 6-23, with lower scores at-risk starting around 16-18
Waterlow Scale – 1987 – Never took off. Score betw 4-40, higher scores 10+ = at risk
Categories Graded in Braden Scale
• Sensory Perception (1-4) • Moisture (1-4) • Activity (1-4) • Mobility (1-4) • Nutrition (1-4) • Friction and Shear (1-3) ** Higher score = LESS risk
Braden Scale – Manage Moisture
- Use commercial moisture barrier
- Use absorbent pads/diapers that wick/hold
- Address cause if possible
- Offer bedpan/urinal and glass of water in conjunction with turning schedules
Braden Scale – Manage Nutrition
- Increase protein
- Increase calorie intake to spare proteins
- Supplement with multivitamin (A, C, E)
- Act quickly to alleviate deficits
- Consult dietician
Braden Scale – Manage Friction and Shear
- Elevate HOB no more than 30˚
- Use trapeze when indicated
- Use lift sheet to move patient
- Protect elbows and heels if exposed to friction
Braden Scale – Other General Care
- No massage of reddened bony prominences
- No donut type devices
- Maintain good hydration
- Avoid drying the skin
Braden Scale – Predictive Cut-Off Values
Acute Care: 16
Home Residents: 18
Home Health Patients: 19
*Considered at risk at these scores or lower
Stage 1 Pressure Sore
- Skin intact
- Red skin that doesn’t lighten/blanch when touched
- On darker skin, may be no color change but also doesn’t blanch; may be bluish or ashen
- Site may be painful, firm, soft, warmer or cooler than surrounding skin
Stage 2 Pressure Sore
- Open wound
- Outer layer of skin (epidermis) and part of underlying layer (dermis) are damaged/lost
- Ulcer may appear as shallow pinkish-red, basin-like wound
- May also appear as intact or ruptured blister
Stage 3 Pressure Sore
- Ulcer is now a deep wound
- Loss of skin exposes some fat
- Ulcer has crater-like appearance
- Bottom of wound may have yellowish dead tissue (slough)
- Damage may extend beyond primary wound below layers of healthy skin
Stage 4 Pressure Sore
- Ulcer exhibits large-scale loss of tissue
- Wound may expose muscle, bone and tendons
- Bottom of wound likely contains slough or dark, crusty, dead tissue (eschar)
- Damage extends beyond primary wound below layers of healthy skin
Treatment Options for Stages of Pressure Sores
Stage 1: Pressure relief
Stage 2: Pressure relief, keep tissue clean/moist (avoid scabs)
Stage 3: Pressure relief, remove infected tissue (Wound Care steps in)
Stage 4: Pressure relief, remove infected tissue (Wound Care still involved)
Preventing Skin Breakdown
- Diligent inspection of skin by therapist, nurse, caregiver, AND patient
- Patients may need a mirror to check all areas of body
- Remember: Skin damage can occur in as little as 30 minutes!
General Tips on Pressure Relief
- NO DONUTS
- No evidence for sheepskin/egg crates helping, but don’t hurt
- Turn pt every 2 hours
- Keep back at 30˚ to bed (alleviates pressure on trochanter and lateral malleolus)
- Float heels
- Keep HOB at lowest possible angle to minimize shear stress/slippage
- Drawsheet and trapeze can reduce shear
Equipment to Prevent Skin Breakdown
- Wheelchair seat cushions (custom or off-the-shelf)
- Padding for bony prominences (ie: heel and elbow cuffs)
- Adjustments to hospital bed (raise/lower entire bed, food/head, chair position, etc.)
- Rotating Bed (allows continuous turning of immobilized pt)
- “Freedom Bed” (lateral rotation therapy) – seen in hospitals
- Rotating air mattress (slowly/gently rotates 24 hr/day)
- Alternating Pressure Mattress (seen in SNFs; cheaper option)
Ergonomics (def.)
Science of designing a person’s environment so it facilitates the highest level of function.
Anthropometrics
Science that measures range of body sizes in a population.
• Considered in design of products/work spaces
• Engineers design for size range from 5th percentile female to 95th percentile male (about 64-68” height)
Ergonomic Injury Risk Assessment
Some jobs cause injury due to:
• Repetitive movement
• Heavy lifting
• Awkward body position
Ergonomists evaluate workers to determine injury risk with assessments like REBA.
Rapid Entire Body Evaluation (REBA)
Tool used by ergonomists to determine risk of work-related injury. Analyzes/scores: • Part A: Neck, Trunk and Legs • Part B: Arm and Wrist • Adds “Activity Score” • Total (1-11+) indicates risk level. 1=Negligible 11+=Very High Risk
OTA Role in Ergonomics
- IDENTIFY AND ELIMINATE: accident/injury risk factors in workplace
- ANALYZE: job functions/descriptions based on tasks
- DESIGN: pre-hire screenings to determine suitability to job
- MODIFY: tools/equipment
- PROVIDE: education/training on prevention
- DETERMINE: accommodations in compliance with ADA
- RECOMMEND: changes employer can make
Workplace Injury Factors
- Repetition of movement
- Force
- Fixed/awkward postures
- Poorly designed tool handles
- Heavy loads
- Distance
- Vibration
- Noise
- Extreme temperatures
- Poor lighting
- Psychosocial/occupational stressors
Factors of Body Position
- Head posture
- Spinal curves
- Seated posture
- Arm position
- Wrist/hand position
Ideal Sitting Position
- Back straight
- Shoulders back
- Butt touching back of chair
- 3 normal back curves
- Even weight distribution on hips
- Knees at 90˚, even or slightly higher than hips (use foot rest if needed)
- Feet flat on floor
Friction
The resistance to motion in a parallel direction relative to the common boundary of two surfaces.
Pressure
The force per unit area exerted perpendicular to the plane of interest.
Shear
The force per unit area exerted parallel to the plane of interest.
Mechanical Load
Force distribution acting on a surface.
Force
A push-pull vector with magnitude (qty) and direction (pressure, shear) that is capable of maintaining/altering the position of a body.
