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Maximize Activity and Mobility by Reducing or Eliminating Friction and Shear


Definition of Pressure, Friction, and Shear

According to Keast et al. it is vital to treat the cause by modifying situations where pressure may be increased. Relieving pressure and proper positioning especially over bony prominences is crucial to heal the pressure ulcers and to prevent the development of new ulcers. Pressure must be assessed on all surfaces which would include the patient’s wheelchair, commode, toilet seat, couches, and chairs. Pressure is defined as the perpendicular force that is applied to the skin distorting and compressing underlying soft issues especially over bony prominences1.

Friction is defined as a resistance to movement created between two surfaces2. For example, friction may be produced when skin surfaces rub together or when skin rubs against clothing or absorptive incontinence briefs causing a moisture-related lesion. This progression can lead to skin erosion and the damage extends to and possible through the basement membrane involving both epidermal and dermal loss resulting in a partial thickness wound.

Shear is defined as force generated when the skin is moved against a fixed surface such as a bony skeleton moving in an opposite direction to the surface skin. It is important to note that any pressure injury that is accompanied by other forces (shear and friction) will result in a debilitating tissue injury3.

According to NPUAP & EPUAP, a moisture-related lesion can be defined as inflammation and/or erosion (denudation) of the skin caused by excessive exposure to moisture including urine, liquid stool, or exudate from a wound4. Compromise of the skin’s moisture barrier when coupled with ongoing exposure to irritants such as pH in urine creates an environment that leads to persistent erythema (redness). Once the skin becomes over saturated it tends to drag more when it comes in contact with other surfaces resulting in friction.


Prevention & Treatment Plan and Documentation using Braden and RNAO Interventions

A patient’s overall score may be normal (not “at risk”) yet may be low-scoring in a subcategory such as moisture. If so, the patient benefits from targeted prevention interventions to address the identified risk factor. In addition, these same interventions are necessary to “treat the cause” once a pressure ulcer has occurred. Documentation should include a care plan that includes the following:

Plan of Care based on Braden Interventions5 and RNAO BPCG Recommendations6

Implement for any individual who scores AT RISK for total and/or subscale score
Caregiver means formal, informal e.g. PSW, Health Care Provider, Attendant Care
For People Restricted to Bed Rest:
  • Utilize an interdisciplinary approach to plan care (see mobility and activity).
  • Use devices to enable independent positioning and lifting) (e.g., trapeze, bed rails).
  • Reposition at least every 2 hours or sooner if at high risk. If using a high density foam mattress, the turning routine can be modified to every 2-3 or 4 hours, provided that a visual check of all at-risk areas is made at each turn.7
  • Use pillows or foam wedges to avoid contact between bony prominences.
  • Use devices to totally relieve pressure on the heels and bony prominences of the feet.
  • A 30° turn to either side is recommended to avoid positioning directly on the trochanter.
  • Do not use donut type devices or products that localize pressure to other areas.
  • Reduce shearing forces by maintaining the head of the bed at the lowest elevation consistent with medical conditions and restrictions.Teach client/caregiver to keep head of bed at or below 30°. Head of bed may be elevated for meals then lowered within one hour after the meal
Pressure Redistribution:
  • People at risk of developing a pressure ulcer should NOT remain on a standard mattress. A replacement mattress with low interface pressure, such as high-density foam, should be used. Refer to Occupational Therapist (OT) or Physiotherapist (PT) their assessment is needed to obtain this in your setting
  • For high risk clients experiencing surgical intervention, the use of pressure-relieving surfaces intra-operatively should be considered.
  • Teach client and caregiver to change position to alter pressure points at least every hour. Do not use donut devices.
  • Consider postural alignment, distribution of weight, balance, stability, support of feet and pressure reduction when positioning individuals in chairs or wheelchairs.
  • Refer to OT for wheelchair cushion (see Interdisciplinary referrals)
  • If high risk for skin breakdown, teach client to change position every 15 minutes and limit wheelchair use to 1 hour intervals
Transferring Client:
  • Refer to OT/PT for assessment for assistive device (e.g. trapeze) (see Interdisciplinary referrals)
  • Teach caregiver to keep skin and bony prominences from rubbing on surfaces when lifting/transferring client
Moisture and Skin Care:
  • Ensure hydration through adequate fluid intake.
  • Individualize the bathing schedule.
  • Avoid use of hot water and alkaline soaps.
  • Assess and manage excessive moisture related to body fluids (e.g., urine, feces, perspiration, wound exudate, saliva, etc.)
  • Teach client/caregiver to clean skin after incontinent episodes with Ph-balanced skin cleansers. Aim to keep the perineal skin in acid-base balance (alkaline skin is more prone to yeast infections and breakdown).
  • Avoid force and friction when cleansing and drying.
  • Teach client/caregiver to use protective ointments or creams with minimal alcohol content
  • Establish a bowel and bladder program
  • Teach client/caregiver to use absorbent pads, dressings or briefs that wick moisture away from the skin. Replace pads and linens when damp.
  • Initiate fecal incontinence containment device for severe situations
  • Teach client not to use multiple incontinence pads/linens, baby powder or corn starch
  • Teach client to seek medical intervention for fungal dermatitis
  • Use protective barriers (e.g., liquid barrier films, transparent films) or protective padding to reduce friction injuries.
Activity and Mobility:
  • For clients with an identified risk for pressure ulcer development, minimize pressure through the immediate use of a positioning schedule.
  • Use proper positioning, transferring, and turning techniques.
  • Consult Occupational Therapy/Physiotherapy (OT/PT) regarding transfer and positioning techniques and devices to reduce friction and shear and to optimize client independence.
  • Encourage activity as tolerated
  • Refer to OT/PT for assessment for mobility aids to improve activity level (see Interdisciplinary referrals)
  • Institute a rehabilitation program, if consistent with the overall goals of care and the potential exists for improving the individual’s mobility and activity status. Consult the care team regarding a rehabilitation program.
Nutrition:

A nutritional assessment with appropriate interventions should be implemented on entry to any new health care environment and when the client’s condition changes. If a nutritional deficit is suspected:

  • Consult with a registered dietitian (RD).
  • Investigate factors that compromise an apparently well-nourished individual’s dietary intake (especially protein or calories) and offer him or her support with eating.
  • Plan and implement a nutritional support and/or supplementation program for nutritionally compromised individuals.
  • If dietary intake remains inadequate, consider alternative nutritional interventions.
  • Nutritional supplementation for critically ill older clients should be considered.
Friction:
  • Refer to OT/PT for assessment for mobility aids to reduce friction (see Interdisciplinary referrals)
  • Use protective barriers (e.g. liquid barrier films, transparent films, and hydrocolloids) or protective padding to reduce friction injuries
  • Use/teach caregiver to use drawsheet to reposition
Pain:
  • Consider the impact of pain. Pain may decrease mobility and activity. Pain control measures may include effective medication, therapeutic positioning, support surfaces, and other non-pharmacological interventions.
  • Monitor level of pain on an on-going basis, using a valid pain assessment tool
Sensation:
  • Consider the client’s risk for skin breakdown related to the loss of protective sensation or the ability to perceive pain and to respond in an effective manner (e.g., impact of analgesics, sedatives, neuropathy, etc.).

Address Patient-Centred Concerns
  1. Braden, B. http://www.vhqc.org/docs/Braden_Scale_and_Interventions_final041712_508C.pdf
  2. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Updated 2011.
  3. Bergstrom, N., Horn, S.D., Rapp, M.P., Stern, A. Barrett, R. and Watkiss, M. Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc 61:1705–1713, 2013.
  4. (Defloor T, Schoonhoven L, Fletcher J, et al. Statement of the European pressure ulcer advisory panel-Pressure ulcer classification. J WOCN. 2005; 32(5):302-306).
  5. Braden, B. http://www.vhqc.org/docs/Braden_Scale_and_Interventions_final041712_508C.pdf
  6. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Updated 2011.
  7. Bergstrom, N., Horn, S.D., Rapp, M.P., Stern, A. Barrett, R. and Watkiss, M. Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc 61:1705–1713, 2013.

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