If a patient is on a support surface that isn’t appropriate for their needs and doesn’t suitably support them when either laying down or sitting, this can result in inadequate blood flow to the tissue causing pressure ulcers (Fletcher,2020). Pressure ulcers occur when an area of skin over a bony prominence such as the sacrum, heels, shoulders or elbows, are subjected to prolonged pressure or pressure with shear (European Pressure Ulcer Advisory Panel (EPUAP), 2019).
Healthy people with no mobility issues will sit in many different places and positions throughout a day. When seated their brain will automatically tell them to move if they are feeling uncomfortable thus preventing pressure damage. In contrast, patients with ‘reduced sensation’ or with reduced independent mobility will inadvertently be putting their skin under continual pressure which then leads to tissue damage and pressure ulcers (Fletcher, 2020).
When in a seated position approximately 75% of the weight of the body is placed on only 8% of the body surface largely through the ischial tuberosities (Fig.1) which have the lowest point of contact with the seat. The ischial tuberosities are vulnerable to pressure damage in seated individuals; similarly other areas at risk when subjected to prolonged pressure in a chair are the sacrum, the greater trochanter (Fig.2), popliteal fossa (Fig.3) and the bony prominences of the spine and scapula (Bartley and Stephens, 2019).
Seating assessments present challenges as there are many factors requiring consideration. Patients require seating which will be big enough for them and will not squash them in their chair. Consideration of the width, depth and the height of the chair is required. A chair that’s too small could cause misalignment of the pelvis and spine rotation, which may then lead to ‘seating instability’. It’s important to also assess whether using a chair and a cushion and whether they will work together, or if it’s one unit, that it fully meets the patient’s needs (Fletcher, 2020).
The seated surface under our patients needs careful consideration to reduce pressure damage. Ensuring there is as little as possible between the pelvic region and the surface of the cushion, slings not left under patients, catheter tubing and straps not left under the buttocks and legs and thinking about the ridges in pads and seams in underwear.
Nurses also need to consider whether the chair they are putting in place affects the patient’s independence, whether it impacts on a falls risk, is it comfortable, will it exhaust them or be beneficial, can it impact on physiological needs such as breathing issues (Fletcher, 2020).
Additionally, when putting in a plan of care we need to consider the time spent in the chair. We know that pressure ulcers can develop quickly, and we know that when seated, the amount of pressure on a very small area is increased. The NICE guidelines advise that after 2 hours seated patients should be repositioned.
It’s important to remember patients have a voice, needs and desires in order to fulfil their emotional and social needs. Just telling a patient they have to stay in bed because their risk of pressure damage is high will not usually work and is not best practice in meeting the patient’s holistic needs. Working with our patients, ensuring they are given all the appropriate information and risks, empowers them to make informed decisions. Being able to sit in a garden, sit with family and lead a ‘normal’ life for however long or short that is, may be an essential part of your patient’s life and requires thought and recognition. As nurses we need to assess their holistic needs, communicate clearly with our patient’s risk assessment and then implement a plan of care that best meets their emotional, social and physical needs (University of Salford, 2017).
References
Bartley,C. and Stephens. M. (2019) ‘Development of pressure ulcers when sitting’, Wounds UK, 15(!). pp.34-39.
European pressure Ulcer Advisory Panel (
Fletcher, J. (2020) ‘Pressure Ulcer Education 4: selection and use of support surfaces, Nursing Times,116(1). pp.41-43.
Stephens, M. and Bartley, C.A. (2017) ‘Understanding the association between pressure ulcers and sitting in adults what does it mean for me and carers? Seating guidelines for people., carers and health & social care professionals’, Journal of Tissue Viability, 27(1), pp. 59-73.
Stockton, L. and Flynn, M. (2009) sitting and pressure ulcers 1:risk factors,self repositioning and other interventions, nursing times, 105 (24), pp.
University of Salford and Tissue Viability Society
Findings from the amendment of the tissue viability seating guidelines: listening event
University of Salford, Salford (2017)
