This is a question I get asked frequently and it can be a grey area. Particularly around the end of life or cases of rapid skin failure where balancing up regular repositioning to the quality of life of the patient is paramount. Involving Multi-Disciplinary teams into this decision is important to help come up with individualised and enhanced moving and handling plans and repositioning plans.
As providers we must adhere to our Nice pressure ulcer prevention and management guidelines which currently say that 2, 4, 6 hourly repositions need to be prompted and documented. Clinically, this is done mostly on the repositioning chart either at the bedside of through electronic care plan systems.
For a resident with rapid skin failure in bed, is this enough? Quite often we will recommend more regular repositions through the day and sometimes night. The reason being is that, from what we know from the research, there is a 20 min ‘window of prevention’ for tissue hypoxia to occur on a local vascular supply. Waiting 2, 4, and especially 6 at night may be too long and increase the risk of tissue decline. However, will your patient want to be repositioned every 20 minutes?
Although the single most effective prevention method from tissue hypoxia, leading to a category 1 pressure ulcer, is to remove the pressure forces on the affected area, this may not always be possible. Not just with compliance but due to physical factors sucks as contractures, MND, MS or palliative care.
WHAT CAN YOU DO:
Working with your multi disciplinary team, either Physiotherapists, Occupational Therapist, Tissue Viability Nurse, District Nurse, you may come up with some alternative plans. This can be documented as the home have explored all alternatives and worked for active solution. This is as important as just saying the resident cannot be moved is not enough, we must be clear as to why and that alternatives have been explored.
Lateral tilt mattresses.
Lateral tilt mattresses – Although an AIR mattress may be in place, there will still be a point of contact whereas with most pumped devices the cells will offer temporary offload alternately.
The use of lateral tilts have been around for a while and vary in comfort. With OSKA offering inbuilt lateral technology. No lateral device can replace a manual turn, so these still need to be prompted as per NICE guidelines. If you’re not sure seek advice from your local TVN.
Where the recommendations are to gain a 30 degree angle tilt on turns, it may not always be possible. Any movement is better than none, so if you are able to encourage micro-movements this may offer a degree of offloading. This may be achieved with the use of wedges, beanbags (decubitus cushions).
Seating acquired pressure ulcers are among the highest. When residents are sat comfortably in their chair are they still prompted to reposition? This is especially an issue in peoples own homes where getting in and out of bed is becoming increasingly difficult. It is again vital that residents are prompted to reposition and this is documented in their care or reposition plan depending on their level of mobility. The use of air, gel cushions, wheelchair services, rise recliners and, where available, support from occupational therapists for specialist chairs, should be utilised for those at risk.
REACT TO RED
Demonstrate to all care staff, and the resident that has capacity, how to pick up early stage pressure damage (refer to earlier published blog for more information on this, including identifying on darker skin).
The below blanching 1 min video by React to Red is a great demonstration.
This is a debate which is discussed everywhere I go!
As ever, sharing tips and ideas on this subject is beneficial for all of us and our patients and residents in reducing harm. On my professional rounds I have seen some great ideas and outstanding practice on repositioning.