Let us start off this post with a typical scenario. You walk into any facility or institution and you see a patient slouched in their wheelchair, with no wheelchair cushion. You notice part of their brief hanging out of the top of their pants, so you assume the patient may be incontinent. So let’s think about this for a minute. We most likely have friction, shear, and moisture going on with this patient.

This scenario is the perfect recipe for a pressure injury. So what can we do to help this patient and prevent a pressure injury from developing? We must first identify the cause, and then remove the cause. The cause in this example is shearing, friction, moisture, and pressure. We will remove the pressure injury causes with interventions such as using a 4 inch viscoelastic wheelchair cushion, non-slip matting to keep the patient in place, and offloading the patient every hour while up in wheelchair.

The NPUAP pressure injury definition states that the ability of soft tissue to tolerate shear and pressure may also be affected by the factors of microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. We still do not know whether shear damages muscle more than fat, the relationship between external and internal shear, or the affect of postural changes (frequency of speed or changes have on shear force).

Identifying Signs of Shearing and Friction

Many times you may identify signs of shearing stresses within a wound that presents an irregular shape and undermining. There may even be evidence of excoriation and blistering on areas in contact with support surfaces. Friction usually, but not always, accompanies shear. Friction is the force of rubbing two surfaces against one another. Shear is a gravity force pushing down on the patient's body with resistance between the patient and the chair or bed.

What can we do to reduce friction and shearing in managing our patients?

1. Pad and protect vulnerable areas (transparent, hydrocolloid, composite, foam dressings) as per facility protocol.
2. Use heel or elbow protectors for hospice/palliative patients.
3. Educate caregivers and nursing staff about how to identify key factors for pressure injuries.
4. Ensure that support surfaces provide for individual's particular needs: pressure redistribution, shear reduction, and or microclimate control.
5. Utilize positioning devices in wheelchairs or chairs to reduce shearing.
6. Establish a risk assessment per facility protocol.
7. Use draw sheets to pull up, transfer and position your patient. DO NOT DRAG.

Education is the most powerful weapon which you can use to change the world.
-Nelson Mandela

References:
Watanabe, L. Shear: Physics, Risks, Assessment & Management of a Long-Time. Mobility Management [Online], April 1, 2012. Aavailable at https://mobilitymgmt.com/articles/2012/04/01/shear.aspx. Accessed on November 19, 2016.

National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury [Press Announcement]. National Pressure Ulcer Advisory Panel, April 13, 2016. Available at https://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-anno…. Accessed on November 19th, 2016.

Shear: A contributory factor in pressure ulceration (presentation aimed at cliniciansand associated professionals). National Pressure Ulcer Advisory Panel, 2012. Available at http://www.npuap.org/wp-content/uploads/2012/03/Shear_slides_with_anima…. Accessed on November 19, 2016.

International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document.
London: Wounds International, Wounds International Pressure Ulcer Prevention, 2010. Available at http://www.woundsinternational.com/media/issues/300/files/content_8925…. Accessed on November 19, 2016.

About the Author
Cheryl Carver is an independent wound educator and consultant. Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter. She is the first LPN to be inducted as an Association for the Advancement of Wound Care (AAWC) speaker.