Part 2 in a two-part series looking at the basics of correctly using support surfaces to help redistribute pressure. Read Part 1 here.

Certain patient populations—such as the critically ill, those with spinal cord-injuries, and bariatric individuals—need special interventions and support surfaces to prevent pressure ulcers. These recommendations address the unique needs of these special populations in relation to pressure redistribution, shear reduction, and microclimate control.

Spinal Cord-Injured Individuals

Ideally, ischial ulcers should heal in an environment where the ulcers are free of pressure and other mechanical stress. Total bedrest may be prescribed to create a pressure-free wound environment. However, this approach comes with potential physical complications (e.g., muscle wasting, deconditioning, respiratory complications), psychological harm, social isolation, and financial challenges for the individual and his or her family. Balancing physical, social, and psychological needs against the need for total offloading (i.e., total bedrest) creates a challenging dilemma for the individual and the professional.

Use of a wheelchair is imperative for spinal cord-injured individuals. Sitting time may need to be restricted when ulcers are present on sitting surfaces. Seating cushions must be high-immersion, uniform-loading distribution cushions. Refer individuals to a seating professional for evaluation if sitting is unavoidable. Select a cushion that effectively redistributes the pressure away from the pressure ulcer. Select and periodically re-evaluate wheelchair and seating systems.

Wheelchair and Cushion Characteristics and Maintenance
Seat spinal cord-injured individuals with ischial ulcers on a seating support surface that provides contour, uniform pressure distribution, and high immersion or offloading. Use alternating-pressure seating devices judiciously for individuals with existing pressure ulcers. Weigh the benefits of offloading against the potential for shear based on the construction and operation of the cushion. Select a stretchable cushion cover that fits loosely on the top surface of the cushion and is capable of conforming to the body contours. Assess the cushion and cover for heat dissipation. Select a cushion and cover that permit air exchange to minimize temperature and moisture at the buttock interface. Inspect and maintain all aspects of the wheelchair seating system at appropriate regular intervals to ensure proper functioning and meeting of the individual's needs. Provide complete and accurate training on use and maintenance of wheelchair and cushion devices delivered to the individual.

Bariatric (Obese) Individuals

Fit the individual to the bed from the time of admission. Use beds that support the weight of the individual. Check for "bottoming out" of the mattress. Ensure that the bed surface is sufficiently wide to allow turning of the individual. Confirm that the width of the bariatric individual does not reach the side rails of the bed when the individual is turned from side to side. Consider using features that provide air flow over the surface of the skin to facilitate fluid evaporation if the skin is excessively moist.

Equipment Selection
Use a wheelchair and chair wide enough to accommodate the individual's girth. Provide bariatric walkers, overhead trapezes on beds, and other devices to support continued mobility and independence.

Assessment and Positioning
When performing physical assessments, get adequate assistance to inspect all skin folds fully. Pressure ulcers may develop in unique locations, such as beneath folds of skin and in locations where tubes and other devices have been compressed between skin folds. Pressure ulcers develop over bony prominences, but they may also result from tissue pressure across the buttocks and other areas of high adipose tissue concentration. Avoid pressure on skin from tubes and other medical devices. Use pillows or other positioning devices to offload pannus or other large skin folds and prevent skin-on-skin pressure. Utilize moisture control techniques to prevent skin-to-skin irritation that often results in skin breakdown.

As always, this is cyclic: plan, do, check, act, repeat. There is no common sense to use here, only common knowledge, and that is only the knowledge provided and learned from assessment, trial, evaluation, and success.

About the Author
Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary, is Wound Care Certified through National Association of Wound Care since 2004. Currently, she consults in long-term care and alternate care settings on wounds, skin care, and various other issues. She has been employed in the long-term care setting since 1969, spending 25 years in a long-term care rehabilitation facility where the focus was wound healing therapies.

NADONA/LTC has been a leading advocate and educational organization for DONs, ADONs, and nurses in long-term care since 1986. With 40 state chapters, it continues to be the largest organization representing nurses working in both post-acute and long-term care settings. NADONA/LTC offers a wide array of services to its members, including educational materials; conferences; executive fellows program, webinars, scholarships; Nurse Leader, Licensed Practical Nurse and Assisted Living certification programs; a mentoring program; and a quarterly journal, The Director. Through its publications and programs, NADONA/LTC reaches approximately 20,000 nurses who are employed in long-term care. For more information regarding NADONA/LTC, please contact their offices at 800-222-0539 or visit their website at https://www.nadona.org.