Page 20 - Mobility Management, March/April 2021
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ATP Series
Pressure Injuries: It’s Not Always the Cushion
There’s something that happens, and they don’t necessarily have a way to address the situation, or the knowledge to address that particular scenario.”
Another factor: Changes in prevention behaviors. “The longer you’re doing a prevention behavior like shifting your weight, and the further you are away from a medical appointment, the [more] the behavior deteriorates,” Norton said. “The focus on it becomes less. It happens with medication, it happens with all kinds of things, not just in this domain.”
Jackson also identified the “lifestyle risk ratio,” which Norton described as “the balance of how many liabilities are in that person’s life around developing a pressure injury versus the things that buffer it. A liability might be not having the right bed surface, but the buffer can be a caregiver who does consistent repositioning.”
The factor most closely related to her own research, Norton said, is “how well does the healthcare provider individualize the
treatment? Do we just hand people a sheet that says, ‘Shift your weight every 20 minutes?’ Do we move alongside the patient and help them figure out how they integrate weight shifting into their day, rather than just giving them a task to do?”
Norton compared the current pandemic to the constant pressure injury vigilance wheelchair users and caregivers need to practice: “We’re seeing it now in terms of what people are calling COVID fatigue. People who are at risk for pressure injuries prob- ably have pressure injury prevention fatigue, too.
“Preventing a pressure injury is a long-term goal, but in the short term, you have the opportunity to go to a wedding or do something really fun and exciting. You might recognize you’re
at risk, but you don’t want to miss that activity. When you’re in
a healthcare setting, one of the dangers is you [as the healthcare professional] are focused on whatever the medical issue is. But as the patient, that’s only one of the things [they’re] focused on.”
Under Pressure: Q&A with Denise Harmon, ATP/CRTS
Mobility Management: When wheelchair users develop pressure injuries, the seat cushion often gets the blame. Is that fair?
Denise Harmon: It’s complicated (sometimes, the path to discovery of a simple causal factor is the complication!). The cushion is the first cause to be suspected, but often we find that other factors have contributed.
MM: It’s natural to think about pressure injuries as weight that stays in one place for too long. But how much impact do other factors have?
DH: I think often if the consumer comes into the evalua-
tion with a bias (either from personal observation or physician commentary, etc.) that the cushion has caused a pressure injury, we often jump to the conclusion that the seat cushion needs to be re-considered.
It’s important to develop and follow a practice of thorough risk assessment, which includes both physical evaluation and interview of activities of daily living. There are a number of other causal factors: type of transfer, appropriate seating dimensions (seat depth, seat-back angle, knee-heel angle, footrest height), weight loss, microclimate, incontinence, comorbidities, etc.
It’s sometimes more difficult to determine, but often providing education and resources regarding effects of, for example, micro- climate can go a long way in affecting pressure. Undergarments can have an impact on pressure: There are very lightweight, stretchy, seamless undergarments available in department stores or online that can have positive effects in protecting bony areas.
I worked with an individual who, in spite of our recommen- dations, continued to wear heavy jeans with heavy pockets and seaming, which put pressure directly on his stage IV wounds. Multiple appointments, re-educating with the same words consis- tently regarding his selection of garments (you can look just as good in a pair of stretch athletic pants with no pockets) helped to change his “wardrobe approach.”
MM: Weight-shifting requires the client (plus maybe a care- giver) to perform weight shifts according to recommendations
from the seating team. How much do we need to examine whether the client is following recommendations?
DH: 100 percent! Client education and compliance are key. Our approach should be one of interview, education and review, each and every time we are with the client. The emerging “connected chair” technology for power chairs allows clinicians to review the client’s history in utilization of tilt, recline/power seat functions. This is an extremely useful tool and important for us to expand on, to enhance our individual practices.
MM: Can non-compliance come from a lack of education? DH: Yes. As we learn more and more about the key contrib-
uting issues to risk/cause of pressure injury, we need to make sure we continue to share the information with our clients. So many individuals we see, in spite of best intentions, have a lot going on in their daily lives, and the message can get lost over time.
Messaging to the client should be consistent and ongoing. Being proactive is key: In working with high-risk individuals, it’s important to schedule continued appointments for monitoring of their skin/situation and hopefully progressively building into both their own knowledge base as well as daily habits (versus waiting for a call after the problem arises or has escalated).
MM: Let’s say a client has developed a pressure injury and you are assessing for new seating. What questions do you ask?
DH: If there is a report available from the physician or wound care specialist, this is important to access. Inspect the pressure injury: Visual inspection informs us. Observe seated posture
both in the mobility base, as well as on a mat table: Seeing the individual in both seated environments is critical in looking at postural asymmetries, etc. Of course, physical assessment with the clinician is key: measuring balance, body angles and shapes, points of support needed for off-loading pressure, etc. Often you will spot a very subtle postural asymmetry that has a huge impact on pelvic position/pressure to a bony prominence. When inter- view and physical assessment don’t result in informing to cause of pressure, pressure mapping is a key tool to utilize. m

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