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