Pressure Ulcer Prevention and Management - Sydney South West ...

Policy DirectivePressure Ulcer Prevention and ManagementDocument No:Functional Sub-Group:Summary:Approved by:SSW_PD2008_008Corporate GovernanceClinical GovernanceGuidelines for the prevention and management ofpressure ulcers in conjunction with the Warterlow RiskAssessment and Management Tool.Ms Kerry Russell, Area DON&MS(Endorsed by: Area Clinical Quality Council & NursingExecutive Committee)Publication (Issue) Date: March 2007Next Review Date: April 2010Replaces Existing Policy:Previous Review Dates:N/AN/ANote:Sydney South West Area Health Service (SSWAHS) was established on 1 January 2005 withthe amalgamation of the former Central Sydney Area Health Service (CSAHS) and the formerSouth Western Sydney Area Health Service (SWSAHS).In the interim period between 1 January 2005 and the release of single Area-wide SSWAHSpolicies (dated after 1 January 2005), the former CSAHS and SWSAHS policies wereapplicable as follows:-• SSWAHS Eastern Zone : CSAHS• SSWAHS Western Zone: SWSAHSCompliance with this policy directive is mandatory Page 1 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008PRESSURE ULCER PREVENTION AND MANAGEMENTCONTENTS1. Introduction1.1 Risks – Clinical1.2 Aims / Expected Outcomes2. Policy Statement3. Principles / Guidelines3.1 Background3.2 Guidelines3.2.1 Risk Assessment and documentation for all Patients WITHOUT aPressure Ulcer3.2.2 Risk Assessment and Documentation for all Patients WITH a PressureUlcer3.2.3 Pressure Ulcer Prevention Strategies3.2.4 Maintenance of Skin Integrity3.2.5 Repositioning Intervals according to pressure devices classification3.2.6 Training and Education4. Performance Measures4.1 Monitoring and Ongoing Reporting of Pressure Ulcers4.2 Monitoring and Evaluation5. Definitions6. ReferencesAppendix 1:Appendix 2:Appendix 3:Appendix 4:Appendix 5:Appendix 6:Appendix 7:Waterlow Pressure Ulcer Risk AssessmentWaterlow Pressure Ulcer ManagementSummary of Prevention StrategiesPressure Ulcer GradesIntervention GuidelinesDevicesClassification of DevicesCompliance with this policy directive is mandatory Page 2 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008• Interventions are to be documented and based on the SSWAHSPressure Ulcer Prevention and Management Policy InterventionGuidelines (Appendix 3 & 4).• Pain management must include adequate analgesia as appropriate.• Strategies implemented to promote pressure ulcer healing andprevent further breakdown must be documented in the patient /client’s health care record.• Current risk assessment, existing pressure ulcers of all grades andpresence of pressure relieving devices are to be documented in thepatient / client’s health care record on transfer or discharge.• Implement appropriate prevention strategies as per WaterlowPressure Ulcer Management Flowchart (Appendix 2)• All existing pressure ulcer must be reviewed and documented on thepatient/client’s discharge summary3.2.3 Pressure Ulcer Prevention StrategiesPressure injury prevention strategies, directed at reducing or modifyingpressure ulcer risk factors, should be incorporated into the patient / client’smanagement plan. All patients identified ‘at risk’ should have a plan of carethat incorporates measures such as pressure support systems, positioning,skin care and nutritional interventions. These strategies include:(i)(ii)(iii)(iv)maintenance of skin integrity;minimisation of pressure, shear and friction;implementing pressure relieving positions and a pertinent turningschedule, including repositioning intervals; andprovision of an appropriate support surface.3.2.4 Maintenance of Skin IntegrityMaintaining the integrity of the patient / clients skin is the key to anyprevention program. As skin has a normal pH of 4-6.8, the skin’s acidity,normal flora and the natural anti-bacterial substances found in sebum delaymicro-organism growth. Maintaining a stable skin pH discourages thecolonisation of bacteria and reduces the risk of opportunistic infection.Patients at risk should have a skin inspection daily, or more often ifwarranted, paying particular attention to skin over bony prominences andweight bearing areas. A systematic inspection is integral to the earlyidentification of skin damage and provides a baseline for care planning andevaluating interventions. Actions to maintain skin integrity include:(i)Routinely Assess Skin:• Conduct a skin assessment on admission and at regularintervals, especially skin over bony prominences which is notdesigned to support sustained external pressure eg. Sacrum,heels and greater trochanters.Compliance with this policy directive is mandatory Page 6 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008• Assess patients carefully for compromised peripheral circulationand diabetes.• Use vigilance to assess patients with casts, traction and supportstockings.• Document pre-existing ulcers in the patient / client health carerecord in terms of location, severity, size, description of ulcerand surrounding skin.(ii)Prevent Exposure to Excessive Moisture or Dryness:• Implement continence training with toileting / bowelmanagement regimes where applicable.• Minimise skin exposure to urine or faeces, excessive sweatingor wound drainage as these can increase the pH of the skincausing chemical damage, maceration and denuding of the skin.• Consider medical assessment (eg. medication review) for highrisk patients to manage reversible cases of incontinence.(iii) Promote Optimal Skin Hygiene:• Cleanse the skin gently to improve overall hygiene and stimulatecirculation.• Treat dry skin with appropriate moisturising creams.• Avoid vigorous rubbing or massaging over bony prominences.(iv) Promote Optimal Nutrition:• Encourage a balanced diet to provide adequate protein andcaloric requirements.• Assess nutrition and hydration and other indicies of nutritionalstate, eg. body weight loss, muscle wasting or any signs ofvitamin or mineral deficiencies.• Consult a dietician when nutritional deficits compromise tissueintegrity.(v)Minimisation of Pressure Shear and Friction. Damage to the skin iscaused by pressure, shearing forces or friction, or a combination ofthese:• Patients / clients who are immobile, inactive and elderly are atgreatest risk.• Skin assessment is critical in providing an indication of the skin’stolerance to pressure shear and friction.• Correct positioning, transferring and handling techniques shouldbe employed(vi) Protect Against the Forces of Shear and Friction:• Use aids that eliminate dragging and friction eg. Hoists, slidesheets, slide boards and slings.• Take care when transferring patients / clients between bed andchair• Avoid the overuse of plastic sheets / kyliesCompliance with this policy directive is mandatory Page 7 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008• Avoid shearing forces by using profiling beds and / or notelevating the head of the bed more than 30 degrees (asappropriate to the patient / clients clinical condition)(vii) Reduce Heel Pressure:• Protect heels against pressure injury, particularly those patient /clients confined to bed or with immobilised lower extremities.• Prevent constriction of the foot by tight or heavy bed linen withaid of a bed cradle.(viii) Promote Activity and Mobility:• Maximise activity and mobility status consistent with patient /clients medical condition and ability eg. Encourage earlymobilisation following surgery or stroke.• Use assist devices with active rehabilitation and earlyambulation to relieve pressure from stressed or damaged tissueand improve circulation eg. Trapeze, rollator, cane or walker.(ix) Pressure Relieving Positions:• Specific attention should be paid to patients / clients in bedassessed to be ‘at risk’ for pressure ulcer development.• A care plan for systematically turning and repositioning thepatient should be developed that includes the use of positioningaids and pressure devices to relieve pressure from bonyprominences.• Repositioning schedules should consider the patients medicalcondition and comfort level.• Positioning frequency is based on skin inspection and should beincreased if skin discolouration is evident.(x)Pressure Repositioning Intervals:• When patients are unable to move themselves and relieve thepressure, clinical staff must intervene and reposition the patientregularly, being careful to eliminate any shearing forces to otherareas of skin eg. dragging heels along the sheet. Appropriatelifting aids and manual handling equipment must be used at alltimes.• The frequency of repositioning is dependent on the individualpatient / clients skin’s tolerance to pressure. The repositioningschedule should consider the patient/client’s medical condition,comfort, overall plan of care as well as the support surface used.Repositioning decreases the time a patient / client spends in oneposition and pressure relieving devices reduce pressureintensity• Reposition the patient more frequently if sitting up and / or use amore efficient support system if the patient / clients skin colourchanges. Conduct a skin inspection of all pressure points todetermine the effectiveness of the repositioning scheduleCompliance with this policy directive is mandatory Page 8 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 20083.2.5 Repositioning Intervals According to Pressure Devices Classification (forpressure relief)Product descriptionFoam replacementmattressesContoured surfaces ordifferent density foamsVery high risk( 20+ )Patient risk categoryHigh risk( 15+ )At risk( 10 )1 hour 2 hours 3 hoursStatic air-filledmattresses 2 hours 3 hours 4 hoursAlternating pressureoverlays2 Cell CycleAlternating pressuremattresses2 Cell CycleAlternating pressuremattress3 cell cycle4 hours 5 hours 6 hours6 hours 8 hours 8 hours8 hours 8 hours 8 hours3.2.6 Training and EducationTraining and education programs for the prevention of pressure ulcers shouldbe structured, organised and comprehensive. They should be directed at alllevels of health professionals, patients / clients, families and carers involvedin patient / client management. The basic education should include thefollowing content:• Patient / Client assessment;• Aetiology and risk factors;• Risk assessment tools and their application;• Uniform staging classification;• Skin assessment and skin care;• Selection of appropriate pressure redistributing equipment;• Implementation of an individualised management program whichincludes discharge planning needs; and• Positioning / handling techniquesIn addition education should also focus on:• Principles of wound healing and product selection;• Relevant policies and procedures;• Documentation of relevant data;• Clinical audit processes of preventative and therapeutic interventions;• Clinical governance which includes commitment to and availability ofeducation and training;• Where to get further advice eg. Resource persons in organisation;andCompliance with this policy directive is mandatory Page 9 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 20084. Performance Measures• Roles and responsibilities of the multidisciplinary team.4.1 Monitoring and Ongoing Reporting of Pressure UlcersIf a patient / client is identified as having a pressure ulcer the following mustoccur:(i)(ii)(iii)(iv)(v)A notification in the patient / client healthcare record via the pink notificationsticker must occur after the incident is notified in IIMS;Each month on a nominated day a prevalence audit is to be conducted bythe Nursing Unit Manager (NUM) or delegate. The results of this audit areto be sent to the Quality Unit and copies of the audit are to be kept by theNUM as evidence;The Quality Unit will then generate a monthly report for distribution to eachNursing Unit Manager, Department Head & Clinical Manager in order toupdate and monitor the pressure ulcer status of each patient / client with adocumented pressure ulcer;The Quality Unit will generate a trended monthly report from the aggregateddata; andBi-Annually Clinical Nurse Consultants will conduct a prevalence audit of allpatients in the facility.Incidence and prevalence of pressure ulcers by site, grade and intervention mustbe reported and discussed at the appropriate local clinical meetingMonthly aggregated reports are to be directed to the Facility Director of Nursingor Community Health Director of Nursing.An aggregated quarterly report from each Facility and Community Health QualityUnit indicating incidence and prevalence of pressure ulcers by site, grade andintervention must be tabled at the SSWAHS Nursing Clinical Practice CommitteemeetingAny incidence of grades 1 - 4 pressure ulcer must undergo a SeverityAssessment Code score in IIMS.Aggregated monthly incidence and prevalence rates on grade and site of allpressure ulcers are to be presented to relevant teams and committees.Identification of any contributing factors and recommendations on strategies toreduce the incidence are to be recorded and implemented with minimal delay.Review of the effectiveness of the strategies and actual outcomes is to beassessed and recorded by teams and relevant committees.4.2 Monitoring and EvaluationNursing managers are responsible for maintaining high standards of care andensuring the resources, educational programs and audit systems are in place tosupport an effective pressure ulcer prevention and management program.Regular evaluation is part of an ongoing process of monitoring and assessing.The monthly clinical audit forms an integral part of the organisations qualityCompliance with this policy directive is mandatory Page 10 of 20

Sydney South West Area Health ServicePolicy No: SSW_PD2008_008Date Issued: January 2008improvement plan. The principles and process ensure that agreedoutcome measures are achieved. Pressure ulcer monitoring must include:• Monthly incidence reports both at clinical and organisational level• Monthly clinical pressure ulcer prevalence audits5. DefinitionsBlanching Hyperaemia - reddened areas turn white following application of fingerpressure; this indicates that the microcirculation is intact.Epithelialisation - regeneration of the epidermis across the wound surface.Erythema - redness of the skin surface caused by vasodilation.Eschar - brown or black necrotic tissue.Exudate - any fluid that has exuded out of a tissue or its capillaries because of aninjury or inflammation and is high in protein and white cells.Friction - a force created by two surfaces in contact moving across each other.Granulation - healing tissue composed of newly formed capillaries and fibroblasts.Incidence - the frequency of occurrence of any event or condition over a period oftime and in relation to the population in which it occurs, as an incidence of a disease.Ischaemia - deficiency of blood, due to obstruction or constriction of a blood vessel.Necrosis - death of tissue.Non-blanching Hyperaemia - persistent redness when finger pressure is applied toan area of reactive hyperaemia indicating disruption to the microcirculation.Pressure - a perpendicular load or force.Pressure Reducing Support Surfaces - support surfaces that maintain tissueinterface.Pressure Support Surfaces - support surfaces that maintain tissue interface pressurePressure Ulcer - an area of localised tissue damage caused by unrelieved pressure,friction or shear. Pressure ulcers occur most commonly on the sacrum and heel butcan develop anywhere on the body including the coccyx, occiput, clavicle, ear andnose. Other terms for a pressure ulcer are pressure sore, bedsore and decubitus ulcer.Prevalence - the number of existing cases of a particular disease or condition in agiven population at a designated time.Reactive Hyperaemia - a normal compensatory mechanism following an episode ofreduced skin perfusion to the tissues as a result of pressure. Relief of pressure resultsin reddening of skin caused by blood returning back into ischaemic tissues.Compliance with this policy directive is mandatory Page 11 of 20

Appendix 1Waterlow Pressure Ulcer Risk Assessment ToolCircle scores in the table below and calculate the total to obtain risk score. (Several scores per category can beused).Has the patient previously had a pressure ulcer? Yes □ No □Has this pressure ulcer been entered into IIMS? Yes □ No □Sex/Age Build/Weight for Height (BMI) Special RisksMaleFemale14-4950-6465-7475-8081+12123450Average (20-24.9)Height (m) 2Above average (25-29.9)1Obese >302Below average 4hrs ## - scores can be discounted 48hrspost op provided pt is recoveringnormallyCytotoxinsSteroidsAnti-inflammatory(max score 4)Malnutrition Screening Tool (MST) – circle and add for a totalB. How much weight has the ptlost?Go to question BGo to question CScore 2 and go to C0.5-5kg5-10kg10-15kg>15kgUnsure12342MedicationsC. Has the pt been eating poorlybecause of a decreased appetite?NoYesTotal MalnutritionScoreIf the patient’s malnutrition screening score is 2 or more pleaserefer pt to a dietician.Total WaterlowScoreDate Referred:Signature:(total all scores +MST score)Waterlow Pressure Ulcer Risk 10+ At risk 15+ High Risk 20+ Very High Risk© J Waterlow 1985 Revised 20050184

Appendix 2Waterlow Pressure Ulcer Management FlowchartNOT AT RISK < 10AT RISK 10+HIGH RISK 15+VERY HIGH RISK 20+PRESSUREULCERNo managementunless change inconditionWaterlow assessmentto be completed everyweek or morefrequently if change inconditionDocument in thepatient/client healthcare record and on thecare planIdentify level of riskManage as perprevention strategiesChoose a pressuresupport system accordingto the level of risk(Appendix 4)Dietician referral to assessthe patient/clients nutritionalstatus & dietaryrequirementsWaterlow assessment to becompleted every week ormore frequently if change inconditionEnter into IIMS. Whenappropriate contact woundcare specialistDocument in thepatient/client health carerecord and on the woundmanagement chartChoose a pressuresupport system accordingto the level of risk(Appendix 4)Dietician referral to assessthe patient/clients nutritionalstatus & dietaryrequirements & hydrationPressure ulcer woundmanagement as pertreatment protocolsContact wound carespecialist for advice &assistance re pressureulcerReview ulcer at eachdressing change. Documentin health care record woundmanagement chartDocument in thepatient/client health carerecord and on the careplanAny patient/client with agrade 3-4 pressure ulcer isto remain at High Risk fortheir entire admissionService required Date contacted SignatureEntered into IIMS YES NOEquipment Hire required YES NOCompany contacted YES NOWound Care Specialist YES NODietician YES NOInterventional strategies implemented:PLEASE NOTE: Any patient that has suffered a Stage 3 or 4 pressure ulcer in the past is ‘At Risk’ of developinganother and is to be treated as HIGH RISK throughout their entire admission

Appendix 3Summary of Prevention Strategies• Assess all patients/clients using the Waterlow Pressure Ulcer Risk Assessment Tool• Assess the patient/clients nutrition, function, continence and general medical condition• Involve all relevant members of the multi-disciplinary team• Initiate the following interventions and evaluate the outcomesMaintain skinintegrityEliminatepressure, shear& frictionInitiatepositioning, turnschedule &support surfaceDocument &communicateConduct a dailysystematic skininspection of ‘at risk’patients for signs ofimpaired skin integrityEliminate orminimise allpotentially irritatingskin substancesStabilise skin &body temperaturePromotecontinenceassessment/training & self careindependenceAvoid direct contactbetween bonyprominences with pillowsor foam wedgesKeep the head of thebed at the lowest levelfor the patients/clientsconditionRelieve heel pressure inbed-boundpatients/clients or withimmobilised lower limbsEmploy proper lifting& manual handlingtechniquesMaximisepatient/clientsactivity &mobilisationconsistent withmedical condition &abilityRepositionpatient/clientsaccording to theirrisk status and asfrequently as skin’stolerance dictatesAllocate an appropriatesupport surface foridentified level of risk. Usein conjunction with anindividualised turningregimenInvolve relevant membersof the multi-disciplinaryteam• physiotherapist• occupationaltherapist• dietician• medical staff• nursing staffDocument clearly all riskassessments,interventions &outcomesRegularly assessresponses tointerventionsAvoid prolongeduninterrupted sitting in achair or wheelchair(> two hours)Avoid positioningpatients on thetrochanter

Appendix 4Pressure Ulcer GradesGrade Definition Explanatory NotesOneObservable pressure-relatedalteration(s) of intact skin mayinclude changes in one or moreof the following: skin temperature(warmth or coolness) tissueconsistency (firm or boggy feel)and/or sensation(pain/itching)The ulcer appears as a defined area of persistentredness in lightly pigmented skin, whereas in darker skintones, the ulcer may appear with persistent red, blue andpurple hues.TwoThreePartial thickness skin lossinvolving epidermis and/or dermisFull thickness skin loss involvingdamage or necrosis tosubcutaneous tissue andextending down to, but notthrough, the underlying fasciaThe pressure ulcer is superficial and presents clinically asan abrasion, blister or shallow crater.Can present as necrotic tissue or eschar.The ulcer presents clinically as a deep crater with orwithout undermining of the adjacent tissue.FourFull thickness skin loss withextensive destruction, tissuenecrosis or damage to muscle,bone, or supporting structures(forexample, tendon or jointcapsule).Undermining and sinus tracts may also be associatedwith Grade 4 pressure ulcers.

Appendix 5Intervention GuidelinesPressure Ulcer Grade 1ObjectiveRelieve pressurePrevent friction and sheeringProtect skin from moistureProtect fragile skin and bony prominencesRecommendationEstablish a repositioning regime. If indicated, usepressure relieving devices according to PressureScore Risk Assessment and the Pressure UlcerPrevention Protocol Flow Chart.Do not drag patient. Use correct manual handlingtechnique and appropriate equipmentUse continence management systems. Use barrierskin cream to prevent skin maceration. Gently cleansite, rinse and dry well daily. Keep site clean anddry.Dermal pad, heel protector, hydrocolloidPressure Ulcer Grade 2 (Grade 1 plus the following)ObjectiveRecommendationPromote new tissue formationAttend dressing using appropriate materials Changedressing when strike through occurs or PRN.Change dressing daily if wound infected.Remove/control exudatePressure Ulcer Grade 3 (Grade 2 plus the following)ObjectiveRecommendationPromote new tissue formationAttend dressing using appropriate materialsChange dressing when strike through occurs orPRN.Change dressing daily if wound infected.Remove/control exudatePressure Ulcer Grade 4 (Grade 3 plus the following)ObjectiveRecommendationTreat infection and control any odourIn addition to surgical debridement systemicantibiotic cover is recommendedDebride necrotic areaSurgical debridement is required for all necroticwounds or as per Facility / Community HealthCentre Policy. The size of the wound willdetermine if debridement is attended in OT or inthe clinical area.

Appendix 6DevicesEquipment does not replace nursing care, but is an adjunct to pressure relief such as repositioning.Good pressure area prevention practices MUST continue whilst patient is sitting out of bed, with theassistance of static or alternating cushions.TYPE OF DEVICE DESCRIPTION EXAMPLE WATERLOWSCORESTATIC PRESSURERELIEVING/REDUCING DEVICE• Support Surfaces can containfoam, gel, air or water.• Reduce pressure byincreasing the supportingsurface area (by) conformingto the body.• Decrease friction andshearing.• Also includes seating devices.Standard Hospital MattressPressure relieving mattress• Contoured foam• Different density foamMattress Overlay(Placed on top of hosp mattress)• Foam Fibre Filled• Air filled10 + Medium RiskDYNAMICPRESSURERELIEVING/REDUCING DEVICE• Non-powered overlay supportsurface• Dynamic air filled chambersthat allow air exchangebetween compartments whencompressedMattress Overlay• Air-filled chambers 15+ High RiskALTERNATINGPRESSURERELIEVING/REDUCING SYSTEM• Consists of rows of cells thatdeflate and inflate alternately.• Transfer pressure loading fromone body part to another.• Come as mattress overlay ormattress replacement• Also includes seating devices1. Mattress Overlay(Placed on top of hosp mattress)• 2 Cell Cycle15 + High Risk2. Mattress Replacement• 2 Cell Cycle20 + Very HighRiskExisting PressureUlcersSPECIALTY BEDSLow Air Loss: Pressure reduction forvery high Risk patients. Ideal forpatients who are unable to toleratemoving surface. For example: PlasticSurgeryMattress Replacement• Overall low air loss cells Burns Unit andCritical CareNote: The above is not an exhaustive list of products available. Manufacturer’s instructions need to befollowed.(a) N.B. Devices not recommended for the prevention of pressure ulcers:• Doughnut cushion- not recommended as it reduces tissue oxygenation and the centre of the ringcan create tissue congestion and pressures in the areas surrounding the donut.• Massage - Not necessary and no evidence that prevention of pressure ulcers occurs.• Sheep skin - Can relieve friction but does not relieve pressure.• Cream – No evidence to support it relieves pressure or friction.• Water filled gloves / casks – Not recommended

Appendix 7Classification of DevicesConstant low pressure devicesConstant low pressure devices’ characteristics/features include:• may be foam, gel pads, air overlays and mattresses (static air or low air loss devices)• constant low pressure applied to the skin can still cause tissue ischaemia and necrosishence the device must be complimented with a turning regime relating to thepatient/clients risk status eliminating pressure at frequent intervals to allow blood tocirculate to ischaemic tissues• tight/knotted wrinkle free bed linen produces a ‘hammocking’ effect, undermining thepressure reducing qualities of the support systemGel filled padsFoam devicesStatic/Dynamic air devicesLow air loss devices• used on operating theatre and x-ray tables• may be used to protect the sacral area of ‘low risk’patient/clients in wheel chairs• durable, heavy to handle and lack air flow• need to observe and correct gel migration within thepad with position changes• available in a variety of sizes, density and thicknessfor use as mattress replacements or overlays on bedsand trolleys, or as chair cushions• life expectancy of products is generally one to twoyears for an overlay and five years for a mattress• foam device covers should be a two-way stretch,waterproof and vapour permeable• are non-mechanical, non-powered support surfacesthat remain motionless, except in response to patientmovement eg. RoHo• they may have interconnected chambers that allow airexchange between compartments when compressed• devices should be regularly checked and adjusted tothe patients body weight to avoid over and underinflation that may increase the interface pressure• available as an overlay, a replacement mattress or aspecialty bed• provide a continuous flow of air from the entiresurface of the mattress, using a micro-porous material• powerful motor provides the air necessary to maintainair cell inflation, despite constant air loss• pressure within the air cells is maintained at thelowest possible level for adequate patient support andbody alignment

Appendix 7Alternating pressure devicesAlternating pressure devices’ characteristics/features include:• dynamic and active pressure relief systems that require an electric power source• supplied as pressure cushions, overlays, single or multilayered mattress replacements• some devices automatically adjust to patient weight and position changeAlternating pressure devices• generate alternating high and low pressures betweenan individual’s body and the support surface• cyclically inflate and deflate groups of air filled cellsgenerally placed transversely across the mattresssurface• support the body via inflated cells, while deflated cellsreduce contact pressure; this allows oxygenation andnutrition to the tissues• significantly lower tissue interface pressure whencompared with a basic hospital mattress• require checking of mattress for puncture, tubingkinking and noise factor• the pressure relieving qualities of the device arereduced by plastic sheets, incontinence sheets andsheepskins between the patient and the surface• devices must have CPR and transport facility