Take the load off by choosing

the right support surface

Bewildered by the
plethora of choices
in pressure-reducing
surfaces? Find out how
they work so you can
choose wisely and
appropriately.
By JoAnn Maklebust
RN, AOCN, APRN,BC, MSN

ACCORDING TO THE National Pressure Ulcer Advisory

Panel, most pressure ulcers are treatable and most are preventableyet patients still die of pressure-ulcer-related
complications. One way you can make a difference in your
patients care is by learning how support surfaces, such as
mattress overlays, mattress replacements, and specialized
beds, relieve or redistribute pressure on skin and prevent
pressure ulcers from forming or worsening. To understand
why support surfaces help, first consider the pathophysiology of pressure ulcer formation.

tends to slide downward. Her skin sticks to the bedclothes

or sheets, pulling away from underlying tissue and becoming distorted. In the process, capillaries stretch and tear, reducing local blood flow. The result may be a shear ulcer with
wide areas of undermining between the skin and deeper tissue. Shear combined with pressure may be responsible for
the high incidence of sacral pressure ulcers.
Reducing pressure

Three major components contribute to pressure ulcer development: pressure duration and pressure intensity, for
which you can intervene, and tissue tolerance (more on this
later).
Repositioning the patients body reduces the duration
of pressure and using support surfaces reduces the intensity
of pressure. Use these interventions to take the load off body
pressure points.
To reduce pressure and sacral shear, elevate the head of
the patients bed no higher than 30 degrees. If she cant lie
flat because of cardiopulmonary conditions or enteral tube
feedings, keep the head of the bed at the lowest possible angle. When you reposition her side to side, support her in a
30-degree lateral position rather than on her trochanter at
a 90-degree angle. Using a 30-degree side-lying position
avoids putting pressure on the sacrum and the trochanter
simultaneously.

Damaging duo: Pressure and shear

Two forces can damage soft tissue: pressure and shear.

Pressure ulcers are caused by compression of soft tissue
between bony prominences and an external surface, such
as a chair or bed. When external pressure exceeds capillary
blood pressure, blood flow is impeded, causing tissue ischemia and breakdown. Because muscle is more sensitive
to pressure than skin, underlying tissue may be necrotic by
the time you see a lesion on the skin surface.
Shearing forces reduce the ability of tissue to withstand
pressure: Tissue subjected to shear force can suffer ischemia
at only half the pressure that would cause ischemia without
shear.
Shear can occur when the head of the bed is raised more
than 30 degrees. Positioned at a steeper angle, the patient
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Use pillows or foam wedges to separate bony prominences, such as knees and ankles, and place pillows under
the patients lower legs to lift her heels off the bed.
Neither time nor pressure alone causes tissue ischemia.
Weve been taught to reposition patients at least every 2
hours because of the inverse relationship between pressure
and time: A person can endure a great amount of pressure
for a short amount of time without sustaining tissue damage; a ballet dancer standing on her toes is a good example.
Long periods of low pressure cause more tissue damage than
short periods of high pressure. Also, repeated pressure insults to the same area before it has a chance to recover may
cause cumulative tissue damage, which can lead to a pressure ulcer.

Keep the head of the bed at 30 degrees or less to reduce pressure

and shearing forces on the sacrum.

to maximize contact, then redistribute the patients weight

as uniformly as possible. Theyre designed to work on the
Tackling tissue tolerance
principle of Pascals law: The weight of a body floating on a
Every patient has a different tissue tolerance, or the amount
fluid system is evenly distributed over the entire surface. As
of time she can tolerate the effects of pressure. Youll need
pressure is increasingly distributed over more body surface
to determine how long your patient can tolerate pressure
area, the intensity of pressure decreases over all body areas.
against the skin. An elderly patient with fragile skin or little
Support surfaces also use the principle of deformation: They
soft tissue may not be able to tolerate one position for even
must be capable of deforming enough to permit prominent
2 hours without damage. Use a pressure ulcer risk assessareas of the body to sink into the support. Finally, they must
ment tool to determine your patients risk. If shes at risk
be able to transmit pressure forces from one body area to
for skin breakdown, check her skin over bony prominences
another.
for signs of pressure intolerance: nonblanchable erythema,
The degree of head elevation can affect the clinical
pain, edema, heat, or changes in skin color compared with
effectiveness of a support surface. When the head of the
baseline. You might also notice persistent redness once presbed is elevated, pressure is shifted to the sacral and issure has been relieved or blue or purple skin tones in a pachial areas of the body. The patient may bottom out if
tient with darker skin. Perform these checks every 24 hours;
the seating area of the support surfaces flattens and loses
more often if redness persists
volume. If bottoming out
with pressure relief.
occurs, the support surface
Characteristics to consider when
If your patient is presno longer provides therachoosing a support surface
sure-intolerant, increase her
peutic benefit.
Pressure redistribution. The surface should support the
turning frequency and put
To determine if bottompatients body weight without harming her skin.
her on a support surface deing out has occurred, place
Skin moisture control. The surface should keep her skin
signed to reduce the intensity
your hand, palm up and findry.
Skin temperature control. The surface shouldnt make her
of pressure between bony
gers outstretched, between
sweat.
prominences and the bed. No
the mattress overlay and the
Friction. The surface should let her transfer but not slide
one product works best for
hospital mattress. The supoff.
all patients in all circumport surface should have
Infection control. The surface shouldnt promote bacterial
stances. By understanding
about 1 inch (2.5 cm) of ungrowth.
the properties and perforcompressed support surface
Flammability. The surface shouldnt ignite if someone
mance characteristics of varbetween your hand and the
drops a lighted cigarette on it.
ious support surfaces, you
patients body. If you can feel
Product service requirements. The owners manual should
can match one with your pathe patients body lying on
describe how to clean and maintain the surface.
tients clinical condition.
your hand, the mattress
Life expectancy. The manual should indicate how long the
needs more depth. Add
surface is expected to last, so it can be replaced before
problems arise.
How support
more air to the mattress or
Fail safety. The manual should tell you what to do if the
surfaces work
provide a thicker support
surface becomes unusable.
To be effective, support sursurface so the patient doesnt
faces must mold to the body
bottom out.
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With proper care, your patients pressure ulcer

Getting specific

Mattress overlays and mattress replacements can provide

pressure relief with foam, air, gel, or water, alone or in combination. All of these mattresses or overlays deteriorate over
time. The Centers for Medicare and Medicaid Services divides support surfaces into three groups:
Group 1 surfaces dont require electricity and include air,
foam, gel, and water mattresses or overlays. These surfaces
are intended for pressure ulcer prevention.
Foam surfaces come in various densities (or weights),
depths, and construction. To reduce pressure, foam must
be high quality and at least 4 inches (10 cm) thick.
Static air overlays have multiple chambers that allow
air exchange between compartments (or cells) when a person lies on the surface. The air exchange between cells allows the surface to deform and permits the body to sink into
the surface, reducing pressure on bony prominences. Maintain adequate air volume with inflation or reinflation devices.
Gel mattress overlays have a tissuelike composition that
reduces shear and supports weight without bottoming out.
Theyre self-sealing if punctured and can be reused. Gel
doesnt deform easily and may become stiff over time.
Group 2 surfaces include dynamic powered surfaces and
advanced nonpowered surfaces. These surfaces are indicated for patients with Stage III or Stage IV pressure ulcers
on the trunk or pelvis, muscle flap repair of a pressure ulcer
within the last 60 days, or multiple Stage II pressure ulcers
that havent improved on a Group 1 surface in the last month,
even with comprehensive care (more on that later).
Dynamic air overlays are used with a mechanical pump
to alternate inflation and deflation of chambers and constantly change pressure points. Air chambers must have
enough depth and be close enough together to lift the body
during alternating cycles.
Low-air-loss systems are available as mattress overlays
and whole bed systems. An air compressor inflates the mattress cushions. It also circulates air across the patients skin
to reduce moisture.
Group 3 consists of air-fluidized beds, a high-air-loss system with ceramic silicone beads that become fluidized as
warm pressurized air is forced up through the beads. This
gives the beads the characteristics of fluid, allowing the paMed/Surg Insider

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should show signs of healing in 2 to 4 weeks.

tients body to float on the surface and minimizing pressure, shear, and moisture. A Group 3 surface is indicated
for patients with Stage III or Stage IV pressure ulcers that
havent improved on a Group 2 surface over the last month,
even with comprehensive care.
See Characteristics to Consider When Choosing a Support Surface for more tips on evaluating support surfaces
for patient use.
Support surfaces are no substitute for careful nursing
care and educating the patient and family about wound
care. Comprehensive care includes a nutrition plan to optimize wound healing, managing incontinence or moisture, good local wound care (including treating wound
infection), repositioning your patient every 2 hours, and
assessing her skin and pressure points for potential problems each time you turn her. If you find persistent pressure areas indicating tissue intolerance, consult a wound
specialist for alternative pressure-reducing devices. He may
recommend a different type of support surface to take the
load off.
With proper care, your patients pressure ulcer should
show signs of healing in 2 to 4 weeks. If you dont see signs
of improvement, reassess your interventions for pressure
reduction, adequate nutrition, and good local wound care.
All three areas are key to healing your patient.
SELECTED REFERENCES
Brienza, D., et al.: Seating, Positioning, and Support Surfaces, in
Wound Care Essentials: Practice Principles, S. Baranoski and E.
Ayello (eds). Philadelphia, Pa., Lippincott Williams & Wilkins,
2004.
Cuddigan, J., and Ayello, E.: Treating Severe Pressure Ulcers in
the Home Setting: Faster Healing and Lower Cost with AirFluidized Therapy, The Remington Report. 12(3):6-10, May/June
2004.
Cullum, N., et al.: Beds, Mattresses, and Cushions for Pressure
Sore Prevention and Treatment (Cochrane Review), Chichester,
United Kingdom, The Cochrane Library, John Wiley and Sons,
Issue 2, 2004.
National Pressure Ulcer Advisory Panel: Pressure Ulcers in
America: Prevalence, Incidence and Implications for the Future.
Reston, Va., National Pressure Ulcer Advisory Panel, 2001.
JoAnn Maklebust is a wound care clinical nurse specialist and a
nurse practitioner in the department of surgery at Barbara Ann
Karmanos Cancer Institute at Detroit Medical Center and associate
clinical professor of nursing at Wayne State University, both in
Detroit, Mich.

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