Introduction

Offloading is a cornerstone of pressure injury (PI) prevention. Certain patient populations, conditions, and environmental or institutional factors pose challenges to effective offloading that providers must mitigate to prevent PIs. It is important to note that these challenges often overlap with other complication risk.

Wheelchairs

Patients who use wheelchairs have limited mobility and may have altered sensory perception that renders them unaware of the effects of increased temperature and moisture caused by prolonged wheelchair contact.¹

Tips: Use pressure redistribution surfaces such as specialized cushions or even specialized wheelchairs.¹ Clinical practice guidelines recommend the patient reposition every 15 minutes to an hour,² and recommend limiting wheelchair use to 2 hours at a time.³ These repositioning techniques can include vertical push-ups and lateral and forward leans. Providers can use sensors to detect pressure at various points of contact and send an alert for a position change.⁴

Spinal Cord Injury

The reported incidence of PIs in patients with spinal cord injury is very high, 25% to 66%.¹ Risk factors include⁵:

• Immobility
• The absence of sensation
• Decreased soft tissue resilience
• Impaired blood flow response
• Smoking
• Urinary incontinence
• Lack of adequate nutrition

Tips: Educate the patient about ways to offload pressure, and encourage self-management as much as possible.⁵ To restore blood flow to tissues, many guidelines recommend weight shifts if the patient is sitting for a prolonged amount of time. Providers and caregivers should reposition the patient in supine and lateral postures. Clinicians should use advanced technology such as pressure sensor systems or other objective monitoring systems to ensure that pressure-relieving activities are occurring as needed.^5-6

Neonates

Infants in neonatal intensive care units (NICUs) have a higher frequency of PIs than older pediatric patients.⁷ The nose is particularly predisposed to PI in these patients.⁷

Tips: Use a pressure redistribution surface or positioner as needed.⁸ Although evidence is limited, surveyed NICU nurses recommended using a rolled blanket and a small soft object, neonatal mattress overlays, sheepskin, or foam.⁸ A literature review identified the use of appropriate support surfaces and frequent turning as effective offloading measures.⁹

Immobility

Immobility may lead to functional decline and is a major risk factor for PIs.³ Older adults are especially vulnerable to the effects of immobility and often have contributing comorbidities.¹⁰ In some long-term care facilities, patients are confined to a bed to avoid falls, but this increases PI risk, as does prolonged sitting.³

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Tips: Reposition bedridden patients every 2 hours or per facility protocol.2 Avoid friction or shear when moving patients 2 Consider an alternating air mattress.² Offload heels and other at-risk areas.⁹ For ambulatory patients with limited mobility, encourage movement as much as possible.³

Bedding and Clothing

Bedding can be a source of pressure when a patient is positioned or turned improperly, thus creating friction and shear.² Ill-fitting shoes can create pressure on the toe, leading to serious foot problems, especially in diabetic patients.¹¹

Tips: Use proper positioning and turning techniques (lift rather than drag) when moving patients in bed, and reposition every 2 hours.¹² Offload heels, and place a pillow between a patient’s knees.¹³ Ensure that diabetic patients consult a podiatrist to evaluate and prescribe appropriate footwear or orthotics, such as metatarsal additions, apertures, and arch profiles, to offload plantar pressure.¹¹

Staffing and Resource Issues

Health care staff shortages are an ongoing problem affecting all aspects of patient care, especially since the COVID-19 pandemic.¹⁴ Digital decision clinical support tools have been proposed to ease the effects of understaffing, but uptake of these tools so far has been limited.¹⁴

As for resource allocation, a large study of hospital-acquired PIs determined how cost-effective PI prevention is and that hospitals should invest in nursing staff to enable compliance with PI prevention guidelines.¹⁵ Another study found that the cost savings to the health care system after implementing a PI prevention program were statistically significant.¹⁶

Tips: Advocate for making offloading a priority in your facility. Assess staffing and resource availability, and create an effective protocol within that framework.

Conclusion

With vigilance and proven offloading techniques, PIs may be prevented, even in patients with challenging conditions or predisposing circumstances.

References

1. Razmus I. Wheelchairs and pressure injuries: what do we know? WoundSource. 2019. Accessed October 2, 2023. https://www.woundsource.com/blog/wheelchairs-and-pressure-injuries-what…
2. Pressure injuries. Johns Hopkins Medicine. Accessed October 2, 2023. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pressure…
3. 3 common patient challenges associated with pressure ulcers/injuries. Practice Accelerator. WoundSource. 2017. Accessed October 3, 2023. https://www.woundsource.com/blog/3-common-patient-challenges-associated…
4. Tavares C, Domingues MF, Paixão T, Alberto N, Silva H, Antunes P. Wheelchair pressure ulcer prevention using FBG based sensing devices. Sensors (Basel). 2019;20(1):212. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6983175/
5. Brienza DM, Campbell KE, Sprigle S. The past, present, and future of pressure injury prevention in patients with spinal cord injury. Adv Skin Wound Care. 2022;35(2):84-86. https://journals.lww.com/aswcjournal/Fulltext/2022/02000/The_Past,_Pres…
6. Fryer S, Silvia C, Major D, Bader DL, Worsley PR. Continuous pressure monitoring of inpatient spinal cord injured patients: implications for pressure ulcer development. Spinal Cord. 2023; 61: 111-118. https://www.nature.com/articles/s41393-022-00841-7
7. Razmus I. Neonatal pressure injury prevention. WoundSource. 2020. Accessed October 2, 2023. https://www.woundsource.com/blog/neonatal-pressure-injury-prevention
8. Razmus I. Repositioners or redistribution surfaces for neonates. WoundSource. 2022. Accessed October 2, 2023. https://www.woundsource.com/blog/repositioners-or-redistribution-surfac…
9. Cummins KA, Watters R, Leming-Lee T'. Reducing pressure injuries in the pediatric intensive care unit. Nurs Clin North Am. 2019;54(1):127-140. https://www.sciencedirect.com/science/article/abs/pii/S0029646518300963…
10. Jaul E, Barron J, Rosenzweig JP, Menczel J. An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatr. 2018;18(1):305. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6290523/
11. Collings R, Freeman J, Latour JM, Paton J. Footwear and insole design features for offloading the diabetic at risk foot-A systematic review and meta-analyses. Endocrinol Diabetes Metab. 2020;4(1):e00132.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831212/
12. Turning and positioning for pressure injury prevention. Practice Accelerator. WoundSource. 2022. Accessed October 2, 2023. https://www.woundsource.com/blog/turning-and-positioning-pressure-injur…
13. Wolfson J. Making a daily difference in preventing pressure injuries. 2017. WoundSource. Accessed October 3, 2023. https://www.woundsource.com/blog/making-daily-difference-in-preventing-…
14. Lapp L, Egan K, McCann L, Mackenzie M, Wales A, Maguire R. Decision support tools in adult long-term care facilities: scoping review. J Med Internet Res. 2022 Sep 6;24(9):e39681. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9490521/
15. Padula WV, Pronovost PJ, Makic MBF, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf. 2019;28(2):132-141. https://qualitysafety.bmj.com/content/28/2/132
16. Singh C, Shoqirat N, Thorpe L. The cost of pressure injury prevention. Nurse Leader. 2022;20(4):371-374. https://www.nurseleader.com/article/S1541-4612(21)00256-1/fulltext