Prevent pressure sore right ischium

[Kitiger, RN]

The person - who cannot walk - has red areas on his buttocks that correspond to the ischial tuberosities, the "sit bones". One site has skin breakdown, which we are treating. Sitting should be restricted, but the family wants him up in the chair at least part of the time. The wheelchair has a Tilt-In-Space function, so I can tip him back to let his back take some of the weight. I have also padded the seat of the wheelchair to put most of his weight on his thighs, and less pressure on the sacrum and "sit bones". 

He is unable to reposition himself, and is dependent for all ADLs.

We have a referral to a company that specializes in equipment and furniture for positioning patients and preventing pressure sores. I have foam pieces under his thighs, but not under his buttocks. What else can I do?

This is my first experience with this exact problem, and I've been a nurse for 42 years, working private duty in the homes since 1987. Crazy, huh?

[amoLucia]

I was going to suggest a home wound care consult, but I think you're on top of it already.

[Kitiger, RN]

2 minutes ago, amoLucia said:

I was going to suggest a home wound care consult, but I think you're on top of it already.

Yes, we have that, too. 

[amoLucia]

Mea culpa.

I'm sorry, but I didn't realize it was you. I should have read the post more closely. You would have known that a consult was in order already. My dumb!

 

[Kitiger, RN]

1 hour ago, amoLucia said:

Mea culpa.

I'm sorry, but I didn't realize it was you. I should have read the post more closely. You would have known that a consult was in order already. My dumb!

 

Not at all. I posted because I'm hoping someone will have more ideas. Also, if positioning differently would help, I want to know.

[amoLucia]

Do they make alternating pressure mattresses only wide enough for that tilting whch?

[NRSKarenRN, BSN, RN]

1. Wheelchair should have a gel cushion:

 

2. I've found sheepskin pad overtop allows one to reposition client easily and provide additional comfort overtop gel pa --helps prevent sheering forces sliding down in WC.

There are sheepskins available for several sections of wheelchair to provide support/skin breakdown prevention.

 

3. Pressure reduction with foam dressings best to apply to reddened pressure point areas to treat/prevent skin breakdown worked well for my husband and my homecare patients, especially ischial areas:

4.  OT eval for wheelchair seating advice helpful if DME company supplying specialized WC doesn't supply this service.

Be careful that additional "padding" not too much and causing additional pressure.  Thank you for thinking of ways to help your patient.

[Kitiger, RN]

1 hour ago, amoLucia said:

Do they make alternating pressure mattresses only wide enough for that tilting whch?

The wheelchair reclines and it also tilts back, so the front of the wheelchair seat lifts up and the back of the seat is the lowest point. 

We're looking at the possibility of an alternating mattress, as the "sit bones" are not the only problem spots.

[Hannahbanana, BSN, MSN]

Suggest you advocate strongly for a specialty bed that has microclimate control, shear reduction, and pressure relief AND that can be maneuvered into an upright sitting position like a chair, not just a raised head of bed. You’ll get pushback but for something like this, it’s the only way to go. HillRom and Invacare both make these. 

And if not, explain to the family that you cannot adequately offload his ischial tuberosities in a seated position, and have the risk manager type up a release for them to sign. This will either get their attention enough to pay attention to you, or document that you’ve done everything you can to prevent a deep tissue injury (which can have dead tissue down to the bone before the skin breaks down) and the family refuses to let you do it. This will protect you from the near-inevitable lawsuit for substandard care AND from Medicare or other carrier refusing to pay for care for a pressure injury while he is under your care. 

[CalicoKitty, BSN, MSN, RN]

There are "seating clinics" (often they will be at a wound care center once every week or two) where they can do pressure mapping to find a seat/pad that would do a good job of pressure reduction.

He should be repositioned as often as possible (such as getting into the chair for mealtimes, but, back to bed for periods of time during the day). 

Ensure he clean and dry as much as possible (don't use diapers if possible). Moist skin increases the risk for breakdown. Use some barrier cream (with zinc)  over the trouble spots.  Make sure he's getting enough nutrition and fluids).