Hi participant once again
Last time we showed interest to the ABSA body-elements. This time we are going
to look at the surrounding-elements. As described earlier it gives no final answer to
why pressure ulcers emerge, but you are welcome to follow the newest tendencies
as to pressure ulcer prevention and have exiting inputs for your work by following
us at LinkedIn.
Let us get started.
Lesson 5:
Understand the importance of the
surrounding-elements to stability and
pressure distribution
ABSA in practice
As you probably remember, we are working with the following 4 elements.
1.Body-elements
2. Surrounding-elements
3. Activity- and participation-elements
4. Personal-elements
After having gone through how to manage the body-elements we must show
interest to the surrounding-elements – so tighten your belt – now we throw
ourselves into it:
Surrounding-elements
--In this lesson, you are going to examine, assess and analyze how the assistive
technologies used in the seated position e.g. wheelchair or cushion, car seat, sofa,
bed, easy chair or technology used for transfers are meeting the needs of the user
as to stability and pressure distribution.
You must examine the possible potential
for changes as to minimizing the risk of
pressure ulcer development.
Assistive technology for seating – like wheelchair and cushion. You begin with the
examination of the assistive technology. Does it support the user sufficiently
enough to make it possible for him to remain seated in a stable position and
pressure distributed – all the time. This means whenever he I seated in his
wheelchair and whatever his activities are. It might be everyday activities like
cleaning, cooking, PC-work and activities related ‘to sit’, ‘to change position in
chair’ or ‘to manoeuver the chair’
You may perhaps find ADL-taxonomien useful as a memo to get all the way
round.
If it is secure – and there is no risk at all for the user to fall out of the chair a tiny
little trick with a friction reducing material could perhaps do to demonstrate to the
user (and you) – but only demonstrate – the importance of being seated in a stable
and pressure distributed optimal position.
If you observe that the user is sliding forward – when he is sitting still or even when
he is propelling the wheelchair – the seated position is not stable. Then the
challenge is to adjust the wheelchair and the cushion in a way that might support
the user to remain seated even sitting on a piece of friction reducing material.
During activity performance, you must assist the user to find strategies to prevent
him to move on the seat surface and to prevent him from sitting unequally or
asymmetrically.
If you do not succeed and the displacement is going on anyhow –the displacement
(shear & friction will still be going on even when you have removed the friction
reducing material – though now the displacement is instead going on in the tissue
and is now causing deformation of the tissue.
Squeezing the tissue between bones and seat like a beef in a sandwich.
Assistive technology and procedures for transfer – like hoist, sling, sliding board
and so on. You must as the very first thing examine the individual procedures in
everyday life and you must specifically check if the user makes the best possible
use of his assistive sitting technology – even through transfers TO the seated
position. You must observe and examine is the user able to obtain a stable and
pressure distributed seated position with the least possible risk to catch a pressure
ulcer. Make sure that the sling is intact and used correctly. You cannot always take
it for granted.
Notice if any kind of ’disturbances’ of the ’perfect landing’ in a wheelchair seat
might be disastrous to the wheelchair user’s opportunity to remain stable in the
seated position. Therefore –if anything went wrong, you must perform a second
‘landing’.
Try out for yourself underneath your Ischial Tuberosity the serious disturbances
you may produce to a stable sitting position as you lift a knee (imagine to remove a
sling strap or to fit a footrest after a transfer procedure).
Find out how to instruct any caring person close to the user. How to remove a sling
or how to fit a footrest without any ‘disturbances’ of the stable seated position.
At the same time you must examine if and how the wheelchair user does his sitting
transfers between 2 seats by his own. Is he in fact capable of – in a safe way – to
lift himself 100% from the support? Is he sure that the lasting ‘landing’ in the chair
or seat in no way is going to perform a tissue displacement? If not that is he will be
on the track to severe risk of pressure and tissue damages.
Be aware that a wheelchair user after a hospital stay followed by muscular
weakness e.g. around the shoulder can end up with a serious risk of pressure
ulcers development on the buttocks because of a poorer transfer capacity than
before he was hospitalized. This user might need physical strengthening to regain
his former capacity to manage his own transfers. Meanwhile it would be a very
good idea and investment to persuade and to offer this user a temporary use of a
hoist and a sling to prevent pressure ulcer development after a temporary loss of
function.
Helpers, caring staff, relatives, structural and organizational elements.
A great deal of these surrounding- elements are about the assisting health
professional’s organizational options and possibilities in supporting the user in his
everyday life. You must examine and analyze the specific and realistic resources in
the user’s surroundings if you would like to introduce any changes in the usual
procedures or assistive sitting technologies. Are the health professional persons in
fact motivated for changes – or do you need to work on that too – to implement
new procedures or technologies.
You must check out to find a special dedicated person or relative with a continuous
talent to keep the focus on the arrangements among the changing corps of helpers
– or even better – to check out if the user himself is able to manage this challenge.
If so, we recommend you to concentrate on the user, as he will always be there.
Unfortunately, the user is not always able to cope with the challenge and that is
very important to identify and to be realistic about.
You need to examine if your own organization make any barriers to succeed in
support of a pressure ulcer preventive activity performance of the individual – and
if so you must find some feasible ways to oppose them. Perhaps it is necessary to
document and argue from case to case – and hold on to that it will be a good way
to gain good results.
Other physical surroundings – e.g. adaptation of home, car, work and so on. You
must analyze any other surrounding-elements with any possible effect on the
quality of the seated position. It might be all about physical barriers in case of
performing a transfer in the bathroom, bedroom, kitchen or car.
It might be about the computer-working place or the height of the dinner table or it
could be the location of an essential grab in the car.
It is the intention that you become aware of if the seated position in the specific
sitting assistive technology is a challenge to the users sitting ability while he is
performing those activities that he most of all prioritize in his everyday life.
That is why it is your job as a therapist to observe the users actual and specific
way of performing relevant activities in his own context – exactly where he is
performing them in his everyday life. Therefore, it is no good just talking about it.
You will have to see it yourself and to work closely together with the user himself.
It is not definitely to ‘re-built’ but to ‘re-design’ the assistive technology, the
surroundings or the procedures to reduce the risk in activity performances.
Your job is to create the very best opportunities to the best interaction between the
body, the assistive technology, and the activities.
It may be a very big challenge and sometimes it might be wise to take contact to a
specialist in seating assessment – which is what is recommended in the latest
international guideline about pressure ulcer prevention and cure from
NPUAP/EPUAP/PPPIA 2014.
Practice

Imagine that you are going to empty your dishwasher while you are
seated in your wheelchair.

Be seated on a double friction reducing material while you reach out
over your support surface – meaning out on the wheelchair’s one side.

Lift three dishes or a small casserole from the lowest basket in the
dishwasher and place it on the table (Weight about 1 kilo or 1 liter of
milk).

Notice what is happening under your buttocks on the friction reducing
material and ‘freeze’ your position on the friction reducing material.

Return your upper body to an upright position without moving your but
on the friction reducing material.

Probably you will now have a very oblique pelvis. Haven’t you?

Feel under both your Ischial Tuberosities at the same time. Where do
you press at the highest level into the surface underneath?

Imagine that you do not have any sensibility at all and that you do not
really have any attention to the movement you have just been doing
with your pelvis.

Imagine that you continuously are seated here for more than 15
minutes – or – you might as well try it yourself.

Do you think you will have pain in any other places of the body?
Where? What would you do as a wheelchair user with no sensibility to
stabilize yourself?
We hope that this practice will make it easier for you to think about all possible
risky procedures and activities in everyday life and to incorporate the surroundings
in these considerations in order to gain a stable and pressure distributed seated
position – all the time.
In the next lesson, we are digging deeper into activities and the participation
options.
See you!
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