Problem Solvers

Getting the Right Support

Addressing the unique support surface needs of bariatric mobility patients.

Wound prevention and care in bariatric patients is a continual battle. Due to weight, heat and moisture, along with poor nutrition and co-morbidities, such as diabetes, bariatric patients run a great risk of developing pressure sores. To combat that support surface makers have developed a variety of advanced mattresses that can protect bariatric patients from pressure ulcers and quickly treat those wounds if they do develop. But what about mobility solutions forbariatric patients.

Most bariatric patients get around via mobility devices. Because they are sitting, bariatric patients run the same risks for wounds that they do in when in bed or in other environments. What are the wound care risks for bariatric mobility patients and how can providers address those risks?

The first issue of wound care as it relates to bariatric mobility patients is obviously their size, says Sharon Lepper, BSN, RSN, WOCN, a independent wound care consultant for various healthcare clients including nursing homes, homecare firms, HME providers and support surface manufacturers such as EHOB, Inc. (Lepper can be reached via email at skayhowell@yahoo.com.) For average height individuals that weight several hundred pounds and have BMIs well over 30 and that are clearly bariatric patients, obviously not all equipment is going to suit them.

“Most equipment won’t handle anything over 300 or 400 pounds,” she says. “So if you have a patient that weighs 700 pounds, what in the world are you going to put them on that will stand up to that? There are very products that will handle that and support them comfortably.”

Also, most bariatric patients are malnourished, and because they are not getting the correct nutrient content their wounds are slow to heal and lack the muscle tone required for them to reposition or elevate themselves. So they need to have support surfaces in their chairs that can help hold them in a position that will prevent or care for wounds that is still comfortable. That makes for a difficult product search, Lepper explains.

So specialized cushions that have been developed that are made specifically for patients. The weight capacities can range from 350 pounds all the way up to 800 pounds depending on the product or manufacturer. Some makers of these types of products include Blue Chip Medical Supplies, EHOB Inc, and The ROHO Group. The types of support surfaces range between air filled cushions that are made of a sort of honeycombed set of sells, and cushions like those made by ROHO group that are made up of finger-sized cells that can be filled with variable amounts of air to have the shape of the cushion better conform to the patient’s weight.

“If the patient gains weight or loses weight, each one of those little fingers has to be separately measured and manipulated so that it supports them in the right way,” Lepper says, adding that typically this process is done by physical therapy.

To fill the air cells of either type, typically either a hand pump is used, or a separate electric pump about the size of a fish tank pump that can be attached to the cushion. Once the patient is sitting on the pump, the mattress can be checked to ensure it is not underfilled or overfilled.

Support surfaces with these individual cells are often used to support mobility patients that spend considerable times in their chairs, while bariatric patients often spend very limited amounts of time in their wheelchairs because doing so is uncomfortable, Lepper explains. So the use of support surfaces with individual cells for bariatric patients is often limited.

In terms of funding, Medicare will cover the cushions, but the more complex a support surface for a bariatric mobility patient’s chair, the more detailed the required documentation. For instance a ROHO cushion, with the individual cells requires a doctor’s signature, Lepper says. A static air cushion can be signed for by a nurse and doesn’t require as much documentation.

Needs Assessment

A key factor in determining which type of support surface is best for preventing or treating a wound in a bariatric mobility patient depends on where the problem area is located on the patient.

For instance if the wound is on the cheek of the buttocks, where the top of the leg meets the gluteus maximus then the patient would need to be positioned so they were not sitting on that area, but rather on the other side, or were tilted slightly to foster better blood flow and air to the area, Lepper says.

Generally, whatever mobility device the bariatric patient is using is typically a very short-term interruption in his or her day.

So, the wounds that a bariatric patient might experience tend to be more linked to their other activities. Bearing that in mind, there are some general trends in bariatric patients’ wound location. Lepper says that wounds are often located either on the abdomen (due to surgery) or on the legs, because of blood flow or diabetes.

“You normally don’t get [wounds] on their backside, because if they are in bed, they’re usually not comfortable sitting all the way up or all the way back,” she explains. “It’s really hard for them, with all that extra weight pressing on their stomach or chest, to breathe when they are laying flat. They just can’t.

“And if they are sitting up, then it puts too much pressure on their stomach and the tops of their thighs,” she continues. “So they are usually laying in a 15 to 20 degree head elevated position.”

Managing the Micro Climate

That said, the seating surface remains a critical area of concern, says Jim Rathmell, director of field services, Blue Chip Medical Products, which makes various support surfaces for bariatric patients, including wheelchair cushions. Rathmell was an ATP for nine years during his career and has worked with bariatric patients throughout his career.

“A significant challenge with bariatric patients is managing what I call the micro climate between the skin and the seating surface,” Rathmell says. “You have to be very wary of moisture in heat build-up. It’s one of the biggest challenges we have.”

Even with individualized cell support surfaces it is very difficult to get that moisture and heat “transportation” away from the patient’s skin, Rathmell says. Patients have to engage in movement and repositioningfor that heat and moisture transportation to take place.

“It’s a patient education issue,” he explains. “Just like you do in pressure relief, you can do a forward lean that will open up the back of the ITs and help allow for some migration of fresh air in or migration of moisture and heat out of the area. Or, you can do the side leans. It’s important for patients to understand that’s not only very important for pressure relief but for managing heat and moisture.”

Also, Rathmell says that one thing wheelchair manufacturers need to address is the ability to accept that adipose or redundant tissue that congregates at the back of the patient’s buttocks pushes the client forward in the chair which makes it difficult for the patient to get adequate back support.

“What happens is that when you put a bariatric patient in the chair, and they sit down, it’s not like someone would sit, where there is typically not a lot of difference where the back of the buttocks falls and how it lines up with their back,” he says. “With a bariatric patient with a lot of redundant tissue, there’s not place for that to go, so it forces them forward, and forces a great amount of seat depth, while at the same time it pushes their back away from their back support.”

Another key concern Rathnell highlights is front cushion crush.

“When you seat someone that has bariatric weight in their legs and calves, a lot of time the leg rests don’t get adjusted correctly,” he says, adding that those patients often get seated on cushions incorporating foam. “If you press foam in the middle of the cushion it’s very structurally sound. It has a lot of strength and resists that crushing action very well. But the next time you have a cushion in your hand, go to the edge of the cushion where the thigh comes off the end of the cushion and see how easy it is to crush it. It has lost its structural dependency on the next cell over because it has been cut off, it’s real easy to crush that front edge of the cushion.”

This represents a key problem area for bariatric patients. On first glance the patient might appear to be properly positioned, but if the provider expert doesn’t get under and expect the edge of the cushion, that patient could be at risk for developing a wound. The foot plates might need to come up to ensure the bottom of the feet are helping support the weight.

“When putting someone in a bariatric chair, I always spend plenty of time making sure there’s proper balance between the back of the thigh and how much weight is being supported by the cushion and the bottom of the foot in the foot place, and how it set in relation to the top of the cushion,” Rathmell advises.

This article originally appeared in the February 2011 issue of HME Business.

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