Surface selection and use

As stated by international guidelines⁵ and the aSSKINg¹ ² ³ care bundle framework, selecting a support surface that minimizes pressure, shear, and friction is one of the key elements in pressure ulcer/injury prevention.⁶ To ensure that the support surface is adapted to the patient’s individual needs, three types of assessments should be considered:

Risk assessment
Skin assessment
Assessment of mobility level

Risk Assessment

Selecting a support surface is closely connected to the risk assessment, as the risk level helps guide the selection of an appropriate support surface. By performing risk assessments, patients at risk of developing pressure ulcers/injuries can be identified early.⁴

Several commonly used tools help evaluate the risk of pressure ulcer/injury development.⁴ These include the Braden, Waterlow, Norton, RAPS, Purpose-T, and PUSH tools. These tools assess various factors that contribute to pressure ulcers/injuries, such as mobility, skin integrity, sensory perception, and nutritional status. Based on the assessment, patients are categorized into different risk levels (e.g., low, moderate, high, very high).

While performing a risk assessment gives a valuable indication of which support surface to select, relying solely on the assessment tool provides limited guidance.⁵ The risk assessment must be part of a holistic evaluation that also includes a full skin assessment and an assessment of mobility level.¹¹

Skin assessment

Performing regular skin assessments is critical for preventing pressure ulcers/injuries and for selecting an appropriate support surface. These assessments allow healthcare providers to identify early signs of pressure ulcers/injuries, such as redness, discoloration, or skin breakdown. Early detection enables prompt intervention, potentially preventing the development of more severe pressure ulcers/injuries.⁵ ⁷

The patient’s skin should be examined systematically from head to toe. While pressure ulcers/injuries most commonly occur over bony prominences, they can also develop under medical devices such as masks or tubing. The most vulnerable areas should be checked at least once a day.⁷

Best practice guidelines emphasize that skin assessments must be performed with an awareness of skin tone. Research shows that many signs clinicians are trained to look for, such as redness or blanching, may present differently depending on the patient’s skin tone. For example, dark skin rarely shows the blanching response that is often used to identify early-stage pressure injuries.⁸ It is therefore essential to adapt skin assessments to account for differences in skin tone as part of a full holistic evaluation.

Additionally, it is important to be aware that patients who have had previous pressure ulcers/injuries are more prone to developing new ones. Former pressure ulcers/injuries can leave the skin and underlying tissues weakened or scarred, making these areas more susceptible to future damage.⁹

Summary
Skin assessments help determine the patient’s overall risk for developing pressure ulcers/injuries,⁷ which directly influences the choice of a support surface. Ongoing skin assessments also allow caregivers to evaluate the effectiveness of the chosen support surface and other preventive interventions. If skin integrity worsens, it may indicate the need for a different support surface or additional preventive measures.

Assessment of mobility level

While risk and skin assessments are essential when selecting a support surface, mobility assessment remains the most critical, as immobility is a leading cause of pressure ulcers/injuries.⁵ ¹¹

When a patient becomes immobile or loses sensation⁵ due to disease, spinal cord injury, sedation, or paralysis, the body’s natural protective mechanism of spontaneous movement is impaired. This absence of movement exposes patients to a significant risk of pressure ulcers/injuries. Without regular movement, areas of the body in contact with a support surface endure prolonged periods of unrelieved pressure, with or without shear. Sustained pressure restricts blood flow to the tissues, depriving them of oxygen and nutrients, which can cause tissue damage and necrosis, leading to pressure injuries.⁵

Immobile patients, especially those with conditions affecting sensory perception (e.g., spinal cord injuries), may not feel discomfort or pain that would normally prompt them to change positions. This lack of sensory feedback further contributes to prolonged pressure and the development of pressure ulcers/injuries.⁵

In an older population, common chronic diseases can lead to immobility and, in turn, to poor blood circulation. Inadequate blood flow means tissues do not receive enough oxygen and nutrients, making them even more susceptible to damage from prolonged pressure.¹²

Continuously evaluate the patient’s mobility level and chose a support surface that encourages independent movement

For patients who have experienced prolonged immobility, such as after surgery or due to critical illness, maintaining and restoring mobility is essential for recovery and overall well-being. Encouraging movement, even in small steps, can play a transformative role in improving patient outcomes.

To effectively promote mobility, it is essential to continuously assess the patient’s mobility level and choose a support surface that encourages independent movement. Foam surfaces often provide superior support and are more effective at promoting movement compared to air mattresses.

By selecting the right support surface tailored to the patient’s needs, healthcare providers can create an environment that not only helps prevent and treat pressure injuries but also supports patients in regaining or maintaining their mobility and independence.

Preventative foam mattresses

Preventative foam mattresses work by redistributing pressure to minimize the risk of pressure ulcer/injury development. Foam mattresses are designed to distribute the patient’s weight over a large surface area, which helps reduce pressure on any single point, particularly over bony prominences such as the heels, sacrum, and hips. The foam conforms to the contours of the body, ensuring that pressure is evenly distributed.

Hybrid mattresses

There are many variations of hybrid mattresses. Typically, hybrid mattresses work by combining foam and air cells to provide enhanced pressure redistribution, support, and comfort. Both powered and non-powered hybrid mattresses are available (e.g., AreaZone, Cirrus).

The foam layers in a hybrid mattress conform to the body’s shape, distributing weight evenly across the surface. This helps to minimize pressure points, particularly over bony prominences. The air cells can be adjusted using different techniques to change the firmness and support. This adjustability allows for customized pressure relief and support tailored to the patient’s needs.

Some hybrid mattresses, like Cirrus, have a dynamic function where the air cells periodically inflate and deflate. This dynamic action creates pressure relief, reducing the risk of prolonged pressure on any single area.

Constant Low Pressure (CLP) mattresses

In Constant Low Pressure (CLP) mattresses, the pressure in the air cells is evenly distributed over the entire support surface. CLP mattresses work by redistributing pressure across the body to minimize peak pressure points that can lead to pressure ulcers/injuries.

A powered CLP mattress adjusts the pressure within the cells according to the patient’s weight and therefore offers several benefits over a foam mattress, particularly in terms of pressure redistribution, comfort, and overall effectiveness in preventing pressure ulcers/injuries.

Thus, powered CLP mattresses allow for customization of pressure settings based on individual patient needs, offering a level of personalized care that foam mattresses cannot provide.

Dynamic mattresses

A dynamic mattress creates pressure relief and improves tissue perfusion (the flow of blood throughout the body carrying nutrients, oxygen, and removing waste from cells) through alternating movements. As the air cells inflate and deflate, pressure is alternately applied and released from different areas of the body in contact with the mattress.

The cyclical pressure relief stimulates blood circulation and prevents tissue ischemia (lack of oxygen), which is crucial for maintaining tissue perfusion.

Dynamic mattresses offer the highest level of pressure relief and are ideal for patients at high or very high risk of pressure ulcers/injuries or those with existing severe pressure ulcers/injuries.

Selecting among Care of Sweden’s mattresses

How can this risk assessment guide me?
When selecting a support surface, it is cmucial to have a holistic approach and consider both the results from the risk assessment as well as the skin assessment. However, the level of mobility must also be taken into consideration, as immobility leads to prolonged pressure, increased shear and friction forces, reduced blood flow, and, in the end, pressure ulcers/injuries.

Risk assessment can be used as a tool to guide the selection of a support surface according to the table below.

Level of mobility

When assessing the level of mobility, key things to look for are:
How much can the patient move independently?
Can the patient change positions in bed or a chair without assistance?
Does the patient require help to reposition or shift weight?
Is the patient confined to bed, or can they sit up in a chair or ambulate for short distances?
How often is the patient able to get out of bed or change positions?
The personas below visualize how the level of mobility can be used as a guide to select the correct support surface.