Wound, Ostomy and Continence Nurses Society™

An Evidence-and Consensus-Based Support Surface Algorithm

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Funded in part by an unrestricted educational grant from Hill-Rom

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An Evidence-and Consensus-Based Support Surface Algorithm

Support surfaces are an integral component of pressure ulcer prevention and treatment, but there is insufficient evidence to guide clinical decision making in this area. In an effort to provide clinical guidance for selecting support surfaces based on individual patient needs, the Wound, Ostomy and Continence Nurses Society (WOCN®) set out to develop an evidence- and consensus-based algorithm. To learn more about the algorithm's development, view the accompanying Journal of Wound, Ostomy and Continence Nursing article.

The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box.

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Tap or click the "Back" button to return to the previous page or step.

Tap or click the home icon to return to the beginning.

Click the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box.

Tap or click any number to return to that step in the process.

Tap or click the "Full Screen" button to optimize the fit to your device's viewable area.

RISK ASSESSMENT
Initial skin assessment

RISK ASSESSMENT
Pressure ulcer risk assessment

Yes, at risk Braden ≤ 18
Not at risk Braden > 18

RISK ASSESSMENT
Pressure ulcer present?

Yes
No

RISK ASSESSMENT

Consider Treatment Support Surface

Supporting information:

RISK ASSESSMENT
Progress to Treatment Support Surface?

Yes
No

RISK ASSESSMENT
Here is your result

You have opted not to progress to treatment.

Supporting information:

RISK ASSESSMENT
Pressure ulcer present?

Treat per facility/agency protocol

RISK ASSESSMENT
Here is your result

Skin and pressure ulcer risk reassessment per facility/agency protocol

Test again

Supporting information:

RISK ASSESSMENT
Pressure ulcer risk assessment

RISK ASSESSMENT
Pressure ulcer risk assessment

Yes, at risk Braden ≤ 18
Not at risk Braden > 18

PREVENTION
Pressure ulcer risk assessment

Preventive Support Surface

RISK ASSESSMENT
Pressure ulcer risk assessment

Continue using current support surface

RISK ASSESSMENT
Here is your result

Skin and pressure ulcer risk reassessment per facility/agency protocol

Test again

Supporting information:

PREVENTION
Consider Braden subscale scores

  1. Choose Support Surface based on:
    • Current patient characteristics and risk factors a-d
    • Previous support surface usage
    • Precautions / Contraindications

    Refer to Table A: Suggested Support Surface Selections and Table B: Support Surface Precautions & Contraindications

  2. Place patient on support surface e
  • Consider patient weight and weight distribution in determining the need for a bariatric mattress and appropriate bedframe.
  • When choosing between a mattress or overlay, consider fall/entrapment risk associated with use of overlays.
  • Consider risk for developing new pressure ulcers and history of previous pressure ulcers.
  • Consider fall risk in determining the need for a low bed.
  • Ensure that the support surface is functioning properly and used correctly. Minimize the number and type of layers between the patient and the support surface.

PREVENTION
Skin reassessment per facility/agency protocol

PREVENTION
Pressure ulcer risk assessment

PREVENTION
Pressure ulcer risk assessment

Yes, at risk Braden ≤ 18
Not at risk Braden > 18

PREVENTION
Pressure ulcer present?

Yes
No

PREVENTION

Progress to Treatment Support Surface

PREVENTION
Pressure ulcer present?

Treat per facility/agency protocol

PREVENTION
Here is your result

Continue using current support surface or consider changing to a different suport surface

Test again

Supporting information:

PREVENTION
Pressure ulcer risk assessment

Yes, at risk Braden ≤ 18
Not at risk Braden > 18

PREVENTION
Here is your result

Continue using current support surface or consider changing to a different suport surface

Test again

Supporting information:

PREVENTION
Here is your result

Reassess need for support surface

Test again

Supporting information:

TREATMENT

Treatment Support Surface

TREATMENT
Consider Braden subscale scores

  1. Choose Support Surface based on:
    • Current patient characteristics and risk factors f-i
    • Previous support surface usage
    • Precautions / Contraindications

    Refer to Table A: Suggested Support Surface Selections and Table B: Support Surface Precautions & Contraindications

  2. Place patient on support surface j
  • f. Consider weight and weight distribution in determining the need for a bariatric mattress and appropriate bedframe.
  • g. When choosing between a mattress or overlay, consider fall/entrapment risk associated with use of overlays.
  • h. Consider number, severity, and location of existing pressure ulcers, as well as risk for developing new pressure ulcers and history of previous pressure ulcers.
  • i. Consider fall risk in determining the need for a low bed.
  • j. Ensure that the support surface is functioning properly and used correctly. Minimize the number and type of layers between the patient and the support surface.

TREATMENT
Skin reassessment per facility/agency protocol

Non-intact/Pressure ulcer present
Intact/Closed

TREATMENT
Pressure ulcer risk assessment

Yes, at risk Braden ≤ 18
Not at risk Braden > 18

TREATMENT
Here is your result

Continue current Treatment Support Surface or consider changing to a different Support Surface

Test again

Supporting information:

TREATMENT
Pressure ulcer risk assessment

TREATMENT
Pressure ulcer risk assessment

Yes, at risk Braden ≤ 18
Not at risk Braden > 18

TREATMENT
Here is your result

Reassess need for support surface

Test again

Supporting information:

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Table A:

Suggested Support Surface Overlay or Mattress Selections for Pressure Ulcer Prevention & Treatment Based on Braden Mobility & Moisture Subscores

  • Braden B, Bergstrom N. http://bradenscale.com/images/bradenscale.pdf. Copyright 1988. Accessed August 8, 2014.
  • In this table, Reactive/CLP refers to all types of Support Surfaces in this category with the exception of AMG sheep skin overlays, which are noted separately.
  • AMG sheepskin is available for purchase through online suppliers.
Note: Persons with multiple Stage II, or large (of sufficient size to compromise a turning surface) or multiple Stage III or Stage IV pressure ulcers on the trunk or pelvis involving more than one available turning surface should be placed on a support surface with a low air loss or an air fluidized feature.
Braden Mobility Subscale Scoresa
Braden Moisture Subscale Scores 4 or 3
No limitation or slightly limited
2 or 1
Very limited or completely immobile
4 or 3
Rarely or occasionally moist
  • Reactive/CLPb (air, foam, gel, fiber, or viscous fluid, or combinations)
  • AMG sheepskin overlay (Prevention only) c
  • Reactive/CLP
  • Active with AP feature
2
Very moist
  • Reactive/CLP
  • Reactive/CLP with LAL feature
  • Reactive/CLP with LAL feature
1
Constantly moist
  • Reactive/CLP
  • Reactive/CLP with LAL feature
  • Reactive/CLP with LAL feature
  • Reactive/CLP with AF feature (Treatment only)

AF = air fluidized; AMG = Australian Medical grade; AP = alternating pressure; CLP = constant low pressure; LAL = low air loss.

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Table B:

Select Support Surface Precautions & Contraindicationsa

SUPPORT SURFACE PRECAUTIONS CONTRAINDICATIONS
High-specification foam
  • Braden moisture subscale score of 2 or 1b
  • Weight limitations for surface–may require another product in this category with higher weight limit
Reactive/CLP
  • NA
  • Unstable cervical, thoracic or lumbar spine
  • Cervical or skeletal traction
  • Weight limitations for surface– may require another product in this category with higher weight limit
Active with AP feature
  • NA
Reactive/CLP with LAL feature
  • Combative/restless/agitated state
Reactive/CLP with AF feature
  • Combative/restless/agitated state
  • Need for aggressive pulmonary toilet
  • Need for frequent head elevation
  • Need for mobilization
  • Claustrophobia
  • Unstable cervical, thoracic or lumbar spine
  • Cervical or skeletal traction
  • Weight limitations for surface– may require another product in this category with higher weight limit
  • Trendelenburg positioning

AF = air fluidized; AP = alternating pressure; CLP = constant low pressure; LAL = low air loss.

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Critical thinking point:

While it may be true that a patient has a Braden score of less than 18 and a pressure ulcer on the trunk or pelvis, it may not be necessary for them to have a different level of support surface. There are some factors that cannot be reflected on an algorithm and while few, they exist. At those moments, a skilled clinical assessment with critical thinking/decision making is required.

For example, a patient may have a Braden score of 17 and a Stage I or II on their sacrum or trunk but are able to turn side to side so would be able to stay on their current surface. However, if they have a medical condition that prohibits turning to one side (e.g., SOB, cardiac rhythm changes, device in place, etc.), they would need to be moved to a higher-level support surface because they have only one available turning surface.