Seating is important when we think of preventing pressure ulcers, but it is often overlooked when making purchases for a chair. When we think of seating in the nursing and care environments, we need to make sure that the prevention of pressure damage remains at the top of the list.
Many health professionals focus on beds and mattresses for preventing pressure ulcers, and sometimes forget the chair, despite many people sitting in them all day. Within the community, there is no such thing as a standard piece of furniture. This can make it difficult to prescribe cushions or chairs for reducing pressure or correcting posture.
The factors named above are not exhaustive as there are other less common risk factors. There is a useful test to assess risk on the React to Red website, this can be used by anyone who has concerns or needs more understanding of pressure ulcers.
It is important to assess risk factors for pressure ulcer formation for people that are seated, as this will help those providing care to be risk aware and implement care and equipment to reduce that risk.
Chair Seat Width -The width of the seat is important as it can affect a person's posture and pressure areas. If a seat is too narrow it can lead to pressure damage to the hips, buttocks, and the back of the knees. If a seat is too wide, the person may feel unsupported which could result in posture and pressure problems with the hips and spine. This may also make it difficult to fix equipment to the seating system such as lap belts, and hip and thigh supports.
Good practice recommends a minimum of 2.5 cm clearance between the hip and the side of the chair/wheelchair.
Chair Seat Height - If a seat is too high, the individual may slide down the seat in order to place their feet on the floor or footplates to support themselves. This could also lead to pressure damage to the skin around the tailbone area. To check the appropriateness of the height of the seat for an individual make sure they can comfortably place their feet on the floor or footplate with the ankle ideally in a normal position.
Adding extra cushions will affect seat height.
Chair Seat Depth - If the seat depth is too long, this may cause sliding down in the seat in order to reach the front edge of the seat with the knees. The person is likely to slide forward to place their feet on the footplate or floor, affecting their posture and stability and increasing pressure on the buttocks. Pressure ulcers may also occur against the back of the knee. If the seat depth is too short, pressure is increased at the thighs with a risk of pressure ulcers in the mid-thigh region.
Good practice recommends a minimum of 2.5 cm clearance between the edge of the seat and the back of the knees.
Chair Backrest -The backrest provides support and strength to the trunk. If the backrest is too low, it can lead to postural problems and weakened sitting balance and cause incorrect placement of supports for the shoulder/chest. This can increase the risk of pressure damage. If the backrest is too high, it can affect function such as wheelchair propulsion. Shoulder blade movement can be reduced leading to postural problems in the trunk affecting sitting balance.
Back Width – This is usually set by the seat width but can be different with certain wheelchair/seatback choices. Chest width and the need for trunk supports are important considerations. If the back width is too wide, it may hinder fixing supports and arm function. If the back width is too narrow, it can result in edges/back posts digging into the person's back and insufficient room for supports.
Chair Seat To Back Angle - Not all chairs offer the person a natural sitting position as the backrests are often slightly reclined. This may result in sliding down in the seat, therefore increasing the risk of pressure damage.
Chair Armrests - Armrests provide steadiness in sitting and help the person to transfer safely.
Armrest height needs to support the bent elbow when seated as well as supporting the possibility of additional equipment such as trays and arm supports. If the armrest is set too high, it can increase pressure on the elbow joint causing pain and discomfort.
If the armrest is set too low, it can create postural issues that contribute to pressure damage in the buttocks due to lack of support for the elbows, shoulders, and trunk.
Armrest length varies depending on the amount of support required. If the armrest is too long, it can stop the chair from being positioned under a table.
If the armrest is too short, it may result in difficulty with sit-stand transfers and may not support equipment such as lap trays.
Chair leg rests/footplate - In the best possible seated position, the length of the leg rest should be set so that the thigh is supported correctly on the seat with the foot comfortably placed on the footrest or floor. Ankle and foot deformities need to be taken into consideration. If the leg rest length is too long it can cause increased pressure on the buttocks and thighs and may result in the person sliding down in the chair to meet the footplates/floor. If the leg rest length is too short, it can increase pressure on the buttocks, calves, and heels, which will be forced against the leg rest hangers.
The standard setting of a footplate is a 90° angle, however, people with fixed postural problems of the ankle will need the footplate adjusted to meet their needs.
Headrest - A headrest is important for people with weak neck muscles and who are unable to hold their head up independently. A headrest can help with breathing and swallowing as well as helping the person to maintain eye contact. Care should be taken as pressure can increase at the back of the head causing damage.
Seating Assessments are complex and require a trained person to carry them out as they are comprehensive, evidence based, and need a person-centred approach which will be documented in the person’s medical records. Using a Seating Assessment helps to inform the individual, the family, and carers of the need for cushions or chairs, and how to maintain the equipment. Chairs and cushions have an impact on individuals and will aid pressure ulcer management and prevention as well as aiding wellbeing.
In order for the individual to both accept and use the seating equipment there may need to be a trade-off between what the healthcare professional considers the ideal seating should be, and what is manageable for the individual's lifestyle, capabilities, and personal preference. This can sometimes involve careful negotiation as the individual’s preferences can differ from those of the health professional. Equipment abandonment is likely if the individual or family do not understand the reason why the choice has been made, or how to use the equipment effectively.
Sample of a Chair Assessment – taken from The Journal of Tissue Viability
For people with short or long-term mobility issues the assessment and prescription of seating equipment should take into account the person’s and carer’s opinions and address the following outcome measures:
Guidance on repositioning when seated must be given to both carers and people with acute or long-term mobility problems. This intentional movement can be carried out in three main ways. Guidelines suggest performing pressure relief every 30 minutes lasting 30 seconds for individuals who can do so independently. For those requiring help, repositioning assistance can be given as advised by a healthcare professional.
Advice from the NICE guidelines suggests a person who is at risk of pressure ulcers should not remain seated for longer than two hours or a person who already has an established pressure ulcer should not sit out. In instances like this, you may consider lying on the bed for a short period of time to offload pressure on the areas at risk.
Image Source: culpepperplaceassistedliving