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The National Pressure Ulcer Advisory Panel (NPUAP), in collaboration with Creighton University Health Sciences Continuing Education, recently hosted a webinar titled “Considerations for Bariatric Patients in Pressure Injuries and Wound Care.” This program highlighted the “how” and “why” long term and post-acute care (LT/PAC) providers do what they do when caring for residents with a bariatric diagnosis as their needs are often different from those of other residents.Mentioned in the webinar were the International Guideline Recommendations for Organizations, which include:

1. Provide safe, respectful care and avoid injuries to both the individual and health professional;

2. Maximize workplace safety by implementing organization-wide bariatric management strategies that address manual handling techniques; and

3. Provide pressure redistribution support surfaces and equipment appropriate to the size and weight of the individual.

As NPUAP representatives said, “There is nothing that makes an obese person ordinary when it comes to being a patient or a resident.”

Keeping this distinction in mind, a key element of the typical skin risk assessment process is to assess a person’s risk using their body mass index (BMI) score. However, this process does not take into consideration the size of the person, and in fact is not accurate for those with a bariatric diagnosis.

In addition to the BMI index not being an accurate measure of risk, residents with a bariatric diagnosis also tend to have reduced tissue perfusion, compromised moisture barrier, chronic inflammation, and thinning skin. All of these increase the risk of impaired skin integrity.

Using a comprehensive approach in assessment and prevention is critical for individuals with a bariatric diagnosis.

The webinar recommended the following four-step process:

1. Assessment

2. Proper support surface

3. Skin care

4. Skin injury prevention protocols

While these steps reflect a standard approach for many providers already, it’s always a good time to review care processes. The assessment approach for this population should be to assess skin daily and with any change in condition. Performing a thorough skin assessment includes looking inside skin folds, places where skin areas may be against other skin areas for prolonged periods.

Although skin to skin may not appear to be a “pressure area,” it is important to remember that any time skin is against skin, there is pressure. Another risk with skin-to-skin contact is the risk for MASD (moisture-associated skin damage). When performing a thorough skin assessment, any indication of moisture-related injury should be addressed immediately to assist in preventing increased tissue damage.

Then of course comes the mandatory nutritional assessment. Remember, just because a resident or patient is outside of expected weight parameters does not mean they are nutritionally sound. Many residents with a bariatric diagnosis make poor food choices and may be malnourished. NPUAP recommends assessing nutritional lab values and focusing on visceral protein stores. Gone are the days when an albumin or total protein level are considered the standard for a comprehensive nutritional assessment. Be sure to include a licensed dietitian to make the determination as to what lab values and nutritional support interventions would be beneficial for residents at risk.

Weight capability is only one factor when selecting a support surface for residents with a bariatric diagnosis. When it comes to surfaces, identify how the device removes excess moisture and controls the temperature, if it reduces or increases friction/shearing, and how difficult it is for the resident to rise independently. Residents with decreased mobility tend to remain in static positions for long periods of time, creating a viable environment for moisture, friction, and shearing.

Seating devices also need to be considered when reviewing support surfaces.

Wheelchairs should be properly sized, not bind at the sides, and have proper padding to avoid sharp edges.

Remember, wheelchairs were designed for transporting residents and should never be used for prolonged seating. The seat cushions should be specific for the individual and prescribed by a professional who will re-evaluate the device at least yearly, but preferably every six months.

Consider establishing an algorithm for support surface selection based on individual needs. It is also important to think of support surface devices as a good pair of running shoes. Replace them on a scheduled basis, as they lose their ability to support and redistribute weight effectively.

Daily cleansing in areas of high risk such as skin folds, under breasts, perineal area, and any areas with excessive moisture is a standard. The use of pH-appropriate products is helpful, and many incontinence cleansers provide this protection. Also keep in mind that skin needs to be thoroughly dried using a “pat dry” method and NEVER use heat.

Skin should be moisturized frequently using humectants or emollients to keep the skin from drying out as this increases the risk of impaired skin integrity. Moisture barrier creams are also helpful in skin folds and perineal areas.

Consider using products with wicking properties in skin fold areas, such as gauze squares.

Turn and reposition schedules should be based on individual need and include repositioning while up in chairs. Remember, the resident doesn’t have to completely lift their body from a seated position to relieve pressure, merely shifting weight from side to side every 30 to 60 minutes is helpful. The head of the bed should be maintained at 30 degrees or lower, as when the head of the bed is raised higher there is an increased risk for shearing/friction. Friction- and shear-reducing linens are now available and have shown to be effective.

Remember, however, that for residents with enteral feedings, the head of the bed should be maintained at 30 degrees during infusion and at least an hour post-infusion to help prevent aspiration.

It is also important to maintain adequate hydration, as hydrated skin is healthier than dehydrated skin. If medical devices are being used (trach ties, bed pans, catheters), monitor sites frequently and address any reddened or irritated areas immediately. Avoid positioning on pressure injury sites and devices that create heat. Many residents will need assistance with repositioning more often than every two hours.

When it comes to safety, proper equipment and technique are key. Always obtain proper bariatric equipment, including beds, chairs, wheelchairs, stretchers, canes, lifts, slings, transfer devices, tables, and seating cushions.

Transfer slings must be in good condition and compatible with the mechanical lift being used. Strictly adhere to the manufacturer’s recommendations for replacing slings because even if they might not show signs of wear and tear, simple laundering can weaken the fabric.

Avoid lifting or turning a resident manually; use equipment as needed. Proper equipment provides the best measure of safety and care for residents, as well as caregivers. For guidance, refer to the Safe Patient Handling Guidelines at www.publichealth.va.gov/employeehealth/patient-handling/.

It is important to remember that residents with a bariatric diagnosis most often have no control over their situation and need support. Because of this, it is important to allow them as much autonomy and control over what they can control in a safe manner. Encourage residents to make healthy lifestyle choices. Even if caregivers don’t always agree with these decisions, they can continue to educate and support the resident.

Avoid using terms such as “large chair” or “big boy bed.” Instead, document with the terms “more comfortable chair/bed” and educate staff on the importance of treating each resident with dignity and respect. Recognizing that obesity is not a personal problem but a universal health problem with major health consequences is key.