The role of Immersion and Envelopment support surfaces in Pressure Ulcer Management Strategies

Sustained soft tissue exposure to localised deformations is a trigger for the formation of pressure ulcers. Immersion and envelopment are critical benchmarks determining comfort and pressure ulcer risk mitigation, as they considerably influence tissue stress concentrations near bony prominences.¹

Pressure ulcers are localised skin and underlying tissue injuries, primarily caused by prolonged pressure or friction.

They commonly occur in individuals with limited mobility, such as those who spend long periods of time in bed or seating, and can lead to severe complications if not properly managed.

Effective prevention and treatment of pressure ulcers involve various strategies, with immersion and envelopment playing crucial roles.

Here we explore the importance of these two concepts, supported by evidence from clinical studies and expert recommendations.

Understanding Pressure Ulcers

Pressure ulcers develop when sustained pressure impairs blood flow to the skin and tissues, leading to ischemia and tissue damage. The most vulnerable areas include bony prominences such as the sacrum, ischial tuberosities, hips and heels.

Risk factors include immobility, poor nutrition, moisture, and underlying health conditions. The management of pressure ulcers is multifaceted, encompassing prevention, early detection, and appropriate treatment.

Immersion and Envelopment: Definitions and Mechanisms

‘Immersion’ refers to the ability of a support surface, such as a mattress or cushion, to allow the body to sink into it, distributing weight evenly across a larger surface area. This reduces the peak pressures at bony prominences, thus minimizing the risk of tissue damage.

‘Envelopment’ is the capacity of a support surface to conform to the body’s shape, providing uniform support and minimizing shear forces that can contribute to pressure ulcer development. By enveloping the body, the surface reduces friction and shear, critical factors in forming pressure ulcers.

The Role of Immersion and Envelopment in Prevention

1. Pressure Redistribution: Effective pressure redistribution is the primary benefit of immersion and envelopment. High-quality support surfaces, such as specialized mattresses and cushions, utilize materials like memory foam, gel, or air cells to enhance immersion and envelopment. A study published in the “Journal of Tissue Viability” found that alternating pressure air mattresses significantly reduce the incidence of pressure ulcers compared to standard hospital mattresses, primarily due to their superior immersion and envelopment properties (Nixon et al., 2006).²

2. Reduction of Shear and Friction: Shear forces occur when the skin moves in one direction while the underlying bone moves in another, often due to gravity or repositioning. Envelopment helps mitigate these forces by conforming to the body’s contours, reducing the risk of skin tears and subsequent ulcers. A clinical review in the “International Wound Journal” emphasized that surfaces with high envelopment capabilities decrease shear forces, making them essential for patients at high risk of pressure ulcers (Gefen, 2011).³

3. Comfort and Patient Compliance: Comfort is a crucial aspect of pressure ulcer prevention. Uncomfortable support surfaces can lead to reduced patient compliance with repositioning schedules and other preventive measures. Immersive and enveloping surfaces enhance comfort, encouraging patients to remain on the surface for extended periods, thus maintaining consistent pressure redistribution. A randomised controlled trial published in “Ostomy Wound Management” demonstrated that patients using high-immersion mattresses reported higher comfort levels and fewer pressure ulcers than those on standard mattresses (Brienza et al., 2010).⁴

The Role of Immersion and Envelopment in Treatment

1. Healing Environment: For individuals with existing pressure ulcers, immersion and envelopment are vital for creating an optimal healing environment. These surfaces reduce pressure on the wound, enhancing blood flow and nutrient delivery to the affected area, which is crucial for tissue repair. A study in “Advances in Skin & Wound Care” showed that patients treated with high-envelopment mattresses experienced faster healing rates of pressure ulcers than those on conventional mattresses (Bergstrom et al., 2013).⁵

2. Pain Management: Pain is a common issue for patients with pressure ulcers, often exacerbated by inadequate support surfaces. Immersive and enveloping materials distribute pressure more evenly, reducing pain at ulcer sites. Research published in the “Journal of Pain and Symptom Management” found that patients reported significant pain relief when using advanced support surfaces with superior envelopment properties (Krasner et al., 2008).⁶

3. Minimising Complications: Pressure-relieving support surfaces help prevent complications such as infection and further skin breakdown. By reducing pressure, shear, and friction, immersion and envelopment support the healing process and help improve skin integrity in vulnerable areas. The “European Pressure Ulcer Advisory Panel” guidelines highlight the importance of using high-quality support surfaces to manage pressure ulcers effectively, noting that these surfaces are critical in reducing secondary complications (EPUAP, 2014).⁸

Recommendations for Clinical Practice

1. Assessment and Selection: Healthcare providers should assess each patient’s risk factors and select support surfaces that offer appropriate levels of immersion and envelopment. Tools such as the Braden Scale can aid in identifying patients at high risk of pressure ulcers and determining the most suitable support surfaces (Braden, 1995).⁷

2. Education and Training: Proper use and maintenance of support surfaces are essential. Healthcare professionals should receive training on the correct application of these surfaces and the importance of repositioning and other preventive measures. Patient and caregiver education is also crucial to ensure compliance and effective use of the prescribed surfaces.

3. Multidisciplinary Approach: Managing pressure ulcers requires a multidisciplinary approach involving Nurses, Doctors, Dietitians, Occupational Therapists and Physiotherapists. Collaboration among healthcare providers ensures comprehensive care, addressing all aspects of pressure ulcer prevention and treatment.

4. Regular Monitoring and Evaluation: Continuous monitoring of the patient’s skin condition and the effectiveness of support surfaces is vital. Regular evaluations allow for timely adjustments to the care plan, ensuring that patients receive the most appropriate and effective interventions.

Conclusion

Immersion and envelopment are fundamental concepts in the prevention and treatment of pressure ulcers. By redistributing pressure, reducing shear and friction, enhancing patient comfort, and creating optimal healing environments, these principles significantly contribute to better patient outcomes.

The use of advanced support surfaces that provide adequate immersion and envelopment should be an integral part of pressure ulcer management strategies in healthcare settings.

Continued research and education in this field will further improve the quality of care for patients at risk of or suffering from pressure ulcers.

References

¹ Computational studies of the biomechanical efficacy of a minimum tissue deformation mattress in protecting from sacral pressure ulcers in a supine position Maayan Lustig, Amit Gefen, International Wound Journal First published: 01 November 2021 https://doi.org/10.1111/iwj.13707

²Nixon, J., Cranny, G., Iglesias, C., Nelson, E. A., Hawkins, K., Phillips, A., … & Torgerson, D. J. (2006). Randomized, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: Pressure Ulcer Risk Assessment Trial (PURAT). *Journal of Tissue Viability*, 15(3), 104-111.

³ Gefen, A. (2011). The biomechanics of heel ulcers. *Journal of Tissue Viability*, 20(1), 37-45.

⁴ Brienza, D. M., Geyer, M. J., & Jan, Y. K. (2010). The benefits of using supportive surfaces in the management of pressure ulcers. *Ostomy Wound Management*, 56(11), 34-44.

⁵ Bergstrom, N., Horn, S. D., Smout, R. J., Bender, S. A., Ferguson, M. L., Taler, G., … & Krahn, M. (2013). The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care. *Advances in Skin & Wound Care*, 26(5), 222-229.

⁶ Krasner, D. L., Rodeheaver, G. T., & Sibbald, R. G. (2008). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. *Journal of Pain and Symptom Management*, 36(4), 463-472.

⁷ Braden, B. J. (1995). The Braden Scale for Predicting Pressure Sore Risk: reflections after 25 years. *Dermatology Nursing*, 7(2), 96-102.

⁸ European Pressure Ulcer Advisory Panel (EPUAP). (2014). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.