Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 13

CLINICAL PRACTICE GUIDELINE

In people of comparable age, SCI severity, and
pre-injury health, athletic involvement was shown
to be protective of pressure ulcer development
(Stotts, 1986).
H I S T O RY O F PRIOR PRE S S URE ULCE RS

Individuals with SCI who have had a history
of pressure ulcers, especially if treatment included
surgery, are at high risk for recurrence.
Descriptive studies of different populations,
including veterans have reported recurrence rates
which range from 35% to 63% (Bates-Jensen et
al., 2009; Lehman (1995); Niazi et al. (1997).
Vidal and Sarrias (1991) found that
recurrence of pressure ulcers was a highly
significant risk factor for increased severity of
the ulcer. Recurrence has also been associated
with younger age, black race, unemployment,
nursing home residence, previous pressure ulcer
surgery, smoking, diabetes, and cardiovascular
disease (Niazi et al., 1997; Disa et al., 1992;
Guihan et al., 2008). Lack of social supports,
inadequate pressure ulcer prevention knowledge,
ineffective or nonparticipation in preventive
practices, and poor psychological well-being also
have been associated with recurrence (Disa et
al., 1992; Jones et al., 2003; Heilporn, 1991).
Recurrence following pressure ulcer surgery
has been associated with poor patient compliance,
the lack of control of comorbidities, and
incomplete presurgical debridement (Sorensen et
al., 2004). For those who have undergone
previous pressure surgeries, the median
recurrence time is 4 months post pressure ulcer
surgery (Bates-Jensen et al., 2009).
Hospital-based educational programs are
insufficient to prepare an individual with a SCI
to integrate preventive behaviors into his/her
lifestyle post discharge. In a randomized
controlled trial of 49 male veterans with SCI,
investigators determined that individualized
education and structured monthly contacts have
been shown to delay or reduce the frequency of
pressure ulcer recurrence after surgical repair
(Rintala et al., 2008).
B L A D D E R , B OW E L, A ND MOIS T URE CONTROL

Appropriate bladder and bowel management
programs prevent the skin from becoming
contaminated with urine and feces. Salzberg et al.
(1996) and Salzberg et al. (1998) reported that
bacteria found in stool is destructive to the skin
and that urinary and fecal incontinence were
significant factors in pressure ulcer development
in the SCI population. Control of moisture is
extremely important in preventing incontinence
associated dermatitis, which is not to be confused
with a pressure ulcer.

Comorbid Medical Risk Factors
MEDI CAL COMORBI DI TI ES

In a retrospective chart review of 81 SCI
individuals with pressure ulcers, Rochon et al.
(1993) reported that having more than seven
ICD-9-CM codes on the discharge summary was
significantly associated with pressure ulcer
development. Guihan and Garber in 2008
similarly reported that persons with higher
burden of illness as measured with the Charlson
cormobidity index were at increased risk for
developing pressure ulcers. In a retrospective
chart review by Vidal and Sarrias (1991) of 268
individuals with SCI, a high incidence of urinary
tract infections was associated with pressure
ulcers. Salzberg et al. (1996) related that the
number of comorbidities-cardiac disease or
abnormal EKG, diabetes, renal disease,
pulmonary disease, and sepsis/infection-was a
risk factor in an SCI population. In a later study
by Salzberg et al. (1998), data obtained from
800 individuals with SCI in the community
revealed that renal and pulmonary diseases were
significant risk factors, but cardiac disease,
diabetes, and impaired cognitive function were
not significant risk factors. Mawson et al. (1988)
found that diabetes mellitus and peripheral
vascular disease were insignificant factors for
pressure ulcer development in the immediate SCI
post-injury period. In contrast, both Chen et al.
(2005) and Smith et al. (2008) report in large
studies of individuals followed in Model System
and VA systems respectively that having diabetes
is a significant risk factor for developing pressure
ulcers. Verschueren et al. (2011) found that
pneumonia and/or pulmonary disease during
acute rehabilitation is a risk factor for pressure
ulcer development.
In some individuals with SCI, friction and
shear may be of concern due to increased
spasticity, particularly with higher level injuries,
and the contact of the skin and tissues with
the support surface. In a retrospective study
of 268 individuals with SCI, Vidal and Sarrias
(1991) reported that decreased spasticity
was also a significant risk factor in pressure
ulcer development.
Mawson et al. (1988) reported that
individuals with SCI who developed pressure
ulcers in the immediate post-injury period had
significantly lower systolic blood pressure (≈100
mm Hg) compared to controls (≈120 mm Hg).
In two studies, autonomic dysreflexia was
associated with pressure ulcer development
among individuals with SCI (Salzberg et al.,
1996; Salzberg et al., 1998.

13
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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