Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 14

14

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

Nutrition
Specific biochemical indices of nutrition that
are associated with the risk of pressure ulcers
include total protein, albumin, hemoglobin,
hematocrit, and total lymphocyte count. See the
nutrition section of the "Prevention Strategies"
chapter for more details.

Psychological, Cognitive, Contextual,
and Social Factors: Substance Abuse
and Adherence/Compliance
P S Y C H O L O G I C AL FA CT ORS

Major depression and anxiety disorders, as
well as negative self-concept and poorly managed
anger and frustration can interfere with
cooperation between the individual and his or her
care providers and can be associated with
inactivity, self-neglect, and poor medical
adherence (Cox and Gonder-Frederick, 1992;
Vidal and Sarrias, 1991; Woolsey, 1985). Krause
and Kjorsvig (1992) found lower survival rates,
including death from sepsis following pressure
ulcers, among people with SCI who had reported
lower life satisfaction and adjustment and greater
psychological distress 4 years earlier.
C O G N I T I V E I M PA IRME NT

Cognitive impairments among people with
SCI may result from brain injury accompanying
the SCI or from medication use, substance abuse,
preexisting cognitive dysfunction or learning
disability, or delirium secondary to infection. In a
study of more than 200 individuals with SCI in a
VA setting, Salzberg et al. (1996) identified
impaired cognitive function as a significant risk
factor for pressure ulcers, while Richards et al.
(1991) reported an increased risk for pressure
ulcers among people with SCI who also had
sustained a traumatic brain injury.
S O C I A L E N V I R ONME NTA L CONT E X T UA L A ND
C I R C U M S TA N T I A L FA CT ORS

In recent years, there have been attempts
to identify risk factors, other than obvious
medical and SCI-related ones, within a person's
life that contribute to the development of pressure
ulcers, interfere with healing, and fail to prevent
recurrence. For example, in a disadvantaged
population cohort for whom life context may
include incarceration, homelessness, and gang
membership, it has been shown that such factors
such as perpetually being in a state of danger;
experiencing frequent disruptions or changes
of daily routine; choosing to participate in high
risk activities; and lacking access to care,
services, and supports can indeed influence

the development of pressure ulcers (Clark, et al.,
2001; Clark, Rubayi et al., 2006, Jackson et al.,
2010). In persons with chronic SCI and pressure
ulcers, it is important to assess the individual's
motivation to stay ulcer-free (Clark et al 2006;
Jackson et al, 2010). Motivation drives the daily
actions or inactions of the individual. Lack of
motivation to perform preventative activities may
be associated to depression, lack of social support
or poverty. Conflicting motivations, such as
wanting to stay fully engaged in either vocational
or recreational pursuits, may interfere with a
maintaining a strict regimen of pressure ulcer
prevention. Understanding life context, daily
routines and central daily activities should result
in a balance between ones daily occupations and
pressure ulcer preventative routines. Therefore, in
order to most effectively prevent and treat
pressure ulcers in any individual, it is important
to not just evaluate the usual risk factors as
described throughout in this guideline, but also to
evaluate the context in which the individual with
SCI lives, for, if these other factors are not
addressed as well, any intervention is not likely
to be successful.
SUBSTANCE ABUSE

Substance abuse is a risk factor for pressure
ulcer development after SCI (Vidal and Sarrias,
1991). Substance abuse can lead to impairments
in cognition and judgment (Cleaveland and
Denier, 1998) and is associated with less
adherence to health regimens (Pablos-Mendez
et al., 1997; Umpierrez, et al., 1997). Substance
abuse may be a direct or indirect risk factor
(e.g., excessive alcohol intake can increase the
risk of poor nutritional intake or it can cause
bladder distension and potential urinary
incontinence). Hawkins and Heinemann (1998)
found increased risk in illicit substance abusers
in a sample of 126 individuals with SCI; while
data collected by Krause et al. (2001, 2004)
suggest that hospitalization for pressure ulcer
treatment is associated with reported alcohol
or drug treatment.
Based on the known physiological effects
of smoking, it is reasonable to assume that
smoking is a risk associated with the development
of pressure ulcers and would interfere with
healing. Salzberg et al. (1996) found that
individuals with SCI who had pressure ulcers
were twice as likely to be current smokers.
Krause, in turn, (2001, 2004) reported that
pressure ulcers are more likely to occur in
persons who use pain medications and in those
who smoke (past or present).
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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