Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 15

CLINICAL PRACTICE GUIDELINE

A D H E R E N C E / COMPLIA NCE

Adherence/compliance relates to the success
of an individual in following through consistently
with health recommendations for preventing and
treating pressure ulcers. A major factor that has
been associated with suboptimal adherence is a
misconception about risk. Rodriguez and Garber
(1994) found that more than 80% of a sample of
people with SCI who had experienced a previous
ulcer did not believe they were at risk of future
ulcers. As a verbal or written commitment from a
person to follow through with a health behavior
recommendation has been associated with better
adherence (Cox and Gonder-Frederick, 1992;
Meichenbaum and Turk, 1987), such commitment
should be sought routinely. The person's ability to
verbalize his or her health behavior regimen
seems to be a minimum indicator of adherence
(i.e., understanding is necessary but not sufficient
to produce the recommended behavior)
(Rodriguez and Garber, 1994). Potential points of
disagreement between the health-care provider
and the individual with regard to
recommendations offered should be assessed
directly by the provider because, at a minimum,
this gives the provider a chance to learn where
and how to provide more information about and
a rationale for a given recommendation.
The regimens involved in managing SCI are
complex and require lifestyle changes. Many of
the recommendations for prevention, such as
performing pressure redistribution, require
understanding, cooperation, and initiative.
Some of the factors associated with pressure
ulcers may involve the behavior of the individual
who has the injury as well as the behavior of
those in formal and informal support networks if
assistance is needed in order to perform certain
activities or tasks. Management of other factors,
which can complicate the prevention and
treatment of pressure ulcers (e.g., comorbidities
such as diabetes, or complications of SCI such as
incontinence), may also involve demanding and
complex procedures. Evidence from the
behavioral medicine literature indicates that
complex regimens and/or those involving lifestyle
changes are associated with poor adherence (Ary
et al., 1986; Glasgow et al., 1992; Hulka et al.,
1976). Studies by Clark, ( 2001) and, Jackson,
(2010) describe the intricate balance between
buffers (protective behaviors and contexts) that
reduce the risk of recurring ulcers and liabilities
(negative behaviors and circumstances) that
increase risk of developing recurring ulcers.
These studies shed light on the complex and
highly individualized scenario of a person's ulcer
history and future interventions. These studies

suggest that to help individuals decrease the risk
of pressure ulcer recurrence, the health-care
provider must engage in a meaningful dialogue
that takes into account individual detailed of
habits and routines. The individual with SCI must
be empowered to embed preventive behaviors
that are doable within their context. For example,
the health-care provider may help the person
with tetraplegia come up with timed alerts to
remind them to recline while being engaged in
distracting activities.

Support Surfaces for Bed
and Wheelchair
The factors related to support surface are
similar for both prevention and management.
Please refer to the chapter "Pressure
Redistribution and Support Surfaces" for details.

Risk-Assessment Tools
Almost all individuals with SCI are at lifelong
risk for developing pressure ulcers. Riskassessment scales distinguish those who are at
risk for developing a pressure ulcer and
determine the extent to which a person exhibits a
specific risk factor. Early risk assessment prompts
the immediate, targeted implementation of
preventive and risk-reduction interventions.
There is evidence that risk-assessment
scales may be used successfully to predict
pressure ulcers in various populations and result
in favorable outcomes (Allman et al., 1995).
Results of risk-assessment measures and their
ability to predict pressure ulcers vary according
to the measure (Arnold, 1994; Hunt, 1993), to
the patient population (Bergstrom et al., 1996;
McCormack, 1996), and to the person who
assesses the individual (Edwards, 1994).
Some risk variables for which there is research
evidence or strong clinical support are not well
represented among existing risk-assessment tools.
Specifically, these variables include psychosocial
factors, such as substance abuse, adherence to
recommended behaviors, depression, degree of
cognitive impairment, and degree of social
support. Additionally, since health status and risk
for pressure ulcers can change rapidly, clinical
judgment is required to guide decisions when
further assessment should be performed. Formal
assessment tools have many limitations and
therefore patient care prevention strategies
based upon the health-care professional's
judgment in conjunction with tool use are justified
(VandenBosch et al., 1996; Watkinson, 1997).

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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