Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 17

CLINICAL PRACTICE GUIDELINE

patient's condition changes, while in U.S.
Department of Veterans Affairs Medical Center
SCI units, risk assessment (using the Braden
Scale) is performed daily during the first week
of admission and then weekly thereafter until
discharge, transfer, or change in medical status
(VHA Handbook 1180.02).

Prevention Strategies
Across the Continuum
of Care
Pressure Redistribution
2. Implement pressure ulcer prevention
strategies as part of the comprehensive
management of acute and chronic SCI and
review all aspects of risk when determining
prevention strategies.


Initiate pressure redistribution as soon
as emergency medical conditions and
spinal stabilization status allow.

(Scientific evidence- I, II, V; Grade of recommendation-A;
Strength of panel opinion-Strong)

Pressure ulcer prevention begins during the
acute phase of SCI management and this includes
pressure relief strategies in the emergency
department (ED) (if patient is on a spinal board)
and the operating room. In the operating room,
factors related to positioning, the immobility
during the intraoperative and immediate
postoperative period (Cherry Moss, 2011;
St-Amaud & Paquin, 2009), anesthesia duration
and the total time of the diastolic pressure less
than 50 mm Hg (Connor et al., 2010), the
duration of surgery, and patient-related factors all
have been shown to affect pressure ulcer
development (Walton-Geer, 2009). All persons
undergoing surgery should be considered atrisk for pressure ulcer development and
perioperative use of dynamic pressure-relieving
devices is recommended. Nevertheless, it should
be noted that Hoshowsky and Schramm (1994)
reported an incidence of 16.8% of category/stage
I ulcers in 505 individuals who had been
positioned with pressure reduction devices and
standard devices intraoperatively.
A rigid backboard should be used for as short
a period of time as possible for initial inpatient
evaluation and stabilization (Vickery, 2001).
Prompt removal from the backboard, after
transport to an ED and initial spine stabilization,
is required to reduce pressure ulcer formation.
For patients with a confirmed SCI, transfer the

patient off the backboard onto a firm padded
surface, ideally within 2 hours, continuing
precautions to protect the spinal column and skin.
Those who have extended transport to the ED or
who are delayed in transfer to the intensive care
unit are at increased risk of skin breakdown.
(Early Acute Management in Adults with Spinal
Cord Injury: A Clinical Practice Guideline for
Health-Care Professionals, 2008)
The duration of unrelieved pressure prior
to a nursing unit admission and the length of
time on the spinal board have been shown to be
significant risk variables for pressure ulcer
development within the first 8 days post spinal
cord injury (Mawson et al., 1988). In one study,
individuals who developed ulcers during the
first 8 days after injury spent an average of 20
hours unturned compared to 11 hours unturned
in the control groups. In a study of 49 individuals
with SCI immediately post injury, Curry and
Casady (1992) found that individuals immobilized
longer than 6 hours developed pressure ulcers at
a significantly greater rate than individuals
immobilized for shorter periods of time.
A study of 32 spinal individuals with SCI
with and without pressure ulcers determined that
those individuals with pressure ulcers were more
likely to have had a prolonged immobilization
in the immediate post-injury period (Linares et al.,
1987).

Visual and Tactile Skin Inspections
3. Conduct daily comprehensive visual and
tactile skin inspections with particular
attention to the areas most vulnerable to
pressure ulcer development, including, but
not limited to the following:


Ischial tuberosities



Sacrum



Coccyx



Greater trochanters



Ankles (malleoli)



Knees (medial aspect especially during
side-lying position)



Occiput



Calcaneous

(Scientific evidence-III, V; Grade of recommendation-C;
Strength of panel opinion-Strong)

Frequent inspection is essential to detect
early skin breakdown (e.g., nonblanchable
erythema). Individuals with lower level injuries
(paraplegia) may perform self-inspection with a

17
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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