Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 19

CLINICAL PRACTICE GUIDELINE

because it is necessary to have a basis of
comparison in order to detect a change in status.
Regardless of the physical ability of a person with
SCI, he or she can still be in control of directing
others to assist in this task unless the person with
the SCI is cognitively or intellectually impaired.
Although pressure ulcers occur most
commonly over a bony prominence such
as the sacrum, ischial tuberosities, trochanter,
and calcaneus, areas where a person's weight
is concentrated while sitting or lying, they can
develop anywhere on the body, especially in
places that are related to the use of medical
devices, such as casts, splints, cervical orthoses,
drainage tubing, and other immobilizers.
Identifying a category/stage I pressure ulcer
in individuals with darker skin tone is challenging
because redness and color changes are not
easily detectable. Other pressure-related skin
changes should therefore be assessed. These
include changes in skin consistency, sensation,
temperature, and moisture. For example, skin can
be firm or boggy, there may be pain and itching,
and the skin may feel warm or moist to touch.
Bates Jensen et al. (2009), in a cohort study
of nursing home residents, performed visual skin
assessment and measured subepidermal moisture
(SEM) using a surface capacitance dermal phase
meter at the right and left buttocks and sacrum
weekly and found that SEM was associated
with future pressure ulcer occurrence in persons
with dark skin tones. Guihan et al. (2008) studied
the feasibility of detecting early pressure ulcer
damage by measuring SEM on the sacrum, right
and left heels, trochanter, ischium, and buttocks
using a handheld dermal phase meter on persons
with SCI and found that SEM was higher in
persons who had category/stage I pressure ulcers,
suggesting a possible relationship between SEM
and skin damage.

Turning and Repositioning
4. Turn or reposition individuals with SCI
initially every 2 hours in the acute and early
rehabilitation phases, adjusting by medical
conditions and/or risk factors.


Avoid overstretching and folding of
skin/soft tissues while positioning and
shearing when individuals are
repositioned or transferred.



Avoid positioning individuals who are
side-lying in bed directly on their
tronchanters.

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

Current practice is to reposition at-risk
persons at least every 2 hours to prevent
capillary and venous occlusion. Kosiak (1961)
recommended a frequency of repositioning of
1 to 2 hours based upon findings found in
uninjured individuals. Norton et al. (1975)
conducted an observational study of older
individuals without SCI and demonstrated that
individuals turned every 2 to 3 hours had fewer
ulcers than those who turned less frequently.
Individuals without SCI have very different
response to constant applied load as compared
to most with SCI. (Bader, 1990)
When in bed, the lowest degree of head of
bed elevation should be maintained consistent
with the medical condition and other restrictions
that may limit the amount of time that the head
of the bed is elevated. Raising the head of bed to
30 degrees or higher increases the peak interface
pressure between the skin at the sacral area and
the support surface. As the a head of a bed is
elevated more than 45 degrees the affected area's
skin-bed interface pressure that is greater or
equal to 32 mm Hg increases as well (Peterson
et al., 2008).
Significantly increased skin-bed interface
pressures have also been shown to apply to
positioning in a lateral position with and without
elevation. Peterson et al. (2010) found that
raising the head of the bed to 30 degrees in the
lateral position significantly increased the
interface pressures at the sacrum, trochanter,
and buttock regions, and increased when using
wedges as compared to pillows to support lateral
positioning. Garber et al. (1982) reported the
effect of side-lying on trochanteric interface
pressures and Seiler et al. (1986) measured the
effect of side-lying positions on transcutaneous
oxygen tension finding that direct positioning
on the trochanter (90 degree angle) produces
high interface pressures and low transcutaneous
oxygen tension, but when individuals are
positioned at a 30-degree side-lying angle,
the body's transcutaneous oxygen tensions
are normal, with significantly reduced
interface pressures.
The technique of turning an individual is as
important as the frequency of turning. A person
should always be lifted as opposed to dragged
across a surface in order to prevent shear related
injuries. Use of sheets can eliminate or reduce
shear, thus reducing the risk of skin damage.
Avoiding shear is also important in minimizing
skin breakdown during transfers from one surface
to another. Using lifting devices to assist in
moving individuals who cannot assist during

19
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

Table of Contents for the Digital Edition of Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury
