Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 20

20

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

transfers can reduce friction or shearing forces
exerted on the skin. Friction may be minimized by
the use of lubricants, protective films, protective
dressings, and protective padding. Massage over
bony prominences should be avoided due to its
possible harmful effects (Bergstrom et al., 1992).
Bumping or scraping the body during transfers,
poor sitting posture, frequent shearing against
bed surfaces during dressing or bed mobility, or
ineffective pressure redistribution techniques can
be contributing factors to this problem.
Proper pillow placement behind the back and
between the legs will help to relieve the pressure
of bony areas touching one another or the surface
of the bed (Land, 1995; Lowthian, 1993). Clothes
should not fit tightly anywhere they could restrict
circulation or cause friction or shear to the skin.
Clothing materials that have a rough texture or
include abrasive features, such as hard fasteners
or studs on rear pockets or double-welted rear
seams, like those on blue jeans, can contribute to
skin abrasions. The types of fabrics that are best
for the skin do not hold heat in to the body.
Lightweight cotton fabrics are better than nylon
or wool. Also to be avoided are tight-fitting shoes,
socks, stockings, braces, splints, and leg bag
straps (Pires and Muller, 1991) as these items
may restrict normal blood flow in the body or
cause undue friction or shear (Krouskop et al.,
1983; Scotzin and Sommer, 1993).
During rehabilitation hospitalization, persons
with SCI are turned according to a specific 24
hour protocol. However, over time, the over-night
turning schedule may be modified to reflect a
person's ability to withstand pressure on
vulnerable areas of the body for longer periods of
time. This is extremely important once the person
is transitioned home so that there are fewer sleep
disturbances for both the person with SCI and
his/her family or caregiver. This is determined
by the person's medical and skin condition. As
tissue tolerance increases, persons with SCI
should not have to be turned so often especially
during the night.

Effective Support Environment
5. Evaluate the individual and his or her
support surfaces for optimal maintenance
of skin integrity.


Prevent moisture accumulation and
temperature elevation at the skinsupport surface interface.



Utilize pressure redistribution support
surfaces preventively to protect soft
tissues from bruise and injury.



When off-loading the calcaneous with
pillow or cushion, ensure the proper
position of the pillow or cushion. It
should be placed lengthwise under the
calcaneous off the bed surface.



Do not use donut-type devices.



Monitor the performance, i.e., continued
effectiveness, of support surfaces for the
bed and wheelchair specific to pressure
ulcer prevention.

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

Cleansing the skin on a regular basis and at
times of incontinence is recommended
(Bergstrom et al., 1992; Rodeheaver, 1999).
Mild cleansing agents that minimize irritation
and dryness of the skin are recommended; while
hot water should be avoided. When cleansing the
skin, clinicians and caregivers should take care
not to exert undue force and friction to the
tissues. When sources of moisture-whether
from incontinence, perspiration, or wound
drainage-cannot be controlled, underpads or
briefs made of materials that absorb moisture
and present a quick-drying surface should be
used (Bergstrom et al., 1992). Wet skin tends to
adhere to bed linens, possibly causing shearing
when the linen is pulled away from the skin
(Krouskop et al., 1983). If someone lives in a
humid climate or if excessive perspiration is a
problem, cotton fiber clothing and/or a change
of clothing during the day may need to be
considered in order for the skin to remain dry
(Krouskop et al., 1983; Nixon, 1985; Scotzin and
Sommers, 1993).
At constant tissue pressures, temperature
reduction can diminish tissue damage (Romanus,
1976); conversely, temperature elevation
will increase tissue injury from continuous or
repetitive stress (Finestone et al., 1991;
Vistnes, 1980).
Those at risk for pressure ulcer development
should be placed on a pressure-redistribution bed
support surface. (See recommendation 22 for
detail on types of support surfaces). The use of
pressure-redistributing devices prophylactically is
effective in reducing the risk of pressure ulcers
(Zernike, 1994). Heels should be offloaded from
the bed surface.
Pillows or foam wedges should be used to
keep bony prominences from contacting one
another. Skin should be inspected between turns
to ensure tolerance (Bergstrom et al., 1992). All
body positions (supine, side-lying, prone) should
be used, as tolerated, for bed positioning
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