Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 54

54

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

pressure ulcer surgery were usually confined to
bed for 6 weeks while the surgical site healed
(Stal et al, 1983). Given modern constraints on
resource utilization, many centers have trialed
shorter courses of bed rest and observed that
there was no difference in outcome; more recent
articles now report bed rest periods of only 3
weeks (Tchanque-Fossuo et al., 2011; Larson et
al., 2012).
Since prolonged bed rest may result in the
stiffening of joints, tendons, and ligaments,
passive ranging of joints should be conducted
prior to sitting (Kierney et al., 1998; Keys et al.,
2010). Because ranging of the hips and knees
may result in tension to the flaps used to close
ischial and sacrococcygeal ulcers, range of
motion therapy should only be initiated when the
incisions are deemed strong enough to tolerate
this. Hip and knee range of motion should be
performed slowly, gently, and incrementally to
avoid flap dehiscence. The ultimate goal of range
of motion exercises is to assess whether or not an
appropriate seating posture can be achieved and
to attain this permissive joint motion. Though
optimal seating posture requires at least
90-degree flexion and the hip and knee, more
limited angles may be accommodated by certain
wheelchair modifications to open the back angle.
Prolonged bed rest decreases strength and
endurance. An upper limb bed exercise program
must begin when the person is medically cleared.
This may include wrist weights, barbells, and/or
elastic resistance bands.
Wheelchair activity is initiated after the
mandated period of bed rest and when hip and
knee range of motion has been optimized. Once
again there is variation on the actual lengths of
time used (e.g., initial seating for 30 minutes
versus 60 minutes, etc.), however, the important
facet is that there is a graduated progression of
seated activity with skin re-assessment after each
sitting episode (Kierney et al., 1998; Keys et al.,
2010; Larson et al., 2012). During the first
episode of post-operative seating, the patient
should undergo a wheelchair and cushion
assessment, with or without interface pressure
mapping, to determine if any modifications are
required to achieve optimal pressure distribution.
There is no consensus on how rapidly to advance
sitting time, however, any increase in time must
be predicated on whether or not the flap and
incisions are tolerating the loading pressure (Keys
et al., 2010). Consistent weight shifting must be
employed during any episode of sitting longer
than 15-30 minutes. Optimal functional endpoints

are the ability to transfer and conduct activities of
daily living (Kierney et al., 1998).
POSTOPERATI VE PATI ENT EDUCATI ON AND
PSYCHOL OGI CAL SUPPORT

In many facilities, persons who have
undergone pressure ulcer surgery are educated
to perform weight shifts once they are bearing
weight on a flap and inspecting the skin with a
long-handled mirror or camera as well as
proper skin hygiene, must be employed for
comprehensive care (Black and Black, 1987
Kierney et al., 1998). They also are encouraged to
inform home-based caregivers about preventing
recurrence. Clinicians also must be concerned
about psychological issues specifically depression
following surgery. Persons confined to bed for
long periods of time during healing may be at risk
for depression (Smith et al. 2008). These
individuals should be encouraged to engage in
activities that allow them to interact with others
and in activities that are enjoyable. Individualized
education and structured follow-up have been
shown to reduce the frequency of or delay the
recurrence of pressure ulcers after surgical repair
(Rintala, et al. 2008). All the principles of
prevention discussed in the earlier chapter should
be reviewed.

Complications of
Pressure Ulcer Surgery
The most common complication following
surgical repair of a pressure ulcer is dehiscence,
specifically suture-line dehiscence or separation.
Most surgeons differentiate the more common
superficial suture-line dehiscence that can be
treated with local wounds care from deeper
disruptions that require re-operative closure
(Keys et al., 2010; Larson et al., 2012).
Superficial suture-line dehiscence may occur
as a consequence of shear or friction from
uncontrolled muscular spasms or inattentive
patient positioning or turning. Deeper disruptions
of surgically close tissue are more reflective of
systemic problems with wound healing (e.g.,
impaired perfusion or hyperglycemia), infection,
or poor surgical technique. These more serious
dehiscences may require debridement and flap
re-advancement.
Seromas occur when interstitial fluid or
transudate collects in potential dead spaces that
were not obliterated during surgery. Well-placed
surgical drains maintained until drainage has
appropriately decreased are usually sufficient
prevention. In time, most small seromas are
resorbed by the body (unless secondary infection
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
