Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 57

CLINICAL PRACTICE GUIDELINE

prevent pooling of the blood in the center of the
wound. Further rationale for avoiding raising of
the head of the bed and repositioning every 2
hours are described in "Prevention Strategies
Across the Continuum of Care."
Individual repositioning at planned, displayed
intervals will enhance caregiver compliance even
when individuals are using pressure-reducing
support surfaces. Individuals with SCI, as well as
their caregivers, should be educated regarding the
optimal turning schedule as part of the
development of their home program.
Some reports indicate the development of
new pressure ulcers in people who are being
treated for other pressure ulcers (Allman et al.,
1995; Rochon et al., 1993) and in those who are
already using pressure redistribution support
surfaces of various types (Jesurum et al., 1996;
Ooka et al., 1995). This indicates the need to
maintain careful monitoring and preventive
positioning while using pressure redistribution
bed surfaces and to ensure they are working as
designed to redistribute pressure.

Bed Support Surfaces
22. Use pressure-redistribution bed support
surfaces for individuals who are at risk for
or who have pressure ulcers (see Table 4:
Support Surfaces).

Select a reactive support surface for
individuals who are able to reposition
themselves enough to avoid weight bearing
on all areas at risk for pressure ulceration
and who have a stable spine.

Select an active support surface for
individuals who are unable to reposition
themselves.

Select an active support surface or a high airloss (air-fluidized) reactive support surface
for individuals who have pressure ulcers on
multiple turning surfaces and/or are status
post flap/skin graft within the past 60 days.

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

There are two types of support surfaces:
reactive support surfaces and active support
surfaces. A reactive support surface can change
its load distribution properties in response to an
applied load, such as a person's movement. It can
be powered or nonpowered. An active support
surface has the capability to change its load
distribution with or without an applied load. Active
support surfaces are powered and dynamically
redistribute pressure at the body-support surface

interface by changing both the magnitude and
duration of the applied load. Active support
surfaces redistribute pressure with or without
tissue load; the cell inflation-deflation cycle occurs
whether or not the individual moves.
Support surfaces redistribute pressure
through immersion and envelopment. Immersion
is the depth of penetration (sinking) into a
support surface (NPUAP 2007). Immersion
,
allows the pressure to be spread out over the
surrounding area rather than directly over a bony
prominence. A support surface's ability to
provide immersion is based on its stiffness,
thickness, and the flexibility of its cover.
Envelopment is the ability of a support surface
to conform, so as to fit or mold around
irregularities in the body (NPUAP 2007) without
,
a substantial increase in pressure.
"Bottoming out" is the term used to describe
the sinking of the individual into the support
surface (bed or wheelchair) while lying flat on the
mattress or sitting up in a wheelchair so much so
that the underlying surface produces an
unintended force upon the body, negating the
effect of the support surface. This occurs if (1)
the pressure setting, also known as the cell
inflation pressure in the support surface is too low
or inadequately set to support the patient's
weight; or (2) the support surface is losing
pressure from an air leak. A subjective estimate of
the compression can be made by palpation of the
support thickness at the bony prominence.
Bottoming out is tested by either placing the
caregiver's hand under the mattress overlay or
wheelchair cushion with palms toward the
individual or by placing the open hand with palm
against the individual's skin or clothing at the
prominence and estimating the seat cushion or
support thickness below by finger flexion and
extension. If the support surface is less than 2.5
cm thick at the measured bony prominence, the
cushion has "bottomed out."
REACTI VE SUPPORT SURFACES

A low-air loss mattress is an example of a
reactive support surface. It consists of a series of
connected air filled pillows that run across the
support surface. The amount of pressure in each
pillow is controlled and can be calibrated to
individual's weight and height. A pump provides
airflow in a continuous pattern and since the
covering of the mattress is porous, it allows for
leakage of air that controls the microclimate of
the patient's skin. The flowing air evaporates skin
moisture (Scales et al., 1974) and reduces
temperature (Flam et al., 1995) while maintaining
a microclimate conducive for tissue healing.

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