Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 58

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

If individuals can reposition themselves or
can assume a variety of positions without bearing
weight on the ulcer and without bottoming out
the support surface, a reactive support surface is
an appropriate option.
In an acute-care setting, the healing of large
pressure ulcers has been shown to benefit from
both the use of air-fluidized (high-air-loss) and
low-air-loss beds (Bergstrom et al., 1994).
Although home versions of air-fluidized beds and
hybrid designs of low-air-loss and air-fluidized
beds are available, low-air-loss beds are more
commonly used in the home care setting because
of the larger size, heavier weight, high power
consumption, and the difficulty encountered with
individual transfers for high-air-loss beds.
Moreover, low-air-loss beds have been shown to
be easily managed and are effective in pressure
ulcer prevention and healing due to their reduced
bulk and facilitation of individual positioning and
transfers (Charles et al., 1995; Ferrell et al.,
1993; Mulder et al., 1994).
A C T I V E S U P P O RT S URFA CE S

An alternating pressure mattress is an
example of an active support surface. It is
designed with chambers or cylinders arranged in
various patterns. Air or fluid pumped through
these chambers at periodic intervals creates
alternating deflation and inflation in opposite
phases. It redistributes pressure through cyclical
changes in loading and unloading characterized
by frequency, duration, amplitude, and rate of
change parameters. Alternating pressure
mattresses have been associated with a lower
incidence of pressure ulcers. Jan et al. (2011)
compared the effect of alternating and constant
pressure on weight-bearing tissue perfusion in
people with SCI. They found that alternating
pressure increased skin perfusion of weightbearing tissues as compared to constant pressure
supporting the concept of using an alternating
pressure support surface to reduce pressure ulcer
risk in the SCI population.
In alternating pressure systems, comfort is
related primarily to cell inflation pressure and the
rate of change of pressure during the cycle. A
high inflation pressure prevents an individual's
pressure points from "bottoming out but leads to
discomfort and high peak contact pressures. On
the other hand, a low inflation pressure can
increase comfort, but limits weight carrying
capacity to support the individual, therefore
increasing the likelihood of "bottoming out."
If someone cannot assume a variety of
positions without bearing weight on the ulcer,
compresses the reactive support surface

(experiencing elevated contact pressures), or the
ulcer does not show evidence of healing, an active
support surface should be used.
Active support surfaces are options for
individuals with category/stage II pressure ulcers
on multiple turning surfaces and a failure to heal
on a reactive support surface. Similarly, the
presence of a large category/stage III or IV
pressure ulcer or a recent tissue graft for ulcer
repair may also suggest the use of an active
support surface (Charles et al., 1995; Day and
Leonard, 1993).
ADDI TI ONAL CONSI DERATI ONS

The individual circumstances of the person
with a pressure ulcer must be considered in the
prescription of a specialized bed or support
surface as these devices may impact the ability to
perform functional activities or affect the ability to
provide core assistance. For example, it is often
more difficult for someone with a higher level SCI
to perform bed mobility or transfers on a active
support surface than on a reactive one that may
limit his or her functional independence and even
require him or her to have additional help that
might not have been needed on certain firmer
reactive support surfaces. Any of these devices
may not be appropriate in all home settings due
to such factors as weight or operating costs.

Wheelchair Seating and Positioning
23. Prescribe wheelchairs and seating systems
specific to the individual that allow that
individual to redistribute pressure
sufficiently to prevent the development
of pressure ulcers.

Obtain specific body measurements for
optimal selection of seating system
dimensions (postural alignment, weight
distribution, balance, stability, and pressure
redistribution capabilities).

Prescribe a power weight-shifting
wheelchair system for individuals who
are unable to independently perform an
effective pressure relief.

Use wheelchair tilt-in-space and/or
recline devices effective enough to
offload tissue pressure.

Use standing wheelchairs to remobilize
individuals with existing pelvic pressure
ulcers.

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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