Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 65

CLINICAL PRACTICE GUIDELINE

pelvis and distribute pressure across a greater
surface area.
Findings from a study using persons
without SCI determined that when a cushion
base with firm thigh support is used, lowering
the footrest length as much as possible causes
a levering motion by lifting the pelvis thereby
reducing ischial tuberosity pressures (Gilsdorf,
et al., 1990).
D Y N A M I C ( A C T IVE S UPPORT ) CUS HIONS

A dynamic cushion system has bellows under
a cushion surface base that uses a recycling air
pump powered by a battery to inflate and deflate
on a sequentially set pattern to increase or
decrease pressure to the sitting surface.
Historically, dynamic cushions have not been used
widely because of their added weight, particularly
when used on manual wheelchairs; reliance on a
power source for activation; the need for battery
recharging; and cost. Developments in technology
have allowed for many of these concerns to be
addressed with smaller, lighter weight
components. Most of these units provide a cycle
of alternating rows or groups of air cells inflating
and deflating at a predetermined cadence,
typically of 4 to 5 minute duration (Ho & Bogie,
2007). There is little research establishing the
most effective cycle duration and pressure
variations for clinical use. For users who find it
difficult to remember to perform a weight shift
maneuver, these dynamic alternative air cushions
may help achieve the necessary offloading of
pressure to facilitate pressure ulcer healing.
A D D I T I O N A L CONS IDE RAT IONS

A cushion will work well only if properly used,
maintained, and replaced. As individuals age,
changes in the skin may increase vulnerability to
pressure ulcer development: Research indicates that
the skin tends to become thinner (Knox et al.,
1994; Waterlow, 1996). For this reason, a routine
cushion reassessment, every two to three years, is
recommended to ensure that the currently used
cushion is appropriate and to determine if a change
is indicated (Garber, 1985; Salcido et
al., 1996).
Wheelchair users need to follow a continuous
inspection and maintenance schedule for their
wheelchairs and seat cushions. Cushions should
be inspected and maintained regularly regardless
of the brand or model of the support surface.
Foam, gel, thermoplastic, and viscous fluid
cushions should be checked monthly, and air
cushions weekly or earlier should any problems
develop. The cover should be washed and
inspected regularly. If the cushion is custom
contoured to the patient's skeletal structure, it

should fit properly on the wheelchair in the right
direction. The cushion should be evaluated for
tears, holes, or flaking in the foam. The covers
should be inspected to ensure that the nonskid
surface is not worn or torn. Cracked or torn
covers and cushion base, and a fluid leak, indicate
a need for replacement. Components and seating
structures of wheelchairs deteriorate with use and
age. Decomposition of wheelchair supporting
structures can have an effect on the support of
the body and may affect pressure redistribution
qualities of the wheelchair thus require attention
and replacement on a regular basis. Persons with
SCI have complex medical and functional needs
necessitating customized medical equipment.
Their needs are best met when assessed by
clinicians who employ a holistic, comprehensive
team approach including education and training
of the person and their caregivers (Coggrave &
Rose, 2003). Consultations with persons with
specific knowledge of complex seating and
positioning equipment should be sought in order
to achieve optimal outcomes.

Support Surfaces for Bathing and
Toileting
25. Prescribe padded toileting and bathing
durable medical equipment items for
pressure redistribution and skin protection
during use.
(Scientific evidence-III; Grade of recommendation-C;
Strength of panel opinion-Strong)

In addition to the wheelchair seating surface,
frequently used bathroom equipment, such as
shower commode chairs, transfer bath benches,
shower benches, raised toilet seats, and others,
should also be evaluated for adequate padding of
these sitting surfaces. When an individual with
SCI is seated in a wheelchair, shower commode
chair, or any other seating surface, the weight of
the body is concentrated over small skin surface
areas, which can lead to high localized pressures.
Management of bladder or bowel routines may
take duration of time that exceeds acceptable
local tissue load tolerance, which, in turn, will
more quickly contribute to tissue damage.
Research studies have reported defecation time
from 45 minutes to 2 hours in spinal injured
persons with the goal being of many individuals
with SCI to complete bowel care in less than 1
hour (Davis et al., 1986; Nelson et al., 1993).
Performing part of the bowel routine in bed to
minimize sitting on the closed ring of the toilet
seat will decrease sitting time on the toilet. Place
suppository and wait for it to work while

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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