Preventing Pressure Ulcers

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August/September 2001

By Heather McDonald, MS, RN

Heather McDonald, MS, RN, goes over the steps for an effective weight shifting routine with a spinal cory injury patient.

Preventing pressure ulcers is a laudable goal as they can have a devastating effect on the lives of people with spinal cord injury (SCI). Pressure ulcers can be potentially life-threatening while also interfering with quality of life, activities of daily living, and rehabilitation. Despite these rather dire consequences, pressure ulcers are common with prevalence rates between 30% and 60%.¹

SCI produces changes in the structure and physiology of the skin. For the first several years after SCI, the rate of collagen catabolism increases, and both the elasticity and the tensile strength of the skin decrease. Studies show that normally enervated skin can withstand ischemia up to 3 hours longer than paralyzed skin.² Changes in the skin, coupled with the absence of subconscious movement (nonparalyzed individuals move every 5-15 seconds) and the absence of sensory information relaying ischemia to the brain, create an environment where pressure ulcers are likely.

In theory, pressure ulcers are preventable. A lesion caused by unrelieved pressure resulting in ischemia and then damage to underlying tissues, a pressure ulcer usually occurs over bony prominences. The forces responsible for the creation of a pressure ulcer include pressure shear and friction. Preventative regimens for pressure ulcers must be multidimensional.

Preventative behaviors are commonly taught in the rehabilitation setting. However, newly injured people may be overwhelmed with the volume of information to be assimilated and/or may be unable to absorb the details of a regimen while they are still struggling with accepting the injury. The aging process also necessitates adjustment to preventative routines. Health care professionals should review preventative regimens with persons who have SCI regardless of the person’s proximity to rehabilitation and/or past success with preventative behaviors.

Risk Assessment

Risk should be assessed using a combination of a risk assessment tool and clinical judgement. Virtually all individuals with SCI are at risk for developing pressure ulcers; however, some are at greater risk than others. There are tools that can assist with identification of individuals at higher risk. Two commonly used scales are the Braden Scale³ and the Norton Scale.⁴ These tools need to be used in conjunction with clinical judgement as neither of them is comprehensive enough to include all possible considerations. Risk assessment must be repeated over time as any change in clients’ lives can affect their degree of risk.

Demographic variables also influence the development of pressure ulcers. Although study findings, on the whole, have been inconclusive, age (increased prevalence in the aged^5,6) and education (increased prevalence with less education⁶) have been consistently implicated.

Physical and psychosocial factors

Physical and medical factors are the most targeted by risk assessment tools, such as activity and mobility level and sensory perception, which are directly related to level and completeness of injury. Persons having the greatest difficulty moving and those who do not feel pain associated with pressure are obviously at the greatest risk. Studies designed to link level and completeness of injury with pressure ulcer formation, however, have been inconclusive.^7,8

A person’s psychological state may be the most significant factor in pressure ulcer formation. Developing a regimen that can prevent pressure ulcers is relatively easy, but the regimen will fail if not actualized. Psychological distress, such as major depression, anxiety, negative self-concept, and poorly managed anger and frustration, has been associated with inactivity and self-neglect.⁹ Cognitive impairment can interfere with a person’s ability to comprehend and follow through with a regimen. Substance use can lead to impairments in judgement. In the final analysis, the success of any preventative regimen depends almost entirely on the psychosocial environment of the individual.

The Preventative Regimen

Participate in an active lifestyle. Individuals engaged in productive, meaningful, satisfying lives have fewer pressure ulcers.¹⁰ The implementation of an exercise plan has many benefits including increased oxygen availability.^11-14 In addition, an exercise plan can help improve transfers and mobility, which may contribute to better weight shifts and bed positioning. Other benefits may be decreased comorbidities such as cardiac disease and diabetes.
Keep skin free of dryness or excessive moisture. The condition of the skin can either facilitate or oppose the development of a pressure ulcer. In general, skin that is neither dry nor moist has the best chance of remaining intact. Dry skin, such as that caused by low humidity or exposure to cold, is usually more fragile. Similarly, skin that is too moist is more likely to abrade and blister. Moisture can lead to maceration, which leads to skin breakdown. Skin that is too warm can also be trouble. External sources of heat such as the sun, hot showers, or beverages can cause burns. Burned skin is extremely fragile. Too much heat on the skin increases the metabolic rate and, therefore, increases oxygen consumption. Skin requiring more oxygen is less tolerant of ischemia and so pressure ulcer development may be hastened. Healthy skin can deal with these forces with the least complications.
Check skin twice daily for evidence of injury. Skin should be inspected twice daily—in the morning before rising and in the evening after going to bed. Areas targeted for inspection include the ischia, sacrum/coccyx, trochanters, heels, ankles, knees, scapula, and elbows. The skin is inspected for nonblanchable erythema or redness that does not reperfuse after pressure has been momentarily applied. Areas that do not reperfuse are already damaged. Red areas should go away within 30 minutes or the area is a pressure sore. Changes in skin color are easier to detect in some skin types. For this reason, skin inspection should include palpation for changes in texture, warmth, wetness, and hardness. Detection of changes in these areas can be a warning sign of pressure ulcer development. People with paraplegia commonly carry out their own inspection using a long-handled mirror. Persons with tetraplegia usually rely on caregivers for inspection.
Eat a well-balanced diet and maintain a healthy weight. Malnutrition is a major risk factor for pressure ulcer development.¹⁵ Intake must be considered while taking into account appetite, food intolerances, allergies, difficulties with chewing and swallowing, and difficulty with food acquisition and preparation. Blood chemistry, including prealbumin, total protein, albumin, hemoglobin, hematocrit, serum transferrin, and total lymphocytes, can be used as a marker for nutritional status.

An adjunct to optimal intake is optimal weight. People who are overweight or underweight are at risk. Underweight individuals develop ischemia over bony prominences faster than their normal-weight controls. However, normal ranges for ideal weight for persons with SCI have not been established. New York Metropolitan Life Insurance Company recommends people with paraplegia subtract 4.4 to 7 kg from their weight charts while those with tetraplegia subtract 7 to 9 kg.¹⁶ Weight control can sometimes be a challenge after SCI because of decreases in energy expenditure. Fat tissue has a poor blood supply and is at increased risk for ischemia. Obesity can affect an individual’s ability to do weight shifts and safe transfers.
Choose a mattress that allows appropriate pressure reduction. The bed chosen can contribute to or be preventative against the development of pressure ulcers. Most individuals with SCI will have some form of pressure-reducing support surface for the bed. Static support surfaces, such as high-density foam mattresses and air mattresses, are usually sufficient in the absence of pressure ulcers. Dynamic surfaces such as the low air loss mattress may be indicated if an ulcer already exists. The basic adequacy of a mattress can be ascertained by checking for and avoiding bottoming out. Bottoming out occurs if a hand placed beneath both the surface and the bony prominence reveals less than 1 inch of surface. The best surface will take into account the individual’s need for pressure relief as well as the bed’s ability to promote activities of daily living, the ease with which caregivers can provide care, as well as cost, weight, heat/moisture control, and bed noise.
Establish a positioning routine. Positioning regimens need to be individually prescribed. If at all possible, all body positions, including prone, should be used. Frequency of changes in body positioning is dictated by the skin’s ability to tolerate a position. Cushions and positioning aids should be used to maintain postural alignment. Other rules in positioning include: totally relieving pressure over the heels and ankles, avoiding donut-type devices, avoiding high trochanter position (sidelying at 30 degrees is sufficient), avoiding contact between bony prominences (eg, the knees), and limiting the amount of time spent with the head of the bed raised more than 30 degrees. If caregivers are involved in positioning, visually displaying the positions and the schedule of turns works best.
Ensure the prescribed wheelchair sufficiently reduces pressure and shear. Time not spent in bed is usually spent in the wheelchair. Wheelchair cushions that reduce or relieve pressure are usually indicated. Cushions can be either air, fluid, or foam filled. In choosing a cushion, consider pressure, shear reduction, comfort, postural support, functional activity level, heat reducing properties, adaptability, cost, care, and maintenance.
Establish a weight shift routine. Positioning in the wheelchair significantly affects pressure. Armrests can deflect up to 10% of body weight.¹⁷ Footplates that allow the pelvis to be level and the thigh horizontal allow for better distribution of pressure. Stable trunk support prevents shear over scapula and sacral areas. Positioning does need to be dynamic. Weight shifting is usually recommended every 30 minutes for 30 seconds or every 60 minutes for 60 seconds. Weight shifting is commonly accomplished by full push-ups off the armrests, and/or lateral or forward leans. Weight shifts can also be accomplished by using the tilt or recline options in the wheelchair. The tilt function allows the pelvic angle to remain constant and, therefore, affords less shearing and spasticity. A 45-degree tilt is usually considered adequate. To encourage people with SCI to remember weight shifts, a watch timer is sometimes advocated. Even more appropriate is encouraging people with SCI to be in constant motion when they are in their chair, for example, leaning forward as they pull up to a table and leaning sideways as they reach out to shake the hands of a friend.
Provide adequate education so the regimen can be successfully implemented. Education is the mechanism for translating knowledge and plans into preventative behaviors. A person with SCI needs a clear understanding of what the regimen includes, as well as at least a rudimentary knowledge of why the components of the regimen have been advised. Before embarking on an educational endeavor, identifying learning styles and appropriate teaching strategies is important. Assess current knowledge level and cognitive abilities, as well as barriers to implementation. Be aware of distraction due to psychological distress. Create an education plan that includes short- and long-term objectives and a variety of teaching strategies. Educational efforts must be evaluated. Assess understanding by direct, specific questioning so that points requiring clarification can be identified. Encourage repeated practice of skills such as weight shifts and skin inspections to allow for better follow-through of behaviors. Successful education motivates the individual to take responsibility.

Heather McDonald, MS, RN, is the clinical nurse specialist for the Spinal Cord Injury Program at G.F. Strong Rehab Center, Vancouver, British Columbia.

References

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Paralyzed Veterans of America. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals. Washington, DC: The Consortium for Spinal Cord Medicine; 2000.
Gilsdorf P, Patterson R, Fisher S. Thirty minute continuous sitting force measurements with different support surfaces in the spinal cord injured and able-bodied. J Rehabil Res Dev. 1991;28:33-38.

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August/September 2001