The importance of pressure management for SCI clients
- Normally, the level of applied pressure needed to cause a pressure injury is acutely painful. Clients with SCI are at greater risk of developing pressure areas because altered or absent sensation compromises this pain warning. In addition, cognitive impairment may compromise appropriate responses to pain and to situations of high pressure injury risk, such as equipment failure.
- Clients with SCI have neurologically impaired skin such as changes underlying soft tissue vascularity, oxygenation and composition, including collagen synthesis and degradation.1
- Muscular atrophy of the lower limbs results in a reduced soft tissue bulk available to support body weight and increase localised pressure around the protruding bony prominences.2
- Co-morbidities such as brain injury or hypotension further increase the risk of pressure injury.3
- Pressure injuries can occur quickly (in less than an hour), with potentially severe consequences for the client. It is much better to prevent a pressure problem than to manage it surgically or with extended bed rest. Even a relatively minor pressure injury can require weeks of bed rest.
- Once the skin is damaged, the prevention of a pressure injury is more difficult.4Following a severe pressure injury it is unlikely that the tissue will completely recover to the pre-injury state, and the inherent risk of future injury typically increases.
What to do if the client has pressure injury located on a seating surface
When a client presents with a pressure injury it is important to respond in a considered and appropriate manner, to ensure the client receives the most appropriate care and advice and limits the damage to tissue beyond its current state. Some strategies which may be relevant include:
- Avoiding positioning or sitting directly on a pressure injury wound. Pending on the individual’s factors, bedrest may be required.
- Investigating the cause and contributing factors of the pressure injury and reducing or eliminating these if possible.
- Monitoring any factors that may lead to a progression of the wound area.
- Assessing and reviewing all current support surfaces such as wheelchair, mattress, commode seat, vehicle seat and other seating that may be used.
- Once a wound is healed, apply a seating protocol to increase sitting duration gradually; skin should be checked after a sitting session to note any skin marking and before the next session to ensure that any marking previously seen has resolved. The protocol should be tailored to the individual context, such as wound location and history, care hours, pressure management strategies being implemented, capacity to perform regular weight-shift during each sitting period.
- Stover SL, Gay RD, Koopman W, Sahgal V, Gale LL. Dermal fibrosis in spinal cord injury patients. A scleroderma variant? Arthritis Rheum 1980;23:1312–17.
- Linder-Ganz E, Gefen A. Stress analysis coupled with damage laws to determine biomechanical risk factors for deep tissue injury during sitting. J Biomech Eng [Internet]. Jan 2009 [cited October 2015];131(1):011003. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19045919 DOI: 10.1115/1.3005195.
- Wilczweski et al. Risk factors associated with pressure ulcer development in critically ill traumatic spinal cord injury patients. Journal of Trauma Nursing. 2012;19(1):5-10. Available from https://www.researchgate.net/publication/221893436_Risk_factors_associated_with_pressure_ulcer_development_in_critically_ill_traumatic_spinal_cord_injury_patients DOI: 10.1097/JTN.0b013e31823a4528
- Fries, J. M. (2005) 'Critical rehabilitation of the patient with spinal cord injury', Critical Care Nursing Quarterly, 28(2), pp. 179-87