Download Pressure Ulcers in Spinal Cord Injured Clients

Pressure Ulcers in Spinal Cord Injured
Clients
A guide for Practitioners
A Summary of the Evidence Based Healthcare review
ACC EBH Group. September 2009
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Pressure ulcers – guide sheet
Definition
Pressure ulcers are areas of localised damage to the skin and underlying tissue caused by a
combination of pressure, shear and friction occurring over bony prominences.
Relevance
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Pressure sores account for 6.6% of readmissions to hospital for Individuals with SCI but
27.9% of bed days
85% of individuals with SCI will experience a pressure ulcer during their lifetime
Who is at increased risk of a pressure ulcer?
¾
¾
¾
¾
¾
¾
¾
¾
¾
Males
Unemployed
A lower level of education
Previous history of pressure ulcer
Pre-existing medical conditions or co-morbidities
Smokers
Those who drink alcohol or take medications to sleep
Depression or mental disorders
Poor nutrition
When are they at risk?
o
o
o
o
There is an increased risk in the first year with a peak in the second year post
injury. There is continued risk in the first 10 years after injury which drops off
after this time and increases again after 15 years post injury.
There are fewer severe grade III and IV ulcers in the first 2 years after injury.
More severe ulcers and recurrent ulcers occur in those who have had their SCI for
a longer time
Completeness of injury – those in category ASIA A are at greater risk of developing
a pressure ulcer.
Prevention
Treatment
Prevention is more cost effective than treatment
The Braden Scale risk assessment tool is the
most valid tool for the identification and
prediction of pressure ulcers.
Best practice prevention:
1. Early attendance at specialised seating
assessment clinics with emphasis on personal
responsibility; inspection of skin; pressure relief;
and appropriate seating systems based on
interface pressures, thermography and
assessment of tissue viability and correct use of
prescribed equipment.
2. Pressure ulcer prevention education
programmes provide knowledge and emphasise
behaviours to reduce the incidence or
recurrence of pressure ulcers.
3. Pressure relief practices: the length of
pressure relief is critical; 15-30 seconds weight
lifts are insufficient to allow for complete
pressure relief.
4. Individual selection of wheelchair cushion
based on pressure mapping, clinical knowledge
and individual characteristics/preference.
ACC EBH Group. September 2009
In addition to the removal of pressure over a
wound and identification of the cause, there is
good evidence for the following treatments:
1. Electrical stimulation for pressure ulcer
healing to accelerate the healing rate of stage III
and IV pressure ulcers when combined with
standard wound treatment.
2. Occlusive hydrocolloid dressings for healing
of stage I and II pressure ulcers.
3. Combining ultrasound and ultraviolet C with
standard wound care decreases the wound
healing time and should be considered as a
treatment when pressure ulcers are not healing
with standard wound care.
4. Non-thermal pulsed electromagnetic energy
treatment accelerates the healing of stage II and
III pressure ulcers.
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ACC EBH Group. September 2009
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Introduction
ACC needs to better understand the nature and timing of secondary disability in
Individuals with SCI in order to provide optimal services to clients throughout
their lifetime. An evidence based review examining pressure ulcers in Individuals
with SCI has been conducted to address the following questions:
1. What are the secondary disabilities and aging effects that clients are most
likely to experience and what impact do they have on functional ability and
support needs.
2. Who is most at risk? Demographics of clients most likely to experience
secondary disabilities.
3. When in the post injury lifespan are these problems likely to occur and
what is the impact of client age?
4. What mitigation strategies exist to prevent, minimise and treat these
problems, and when is the optimum time to intervene. Details of actual
interventions are not included in the scope.
The full review can be viewed at:
This summary document is intended for case managers, GPs, health workers, all
those who work with Individuals with SCI and Individuals with SCI themselves.
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Contents
Table of contents…………………………………………………………………….6
1. Background
1.1 Definition of pressure ulcers…………………………………………….7
1.2 Skin before and after SCI………………………………………………...7
1.3 Aetiology of a pressure ulcer…………………………………………….7
1.4 Stages of pressure ulcer development……………………………………8
1.5 Location of pressure ulcers………………………………………………9
1.6 Seriousness of pressure ulcers – impact and functional consequences…9
1.7 Pressure ulcer risk factors in acute care and initial rehabilitation…….10
1.8 Risk assessment tools……………………………………………………10
2. Risk factors for pressure ulcers…………………………………………………..13
2.1 Sociodemographic risk factors………………………………………….13
2.1.1 Sex…………………………………………………………………..13
2.1.2 Age………………………………………………………………….14
2.1.3 Ethnicity……………………………………………………………14
2.1.4 Marital status……………………………………………………….14
2.1.5 Education…………………………………………………………..15
2.1.6 Employment……………………………………………………….15
2.2 Neurological factors…………………………………………………….15
2.2.1 Age at time of injury……………………………………………….15
2.2.2 Time since injury…………………………………………………..15
2.2.3 Level of injury……………………………………………………...16
2.2.4 Completeness of injury…………………………………………….16
2.3 Factors linked to a medical history of pressure ulcers…………………17
2.4 Medical and biological factors…………………………………………..17
2.5 Health behaviours……………………………………………………….17
2.6 Toxic substances and psychological factors……………………………18
2.6.1 Smoking…………………………………………………………….18
2.6.2 Psychological factors……………………………………………….18
2.6.3 Other factors……………………………………………………….18
3. Pressure ulcer prevention and treatment………………………………………..19
3.1 Prevention………………………………………………………………19
3.1.1 Effect of specialised seating clinics on pressure ulcer prevention.20
3.1.2 Pressure ulcer prevention education……………………………...21
3.1.3 Pressure relief practices on pressure ulcer prevention…………...21
3.1.4 Wheelchair cushion selection and pressure ulcer prevention …..22
3.2 Treatment………………………………………………………………..23
3.2.1 Electrical stimulation for pressure ulcer healing…………………23
3.2.2 Effectiveness of dressings for treatment of pressure ulcers………23
3.2.3 Ultrasound/Ultraviolet C for pressure ulcer healing……………...24
3.2.4 Effects of non-thermal pulsed electromagnetic energy treatment
for healing of pressure ulcers……………………………………...24
4. Resources………………………………………………………………………….26
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1. Background
1.1 Definition of pressure ulcers
Pressure ulcers are defined as an area of localised damage to the skin and
underlying tissue caused by pressure, shear, friction or a combination of these.
Pressure ulcers usually occur over bony prominences and are classified in stages by
the degree of tissue damage observed. Staging is used primarily for the initial
assessment of a pressure ulcer.
1.2 Skin before and after SCI
The skin is the largest organ in the body, 12-15% of body weight, with a surface area
of 1-2 metres. It has multiple roles in homeostasis, including protection, temperature
regulation, sensory reception, biochemical synthesis, and absorption. The skin
consists of two layers, the outer epidermis and the dermis. The damage that results in
a pressure ulcer starts in the dermis before there is any visible breakdown in the
epidermis.
Neurologically impaired skin, such as after a SCI, undergoes many metabolic changes
that include:
-
A loss of collagen immediately after the trauma leading to greater fragility
below the level of the lesion.
-
Reduced blood flow below the level of the injury.
-
A loss of elasticity and tensile strength so that the skin cannot adapt to
mechanical insult.
-
Increased ischemia – normally innervated skin can withstand ischemia three
hours longer that neurologically impaired skin.
-
Reduction in muscle bulk with resulting decreased cushioning and absorption
of mechanical forces.
-
Reduction or loss of sensation and therefore decreased response to repeated
surface pressure loads.
1.3 Aetiology of a pressure ulcer
Pressure usually occurs when soft tissue is compressed against a bony prominence
commonly in the following areas: sacrum, greater trochanter, ischium and heels.
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Compression of blood vessels that feed soft tissues can potentially decrease or
completely obstruct blood flow causing a local ischemia. Prolonged ischemia will
cause a local area of necrosis and a surrounding area that is ischemic. The time for
necrosis to develop is related to the ability of the tissue to resist ischemia, tissue
tolerance and the ability of the skin to redistribute the applied pressure. Shearing
forces (forces exerted parallel to the plane of interest) can cause distortion or
deformation of tissue and may also have the ability to interfere with blood flow to
soft tissue.
Unrelieved pressure initially causes damage in deeper tissue before any visible
breakdown is seen on the surface. Muscle and fat are the tissues at greatest risk of
necrosis when they are deprived of oxygen. For this reason, initially the true depth
of damage due to pressure may be unrecognisable if the skin remains relatively
intact. Therefore skin discolouration or redness may actually be an indicator of
underlying adipose or muscular necrosis.
Friction can occur as a result of poor lifting, transfer technique or spasticity (which
may be secondary to other underlying secondary complications of SCI i.e. urinary
tract infections, bladder stones, syringomyelia, ingrown toe nail) and can remove
the top layers of the skin increasing pressure ulcer risk.
1.4 Stages of pressure ulcer development
Category/Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its colour
may differ from the surrounding area. The area may be painful, firm, soft, warmer
or cooler as compared to adjacent tissue. Category I may be difficult to detect in
individuals with dark skin tones. May indicate “at risk” persons.
Category/Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red
pink wound bed, without slough. May also present as an intact or open/ruptured
serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow
ulcer without slough or bruising*. This category should not be used to describe
skin tears, tape burns, incontinence associated dermatitis, maceration or
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excoriation.
*Bruising indicates deep tissue injury.
Category/Stage III: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or
muscle are not exposed. Slough may be present but does not obscure the depth
of tissue loss. May include undermining and tunnelling. The depth of a
Category/Stage III pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and
Category/Stage III ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep Category/Stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.
Category/Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar
may be present. Often includes undermining and tunneling.The depth of a
Category/Stage IV pressure ulcer varies by anatomical location. The bridge of
the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue
and these ulcers can be shallow. Category/Stage IV ulcers can extend into
muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making
osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly
palpable.
Additional Categories/Stages for the USA
Unstageable/ Unclassified: Full thickness skin or tissue loss – depth
unknown
Full thickness tissue loss in which actual depth of the ulcer is completely
obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown
or black) in the wound bed. Until enough slough and/or eschar are removed to
expose the base of the wound, the true depth cannot be determined; but it will be
either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or
fluctuance) eschar on the heels serves as “the body’s natural (biological) cover”
and should not be removed.
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Suspected Deep Tissue Injury – depth unknown
Purple or maroon localized area of discoloured intact skin or blood-filled blister
due to damage of underlying soft tissue from pressure and/or shear. The area
may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler
as compared to adjacent tissue. Deep tissue injury may be difficult to detect in
individuals with dark skin tones. Evolution may include a thin blister over a dark
wound bed. The wound may further evolve and become covered by thin eschar.
Evolution may be rapid exposing additional layers of tissue even with optimal
treatment.
1.5 Location of pressure ulcers
Pressure ulcers usually occur over bony prominences. Positioning in bed or sitting
in a wheelchair will focus the pressure on different parts of the body. When lying
in bed on the back, pressure is distributed over a greater area than when sitting.
However, the sacrum, coccyx and heels are the most vulnerable when lying in bed.
In very thin people, their shoulder blades also may be at risk. When lying on the
side, the trochanter is the most vulnerable. There may also be risks in the sidelying position, especially if knees or ankles are touching. When sitting in a
wheelchair (or on any other surface), the ischium are at greatest risk. If Individuals
with SCI have problems with posture such as scoliosis, they may sit in a position
that puts more pressure on one side of the buttocks than on the other.
1.6 Seriousness of pressure ulcers – impact and functional consequences
Pressure sores impact on the SCI individual and those around them. Treatment often
necessitates activity modifications and restrictions that can have a negative
psychosocial impact on individuals and their families, including social isolation,
alteration of body image and loss of income. Pressure ulcers can lead to serious
complications and can even be fatal. Complications include local and systemic
infection, osteomyelitis, pelvic abscess, malignancy (Marjolin’s ulcer in ulcers over
20 years). As a consequence of these complications further interventions may be
required, such as surgery or amputation.
Pressure ulcers are one of the many factors that influence the functional status of
individuals. One study found that motor function at discharge from rehabilitation
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was related to severity of pressure ulcers. Patients with more severe ulcer grades
were discharged with lower levels of motor function.
1.7 Pressure ulcer risk factors in acute care and initial rehabilitation
Although this review examines pressure sores after initial rehabilitation, the
incidence during the early stages of acute care and initial rehabilitation have
implications for future incidence.
Pressure ulcer incidence during the acute medical stabilisation of patients with SCI
ranges from 20%-60%.
Risk factors during the acute stage of SCI rehabilitation are essentially linked to
care management treatment modalities and duration of hospital stay. Clinical
factors do not seem to have an effect. There is insufficient evidence to make a
recommendation on medical risk factors except for low blood pressure on
admission to the emergency department, for which there was a moderate level of
evidence.
During initial rehabilitation a higher number of pressure ulcers were associated
with complete neurological injury: 23.1% of complete individuals with paraplegia
and 39.5% of complete individuals with tetraplegia developed at least one sore
during rehabilitation. The percentage of male patients who developed a pressure
ulcer was slightly higher than female patients, 28.1% versus 20.1%. The age of a
patient made no difference.
1.8 Risk assessment tools
All individuals with SCI are at life long risk for developing pressure ulcers. Risk
assessment scales maybe used to predict pressure ulcers. However scales reflect the
individual’s status, not necessarily the quality of care the individual receives.
Since health status and risk for pressure sores can change rapidly, clinical
judgment is required to guide decisions when further assessment should be
preformed.
The Braden scale has the best combined validity and utility evidence.
ACC EBH Group. September 2009
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Braden Scale for Predicting Pressure Ulcer Risk
Patient's Name
__________
Evaluator's Name __________
Sensory
perception
Ability to
respond
meaningfully
to pressurerelated
discomfort
2. Very limited:
Responds only to
painful stimuli. Cannot
communicate
discomfort except by
moaning or
restlessness,
OR
has a sensory
impairment which
limits the ability to feel
pain or discomfort
over 1/2 of body.
3. Slightly limited:
Responds to verbal
commands but
cannot always
communicate
discomfort or need
to be turned,
OR
has some sensory
impairment which
limits ability to feel
pain or discomfort
in 1 or 2
extremities.
4. No impairment:
Responds to verbal
commands. Has no
sensory deficit which
would limit ability to
feel or voice pain or
discomfort.
1. Constantly moist:
Skin is kept moist
almost constantly by
perspiration, urine, etc.
Dampness is detected
every time patient is
moved or turned.
2. Moist: Skin is often
but not always moist.
Linen must be
changed at least once
a shift.
3. Occasionally
moist: Skin is
occasionally moist,
requiring an extra
linen change
approximately once
a day.
4. Rarely moist: Skin
is usually dry; linen
requires changing only
at routine intervals.
Activity
Degree of
physical
activity
1. Bedfast: Confined
to bed.
2. Chairfast: Ability to
walk severely limited
or nonexistent.
Cannot bear own
weight and/or must be
assisted into chair or
wheel chair.
3. Walks
occasionally:
Walks occasionally
during day but for
very short
distances, with or
without assistance.
Spends majority of
each shift in bed or
chair.
4. Walks frequently:
Walks outside the
room at least twice a
day and inside room at
least once every 2
hours during waking
hours.
Mobility
Ability to
change and
control body
position
1. Completely
immobile: Does not
make even slight
changes in body or
extremity position
without assistance.
2. Very limited:
Makes occasional
slight changes in body
or extremity position
but unable to make
frequent or significant
changes
independently.
3. Slightly limited:
Makes frequent
though slight
changes in body or
extremity position
independently.
4. No limitations:
Makes major and
frequent changes in
position without
assistance.
Nutrition
1. Very poor: Never
Usual food
eats a complete meal.
intake pattern Rarely eats more than
1/3 of any food offered.
Eats 2 servings or less
of protein (meat or
dairy products) per
day. Takes fluids
poorly. Does not take a
liquid dietary
supplement,
OR
is NPO[1] and/or
maintained on clear
liquids or IV[2] for more
than 5 days.
2. Probably
inadequate: Rarely
eats a complete meal
and generally eats
only about 1/2 of any
food offered. Protein
intake includes only 3
servings of meat or
dairy products per
day. Occasionally will
take a dietary
supplement,
OR
receives less than
optimum amount of
liquid diet or tube
feeding.
3. Adequate: Eats
over half of most
meals. Eats a total
of 4 servings of
protein (meat, dairy
products) each day.
Occasionally will
refuse a meal, but
will usually take a
supplement if
offered,
OR
is on a tube feeding
or TPN[3] regimen,
which probably
meets most of
nutritional needs.
4. Excellent: Eats
most of every meal.
Never refuses a meal.
Usually eats a total of
4 or more servings of
meat and dairy
products. Occasionally
eats between meals.
Does not require
supplementation.
Friction and
shear
2. Potential problem:
Moves feebly or
requires minimum
assistance. During a
3. No apparent
problem: Moves in
bed and in chair
independently and
Moisture
Degree to
which skin is
exposed to
moisture
1. Completely limited:
Unresponsive (does
not moan, flinch, or
grasp) to painful
stimuli, due to
diminished level of
consciousness or
sedation,
OR
limited ability to feel
pain over most of body
surface.
1. Problem: Requires
moderate to maximum
assistance in moving.
Complete lifting without
ACC EBH Group. September 2009
Date of
Assessment
/
/
/
/
___ ___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
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Patient's Name
__________
sliding against sheets
is impossible.
Frequently slides down
in bed or chair,
requiring frequent
repositioning with
maximum assistance.
Spasticity,
contractures, or
agitation leads to
almost constant
friction.
Evaluator's Name __________
move skin probably
slides to some extent
against sheets, chair,
restraints, or other
devices. Maintains
relatively good
position in chair or
bed most of the time
but occasionally
slides down.
Date of
Assessment
/
/
/
has sufficient
muscle strength to
lift up completely
during move.
Maintains good
position in bed or
chair at all times.
Total Score:
___ ___ ___ ___
Copyright permission to be sought
Perform Braden Scale on admission, quarterly, after major change, after return from Hospital
When Braden Scale Score 16 or less, implement Pressure Ulcer Prevention Protocols
1) Circle type of pressure reduction device used:
State Air, Alternating Pressure, Low Air Loss Mattress, Other ____________ Date: _______ Initials: ________
2) Nutritional Consult ordered: Date: _______ Initials: ________ Date: _____ Initials: _______
3) (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk)
ACC EBH Group. September 2009
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2. Risk factors for pressure ulcers
There are four levels in grading the overall quality of evidence:
HIGH – further research is very unlikely to change the confidence in the estimate
of effect
MODERATE – further research is likely to have an important impact on the
confidence in the estimate of effect and may change the estimate
LOW – further research is very likely to have an important impact on the
confidence in the estimate of effect and is likely to change the estimate
VERY LOW – any estimate of effect is very uncertain
2.1 Sociodemographic risk factors
2.1.1 Gender
There is a correlation between sex and the onset of pressure ulcers: males are more
at risk of developing ulcers; one study reported a 30% increased risk for males.
Males have an increased risk of developing pressure ulcers
Evidence - HIGH
2.1.2 Age
Age has been associated with increased incidence of pressure sores in some studies
but refuted in others. The time post injury is a better predictor of pressure ulcer
risk than the current age of an individual with SCI.
Current age is not a risk factor for the development of pressure ulcers
Evidence - HIGH
2.1.3 Ethnicity
While there are no studies on Maori Individuals with SCI, studies on Americans
have shown a correlation between ethnicity and the incidence of pressure ulcers;
African Americans were 1.7 times more likely than Caucasians to experience a
pressure ulcer and also to experience more severe stage III and IV ulcers.
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It has been suggested that in pigmented skin it is harder to observe skin changes
that are a prelude to the development of a pressure ulcer or that these ethnic
differences could be due to the fact that minorities face more socioeconomic
disadvantage. New Zealand studies have shown that low socioeconomic status
effects health outcomes for Maori but does not explain the total disparity between
Maori and non-Maori outcomes; discrimination also plays a role.
Ethnicity is a risk factor for the development of pressure ulcers
Evidence - HIGH
2.1.4 Marital status
There is conflicting evidence as to whether marriage or co-habiting reduces the
risk of pressure ulcers.
Marriage or co-habiting is protective for the risk of the development of pressure
ulcers
Evidence – VERY LOW
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2.1.5 Education
Studies support increased education as a means of reducing the risk of pressure
ulcers and also the recurrence of ulcers.
A lower level of education is associated with an increased risk of developing pressure
ulcers
Evidence - HIGH
2.1.6 Employment
A number of studies have found a correlation between employment and the
occurrence of pressure sores; one study reported a 25% higher risk of pressure
ulcers for those who were unemployed. Unemployment at the time of the SCI
injury is also associated with the later occurrence of pressure ulcers. A lower
occupational status is associated with increased severity of stage II and IV ulcers,
the risk of experiencing a greater number of ulcers and increased chance of being
hospitalised.
Unemployment is a risk factor for the development of pressure ulcers
Evidence - HIGH
2.2 Neurological factors
2.2.1 Age at time of injury
There is some evidence that those injured at a younger age are at greater risk of
developing pressure ulcers and that those injured at an older age experience more
severe ulcers, but the evidence is insufficient.
Age at the time of injury is a risk factor for the development of pressure ulcers
Evidence – VERY LOW
2.2.2 Time since injury
There is evidence of increased occurrence of pressure ulcers in the first year with a
peak in the second year post injury. There continues to be increased occurrence up
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to 10 years after the injury and then a reduction with a later increase again after 15
years post injury. Severity of pressure ulcers increases with time from injury. Time
post injury is a stronger predictor of pressure ulcer occurrence than the actual age
of the SCI person.
There is an increased risk of pressure ulcers in the first 10 years, particularly the first
2 years
Evidence - HIGH
Time post injury is a stronger predictor of pressure ulcer occurrence than the actual
age of the SCI person
Evidence - HIGH
2.2.3 Level of injury
There is some evidence that younger individuals with paraplegia under the age of
45 and in the early years after injury experience more pressure ulcers that require
hospitalisation than older individuals with tetraplegia over the age of 45. However
there appear to be other factors that act in conjunction with the level of injury to
influence the occurrence of pressure ulcers.
Evidence of a link between the level of injury and the occurrence of pressure ulcers
is low
Evidence – VERY LOW
2.2.4 Completeness of injury
There is strong evidence that a more complete SCI lesion (those in category ASIA
A) is associated with an increased risk of pressure ulcers and risk of more severe
ulcers. The completeness of the SCI affects the level of activity, mobility, degree of
sensory deficit and ability to practice good skin care, all which contributes to the
risk of pressure ulcers.
Those Individuals with SCI with a complete injury are at greater risk of developing a
pressure ulcer
Evidence - HIGH
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2.3 Factors linked to a medical history of pressure ulcers
The best predictor of a future pressure ulcer is a previous history of their
occurrence, at any time from the actual injury. There is a sub group estimated
between 13% and 35% who experience recurrent problems and this group also
have repeated admissions to hospital. Recurrence of pressure ulcers is linked to
other risk factors, namely, ethnicity, high co-morbidity scores, longer sitting time,
smoking, depression or use of medications for sleep, and a low level of activity.
Those Individuals with SCI who have experienced one pressure ulcer are at risk of
developing another
Evidence - HIGH
Surgery for a pressure ulcer increases the risk of another pressure ulcer at that site
Evidence – VERY LOW
2.4 Medical and biological factors
Pre-existing medical conditions or co-morbidities were associated with a higher
incidence and recurrence of pressure ulcers in Individuals with SCI. A number of
medical conditions were identified but the list is not exhaustive. Medical
conditions include: higher collagen metabolite levels, being underweight, using
medication to control spasticity, autonomic dysreflexia, pulmonary disease, renal
disease, diabetes, hypertension, mild liver dysfunction, low albumin levels,
fractures, urinary tract infections and bladder and bowel incontinence.
Pre-existing medical conditions and co-morbidities increase the risk of pressure
ulcers
Evidence - HIGH
2.5 Health behaviours
There is contradictory and limited evidence on the effectiveness of health
behaviours on the occurrence of pressure ulcers. Regular skin inspection may
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detect ulcers earlier and those who have difficulty practicing care may be more
likely to develop ulcers. Pressure relief by position change if sustained for an
appropriate length of time, results in pressure reduction but for most SCI
individuals a push up or vertical lift of 15-30 seconds is unlikely to be sufficient to
allow for complete pressure relief.
Health behaviours to maintain good skin care reduce the risk of pressure ulcers
Evidence – VERY LOW
2.6 Toxic substances and psychological factors
2.6.1 Smoking
There is evidence that smoking increases the risk of pressure ulcers; smokers were
found to have a 42% recurrence rate while non smokers had a 26.2% recurrence
rate.
Smoking increases the risk of developing pressure ulcers
Evidence - MODERATE
2.6.2 Psychological factors
Mental disorders, diagnosis with clinically significant depressive symptomatology,
suicide contemplation or actual suicide attempts were correlated with an increased
risk of pressure ulcers.
There is some evidence that rational problem solving skills and a sense of
responsibility for their own care is protective against pressure ulcers. The existence
of conflicting priorities in Individuals with SCI can become barriers that lead to
non adherence to preventive care.
Mental disorders or depressive illness and psychological factors increase the risk of
pressure ulcers
Evidence - MODERATE
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2.6.3 Other factors
Alcohol and the use of medications to sleep increase the risk of Individuals with
SCI developing pressure ulcers.
Alcohol and the use of medications to sleep increase the risk of developing pressure
ulcers
Evidence - LOW
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3. Pressure ulcer prevention and treatment
3.1 Prevention
Prevention of pressure ulcers begins from the time of injury, through initial acute
care, rehabilitation and on into the home and community setting. Intensive
education and skills training in the rehabilitation phase focus on the spinal cord
injured person learning and using a variety of preventive measures to manage at
home. Most of this information is conveyed at the time the person is an inpatient
and they and their family may suffer from information overload. Education and
skills training ma be required at intervals throughout their lifetime when changes
occur. Pressure ulcer prevention is more cost effective than treatment; pressure
ulcers are potentially preventable.
Strategies recommended by the Consortium for Spinal Cord Medicine include:
1. Examination of the skin daily to allow for early detection of pressure areas,
with particular attention to the areas most vulnerable to pressure ulcer
development: the ischium, sacrum/coccyx, trochanter and heel.
2. Shifting of body weight in bed and in a wheelchair on a regular basis either
independently or with assistance.
3. Maintenance of optimal skin integrity by
-
Using pressure reducing surfaces
-
Preventing moisture accumulation and temperature elevation at the
support/skin interface and cleaning and drying skin promptly after soiling
-
Use of pillows and cushions to bridge contacting tissues
-
A system of follow up to assess equipment performance
4. Provision of an individually prescribed wheelchair
5. Use of a power weight shift system when manual pressure relief is not
possible.
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6. Implementation of an ongoing exercise regimen for those Individuals with
SCI who are medically stable to promote skin integrity, achieve muscle
strength, endurance and prevent fatigue and deconditioning.
7. Providing individuals, families, significant others and health care
professionals with information on effective strategies for the prevention and
treatment of pressure ulcers.
8. Assessing nutritional needs to allow an appropriate and adequate intake of
nutrition.
In addition the European Pressure Ulcer Advisory Panel and National Pressure
Ulcer Advisory Panel has published guidelines and recommendations for pressure
ulcer prevention with a focus on:
1. Risk Assessment
Risk Assessment Policy should include:
•
Establishment of a risk assessment policy in all health care settings
•
Education of health care professionals on how to achieve an accurate and
reliable risk assessment
•
Documentation of all risk assessments
Risk Assessment Practice should include:
•
A structured approach to risk assessment to identify individuals at risk of
developing pressure ulcers
•
A structured approach to risk assessment that includes assessment of
activity and mobility
•
A structured approach to risk assessment that includes a comprehensive
skin assessment to evaluate an alterations to intact skin
•
A structured approach to risk assessment that is refined through the use of
clinical judgement informed by knowledge of key risk factors
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•
Consider the effect of nutritional indicators, factors that affect perfusion
and oxygenation, skin moisture and advanced age on an individual’s risk of
pressure ulcer development
•
Consider the potential impact of friction and shear, sensory perception,
general health status and body temperature on an individual’s risk of
pressure ulcer development
•
The use of a structured risk assessment on admission to be repeated as
frequently as required by the individual’s condition
•
The development and implementation of a prevention plan when
individuals have been identified as being as risk of developing pressure
ulcers.
2. Skin Assessment
•
Ensure that a complete skin assessment is part of the risk assessment
screening policy in place in all health care settings
•
Educate professionals on how to undertake a comprehensive skin
assessment
•
Inspect skin regularly for signs of redness in individuals identified as being
at risk of pressure ulceration
With regard to skin care:
•
An individual should not be turned onto a reddened area; massage or skin
rubbing should not be used for ulcer prevention; skin emollients should be
used to hydrate dry skin and the skin should be protected from exposure to
excessive moisture with a barrier product.
3. Nutrition for pressure ulcer prevention.
•
Screen and assess nutritional status of those at risk using a valid and
reliable tool
•
Have a nutritional screening policy in place at all health care settings and
refer those at risk to a dietician or multidisciplinary team
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•
Provide nutritional support to each individual and follow relevant and
evidence based guidelines on enteral nutrition and hydration
•
Offer high protein mixed oral nutritional supplements and/or tube feeding,
in addition to the usual diet, to individuals with nutritional risk and
pressure ulcer risk because of acute or chronic disease or following surgical
intervention.
4. Repositioning for the prevention of pressure ulcers.
The use of repositioning should be considered in all at risk individuals and the
frequency of repositioning should be influenced by variables concerning the
individual and the support surface in use. Repositioning technique, repositioning
of the seated individual, repositioning documentation and repositioning education
and training are all important.
5. Support surfaces
•
Selection of the support surface should not be based solely on perceived
level of risk for pressure ulcer development, but also based on the surface
that is compatible with the care setting and the appropriateness and
functionality of the support surface.
•
Higher specification foam mattresses rather than standard hospital foam
mattresses should be used for all individuals assessed as being at risk for
pressure ulcer development. An active support surface (overlay or mattress)
should be used for those at risk where frequent manual repositioning is not
possible. Alternating-pressure active support overlay and replacement
mattresses have a similar efficacy in terms of pressure ulcer incidence.
Small-cell alternating-pressure air mattresses or overlays should not be
used.
•
Support surfaces to protect heels: heels should be free of the surface of the
bed and heel protection devices should elevate the heel completely in such
a way as to distribute the weight of the leg along the calf without putting
pressure on the Achilles tendon while the knee should be in slight flexion.
A pillow under the calves so that the heels are elevated should be used.
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•
Support surfaces to prevent pressure ulcers while seated: Use of a pressureredistributing seat cushion is recommended and the time a person spends
in a chair without pressure relief should be limited.
The use of other support surfaces in pressure ulcer prevention: the use of synthetic
sheepskin pads should be avoided and natural sheepskin is preferable in
preventing pressure ulcers.
The Spinal Cord Injury Rehabilitation Evidence (SCIRE), version 2.0 published in
2008 is a synthesis of the research evidence underlying rehabilitation interventions
to improve the health of persons with SCI. In SCIRE the evidence supporting the
use of various prevention measures and interventions has been graded from 1-5
with level 1 indicating that there is good evidence for the intervention.
Interventions for the prevention of pressure ulcers do not show strong evidence of
effectiveness. However, based on the evidence available, best practice would
suggest the following:
3.1.1 The effect of specialised seating clinics on pressure ulcer
prevention post SCI.
Description
The ability to maintain skin integrity and prevent pressure ulcer formation can be
facilitated through seating clinics to provide prevention education including:
-
an emphasis on personal responsibility for maintaining healthy skin
through personal care
-
inspection of skin
-
pressure relief
-
recommendation of appropriate seating systems based on interface
pressures, thermography and assessment of tissue viability and correct use
of prescribed equipment
Verbal and visual feedback is provided to the individual and active participation is
encouraged.
Evidence of effectiveness
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There is level 2 evidence showing that early attendance at specialised seating
assessment clinics increases the skin management abilities of individuals post SCI
Recommendation
•
Early attendance at specialised seating assessment clinics should be part of a
comprehensive rehabilitation programme.
•
More research is needed to determine if early attendance at a specialised
seating assessment clinic results in pressure ulcer prevention over time.
3.1.2. Pressure ulcer prevention education post SCI
Description
Pressure ulcer prevention education programmes for individuals with SCI provide
knowledge and emphasise behaviours intended to reduce the risk of pressure ulcer
recurrence. Most of this information is conveyed at the time of initial rehabilitation
after injury but the patient and their family may suffer from information overload.
There is little time to convey the knowledge and behaviours necessary to prevent
pressure ulcers over their lifetime, and patients may be discharged with potentially
a lack of information.
Evidence of effectiveness
There is level 2 evidence that providing enhanced pressure ulcer prevention
education is effective at helping individuals with SCI gain and retain this
knowledge. However there is no evidence whether or not this enhanced education
results in a reduction in pressure ulcer formation.
Recommendation
•
Structured pressure ulcer prevention education helps individuals, post SCI,
gain and retain knowledge of pressure ulcer prevention practices.
•
Research is needed to determine the specific educational needs of
individuals and to find out if education results in a reduction of pressure
ulcers and/or their severity.
3.1.3.Pressure relief practices on pressure ulcer prevention post SCI
Description
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Teaching regular weight shifting while seated to relieve pressure on at risk tissues
allows for recovery of blood flow and oxygenation of the tissues. There are
different techniques depending on the physical and cognitive status of the
individual: lateral, forward lean or vertical push up. When a manual weight shift
cannot be performed the use of a power tilt feature is an alternative.
Evidence for effectiveness
The evidence demonstrates that pressure relief by position change, if sustained for
an appropriate length of time, results in pressure reduction and recovery of
transcutaneous oxygen tension to unloaded levels.
There is level 3 evidence that 1-2 minutes of pressure relief must be sustained to
raise tissue oxygen to unloaded levels. There is level 3 evidence that forward
flexion is an effective method of pressure relief.
Recommendation
•
The type and duration of pressure relief by position changing must be
individualised post SCI using pressure mapping or similar techniques.
•
For most individuals with SCI a push up or vertical lift of 15-30 seconds is
unlikely to be sufficient to allow for complete pressure relief.
3.1.4. Wheelchair cushion selection and pressure ulcer prevention
post SCI
Description
Various wheelchair cushions and seating systems can offer pressure or risk factor
relief to prevent the occurrence of pressure ulcers.
Evidence of effectiveness
There are individual variations inherent in those with SCI, for example, individuals
with paraplegia and individuals with tetraplegia. Pressure mapping is needed to
assist with individualising a wheelchair cushion prescription. No studies showed
direct evidence of pressure ulcer prevention associated with a particular cushion
type.
There is level 3 evidence that various cushions or seating systems (for example,
dynamic versus static) are associated with potentially beneficial reduction in
seating interface pressure or pressure ulcer risk factors like skin temperature.
Recommendation
•
No one cushion is suitable for all individuals with SCI.
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•
Cushion selection should be based on a combination of pressure mapping
results, clinical knowledge of the prescriber, individual characteristics and
preference.
•
More research is required
3.2 Treatment
There is good evidence that the following treatments are effective:
3.2.1Electrical stimulation for pressure ulcer healing post SCI
Description
Various forms of electrical current have been used historically to augment tissue
repair, although there is some uncertainty as to how it actually works to repair
tissue and variability in the protocols used. Most studies look at the role of
electrical stimulation in pressure ulcers which have failed to respond to standard
treatments.
Evidence of effectiveness
There is level 1 evidence from two randomised controlled trials to support the use
of electrical stimulation to accelerate the healing rate of stage III and IV pressure
ulcers when combined with standard wound management.
Recommendation
•
Electrical stimulation should be added to standard wound management to
promote healing of stage III and IV pressure ulcers.
•
More research is needed to determine which type of electric current and
application protocol will be most useful to enhance healing of pressure
ulcers post SCI.
3.2.2. Effectiveness of dressings for treatment of pressure ulcers post
SCI
Description
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Dressings keep the wound bed moist, revoke excess exudate, provide a barrier
against contamination and gas exchange and can increase healing rates, reduce
pain and decrease infection rates.
Evidence of effectiveness
There is level 1 evidence from a single randomised controlled trial that completion
of healing for stage I and II pressure ulcers is greater with an occlusive
hydrocolloid dressing compared to phenytoin cream or simple dressing post SCI.
There is level 2 evidence from a single small randomised controlled trial that
occlusive hydrogel-type dressings heal more pressure ulcers than conservative
treatment post SCI.
Recommendation
•
Occlusive hydrocolloid dressings are useful for healing of stage I and II
pressure ulcers post SCI
3.2.3. Ultrasound/Ultraviolet C for pressure ulcer healing post SCI
Description
Ultrasound (US) acts mainly at the inflammatory stage of the wound healing and
the ultraviolet C (UVC) is purported to have bactericidal effects indicating use for
infected wounds particularly in antibiotic resistant cases
Evidence of effectiveness
There is level 1 evidence from one small randomised controlled trial to suggest that
combining US/UVC with standard wound care decreases wound healing time of
pressure ulcers post SCI but no evidence to clarify whether UVC or US, used alone,
have a beneficial effect.
Recommendation
•
US/UVC should be considered as an added treatment when pressure ulcers
are not healing with standard wound care post SCI.
3.2.4. Effects of non-thermal pulsed electromagnetic energy
treatment for healing of pressure ulcers post SCI
Description
Electromagnetic fields are believed to stimulate closure of chronic non-healing
pressure ulcers by acting at the proliferative stage of wound healing to promote
production of granulation tissue formation.
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Evidence of effectiveness
There is level 1 evidence from one randomised controlled trial to support the
efficacy of pulsed electromagnetic energy to accelerate healing of stage II and III
pressure ulcers post SCI
Recommendation
•
Pulsed electromagnetic energy improves wound healing in stage II and III
pressure ulcers.
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4. Resources
Consortium for Spinal Cord Medicine. Pressure ulcer prevention and treatment
following spinal cord injury: a clinical practice guideline for health care
professionals: Paralysed Veterans of America, 2000.
Pressure ulcers following spinal cord injury – Chapter 20 in Spinal Cord Injury
Rehabilitation Evidence: version 2.0.
This is available through the internet at www.icord.org/scire
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