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Preventing Pressure Ulcers

After a spinal cord injury, you are at risk for developing pressure injuries. When your body stays in the same position, the skin in the areas that bear the most pressure cant breathe. Thats where a pressure injury can form and do damage to your underlying tissue. You may have heard pressure injuries referred to as bedsores, and another medical term for this type of wound is decubitus ulcers.

Why pressure injuries happen

After your spinal cord injury, you are supporting your weight differently than you did before. Plus, with decreased sensation, you may not feel the need to shift your weight. This puts you at risk for pressure injuries. Dragging your body across a flat or inclined surface, or allowing your skin to be wet for a long time also increases this risk. One of the first signs of a problem may be a red spot, an area of hardness, or discoloration on an area of your skin that supports your body weight.

Pressure injury prevention tips

Your healthcare team will help you obtain a wheelchair cushion and other equipment that can help you avoid pressure injuries. You will also learn how to do pressure releases, or have someone else help you do them. Pressure releases take all the pressure off certain areas for a short period of time.

Once you have the proper equipment and learn the basics, follow these tips consistently to avoid pressure injuries:

  • Do pressure releases every 15 to 20 minutes when you are in your wheelchair
  • Be careful to avoid bumping and scraping

    Wheelchairs: Mechanisms And Pressure Injury Risk

    For persons who are wheelchair dependent, the studies have also varied with regard to the results of different surfaces and pressure injuries. Many of the studies were conducted years ago, starting in the 1930s and 1970s to the 1990s. Wheelchair surface types and technology have changed, and the earlier reports may not be entirely applicable to the wheelchair products currently available. Neurotrophic changes, such as those that occur in SCI, result in diminished or absent sensation thus, the patient is unaware of the pressure overload. Although these neurogenic factors may not be primary in the development of ulcers, the patient is nonetheless prevented from having a normal protective response to the resulting discomfort.2

    Ragan et al. also reported higher pressure loads of smaller areas for patients in wheelchairs and recommended use of a polyurethane cushion up to 8cm to help redistribute this pressure.4 Karatas et al. studied 16 patients with SCI and 18 healthy volunteers.5 These investigators also reported that the center of pressure displacement was smaller than in healthy volunteers in all directions , whereas 46.3% had multiple surgical procedures for their repair, with 17.5% of pressure injuries that had not healed, mostly on the ischial tuberosities.6

    Prone To Sores Every Body Part

    Bony protrusions are not the only parts of the body which are exposed to pressure and friction. Other parts are affected, too. For example, when a patient is lying in a supine position, which is the preferred position for critical COVID-19 patients.

    Askina® DresSil® is a foam with a silicone adhesive which ensures gentle, secure adherence and minimal trauma during dressing changes. It can be cut and shaped for application on smaller areas which need protection.

    Askina® DresSil® Border is a foam dressing with silicone adhesive and an additional adhesive border, are made for difficult-to-dress or moving areas as they are able to conform to a variety of anatomical contours.

    Every foam dressing can be repositioned during application or even lifted up during wear time to check the skin or wound. They can also be applied on wounds as they provide a moist environment promoting natural healing.

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    What Role Do Diet And Skin Care Play

    Some people who are hardly able to move don’t get very hungry or thirsty. In order for them to stay in good physical condition, though, it’s important to make sure they get enough to eat and drink. Eating too little or a very unbalanced diet and hardly having anything to drink may weaken their skin even more. Some people take dietary supplements, but there’s hardly any research on whether these products can help prevent pressure ulcers.

    It’s important to keep the skin from getting too dry, but also to prevent it from being exposed to constant moisture either one increases the likelihood of damage to the skin. There’s not yet enough good research to be able to say whether regular use of creams or lotions can prevent pressure ulcers.

    If You Use A Wheelchair

    Prevention Points

    Make sure your wheelchair is the right size for you.

    • Have your doctor or physical therapist check the fit once or twice a year.
    • If you gain weight, ask your doctor or physical therapist to check how you fit your wheelchair.
    • If you feel pressure anywhere, have your doctor or physical therapist check your wheelchair.

    Sit on a foam or gel seat cushion that fits your wheelchair. Natural sheepskin pads are also helpful to reduce pressure on the skin. DO NOT sit on a donut-shaped cushions.

    You or your caregiver should shift your weight in your wheelchair every 15 to 20 minutes. This will take pressure off certain areas and maintain blood flow:

    • Lean to one side, then lean to the other side

    If you transfer yourself , lift your body up with your arms. DO NOT drag yourself. If you are having trouble transferring into your wheelchair, ask a physical therapist to teach you the proper technique.

    If your caregiver transfers you, make sure they know the proper way to move you.

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    Diet And Lifestyle Changes To Avoid Pressure Sores

    Changes to avoid pressure sores include:

    • Make sure you eat a healthy and nutritious diet. This includes a balanced diet and fluids/water. And if necessary,youre your doctor about vitamin and nutritional supplements .
    • Low body weight or being overweight can cause pressure sores, so make sure you maintain heathy body weight
    • If youre malnourished or at risk of malnutrition, protein, fluid and energy intake should be increased.
    • Be aware of using good hygiene practices.
    • Maintain activity levels, where appropriate.
    • Make sure you quit smoking.

    Starting With A Clinical Problem

    The initiative began in 1993 when an increase in the incidence of pressure ulcers was perceived in our setting. There had been more referrals to the enterostomal therapist and to plastic surgery, and sporadic reporting by clinical staff of their suspicions that skin breakdown was increasing in their areas. At that time no unit based mechanism for capturing reliable data on pressure ulcers was in place nor was it possible to retrieve data from the hospital information system.

    Even though it is a quality issue, the pressure ulcer initiative was set in a larger context of professional practice by linking it to the existing nursing quality improvement, research, and education infrastructures. The nurse specialists for quality improvement and research and evaluation took the lead on the project with support from several clinical nurse educators and managers. Critical to the success of the project was the support of the chief nursing officer who was vice president of patient services.

    The task force recommended that the following issues be addressed in planning for effective care and prudent use of resources:

    • Baseline assessment of the extent of the problem

    • Evaluation of the accuracy of a risk assessment method

    • Practice changes including development of an educational strategy to upgrade nursing skills in pressure area assessment using grading or staging of sores

    • A method for ongoing monitoring.

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    Where To Get Help

    • Domiciliary care staff

    Things You Can Do Today To Prevent Pressure Ulcers:

    EPUAP – Time to move for pressure ulcer prevention
  • Risk assessment: There are many types of risk assessments used to identify threats or risks to a patient developing a pressure ulcer. One risk assessment commonly used is the Braden Scale, developed by Barbara Braden and Nancy Bergstrom in 1988. The scale considers six factors that the patient is scored against to identify if there is a risk of a pressure ulcer developing. The factors are: Sensory Perception, Moisture, Activity, Mobility, Nutrition and Friction and Shear. Using the Braden Scale scoring guide lines, patients are scored from 1 to 4 for each category to get a total score – the lower the number, the greater the risk of a pressure ulcer developing. Ask your health professional to asses your risk if concerned.
  • Inspecting the skin: It is important to inspect the skin regularly, noting any changes in colour, texture, turgor, moisture, pigmentation, any lesions, hair distribution and warmth. If the skin goes white when pressed or if the skin is red with no-contact then the blood flow has impaired and the damage to the skin has begun.
  • Take care of the skin: Making sure the skin is clean and dry is important, especially before putting clothing on. When washing skin try to avoid scented soaps and talc as they can dry out skin and its natural oils. Try not to shower every day and this may have the same effect.
  • Nutrition: It is important to consume a balanced diet to ensure the body gets the nutrients and minerals it needs.
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    Express Comfort Contoured Gel Foam Wheelchair Cushion

    The Express Comfort Contoured Gel Foam Wheelchair Cushion by the Comfort Company offers a cooling sensation, which not only improves someoneâs comfort but it allows the skin to breathe better while seated. The gel is one of the most sought-after materials for pressure relief cushions, since people find them to be optimally durable and accommodating.

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    Encourage Seniors To Maintain A Healthy Diet

    The benefits of a well-functioning circulatory system are only as good as the nutrients it delivers. Seniors should strive to eat a well-balanced, healthy diet, explains Medscape. In fact, optimizing the nutritional status of a senior living with a pressure sore is key to ensuring successful treatment. For seniors living with metabolic disorders, such as diabetes, a healthy diet can go much further than simply preventing or encouraging the healing of pressure sores.

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    Put These Steps Into Action Today

    There are many different paths you can take to reducing pressure sores in your facility, and even if seniors in your care receive services at home, every step can be implemented in different types of care settings. Since it is in the best interest of your organization and the seniors you serve, start using these seven steps today, and be creative if you run out of other ideas. You could even have a brainstorming session with caregivers about the best ways to knock out pressure sores for your specific clients too.

    Interested in Learning More?

    Evidence Is Lacking In All Areas Of Pressure Ulcer Prevention And Treatment

    Stop Pressure Ulcer Day

    Other Cochrane reviews found insufficient evidence to inform practice on the use of nutritional interventions to prevent or promote pressure ulcer healing on topical agents and massage as preventive measures and on treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. with pressure-relieving devices for heel pressure ulcers , ultrasound antibiotics and antiseptics , phototherapy reconstructive surgery electromagnetic therapy and bed rest for wheelchair users with pressure ulcers .

    There is no good evidence to support any particular wound cleansing agent or technique for pressure ulcers . There was no evidence from randomizedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group will be given the intervention being tested and compared with a group which does not receive the intervention . studies on the impact of wound-care teams for pressure ulcer prevention and management . Nor has the use of structured riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as the chance of falling were one in four . This measure is good no matter the incidence of events i.e. common or infrequent. assessment tools been shown to be effective in reducing pressure ulcer incidence .

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    Treatment For Pressure Sores

    There are a variety of treatments available to manage pressure sores and promote healing, depending on the severity of the pressure sore. These include:

    • regular position changes
    • special mattresses and beds that reduce pressure
    • being aware of the importance of maintaining healthy diet and nutrition
    • dressings to keep the sore moist and the surrounding skin dry. There is no advantage of one type of dressing over another.
    • saline gauze dressing may be used if ointments or other dressings are unavailable.
    • light packing of any empty skin spaces with dressings to help prevent infection
    • regular cleaning with appropriate solutions, depending on the stage of the sore
    • there is no advantage of one particular type of antiseptic or antibiotic treatment over another
    • specific drugs and chemicals applied to the area, if an infection persists
    • surgery to remove the damaged tissue that involves thorough debridement of the wound, the removal of underlying or exposed bone, and filling the empty space
    • operations to close the wound, using skin grafts if necessary
    • continuing supportive lifestyle habits such as eating a healthy and nutritious diet, as suggested by the nutritional staff.

    What Are The Stages Of A Pressure Injury

    There are four stages that describe the severity of the wound. These stages include:

    • Stage 1: This stage is discolored skin. The skin appears red in those with lighter skin tones and blue/purple in those with darker skin tones. The skin does not blanch when pressed with a finger.
    • Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost. It may also look like a blister. At this stage, the top layer of skin can repair itself.
    • Stage 3: This stage is a deeper wound. The wound is open, extending to the fatty layer of the skin, though muscles and bone are not showing.
    • Stage 4: This stage is the most severe. The wound extends down to the bone. The muscles and bone are prone to infection, which can be life-threatening.

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    Understanding The Extent Of The Local Problem

    A 12 hour prevalence survey was done on all inpatient units to establish risk of pressure sore development and the proportion of patients with skin breakdown. Volunteer clinical nurses collected the data after instruction about evidence-based practice, clinical practice guidelines, and how to assess prevalence. After a 2 week follow up period, all new occurrences of pressure ulcers were documented and the accuracy of a risk assessment scale was evaluated.

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    Padding Positioning And Turning In Bed

    The 5 key messages to prevent Pressure Ulcers
    • Use a regular schedule of turning at night. Depending on weight and skin tolerance, your turning schedule may vary from every 2 to every 6 hours. Ask your health care provider for advice about a turning schedule. When turning and moving in bed, lift rather than slide across sheets.
    • Use pillows and foam pads to protect bony areas. No two skin surfaces should rest against each other!
    • Unless your doctor tells you to do it, avoid elevating the head of your bed, which can put too much pressure on your buttocks and lower back areas.
    • For individuals at the highest risk for pressure sores, your health care provider may prescribe a special mattress, mattress overlay or bed for long-term use.

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    What Are The Long

    If the wound becomes infected, the infection can spread to other parts of the body. Several conditions that may occur if an infection spreads include:

    Avoid Moisture Associated Skin Damage

    Skin protection products are used to minimize risk of trauma related to excessive moisture. It is essential to avoid overexposure of the skin to moisture and implement prevention strategies focused on maintaining skin integrity.

    Askina® Barrier protects the skin from bodily fluids and provides a long-lasting barrier to the patients skin. It is available in three different formats: Askina® Barrier Cream, Askina® Barrier Film Spray or Askina® Barrier Film Swabs. Askina® Barrier Film may be applied on intact or damaged skin and is particularly indicated for protection of peri-wound skin.

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