Pressure ulcer prevention after spinal cord injury
Taking care of your skin after spinal cord injury is vital to prevent pressure ulcers. That’s why we spoke to Hester Dunne, a Tissue Viability Clinical Nurse Specialist at the National Spinal Injuries Centre, Stoke Mandeville. Read on to learn her top tips for skin care after spinal cord injury.
Please note that Back Up are not medical professionals – we are just sharing information from a specialist in this field. If you are worried you have a pressure ulcer, consult medical advice ASAP.
What is a pressure ulcer?
The definition of a pressure ulcer is “localised damage to the skin and the deeper layers of tissue under the skin, usually over a bony prominence, resulting from sustained pressure” – NHS Improvement 2018.
When this happens, the pressure cuts off the blood supply to the area, denying the area of a well oxygenated blood supply, resulting in damage which can lead to death and destruction to the skin and tissues – as well as damage to the muscle or bone underneath.
How/Why would a pressure ulcer form?
They usually start as a red mark on the skin over the area where pressure has been sustained.
The skin may also get damaged through dragging or scuffing, this is sometimes called ‘shearing’. This may happen during a poor transfer or slowly sliding down the bed, resulting in damage to the underlying muscle fibres & tissues. They get ripped & separated, harming the really small blood vessels. They can also start from a blister.
For all three of the above it is important to know that if pressure continues to be applied to the same area, further damage will easily occur, and the area will break into an open wound/pressure ulcer.
Anyone can develop a pressure ulcer but people with a spinal cord injury are more likely to develop one for several reasons:
· Not being able to move or change position easily to relieve pressure.
· Not being able to feel pain which is one of the first signs of pressure ulcer.
· Having reduced muscle bulk below the level of spinal cord injury, resulting in less structural support to the skin and blood vessels, so they get squashed more easily.
· Complicated by bladder or bowel accidents resulting in damage to the skin.
· Having had a pressure ulcer before.
How to prevent pressure ulcers
· Get into a routine of checking your skin at regular times, you might do this with a mirror, with the camera on your phone or with the help of someone else:
o When getting up in the morning.
o When getting undressed and going to bed.
o When drying after a shower or bath.
o When turning over.
o When taking socks and shoes off.
· Practising pressure relief every hour. The golden standard is every hour for 2 minutes when sat in your wheelchair. This will help to keep the skin and tissues well supplied with oxygenated blood.
· Alternating the side you sleep on, and try to sleep on your side not on your back.
· Turning in bed and not exceeding the length of time you know it is safe for you to sleep on one side without turning.
· The use of protective equipment that has been recommended for you, such as pressure relieving wheelchair cushions, pressure relieving mattresses or booties.
· Think of the long term and look after your skin now for the years ahead. If you neglect your skin now, it might not fare so well in years to come.
· Protect your skin when doing transfers, so that the skin on your bottom does not get dragged or bruised, or your feet and ankles don’t drop or get knocked.
What happens if I get a pressure ulcer?
· Seek help as soon as you notice an area of damaged skin that concerns you or worries you because it’s not getting better. You can ask the District Nurse or your local Spinal Cord Injuries Centre.
· If the skin is broken, you will need a dressing – there are many different types of dressing so seek professional help to ensure you have the correct ones. Keep pressure off it; so, don’t get up into your wheelchair if it means you are sitting on it, or don’t lie on it in bed.
· Don’t put tight shoes on if it’s on your foot, elevate your foot if you can do so safely. Often the best way to do this is to rest on the bed or sofa for a while.
· Find out what caused the pressure ulcer so you can prevent the same thing happening again.
· Review the equipment you are using – is it fit for purpose?
· You may need to contact your wheelchair services about your wheelchair cushion, or the District Nurse about your mattress.
· You may need to request an appointment to be seen in your Spinal Cord Injury Centre if the wound is not improving with the initial treatment, or if a healthcare professional advises you to do so.
Pressure ulcer categories
The European Pressure Ulcer Advisory Panel (EPUAP) describes pressure ulcers in 6 different categories, which simplifies communication about pressure ulcers. The full document is available here.
Top tips for healthy skin
· Good nutrition – our bodies rely on good nutrition for growth and development, preventing ill health, and to aid recovery . A healthy well-balanced diet will help to keep your skin in the best possible health. If you do get a pressure ulcer, additional protein in your diet will help the wound to heal.
· Moisturize the skin every day to help keep it soft, supple and plump. This will help to reduce or prevent dry skin which can easily lead to the skin cracking and breaking down more easily, especially under pressure or when dragged. The massaging motion when applying a moisturiser is also good for your peripheral circulation.
· Be mindful of the clothing and accessories you wear; make sure they aren’t too tight and digging into your skin, make sure you are not sitting or lying on bulky seams, or have objects in pockets. Shoes can easily get tight if your feet swell during the day, so adjustable fastenings or a size larger might be helpful.
· Watch out for burns and scolds on parts of the body you can’t feel, it can happen without you realising! If your get a burn or scold larger than a 50p its best to see a healthcare professional for appropriate treatment.
· Plan ahead; when you know you’re going away to an unfamiliar place to stay, for either a holiday or a hospital stay, find out what mattress you’ll be using, or if you can, take your own. Also make sure you find out about all the other things that you rely on at home such as access and supplies.
NHS Improvement “Pressure ulcers: revised definition and measurement”. Summary and recommendations 2018.
National Institute for Health and Care Exellence (NICE). Pressure ulcers: prevention and management. April 2014