Understanding pressure sores
Spinal cord injury (SCI) is a devastating and life changing event. There is not one facet of life that is not affected after a spinal cord injury and there are many adaptions that a person has to make after the incident. During the initial rehabilitation phase, time is spent on educating patients regarding the injury and the complications and the prevention of complications should be discussed in detail. One of the complications that can have disastrous effects on a patient is pressure sores. Pressure sores are probably one of the most common complications after spinal cord injury and if not recognised and managed appropriately, they can result in many months of bed rest whilst trying to heal the sores. Badly managed sores can also lead to complications such as sepsis, and even death.
The first thing to understand about pressure sores is that a SCI sufferer can develop the condition at any time. Prevention is of course the first step. This will mean that whilst in rehab a thorough evaluation of the pressure prevention measures are undertaken. Not only is education regarding techniques for regular pressure care necessary, but each person needs to be assessed individually, as their specific needs when it comes to pressure relief is different depending on the devices they use. These include wheelchairs, wheelchair cushions and mattresses. Unfortunately, there are no magic products that will completely absolve a person from practising proper pressure care – and the practice of good pressure care should be applied for a lifetime. No matter what type of cushion or mattress you use, pressure care is still necessary. I have too often seen patients who have been in a wheelchair for many years, who have become complacent in their pressure care and have developed a pressure sore. Therefore, always maintain contact with your therapy team and return for regular evaluations of your needs with respect to pressure care.
It is important to remember that your pressure care should be altered over time. What worked for you five years ago, may not be adequate today. Remember as we grow older our bodies change – we either gain, or lose weight. The skin becomes thin and less elastic. An underlying co-morbid disease such as diabetes, could be affecting your circulation. All of these factors influence the likelihood of developing pressure ulcers. Continence or further mobility impairments may also occur in time.
The main factors that cause pressure sores are:
- direct pressure on the affected pressure bearing areas,
- or indirect pressure such as with shear forces (transfers over and across surfaces),
- friction (as with repeat spasm of frictional forces whilst travelling – i.e. vibration especially in an aircraft),
- moisture (incontinence issues),
- or a combination of all the above.
- In addition:
- nutrition is vital and poorly nourished SCI persons are at a greater risk of developing pressure sores.
- Excessive alcohol intake, cigarette smoking and drug abuse are also huge risk factors for developing sores.
The main pressure bearing areas to watch are the sacrum, ischial tuberosity (sitting bones), lateral malleolus (ankle bones), knees, trochanter (hips) elbows and heels. “The take home message here is that prevention is better than cure.” PULL QUOTE
However, should you develop a sore you should be able to recognise the various stages and take appropriate action. Pressure sores can be graded as to the degree and depth of damage and no matter what grade the sore, the first thing to do is to remove ALL pressure – this normally means being confined to bed and not lying or placing direct pressure on the affected part. Another important thing to remember is what we call the iceberg effect – what you see on the surface of the skin is a poor indicator of what is going on underneath. The damage in the deeper layers is always more severe that what is visible on the surface and therefore the seriousness of sores is often under estimated.
Sores can be divided into the following grades
Grade 1. This is a red area, warm to touch and with hardened and firm edges and surrounding tissue. The redness does not disappear with massage and the skin does not blanche. This lesion needs immediate attention. All pressure should be removed and the area should be massaged and have ice rubbed over the affected area, four to five times per day for only a few seconds. This promotes blood flow to the area and reduces further damage and inflammation. Laser treatment can also help healing. The lesion normally resolves after a few days.
Grade 2. This is more serious where a visible blister or small ulcer is visible. The same principles should immediately be adopted when the sore becomes evident. In addition, a suitable dressing should be applied to prevent contamination and infection.
Grade 3. This is a larger ulcer which can have non-viable (black or greyish discoloured) tissue in the cavity. The ulcer affects the skin and underlying fat layers and sometimes even early erosion into muscle.
Grade 4. This ulcer is deep and affects all layers including muscle and bone. There is usually dead or non-viable tissue visible.
Grade 1 and 2 lesions can be treated at home but grades 3 and 4 are very serious and you should consult a doctor, as this will usually entail hospital admission and possibly surgery.
The key factors to remember are:
- Prevention is better than cure. Practice proper pressure care always and maintain your equipment.
- Avoiding smoking, excess alcohol intake, drugs (recreational) and weight extremes.
- Promote a healthy lifestyle and good nutrition.
- When in doubt, get advice from your doctor immediately.