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Skin Management in SCI
Specialist Nurse Kathy Rogstad
Golden Jubilee Regional Spinal Cord Injuries Centre
Middlesbrough
Within this presentation
• What is a pressure ulcer?
• Prevention of pressure ulcers occurring in acute phase
• Prevention long term
• Treatment
• Consequences
• Considerations
The skin
Skin is a barrier and a thermal regulator with a network of
nerves and capillaries.
Following SCI there is a high risk of pressure damage due to:
• Immobility
• Protective sensory feedback lost
“I couldn’t feel it” “I couldn’t see it”.
• Changes in circulation
The risk of pressure damage increases in those with high
BMI, Diabetes, malnourishment, the elderly……….
• Localised injury to the skin of underlying tissue
• Usually over a bony provenance, as a result of pressure or in
combination with shear
• When tissue is exposed to pressure, the blood flow to the
surface of the skin and underlying tissue is partially or
completely obstructed
• Pressure Lack of blood Lack of Oxygen Cell Tissue
damage
• Shear blood vessels stretch blood flow is reduced
Lack of Oxygen Cell/Tissue damage
What is a pressure ulcer?
Pressure, Friction and Shear
Stages - Pressure Sore Grading
• Referral
• Pre-admission assessment visit and advice given
• Admission
• Stabilisation
• Rehabilitation can commence
• Skin tolerance built up on mattress and in wheelchair
on appropriate cushion
Admission – Acute Injury
• Admission
• Assessment
• Complete bed rest until the skin has healed and matured sufficiently to be able to tolerate pressure and mobilisation begin. This can and does take weeks and months in some cases.
Admission
Acute Injury with pressure ulcer/skin damage
In extreme cases transfer to the community for healing
following:
Stabilisation, routines established in skin, bladder and bowel
care, passive range of movement, participation in ADL’s and
education
Learn to direct others and communicate
In extreme cases transfer into the community for healing
following:
• Stabilisation
• Routines established in skin bladder and bowel management
• Passive range of movement
• Participation in ADL’s
• Education
• Learn to direct others – verbal independence
• Care package arranged considering consequences of
necessary bed rest and protect against side effects;
• DVT, Contractures, Spasm, Friction, Constipation, UTI’s etc
• Transfer into the community until skin healed
• Re admission for mobilisation and rehabilitation
• 2 hourly turns to pressure relieve and assess skin
condition
• To continue if chesty or areas of redness, particularly if 2 areas
affected
• Use of pillows under and between legs to keep heels and
ankles free from pressure and knees from coming together
Pressure area care on admission – acute injury
Otherwise this can happen
Pillows between knees
Pillows at the base for support and to prevent foot drop
Positioning on side
As skin tolerance allows
• Increase time between turns
• Aim for approx 6-8 hourly turns overnight
• Consider downgrading from air mattress to foam, baring
in mind independence with turning, overnight skin
tolerance/ if positional changes needed due to spasm
• Increase time up in chair
• Seating review
• Washing and drying thoroughly (do not use talc)
• Observation. Checking for redness/signs of trauma
• If any redness is it blanching or non-blanching?
• Good reliable bladder/bowel management
• If incontinence where from and why?
• Avoid the use of pads. They crease and detract from
pressure relieving qualities of mattress/cushion
Hygiene
Moisture lesion
• Correct equipment
• Slings. Correct type. Careful use and
removal
• Well positioned on padded shower chairs
• Cushion for bath
Hygiene
• Dress in layers (temp control)
• Avoid thick seams
• Seams/clothing straight / pockets flattened
• Loose fitting
• Avoid underpants if possible – extra layer to crease
• Shoes at least one size bigger. Laces not too
tight/tucked in
Dressing
Shoes too tight?
• Mattress. Is it dipping/bottoming out/need up-grading?
• Cushion. Is it inflated to correct pressure, on the chair
the right way round? Still appropriate? Seen better
days!
• Wheelchair. Right size? Sagging? More support
needed?
Potential causes of skin breakdown –
being a detective!
Non-blanching
• Hoisting
• Careful of positioning of sling
• Watch for fraying of strap on hoist
• Plum, straight position in chair.
• Adjustment and alignment for even weight
distribution and persons balance.
• Ease testicles out if trapped
Transferring
• Maintenance of equipment
• Protecting vulnerable areas
• Careful positioning / adjustment
Sliding board transfers
Started as a blister
• Not to sit up in bed for long periods
• Use knee brake facility on bed to lift legs slightly prior to
sitting up, to help avoid shearing. Lower legs again once
sat up.
• Use of slide sheets
• Regular side/side/back turns
Positioning in bed
• High temp – increase turns
• Chest inf. – increase turns and fluids. G.P. D.N.
• Incontinence. Ring D.N.
• Ring Spinal Cord Injury Service for advice
Illness
Other potential courses of skin breakdown
• Failure to relieve pressure from a grade 1 damage
• Underlying illness/increase in spasm (causing friction and
shear)
• Psychological status/compliance
• Social circumstances
• Weakness of scar tissue
• Re-mobilisation post healing too soon, too long, lack of
protection
We recommend that
• Any casts should be bi-valved so daily skin checks can take
place and extra padding added as necessary
• If new mattress, turn more frequently until skin tolerance
known
• If new cushion, check skin regularly as above
• If any new equipment being used check skin frequently at
first e.g splints, heel lift boots
• Be wary of new shoes or any clothing not tried and tested
Treatment Grade 1-4
• Completely relieve all pressure from any areas of redness or
skin damage until skin returned to normal colour…even if this
means complete bed rest
• Dressings
• If patient ill may need admission for iv anti-b’s and
debridement
• Care package ?help with bowel management, carer in-put
• If foot or lower limb affected, elevation needed
Mobilisation post healing of an ulcer
• Usually recommend a few days extra bed rest to allow new
skin to mature prior to re-mobilisation
• Protect healed area when up
• Limit first time up to 30-60 minutes and gradually increase
time up by no more than 1 hr at a time, if no detriment to
skin
• Take protective dressings off at night
• Keep skin supple
Ageing
• Assessment
• Skin becoming less tolerant
• Adapt techniques / routines
• Renew or install new equipment
• Referral to associated specialists as necessary
e.g. Shoulder surgeon
• If air cushion beware of change of pressure on aeroplane
• Dressings
• Protection
• Ask for extra pillows, extra mattress if bed too low, more regular
turns and monitor
Holidays
• 4 weekly clinics with Spinal Cord Injuries Consultant, Consultant in
Plastic surgery, Specialist nurse
Prior to surgery:
• Potential necessary weight loss
• Smoking cessation of 3 months or more
• Lengthy bed rest pre and post surgery (8-10 weeks post surgery)
• Care package pre and post surgery
• Change in lifestyle. Overall time up in chair limited
• Surgery not always an appropriate option or wanted.
• Some choose to live in harmony with their ulcer and limited
time up.
Pressure ulcer clinics/surgery
• See what the day has done
• See what the night has done
Prevention always better than cure
• Spinal cord injuries centre – 01642 282645
• Specialist nurses –
• Kathy Rogstad - 07765242604
• Jess Salvati - 07765242607
• Lesley Kaid - 07765242605
• Carrie Brooks - 07557211375
• Therapists
• Social worker
• Counterparts in the community
Resources
Thank you for listening
Any Questions?