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?