Chapter 12 Pressure Sores

A pressure sore or decubitus ulcer ("decube") is an injury to the skin and tissues below it. It is caused by excessive or prolonged pressure. When pressure is applied for too long, blood supply is cut off. This deprives the cells of oxygen and nutrients, which leads to skin breakdown.

The pressure on the tissues is always greatest at the bone. Your tail bone (sacrum and coccyx), hips (trochanters), sit bones (ischials), or heels are the places to watch. Tissues here get squeezed between a "rock" (the bone) and a "hard place" (your chair or mattress, for example). Before your injury, your body signaled you to squirm around in a chair or change positions to get blood to an area. After spinal cord injury, you may not have the same warning system about your skin. Unless you think and then move by doing a "pressure release", the blood supply to an area can be cut off and result in a pressure sore.

Since pressure is greatest at the bone, the most damage is done there. A sore may look small at the skin’s surface but can be much larger underneath. Think about this like the description of an iceberg: what you see on the skin (tip of the iceberg) is only a small part of the tissue damaged underneath (the biggest part of the iceberg).

It is better to prevent a pressure sore. Even if you are able to heal a wound, especially a deeper wound, the skin and soft tissue below will never be as strong and elastic as before.

When you are at risk for pressure sores, the equipment you use should help relieve and distribute pressure over your bony areas. Special bed surfaces and wheelchair cushions can be chosen to help prevent pressure sores. But the most important prevention is to MOVE YOUR BODY frequently. If you do develop a pressure sore, GET OFF IT. STAY OFF IT until it is healed.

 
PRESSURE SORE CLASSIFICATION

A rating system is useful in identifying and describing the size and extent of a pressure sore. This is important so the treatment of your wound can be planned and carried out effectively. The deeper the pressure sore, the more serious the problem. The most common system for rating the severity of damage has 4 levels:

• Stage 1. This is an area of redness that does not fade or blanch. In darker skinned people, this may look dark red, blue, or purple. The skin is still intact.
• Stage 2. If the skin is broken open at all, the wound is at least a stage 2. This will look like a scrape, blister, or shallow crater.
• Stage 3. This wound will be a deeper crater, which goes all the way through the skin layer into the soft tissue below.
• Stage 4. This wound is deep enough to extend to a tendon, bone, or muscle.

 
COMPLICATIONS OF PRESSURE SORES

 
Sore Worsens

The length, width, and depth of a pressure sore can increase in size. In deep wounds, tunneling between layers of muscle, fat, or bone can occur. This is called tracking. Most of the time you can keep sores from getting worse by immediately getting off the sore and contacting your health-care provider. A pressure sore will not heal if pressure is still being applied to it.

 
Infections

Skin and wound infections can occur with pressure sores. In deep wounds, the bone can also become infected. This bone infection is called osteomyelitis. Sometimes this infection can spread into your bloodstream and make you very sick. By keeping your pressure sore clean and by following recommendations by your health-care providers, you can help prevent infections.

 
Scarring

The formation of scars is common as pressure sores heal. This scar tissue breaks down easier than normal skin without scars because scars have poor blood supply. Scar tissue is also less elastic and may not stretch enough as your body gets into different positions. Scarring of the skin and soft tissue may even decrease your range of motion in nearby joints.

Fortunately, scarring can be prevented by preventing deep pressure sores altogether. It is important not to let a superficial sore (which is likely to heal without a scar) turn into a deeper one. Even if deeper wounds heal, the area will have scar tissue.

 
HEALING SKIN BREAKDOWN

There are different ways to manage pressure sores after they have developed. Managing other body system problems that have an impact on wound healing is essential. Check with your health-care provider for the treatment plan that will work best for you. Some ulcers may even require surgical repair. All ways of treating pressure sores take a long time to work and require keeping pressure off the area (see table 12.A).

TABLE 12.A. Time and Process for a Pressure Sore to Heal

 
Pressure Management

The most important part of treating pressure sores is removing the cause. To treat any stage pressure area, remove pressure. For example, if the sore is on a pressure area related to sitting, don’t sit until the problem is fixed. If your sore is on a pressure area related to lying down (like the tail or hip bones), don’t lie in that position again until the problem is fixed. If this is a heel problem, eliminate pressure by wearing a special splint (for example a l’nard splint) or suspend your heel over the edge of a pillow.

 
Management of Other Body System Problems

Other problems can contribute to the development of a pressure sore. (See table 12.B). For example, urine leakage that causes the skin to be wet for long periods of time can lead to skin breakdown. The urinary drainage must be managed in a different way. Another example might be spasticity that pulls you out of alignment in your chair causing uneven weight distribution and higher risk for skin breakdown. Your sitting posture must be corrected so you can have even weight distribution over your sit bones.

 
Anemia/Loss of Body Proteins

Healing skin requires good nutrition. If you are anemic or malnourished, healing will be slow. The pressure sore itself may cause anemia and malnutrition, especially if there is a large amount of drainage. Your health-care provider will give you advice about treating your anemia or low body proteins. You may need help from a dietitian to get enough of a well-balanced diet. You may need extra calories, protein, vitamins, and minerals.

Smoking impairs your skin’s ability to heal due to constriction of blood vessels and limiting the absorption of some nutrients. If you have a pressure sore, try to stop using tobacco in any form. Call your health-care provider for help with stopping smoking.

 
Wound Care

If you develop a pressure sore, you should take immediate action. But before we talk about what to do if you have a pressure sore, you should know what NOT TO DO:

1. Don’t massage areas of redness.
2. Don’t clean your wound with soap, iodine (e.g., betadine), hydrogen peroxide, alcohol, vinegar, or bleach solutions. These solutions are toxic to your exposed tissues.
3. Don’t try to dry your wound with a heat lamp or hair dryer.
4. Don’t put sugar, vitamins, or antacids into your wound.
5. Don’t use antibiotic ointments in your wound unless prescribed by your health-care provider.

If you have a MINOR skin breakdown, some simple wound care at home may allow healing to occur. Healing is promoted by keeping your wound moist (not wet) and covered. Rinse your wound with normal saline solution or by bathing in the shower. Blot the area dry, then cover with a film dressing (such as Tegaderm®) or a hydrocolloid dressing (such as Duoderm®, Restore®, or Comfeel®). Your wound will make "soup" under these kinds of dressings. Don’t be alarmed if there is a puddle of smelly drainage when you take off the old dressing--this is normal! If your ulcer does not heal or show progress toward healing within a week’s time, call your health-care provider for guidance. A home care nurse may be needed to help manage your wound care.

If you have a deeper wound, or the wound has black, yellow, or gray tissue in it, or the skin around the wound has increasing redness, call your health-care provider right away.

 
SURGERY

Sometimes total pressure relief and good wound care are not enough to heal a pressure sore. In those cases, surgery may be needed. There are different surgical procedures depending on the location and severity of the pressure sore. Some procedures involve moving muscle and skin. Some also remove some bone. Each person with a pressure sore is evaluated for the procedure that will have the best chance of getting him or her back to living an active life.

There are limits to the number of times a pressure sore repair surgery can be performed. You are far better off preventing a serious sore.

 
Getting Ready for Surgery

Before surgery, the pressure sore needs to be well cleaned. This can take several weeks and may involve frequent dressing changes and/or surgically removing all the dead tissue from the wound.

If your sore is infected, your doctor may prescribe antibiotics. Signs of infection include redness and swelling around the wound, foul smelling drainage, and fever.

Also before surgery, your nutritional health will be evaluated to see if additional food (protein, vitamins, minerals) is needed to improve the chances of successful wound healing.

 
After Surgery

After surgery there will be a period of three to six weeks when you will stay in bed (usually a special bed) to allow the surgical site to heal. It is very important not to put pressure on the surgical site and not to pull or stretch the skin of that area. You will need help in turning. You will not be able to smoke for 3-6 weeks after your surgery. So plan to quit before hand.

After healing, range-of-motion exercises to the nearest joint will begin slowly. Next, there will be a gradual buildup of weight bearing or pressure on the site by lying or sitting on it in carefully planned sessions. This process of building pressure tolerance is very slow. Ask your nurse or doctor about this.

This surgical area will need special care for the rest of your life. It will never be as strong as it was before you had the pressure sore. Transfers and pressure tolerance will need to be regularly evaluated. Your seating system and how you do pressure releases may need re-evaluation.

The most important part of healing, whether by conservative methods or surgery, is for you to determine the cause of the pressure sore and to plan how it can be prevented in the future. For more general information about skin care, see Chapter 2.

 

SCI Self-Care Guide Main Page Chapter 1     SCI Anatomy & Physiology Chapter 2     Skin Care Chapter 3     Circulatory System Chapter 4     Respiratory Care Chapter 5     Range of Motion Chapter 6     Bladder Management Chapter 7     Bowel Management Chapter 8     Nutrition Chapter 9     Medications Chapter 10   Nerves, Muscles, and Bones Chapter 11   Autonomic Dysreflexia Chapter 12   Pressure Sores Chapter 13   Psychosocial Adjustment Chapter 14   Sexual Health & Rehabilitation

Chapter 15   Community Resources Chapter 16   Vocational Rehabilitation Chapter 17   Recreation Chapter 18   Driver’s Training Chapter 19   Attendant Management Chapter 20   Home Modifications Chapter 21   Approaching Discharge Chapter 22   Pain after Spinal Cord Injury Chapter 23   Substance Abuse and SCI Chapter 24   Exercise Chapter 25   Alternative Medicine Chapter 26   Equipment Chapter 27   Staying Healthy Glossary