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SKIN MANAGEMENT IN SPINAL CORD INJURY: SKIN SORES: PREVENTION OF SKIN SORES: RELIEVE SKIN PRESSURE

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Relieve Skin Pressure

   In addition to routinely checking your skin, a second important way to prevent pressure sores is to relieve skin pressure by changing position or being positioned so that pressure is taken off a bony area. The purpose of relieving pressure is to let the blood supply get to the skin. If pressure is not relieved, blood will continue to be pressed out of a blood vessel and will not get to the skin to keep it healthy.

We will discuss how to relieve pressure:

  • Of the foot
  • In bed
  • In a wheelchair


HOW TO RELIEVE SKIN PRESSURE FROM THE FOOT

Positioning of the Foot


HOW TO RELIEVE SKIN PRESSURE IN BED

Turning Schedule

   Use a turning schedule that does not allow redness to appear on bony prominences. Depending on your body type, you will tolerate a turning schedule of two to five hours (turning from side to back to side). The length of time between turns can be gradually increased by adding 30 minutes to the amount of time in a given position and then checking for redness.

   You will be asked to provide an alarm clock or some other means of awakening yourself for position changes during the nighttime. Ultimately, it will be your responsibility to either independently position yourself or verbally direct your caregiver to perform the task.

   The only exception to a turning schedule is lying prone (on your abdomen).

Support Surfaces

There are several types of support surfaces for pressure reduction for persons who are at risk for or who have pressure ulcers.

  • Air-fluidized and low air loss beds are dynamic support surfaces used when there is a presence of large Stage III or IV pressure ulcers or pressure ulcers on the multiple turning surfaces.
  • Alternating-air pressure surface, also a dynamic support surface, is for the person who has pressure ulcers that requires more pressure reduction than a static surface.
  • Static support surfaces such as static flotation (air on water), foam or standard mattress are used for prevention of pressure ulcers and when the individual can be positioned off of the pressure ulcer.


Prone Position Padding

   You can safely lie prone for up to eight hours by using plump, firm pillows and small foam pads.

Head:  Small, foam support under head. Size of foam depends on individual comfort. Cover support with materials that are not irritating to your skin.

Chest:  Use one or more pillows according to comfort.

Thighs:  Foam pads placed above the knees to prevent redness of knees.

Shins:  Pad(s) or Pillow(s) under shins to elevate feet height enough to avoid pressure on toes (helps prevent ingrown toenails). An alternative is to allow toes to hang off the end of the bed. Feet should be at right angle to the legs per illustration above.

Between Knees:  Pads placed between knees to keep knees and ankles apart so pressure sores do not develop.

Warning:  Do not substitute folded towels or blankets for foam padding or pillows. These can be too firm and cause skin breakdown.

     Sleeping prone at night is very important for two reasons:

  • Both you and whoever helps you to change your position can have a restful eight hours sleep without interruptions.
  • Lying prone straightens your hips and helps prevent tightness of the hips and knees.

    Alternate positions are side-to-side positioning as well as supine (back) position. Which position works to your benefit will be determined individually.


Side Position Padding

Place pillow behind back:

Head:  Small, foam support under head. Size of foam depends on individual comfort. Cover support with materials that are not irritating to your skin.

Back:  Support behind back to maintain side position. Be sure bottom hip is pulled back to prevent rolling backwards on sacrum.

Hips:  Pad placed above and below the hip joint. When pads are placed correctly, a flat hand can be slid between the body and the bed to be certain that pressure has been relieved. If the pressure has not been relieved, an additional pad can be added.

Ankle:  Pad placed above the ankle joint.

Between Lower Legs:  Pillow placed lengthwise between legs to prevent pressure on the knees and ankle joint.  DO NOT HAVE LEGS DIRECTLY ON TOP OF EACH OTHER.

Warning:  Do not substitute folded towels or blankets for foam padding or pillows. These can be too firm and can cause skin breakdown.


Supine (Back) Position Padding

Place pad between leg:

Head:  Small, foam support under the head. Size of foam depends on individual comfort. Cover support with materials that are not irritating to your skin.

Back:  Place pad under lower back to provide elevation of the sacrum (tailbone). This will relieve pressure on the sacral area and relieve muscle tiredness in the back.

Knees:  The bend at the knee is a natural curvature. Use a pad above the area behind the knee. The pad must not be in the area behind the knee.

Ankles: A small pad is necessary at the back of the heel to relieve tension on the calf of the leg. Also, the heels must be off the bed to prevent skin breakdown.

Feet: A soft foot support is placed to allow simulation of weight bearing on the ball of the foot.

Between Lower Legs: Foam pad or pillow placed between the knees to present possible breakdown at the knee and ankle joints.

Warning: Do not substitute folded towels or blankets for foam padding or pillows. These can be too firm and can cause skin breakdown.

HOW TO RELIEVE SKIN PRESSURE IN A WHEELCHAIR

Weight Shifts:

Weight shifts are the most essential techniques for preventing pressure on the skin and muscle of the sacrum (tailbone) and each hip. Use the method you and your therapists have found to be the most effective for you. Know your skin tolerance at all times. The frequency with which you do weight shifts vary from time to time. It is advisable that weight shifts be performed every 15 minutes.

Cushions:

    A cushion for your wheelchair is essential. Cushions provide pressure relief and weight distribution and thus aid in the prevention of pressure sores. Many types of cushions exist, but there is no "ideal" cushion. Use the cushion recommended by your physical therapist/physiatrist.

  • If air is used in the cushion, check to see that it is filled correctly. If you are going to a different altitude, there will be a change in your cushion.
  • If your cushion is made of foam, check to see that it is firm and in good condition. If it gets dry, powdery and loses its firmness, replace it immediately. Use only good quality foam. Polyurethane foam with a density of 1.2 and compression of 30 to 35 is recommended.
  • If a gel cushion is used, make sure the gel is evenly distributed. These cushions are easy to maintain but are quite heavy.
  • In case of body weight change, you may need to change the width of your chair, the frequency of your weight shifts, and the type of cushion you use.

   Never use rubber air rings or rubber doughnuts. They are dangerous because they block the flow of blood to the skin inside the leg.

Weight shifts are essential. The cushion alone will not prevent pressure sores.

In Addition:

  • Make sure the foot pedals of your wheelchair are adjusted to the right height for you. If your foot pedals are too high, it will put pressure on your hips;
  • Sit up straight in your chair. Slumping or slouching leads to added pressure over the end of your tailbone.
  • Lean forward and from side to side for weight shifts.

Wheelchair pressure relief  by leaning to one side

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