Preventing pressure ulcers is ultimately the best approach and begins at the time of injury. Lifelong prevention recommendations include examining skin daily to allow for early detection of a pressure ulcer, shifting body weight in bed and wheelchair on a regular basis independently or with assistance, keeping moisture accumulation to a minimum and cleaning and drying skin promptly after soiling, having an individually prescribed wheelchair, pressure redistribution cushion and power tilt mechanism if manual pressure relief is not possible, ensuring all equipment is maintained and functioning properly, decreasing or stopping smoking and limiting alcohol intake (Consortium for Spinal Cord Medicine 2000; Houghton et al. 2013). Krause et al. (2001) note that effective prevention strategies require individuals with SCI to take responsibility for their skin care. Prevention strategies must be individualized to promote sustainable outcomes. Individuals with SCI need assistance from health care professionals to integrate realistic prevention strategies into daily schedules (Clark et al. 2006). King et al. (2008) indicated that the value of preventative behavior needed to be emphasized. While in hospital, individuals with SCI need to practice skin care skills daily, know and direct their skin care program, learn to problem solve potential barriers while getting regular feedback on their performance. Support from both family and the health care team is essential. As well, patients need to understand how quickly and quietly a pressure ulcer may appear and how it must be treated promptly. Other strategies suggested for education include training by peers, presenting information in a variety of methods including group learning, simulation exercises and case studies (Dunn et al. 2009).
It should be noted that outcome assessment for pressure ulcer prevention can be measured via either direct or indirect means. That is, the effectiveness of preventative interventions can be determined by direct indicators, such as pressure ulcer incidence, or by indirect indicators, such as IT pressure mapping or transcutaneous oxygen tension (PTCO2) levels. The former are preferred as they reflect definitive indications of the success (or failure) of preventative interventions. Sheppard et al. (2006) indicated that knowing one’s skin tolerance was related to intention to do pressure relief. Attendance at a seating clinic would be helpful as skin tolerance can be measured.
Whenever possible, individuals who are at risk for pressure ulcer development or who are being treated for a pressure ulcer should be referred to a registered dietitian for assessment and intervention as necessary (Keast et al. 2006). In a study by Houghton and Fraser (2008), individuals with either paraplegia or tetraplegia living in the community with pressure ulcers (stage II to unstageable) underwent assessment that included medical and wound characteristics and screening of blood values for the presence of anemia, hydration status, glycemic control and hypoproteinemia. Study subjects with two or fewer abnormal blood values at the time of screening achieved complete wound closure following standard wound care and treatment with adjunctive therapy. Individuals who presented with greater than two abnormal blood values related to nutrition and hydration status did not achieve wound closure. The authors recommended that all individuals with pressure ulcers be screened for underlying inadequacies in nutrition and hydration and receive intervention to address these issues to promote optimal wound healing. Alexander et al. (1995) found that patients with paraplegia and a pressure ulcer had a resting energy expenditure that was hypermetabolic underscoring the need for thorough assessment and adequate nutritional support.
Recommendations for prevention or treatment of a pressure ulcer would include eating a well-balanced, nutritionally complete diet with appropriate calories, proteins, micronutrients (vitamins and minerals) and fluids. The nutrition plan must be individualized based on the assessed needs (Consortium for Spinal Cord Medicine 2000; Keast et al. 2006; Houghton et al. 2013). If a pressure ulcer is present, the plan would need to be optimized using foods, supplements and/or enteral nutrition, if warranted. The individual’s weight would need to be monitored as an undesirable weight trend has been identified as an early indicator of risk (Keast et al. 2006).
There have been numerous recommendations for the prevention of pressure ulcers post SCI but it is important to consider the evidence that informs those recommendations. Potential preventative techniques found in the SCI literature that have been reviewed include effect of electrical stimulation on ischial pressures and blood flow, pressure relief practices, wheelchair cushion selection, effect of lumbar support thickness on ischial pressures, specialized seating clinics, pressure ulcer prevention education, behavioural contingencies, and telerehabilitation.