Prevent Pressure!

Foundations of Good Skin Care in Your Chair from the Bottom Up!

Pressure ulcers, probably the most feared complication of neurological impairments, are viewed by ‘patients’, family members and care professionals as completely preventable – and, well they are – but only if you actually stick with the very strict and unforgiving program of constant prevention and early management.

While this may seem like a boring and mundane topic for a column, the fact that pressure ulcers still develop – both at home and in hospitals (yes that’s right!), means that there is a need for regular reviews of your skin care program, so bear with me.

No matter how long you have been in a chair, I want to remind you of the Basics and redefine the components of a Skin Care Program. In the next issue I will look at Skin Care in Bed, and after that we’ll look at specific Methods of Pressure Relief.

The clock is ticking

Lying or sitting in one position for extended periods restricts the blood supply to the areas of skin, connective tissue and muscle that are trapped between the surface you are on and the underlying bones. This cuts down on the amount of oxygen and nutrients that can be supplied to the trapped cells and leads to a build-up of poisonous waste products. If this situation goes on for a prolonged period of time, cells start to become sick and may die off.

If enough cells die off, the skin will become inflamed, blister and break open – resulting in a pressure ulcer. As more time passes, the pressure ulcer may increase in size and depth. The longer you lie or sit, the worse it gets. The good news is that relieving pressure allows the circulation to temporarily return to these areas, providing the cells with oxygen and nutrients. Doing this regularly allows the skin, connective tissue and muscle to remain healthy.

Sadly, there are no off-days, half-times and no time-outs. However unfair or inconvenient, the clock starts ticking the moment you settle into any one position – and only you can manage its effects.

Good Skin Care in Your Chair

  1. Check that the whole length of both your thighs is well-supported by the surface you are sitting on. This may mean checking the height of your wheelchair’s footplates. If your thighs are well supported, your weight will be distributed over the largest possible surface area. This means that no single area is exposed to excessive pressure.
  2. Ensure that your wheelchair cushion and seat are long enough to support your thighs adequately, without putting pressure over the back of your calves.
  3. Always be aware of your posture, especially when you transfer into your wheelchair. The higher the level of your injury, the less you are able to actively maintain a good posture – and the more you will need extra support from your chair. You may even need a special back rest. If you are concerned that your posture is not up to scratch, speak to your physio, OT or seating specialist. Poor posture leads to unbalanced sitting and to pressure being carried in an unbalanced way – leaving you exposed to pressure ulcers.
  4. Relieve pressure as often as you can. Whether you lift or lean, you need to get it right and do it for at least 60 seconds to re-supply the skin and tissue that you have been depriving of blood, oxygen and nutrients (More about this in a future issue).

Pressure relief

While some people believe that an expensive cushion (gel or air cushion) allows you to do pressure relief at intervals of up to 60 minutes, I don’t agree. “Able bodies” are constantly shifting their weight and position every 7 minutes – and there is little doubt that while this would be ideal, you should be doing pressure relief every 15-20 minutes.

  • Ensure that your cushion and wheelchair are both in good condition. Have your chair seen to at least every year, and don’t leave problems to brew. If you use a foam cushion it should be replaced every 6-12 months, while gel and air cushions should be checked every 12 months by a professional.
  • Make sure that you check your skin at least twice a day (yes that’s right), particularly straight after you have been sitting or lying for some time. If you find that you have any redness over pressure points, take note of its position, check whether the redness blanches (goes white when pressed in) and time how long it takes to fade back to normal skin colour.

If any redness lasts longer than 20-30 minutes, or if the skin does not "blanche", this means that skin damage has probably occurred – and it would be wise to get help or advice from someone who knows about caring for pressure-related changes. Work out what caused the problem, don’t wait for it to happen again. Get professional help.

  • Never sit on red skin, broken skin or on any area where there is hardening underneath the skin. If this is present, you need to ‘rest your skin’ and avoid sitting on the affected area. It would be best to consult a professional if you are unsure about how to handle this situation.

Take time to think these points through. Research says that 10-20% of everyone who has a spinal cord injury, severe brain injury or other paralysing condition will develop a pressure ulcer in the next 5 years. You could make sure you’re not in that group by sticking to these rules at all times. Next issue – Skin Care in Bed.

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