Caring for spinal cord patients can be difficult for nurses as well as patients themselves. Bed-bound patients with a combination of poor nutrition, dehydration, immobility, and incontinence have a greater chance of developing pressure ulcers. Once the ulcer grows, the chances of infection increase as well. Unfortunately, hospitals are the perfect environment for developing pressure ulcers. Thousands of patients acquire them each year, costing hospitals millions of dollars due to increased lengths of stay and complications.
Causes and treatments
A pressure ulcer is an alteration in the skin that results from prolonged pressure to a bony prominence such as the buttocks, ankles, heels, and hips. According to the National Pressure Ulcer Advisory Panel, they come in four stages:
- Stage 1: Skin appears red but blanchable. Darker skin tones may appear ashen or purple.
- Stage 2: Obvious wound and opening to the skin.
- Stage 3: Damage to skin, exposure of fat, crater-like appearance with some slough.
- Stage 4: Large loss of tissue with exposure to bone, muscle, and tendons.
Prevention is key, but treatment can be challenging. Spinal cord patients are taught to inspect their skin daily, shift their weight every 15 minutes, and, when in bed, be turned every two hours. And although patients are taught to be vigilant, they are not always compliant with care.
Treatments for pressure ulcers vary and can be costly. Topical medications are on the front line of this battle, providing moisture that helps healing and prevents scarring. When pressure ulcers become difficult to treat, intricate measures are sought, such as wound Vacuum Assisted Closure (VAC) therapy. Patients that do not respond to the treatment will eventually need debridement and flap surgery, a reconstructive procedure covering severe wounds with tissue rich in blood, fat, or muscle. Complications include infection, hemorrhage, necrosis, or even death. Postoperative care can be costly and time consuming, as well as mentally and physically challenging. Patients must remain in an air-fluid bed for four to six weeks. Movements are extremely limited to prevent tearing the site, and healing comes slowly.
One of the biggest complications is infection, which can lead to sepsis and death. Individuals with a spinal cord injury will have added difficulties, including spasms, incontinence, and autonomic dysreflexia. These complications often increase the length of stay, chance for nosocomial infections, and possibility of lawsuits. Thus, important steps must be taken to ensure patient safety, prevent skin breakdown, and provide education to both staff and patients.
What you can do
Skin inspections should be thorough, daily, and, most importantly, documented. During examination, you should make note of the patient’s overall appearance, history, comorbidities, nutrition habits, and history of incontinence. Document the type of wound, location, depth, and width. Finally, stage the wound. Provide a description of color, odor, and drainage and take pictures of the wound for records.
Documentation of pressure ulcers is essential and is carefully examined during legal cases. Litigation teams know pressure ulcers can be prevented, that they are documented, and that they can cause serious complications. They are also trained to look for gaps left by the medical team, including:
- Measurement of depth
- Signs of wound healing and complications after two weeks
- Absence of wound cultures
- Nutritional reassessment
Pressure ulcers should be documented as per hospital protocol, changes noted, and dressings dated. Frequent nutritional assessments should be done as well. Patient diets should include increased caloric intake, proteins, and vitamins, especially zinc and vitamin C. Hydration is also crucial, and patient intake and outputs should be assessed. Most importantly, albumin levels should be examined and kept around 30 kcal/kg per day.
Pressure ulcers are a crucial issue for patients and their families, and nurses should strive to maintain communication and education during the treatment process. Support and community services can be provided, giving the patient autonomy over his or her care.
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