Returning to sit
Once the area of skin breakdown has fully healed, bed rest can cease and the person may begin to resume sitting. However, newly healed skin remains fragile. A structured return-to-sitting program is essential to minimise the risk of re-injury and protect skin integrity after prolonged bed rest.
What does “healed” mean?
There should be no open areas including scabs and bleeding or hard, scaly tissue.
Management of scar tissue
Scar tissue is structurally weaker than intact skin and has reduced circulation, making it more prone to splitting, slower to heal, and at higher risk of recurrent breakdown.
Promoting healing in a stretched position can help prevent the scar from reopening when sitting is resumed. This may include strategies such as sitting on a commode (if appropriate) and gradually stretching the hip to 90 degrees.
Getting ready to sit
- Address the causative factor.
- Repair and service the equipment.
- Conduct an on-bed postural assessment, even if this isn’t a suspected causative factor. A person’s range of movement may have changed due to prolonged bed rest. This can be performed at any point in time while on bed rest and when preparing to sit.
- The first sit may require the presence of a therapist and nurse, to perform a pre- and post-skin check and gauge the outcomes of the sit. They can assess whether adjustments need to be made to the equipment and transfers, or how quickly the sitting program can progress.
Importance of a sitting program
A structured and gradual return-to-sitting program allows the skin to progressively adapt to pressure, shear, and stretch. This approach enables early identification of any skin changes and increases the likelihood of a safe and successful return to sitting.
During the sitting program
Monitor the area: Perform a pre- and post-skin check with each sit. Wound dressings should not be used when sitting, as they can make it more difficult to check the skin and see how the sitting impacts the newly healed area.
Seating surface: The sitting program should only be done in the wheelchair, not on the bed or the shower commode. Consider an air cushion that will maximise surface area contact.
Transfers: Prolonged bed rest and deconditioning can impact the quality of transfers. Temporary adjustments to hoisting or assisted transfers may need to be considered.
Orthostatic hypotension: Prolonged bed rest and deconditioning can increase the risk for orthostatic hypotension. Caution should be taken with initial mobilisation.
Equipment trials: It is best to avoid introducing equipment trials until the person has completed a sitting program or is back to their usual routine.
Timing of sits: Rest at least one hour between sits and position off the newly healed skin area in bed. This will allow recovery of circulation to the tissue.
If redness or breakdown occurs: Redness that doesn’t disappear within 30 minutes, or any damage to the skin, such as a blister or split, requires offloading until it heals. Once the skin area has healed, it is recommended to restart the sitting program from day one.
Returning to activities: It is recommended to keep activity to a minimum during the sitting program, to allow the skin to recover and readjust to sitting. This can include travelling long distances in the car, shear from travelling across uneven ground, and using different equipment, such as a sports wheelchair or swimming.