Key principles of managing skin breakdown

Early identification of the skin injury

• Gather a history of the skin area such as when it developed, is this new or recurrent, was there any change to the routine or equipment or a contributing event such as a fall or deflated cushion.
• If the area is red and it does not fade within 30 minutes, then this is a stage one pressure injury. More information on pressure injury staging can be found on the staging poster. Free pdf poster on pressure injury stages
• Treat any change to the skin as a cause of concern. This is crucial if it is close to or over a bony prominence. Changes can include pimples, rashes, scrapes, burns, or bruises.
• Intensive short term investment at an early stage can prevent ongoing deterioration of the area and the prolonged presence of pressure injury.

Identify correct body location

Offload

• Removing pressure from the damaged skin will enable blood supply to the tissue to aid in recovery.
• The easiest method to check if the wound is offloaded is to place a hand over the wound in the desired position and feel for any contact with the wound and surface. The hand should move freely between the two contact points.
• For specific advice on how this can be managed for the location of the breakdown, visit the pressure injury location and management page.

Identify the cause

• Try to problem-solve why the skin breakdown occurred. This will assist with preventing future issues and provide an opportunity to seek assistance with any urgent changes to the routine or equipment.
• Manage intrinsic factors such as nutrition, diabetes management, spasticity, joint range, and oedema.

Seek help

• The goal is to perform a holistic objective assessment to review the wound care, causative factors and monitor the progress of the wound. This will determine the best progression for returning to sit, once healed.
• Partner with the person and be realistic about goals and outcomes.
• Seek early assistance and advice from the QSCIS team.

Wound care management

• If there is broken skin, use a dressing. This will create the best environment for healing.
• Perform early wound debridement. A clean wound will have the best opportunity to heal.
• Screen for infection and intervene early if present.
• Cleaning the wound bed in the shower is the simplest technique to clean a wound. An additional use of an antibacterial solution can assist with reducing biofilm formation and preventing infection.
• Remove pressure from the wound. Offloading is crucial to healing any wound.
• Packing causes pressure from within the wound and is not recommended. Packing can include gauze, alginates or foam with all dressing types inclusive of negative pressure wound therapy. Packing becomes hard nubile material that increases pressure to the wound bed.
• Manage exudate as this can macerate the wound edge. This may include the need to increase wound care frequency or dressing absorbency. Shear may also increase wound exudate and should be excluded.
• Keep it simple with wound care. Complex wound care products can increase:
  • issues with following care plans
  • risks with devices such as additional tubing
  • costs
  • expectancies that a complex dressing will have better outcomes than a simple dressing
• Prevent contamination from incontinence. Assess the feasibility of toileting and showering on a mobile shower commode. Consider an indwelling catheter if needed.

Nutrition

• Despite the common belief that pressure injuries increase energy and protein needs, there is no convincing evidence to support this.
• People with spinal cord injury (SCI) have reduced energy needs, are at high risk of weight gain and may need extra support from a dietitian to ensure they are not taking in more nutrition than they need, especially if they are resting in bed for long periods due to more significant stage 3 or 4 pressure injuries.
• A healthy, well-balanced diet that includes foods from all food groups paired with adequate fluid intake is recommended to optimise healing for people with SCI and pressure injuries.
• Consider screening for deficiency with Stage 3 and 4 pressure injuries. Screening should include B12, Folate, Iron studies, and Zinc. Also, consider the need to screen for diabetes mellitus and thyroid dysfunction.
• Evidence supporting the use of arginine-enriched nutrition supplements to aid wound healing is mixed but could be considered where the pressure injury is failing to heal despite adequate nutritional intake.
• Consider pharmacological agents to assist with smoking cessation.

Managing periods of bed rest

Prolonged periods of bed rest can be boring and difficult to adhere to.

Provide support to maintain bed rest which can include:

• supplying nutritious meals and fluids
• care supports to attend hygiene tasks on the bed or review the possible use of a mobile shower commode
• regular positioning and the need for a different mattress
• setting up entertainment such as access to a tablet, phone, laptop, and television including charging of devices and the ability to use the screen from a lying position
• personal safety to enable access to the person’s home without leaving doors unlocked
• collaborate on a plan for work and family commitments
• ongoing monitoring support with wound management. Seeing the benefits of improvements assists with maintaining bed rest and is a great motivator
• psychological support in place

Person-centred care

Ensure the person has ownership of the skin breakdown and management plan.

Have joint open and supportive discussions with the person and the health care team.

This may include:

• seeing the wound (provide photographs if needed)
• discussions about managing routines and lifestyle
• agreements on how the person can manage offloading the wound
• managing a return to sitting program

Conservative vs surgical intervention

Conservative management will always be the primary goal of wound care. It is possible with simple measures to heal most wounds or reduce the size of significant stage 3 and 4 wounds.

Initial key surgical intervention may be required to debride non-viable tissue or address wound infection.

Generic considerations for reconstructive plastic surgery:

• A local flap repair aims to move the scar line away from points of direct pressure, hence reducing the risk of a breakdown in the future.
• A period of extended bed rest of at least 4 weeks is required following a local flap repair to allow healing and reduce the risk of skin breakdown post-operatively when sitting is resumed.
• A lengthy hospital admission is often required and may be a consideration for patients when deciding on surgical vs conservative management