People with spinal cord injury and other conditions that limit movement are at great risk for pressure ulcer development.
Many risk factors predispose people with spinal cord injury to the development of these wounds; factors include impaired sensation, mobility, spasms and respiratory issues.
At Shepherd Center, nurse Cathy Koerner and her colleagues have implemented a comprehensive program to prevent these ulcers among patients while they are in the hospital and after they discharge.
Today, Cathy will share some pressure ulcer prevention strategies, which include scheduled turning and repositioning in beds and wheelchairs; management of bowel and bladder issues; proper support surfaces; and regular checks of the skin.
Selected Podcast
How to Prevent Pressure Ulcers in People with Spinal Cord Injury
Featured Speaker:
Cathy Koerner, RN, CWOCN
Cathy Koerner, RN, CWOCN, CWS, is a certified wound/ostomy nurse at Shepherd Center. She has been a certified wound/ostomy nurse for 29 years working in various healthcare settings, including acute care hospitals, home health, wound care clinics and nursing homes. She has worked at Shepherd Center for the past 10 years. Prevention and management of pressure ulcers is a primary focus of her practice. Cathy has been an educator on the college level teaching all aspects of nursing at various institutions. She is a graduate of Marquette University in Milwaukee, Wisconsin, and the certified wound/ostomy nursing program at Emory University in Atlanta. Transcription:
How to Prevent Pressure Ulcers in People with Spinal Cord Injury
Melanie Cole (Host): People with spinal cord injury and other conditions that limit movement are at a great risk for pressure ulcer development. My guest today is Cathy Koerner. She is a certified wound and ostomy nurse at Shepherd Center. Welcome to the show, Cathy. Tell us, what is a pressure ulcer and how does it develop?
Cathy Koerner (Guest): A pressure ulcer is a wound that occurs usually over a bony prominence--the bones stick out of your skin, like on your wrist or on your sacrum which is on your buttocks, kind of in the middle. The process of what happens is, there is too much pressure over the area. It literally squishes the blood vessels and you don’t have enough circulation to the area. It can be worsened by any moisture and any shearing which is pulling over the surface, dragging over the surface and creating up a friction that opens up the skin, too.
Melanie: What could be the problem that develops? Could it get infected? Is it very painful for patients to have this?
Cathy: It will be painful for patients who can feel the pressure ulcers but at Shepherd Center, we take care mostly of people who cannot feel. They have spinal cord injuries and most of the time they are unable to feel where the pressure ulcers occur. The actual process of what happens is that many times it develops from the very base down by the bone and works its way up because the circulation has been impaired. It looks on the surface like a bruise sometimes, originally, right over a bony prominence and then it starts working its way up. All of the sudden, maybe 10 days later you have an opening that is a wound.
Melanie: So then, do you stage these things? What do you do? Do you keep them covered? Do you want them to stay open and be able to breathe? What do you do for that person?
Cathy: Staging a pressure ulcer? Yes, we do. That’s the only thing that we stage. There is some other staging in the medical field but this is for the regular nurse that works just anywhere. Staging is only done for pressure ulcers. We have Stage I where it’s red. Stage 2 where it’s open but only superficial. Stage 3 and Stage 4 are your much deeper ones where you can have dead tissue on the wound base and it can go all of the way down to bone, tendon or muscle. That’s Stage 4. We also have “Unstageable” which means they have necrotic tissue on the surface of it and we don’t know how deep it is, so we call it an Unstageable. All of these stages are to determine how serious this wound is and, basically, how we are going to treat it. To get to the treatment phase of this we treat pressure ulcers individually. We have to look at three major things. We have to look at the pressure situation. How can we get pressure off of this wound? Especially if they are sitting in a wheelchair all day long, if they have a pressure area on one of their sitting bones, we are going to have a real problem. So, we need to get them off of that periodically. We also have to look at nutrition. We have dieticians that see every one of our patients within 24 hours of admission. They use all kinds of supplements. They assess their ideal body weight and determine what they need to do to encourage better nutrition. With the wound care, yes, we do cover wounds. You don’t leave wounds open to air to dry out. Our grandmothers are wrong about this. Our grandmothers always say, “Let the wound air out. It will get better that way.” No, wounds heal by providing a moist healing environment so that all of the wonderful cells that do the healing can move over the surface and do healing.
Melanie: Do you remove tissue around it as that starts to die out? Do you look for a change in color? What if someone is a home health patient from Shepherd? Do you work with their caregiver and teach them what to look for for these?
Cathy: Yes, we do. We teach the caregivers and the patients what to look for. They look at their bony prominences twice a day to make sure that they’re not getting redness which is Stage I and that’s the beginning of a problem. You’ve got to do something to prevent it right away. We do remove any dead tissue from the wound base. There are several specialists here that can do that, including our plastic surgeon and myself. We have to wait for the wound to what we call “demarcate.” Basically, what that is it’s showing us how big it’s going to be. It’s finally showing us how much damage there has been from the initial insult, whatever that happened to have been. Once we see that demarcation, that’s when we start doing the actual physical debridement using instruments to remove this tissue. The patients do not feel this at all most of the time because they are spinal cord injured. So, it isn’t a process that is terrible for them. If it is something that they feel, we use some local anesthetic.
Melanie: Is there something that you would tell the patient and/or the caregiver about moving from position to position if they are sitting in a wheel chair; about tilting and shifting and moving around so that they’re not in a position that puts pressure on that boney prominence?
Cathy: Absolutely. That is probably the most important thing we teach our patients and our caregivers that the turning and repositioning is so super important. It has to be done on an individual scale. How does it work for this patient? Are we able to prevent pressure ulcers and even just some of that redness if we turn them every two hours? Or, is it at every two and a half hours? Everybody is different. We teach them turning and repositioning. In bed, we use pillows. We use foam wedges, which is just a triangle of foam to hold them over. We use rectangles of foam under their heels so that the heels are literally floating. We do this while they are lying in bed so that they have no pressure on their heels at all. When they are in the wheelchair, we have them do weight shifts at least every 30 minutes. We have them do it for a minute or two minutes. The most recent literature says that it’s two minutes that is most effective in reducing the problem of pressure on the ischial tuberosities, which are your sitting bones.
Melanie: In just the last few minutes, Cathy, give your best advice for prevention of these pressure ulcers and what you really want listeners to know and why they should come to Shepherd Center for their care.
Cathy: Shepherd Center does everything to prevent pressure ulcers. We have very few pressure ulcers that happen here. It is a whole program of preventing pressure ulcers. Turning, repositioning. Pressure redistribution in bed, which means sometimes they have to have a specialty mattress. We use them very commonly here; floating your heels; management of any moisture in the buttock area and the groin area because that is where you see most of the pressure ulcers; doing weight shift in the wheelchair and not forgetting to do them because they’re just so important; transferring safely from the wheelchair to the bed or whatever surface so that you are not creating sheering; having the patients and caregivers do skin checks minimally twice a day, more often if they are having some issues; checking their cushion to make sure it is properly inflated, that it is in the chair correctly so that it’s not backwards or upside down. We sometimes see that because the cushions have covers on them that are washed. If you put the cover on wrong, you can end up with the cushion in wrong and end up with a pressure area because of that. They are taught to keep their skin clean and dry and well-protected with ointments or whatever so that their skin is not drying out. We teach them not to sit up in the bed over 30 degrees if they’re staying in bed for any length of time because that prevents them from sliding down and creating a sheer problem or pressure on their sitting bones. It’s always a good idea to sit up in the wheelchair to eat because sitting is meant for in wheelchairs not in bed and you have an adequate cushion to redistribute the pressure in the wheelchair. It’s best to sit up in the wheelchair to eat and it’s safer, obviously. We teach patients to prone which means lying on your belly. We protect people with pillows at various different points in their bodies so that none of the bony prominences that are down when you are lying on your belly will touch the bed. When they are wearing shoes, if they are able to wear shoes, they need to have them one size larger because otherwise they end up with pressure areas. If they are getting a new pair of shoes, they need to wear them for maybe an hour or two hours and check the feet for any redness on the bony prominences. A lot of our patients wear Crocs and we do not have any pressure ulcers with Crocs. It’s wonderful. I already spoke about the nutritional aspect of it. That’s kind of the whole program and we do that with everybody here.
Melanie: Thank you so much. You’re listening to Shepherd Center Radio and for more information you can go to Shepherd.org. That’s Shepherd.org. This is Melanie Cole. Thanks so much for listening.
How to Prevent Pressure Ulcers in People with Spinal Cord Injury
Melanie Cole (Host): People with spinal cord injury and other conditions that limit movement are at a great risk for pressure ulcer development. My guest today is Cathy Koerner. She is a certified wound and ostomy nurse at Shepherd Center. Welcome to the show, Cathy. Tell us, what is a pressure ulcer and how does it develop?
Cathy Koerner (Guest): A pressure ulcer is a wound that occurs usually over a bony prominence--the bones stick out of your skin, like on your wrist or on your sacrum which is on your buttocks, kind of in the middle. The process of what happens is, there is too much pressure over the area. It literally squishes the blood vessels and you don’t have enough circulation to the area. It can be worsened by any moisture and any shearing which is pulling over the surface, dragging over the surface and creating up a friction that opens up the skin, too.
Melanie: What could be the problem that develops? Could it get infected? Is it very painful for patients to have this?
Cathy: It will be painful for patients who can feel the pressure ulcers but at Shepherd Center, we take care mostly of people who cannot feel. They have spinal cord injuries and most of the time they are unable to feel where the pressure ulcers occur. The actual process of what happens is that many times it develops from the very base down by the bone and works its way up because the circulation has been impaired. It looks on the surface like a bruise sometimes, originally, right over a bony prominence and then it starts working its way up. All of the sudden, maybe 10 days later you have an opening that is a wound.
Melanie: So then, do you stage these things? What do you do? Do you keep them covered? Do you want them to stay open and be able to breathe? What do you do for that person?
Cathy: Staging a pressure ulcer? Yes, we do. That’s the only thing that we stage. There is some other staging in the medical field but this is for the regular nurse that works just anywhere. Staging is only done for pressure ulcers. We have Stage I where it’s red. Stage 2 where it’s open but only superficial. Stage 3 and Stage 4 are your much deeper ones where you can have dead tissue on the wound base and it can go all of the way down to bone, tendon or muscle. That’s Stage 4. We also have “Unstageable” which means they have necrotic tissue on the surface of it and we don’t know how deep it is, so we call it an Unstageable. All of these stages are to determine how serious this wound is and, basically, how we are going to treat it. To get to the treatment phase of this we treat pressure ulcers individually. We have to look at three major things. We have to look at the pressure situation. How can we get pressure off of this wound? Especially if they are sitting in a wheelchair all day long, if they have a pressure area on one of their sitting bones, we are going to have a real problem. So, we need to get them off of that periodically. We also have to look at nutrition. We have dieticians that see every one of our patients within 24 hours of admission. They use all kinds of supplements. They assess their ideal body weight and determine what they need to do to encourage better nutrition. With the wound care, yes, we do cover wounds. You don’t leave wounds open to air to dry out. Our grandmothers are wrong about this. Our grandmothers always say, “Let the wound air out. It will get better that way.” No, wounds heal by providing a moist healing environment so that all of the wonderful cells that do the healing can move over the surface and do healing.
Melanie: Do you remove tissue around it as that starts to die out? Do you look for a change in color? What if someone is a home health patient from Shepherd? Do you work with their caregiver and teach them what to look for for these?
Cathy: Yes, we do. We teach the caregivers and the patients what to look for. They look at their bony prominences twice a day to make sure that they’re not getting redness which is Stage I and that’s the beginning of a problem. You’ve got to do something to prevent it right away. We do remove any dead tissue from the wound base. There are several specialists here that can do that, including our plastic surgeon and myself. We have to wait for the wound to what we call “demarcate.” Basically, what that is it’s showing us how big it’s going to be. It’s finally showing us how much damage there has been from the initial insult, whatever that happened to have been. Once we see that demarcation, that’s when we start doing the actual physical debridement using instruments to remove this tissue. The patients do not feel this at all most of the time because they are spinal cord injured. So, it isn’t a process that is terrible for them. If it is something that they feel, we use some local anesthetic.
Melanie: Is there something that you would tell the patient and/or the caregiver about moving from position to position if they are sitting in a wheel chair; about tilting and shifting and moving around so that they’re not in a position that puts pressure on that boney prominence?
Cathy: Absolutely. That is probably the most important thing we teach our patients and our caregivers that the turning and repositioning is so super important. It has to be done on an individual scale. How does it work for this patient? Are we able to prevent pressure ulcers and even just some of that redness if we turn them every two hours? Or, is it at every two and a half hours? Everybody is different. We teach them turning and repositioning. In bed, we use pillows. We use foam wedges, which is just a triangle of foam to hold them over. We use rectangles of foam under their heels so that the heels are literally floating. We do this while they are lying in bed so that they have no pressure on their heels at all. When they are in the wheelchair, we have them do weight shifts at least every 30 minutes. We have them do it for a minute or two minutes. The most recent literature says that it’s two minutes that is most effective in reducing the problem of pressure on the ischial tuberosities, which are your sitting bones.
Melanie: In just the last few minutes, Cathy, give your best advice for prevention of these pressure ulcers and what you really want listeners to know and why they should come to Shepherd Center for their care.
Cathy: Shepherd Center does everything to prevent pressure ulcers. We have very few pressure ulcers that happen here. It is a whole program of preventing pressure ulcers. Turning, repositioning. Pressure redistribution in bed, which means sometimes they have to have a specialty mattress. We use them very commonly here; floating your heels; management of any moisture in the buttock area and the groin area because that is where you see most of the pressure ulcers; doing weight shift in the wheelchair and not forgetting to do them because they’re just so important; transferring safely from the wheelchair to the bed or whatever surface so that you are not creating sheering; having the patients and caregivers do skin checks minimally twice a day, more often if they are having some issues; checking their cushion to make sure it is properly inflated, that it is in the chair correctly so that it’s not backwards or upside down. We sometimes see that because the cushions have covers on them that are washed. If you put the cover on wrong, you can end up with the cushion in wrong and end up with a pressure area because of that. They are taught to keep their skin clean and dry and well-protected with ointments or whatever so that their skin is not drying out. We teach them not to sit up in the bed over 30 degrees if they’re staying in bed for any length of time because that prevents them from sliding down and creating a sheer problem or pressure on their sitting bones. It’s always a good idea to sit up in the wheelchair to eat because sitting is meant for in wheelchairs not in bed and you have an adequate cushion to redistribute the pressure in the wheelchair. It’s best to sit up in the wheelchair to eat and it’s safer, obviously. We teach patients to prone which means lying on your belly. We protect people with pillows at various different points in their bodies so that none of the bony prominences that are down when you are lying on your belly will touch the bed. When they are wearing shoes, if they are able to wear shoes, they need to have them one size larger because otherwise they end up with pressure areas. If they are getting a new pair of shoes, they need to wear them for maybe an hour or two hours and check the feet for any redness on the bony prominences. A lot of our patients wear Crocs and we do not have any pressure ulcers with Crocs. It’s wonderful. I already spoke about the nutritional aspect of it. That’s kind of the whole program and we do that with everybody here.
Melanie: Thank you so much. You’re listening to Shepherd Center Radio and for more information you can go to Shepherd.org. That’s Shepherd.org. This is Melanie Cole. Thanks so much for listening.