Skin Care and Spinal Cord Injuries

An Education Tool for all Health Care Professionals

QSCIS Education Series

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Chapter 1 Introduction to skin care and Spinal Cord Injuries

Click on any of the links below to go directly to that session OR Just browse through page by page to see whole presentation Each page will also have further links at the top

Chapter 4 Management of Skin Areas

Chapter 2 Anatomy and Physiology of the Skin

Chapter 5 Post Healing, Prevention and Patient Education

Chapter 3 Physical Assessment of the Skin

References

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Chapter 1 Introduction to Skin Care and Spinal Cord Injuries

Upon successful completion of this section the learner will Understand the importance of skin care in people with SCI. Be aware of the prevalence of skin issues in people with SCI. Develop an appreciation of the psychosocial impact of pressure ulcers on the person with SCI.

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Importance of skin care to people with SCI

The development of a pressure ulcer during the initial rehabilitation period can lead to increased costs, increased length of hospitalisation increased need for specialised equipment, and will then increase the total cost of rehabilitation, and the personal cost to the person with SCI. This can then lead to heightened levels of frustration, anxiety and further adjustment issues which lead to poorer short and long term physical and psychosocial outcomes. The development of a pressure area after discharge from hospital can have an equally negative impact. Middleton (2004) indicates that pressure ulcers can interfere with health and well-being, social activity, productive employment and quality of life.

Therefore skin care and its prevention is of major concern to the rehabilitation of the person with SCI to ensure a shorter, smoother initial rehabilitation and improved quality of life over their lifespan.

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Prevalence of skin issues in people with spinal cord injuries

Prevalence can vary across the world from 20% to 54% (Caliri 2005). 50% to 80% of people with SCI receive at least one pressure ulcer throughout their life span (Caliri 2005). Pressure ulcers are more common in paraplegics under 45 years (Middleton et al. 2004). Pressure ulcers account for 25.4% readmission days within the first 2 years of discharge (Pershouse et al. 2000). 20% of people experience at least one pressure area within the first 12 months post discharge (Dorsett 2001).
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SMART Skin Management Rehabilitation Team

QSCIS has recognised the high incidence of pressure ulcers in people with SCI and developed SMART.

SMART is a dedicated team of nursing, allied health and medical staff that overview the management of people with SCI who have been readmitted with pressure ulcers.
The objectives of SMART are to Improve the level of service provided to people with SCI who have pressure ulcers by reducing the waiting time to admission for surgical management Identify gaps in current service delivery and establish best practice in pressure care management for spinal injured patients. Develop and trial a multidisciplinary process to manage pressure ulcer readmissions Provide future recommendations for QSCIS and Queensland Health in the management of pressure issues in spinal injured clients. (Urquhart et al., 2004)

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Psychosocial impact of skin issues

The psychosocial impact of skin issues on people with SCI is enormous. Not only are they already dealing with the difficulties imposed on them by their initial disability as well as the adjustments they need to make in all life domains, the development of a pressure ulcer will further impact on every aspect of their lives.

Pressure ulcers, have long been recognised as one of the most devastating secondary complications among people with SCI (Krause, 1998).

There are many social, financial, emotional and relationship costs associated with pressure ulcers. A number of social and environmental factors can contribute to the development of pressure ulcers such as inaccessible environments, inadequate equipment, inadequate care and other supports, mood related disorders such as depression, adjustment issues, co-morbidities, dual diagnosis, substance dependence, lack of positive social relationships, isolation, and lifestyle choices such as active engagement in work or sport.
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A model developed to depict the life impact of a pressure ulcer to a person with SCI.

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Chapter 2 Anatomy and Physiology of the Skin

Upon successful completion of this section the learner will be able to Understand the anatomy of the skin. Comprehend the physiological impact that a SCI has on the patients skin (Intrinsic factors). Comprehend mechanical forces that can contribute to the development of pressure ulcers (Extrinsic factors).

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Anatomy of the Skin

The skin or integumentary system is the largest organ of the body. Measures 7600 sq cm, 15% of our total body weight, and has 1/3 of our blood circulating around it at any one time (Carville, 2005).
The skins main function is protection, forming a barrier between the internal organs and the outside environment. Constantly regenerating itself, the skin is the external reflection of the bodies health status (Cohen, 2005, Ousey, 2005).

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Layers of the Skin

The skin comprises of three distinct layers:
The epidermis outmost layer, 0.04mm thick and avascular. As the outer cells are worn away it is continually replaced by new cells, this process takes about 4 weeks. The dermis is very vascular and contains all the nerve endings, lymphatics, connective tissue, and collagen protein. Approx 0.5mm thick it is the support framework for the epidermis and is attached to the hypodermis. Subcutaneous tissue the thickest layer of the skin. Functions as the main support framework for the skin and attachment of underlying organs and structures. Made up of adipose and connective tissue and contains blood vessels. Contributes to the function of temperature regulation and storage of lipids (Carville, 2005).
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Function of the Skin

As well as protection, the skin has many other functions, including sensation, communication, thermoregulation, metabolic synthesis and cosmesis.

Protection of the underlying structures from Trauma mechanical, thermal or chemical Pathogen invasion Dehydration Sensation responding to stimuli like Heat/ cold Pain Touch Pressure Vibration Communication through Changes in skin colour Facial expression Body odour

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Function of the Skin - continued

Thermoregulation through Radiation of heat from blood vessels Excretion and evaporation of sweat Convection and conduction of heat Insulation by the subcutaneous tissues and hair follicles Metabolic Synthesis involving keratin, melanin and vitamin D Cosmesis psychosocial consideration in wound healing and scars in regards to body image and quality of life. (Carville, 2005)

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Physiological Impact of SCI on the Skin (Intrinsic Factors)

Somers (2001) states that spinal cord injury brings with it a lifelong vulnerability to the development of pressure ulcers. A SCI results in many changes to the body that in turn creates a high susceptibility to the development of pressure ulcers. These changes include loss of mobility, loss of sensation, impaired circulation and other autonomic functions that result in altered body homeostasis - like sweating (Zejdlik, 1992, Hanak and Scott, 1993), as well as Biochemical factors (Garber, 2000).

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Loss of Mobility
The resulting paralysis from an injury to the spinal cord creates direct and indirect threats to the skin integrity.
Direct threats to the skin are described as prolonged pressure, friction, heat, and moisture. Indirectly, the skin is compromised by nutritional deficits, chemistry imbalances, and renal, or cardiovascular complications (Hanak and Scott, 1993). The level of SCI will affect this risk as the higher the level of injury the greater degree of mobility loss. Even though patients with a lower motor neuron injury (below T12) can be highly mobile, they have associated muscle wastage particularly over the buttock area which places this group to increase risks of injury to their skin as well.

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Loss of Sensation
The effect of sensational loss will vary with the degree of sensory impairment experienced by the person with SCI. Unimpaired sensation warns a person of potential threats to the skin. Loss of temperature sensation can expose a person to risks of burns. Loss of pressure sensation will prevent the person from feeling any threat from prolonged sitting. Loss of pain sensation can impair the persons ability to protect themselves from any potential trauma. Sitting on foreign bodies, injury to feet or toes through physical trauma, poorly executed transfers which result in tissue scrapes over the buttock can all be missed in a person with impaired sensation. Loss of sensation can prevent a persons ability to feel a minor impairment to the skin integrity that coupled with prolonged pressure can rapidly progress to a major pressure ulcer.

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Impaired Circulation
Due to the impact of the SCI on the autonomic nervous system, the circulatory system is no longer functioning optimally. Chronic vasodilation and reduced venous return, due to impaired movement, results in peripheral oedema, poor oxygenation poor waste removal, and reduced capillary closing pressure. All these factors lead to an increased susceptibility to tissue damage (Hanak and Scott, 1993).

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Autonomic Functions

The sweat glands of the skin assist the body to rid itself of toxins, assist with thermoregulation, and lubricate or moisten the skin (Hanak and Scott, 1993).

These functions are no longer effective due to the disruption to the autonomic nervous system following a SCI and thus reduce the health of the skin.
In addition, medical complications can often result in profuse sweating which leads to excessive moisture and potential for maceration of the skin (Hanak and Scott, 1993).

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Biochemical Factors
Neurological impairment of the skin does not stabilise for 3-5 years post injury. Many of these changes are related to the collagen make up of the skin. It has been reported that normally innervated skin can withstand ischemia three times longer than neurologically impaired skin (Garber, 2000).

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Non-spinal specific intrinsic factors

Advanced age many people with SCI are now first sustaining their injury at a more advanced age, and people with SCI in general are aging with their injury, so advanced age is a significant factor that needs to be considered (Carville, 2005). Poor skin condition not only does the impair sensation and changes to autonomic functions of a SCI contribute to poor skin condition; incontinence, difficulty in maintaining hygiene and poor-hydration all contribute to the reduction of the health of the skin and increase the risk of skin areas. Carville (2005) states that undamaged skin is tolerant of pressure, shearing and friction. Therefore any trauma and disruption to the skin integrity, when couple with extrinsic factors (outside the organ/body) are more likely to lead to pressure ulcer development. The following are examples of skin integrity issues that can lead to pressure ulcers if pressure, shear or friction is applied;
burns pimples scrapes rashes.

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Remember
It is important to remember that any change, visible or palpable, to the skin or tissues integrity can lead to the development of a pressure ulcer if extrinsic factors like pressure, shear or friction are applied. This needs to be considered when conducting skin checks and deciding on the management of skin integrity issues. These factors also need to be considered when developing and providing education and developing prevention strategies for people with spinal cord injury in skin care.
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Mechanical Risk factors - Extrinsic

Coupled with the above physiological changes that occur as result of a SCI and increase the susceptibility of a person with SCI to develop pressure ulcers, there are mechanical factors that alone or in conjunction with intrinsic factors can contribute to the development of pressure ulcers. These extrinsic factors are pressure, shear and friction.

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Pressure
Carville (2005) states that both the duration of sustained pressure and the magnitude of the pressure governs the degree of tissue damage,higher pressure will cause damage in a shorter period of time. This is not to forget that low pressure over a long period of time can also cause pressure ulcers (Sussman and Bates-Jensen, 2001). Pressure is induced through the compression of skin and tissue in between a support surface like a mattress or cushion and underlying bony prominences. Over time pressure will occlude blood and lymphatic vessels resulting in deficient tissue nutrition, build up of waste products and ischemia (Sussman and Bates-Jensen, 2001). If pressure is relieved before this critical time is reached; which is a normal compensatory mechanism in people with intact movement and sensation, and tissues nutrition and circulation is not restored, then cell death will occur (Sussman and Bates-Jensen, 2001)
Picture (Carville, 2005)

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Shear
Where pressure is in a perpendicular force, shear is a parallel force. Tissue is displaced laterally to create occlusion of blood and lymphatic vessels leading to the same possibility of cell death as with pressure (See Picture ) (Sussman and Bates-Jensen, 2001).

Picture (Carville, 2005)

Shear is often caused when patients are sat up through elevation of the head of the bed greater than 30, creating a shearing force over their sacrum and could potentially result in a pressure ulcer. The bony structure of the pelvis slide forward through the force of gravity, but the tissue and skin remain in place with the help of the bed linen creating friction (Sussman and Bates-Jensen, 2001).

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Friction
This occurs when two surfaces move across each other, it acts on the tissue tolerance through abrasion and damage to the outer layers of the skin (See Picture) (Sussman and Bates-Jensen, 2001).

Pressure ulcers can then develop if the friction is not relieved or if pressure or shear is then applied to the minor damage caused by friction.
This is often seen in people with SCI when they exhibit spasm. Friction can also happen through ineffective clearance during transfers and the turning of patients in bed. Appliances like slide sheets help to reduce the impact of friction during the movement of patients.

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Chapter 3 Physical Assessment of the Skin

Upon successful completion of this section the learner will be able to Understand the risk factors associated with pressure ulcer development for people with SCI. Understand how to conduct a risk assessment using the Waterlow assessment tool. Understand how to assess the skin of a person with SCI for potential changes in the skin integrity. Be able to identify common sites of pressure ulcer development.

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Risk factors associated with skin issues for people with SCI
All individuals with SCI are at risk for the development of pressure ulcers. Numerous risk factors have been identified and described in the literature [including] demographic, physical/medical, and psychosocial factors (Garber, 2000). Demographics -Age, duration of injury, gender, ethnicity, marital status, and education.

Physical / Medical- Level and completeness of injury, activity and mobility, bladder, bowel and moisture, and co-morbidities e.g. surgical scars, deformity, diabetes, peripheral vascular disease etc. Psychosocial -Psychological distress, cognitive impairment, substance abuse, and adherence. (Garber, 2000)
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Queensland Health and Princess Alexandra Hospital (PAH) has adopted the Waterlow Pressure Ulcer Risk scale to identify patients at risk of developing pressure ulcers.
This tool takes into account the patients physical build, continence, mobility, skin type, nutritional status, sex / age, and associated medical conditions. A risk score is measured for each category and the total then allocates the patient to a risk category.

Risk assessment of skin problems for people with SCI

It is a guide on which to base decisions by ascertaining the level of risk to the patient for sustaining a pressure ulcer. This tool is a guide only and needs to be used in conjunction with a good clinical assessment of each individual. Always consider other risk factors that may be associated such as demographics, physical, medical, and psychosocial status as discussed previously.

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How to physically assess the skin of a person with SCI

Assessment of the skin requires a comprehensive visual and tactile inspection. Particular attention needs to be paid to areas of vulnerability over bony prominences including the ischium, greater trochanters, sacrum/ coccyx and heels. This does not exclude checking all other areas that may be have been exposed to pressure or trauma. Frequent inspection is needed to detect early warning signs of skin changes allowing for earlier intervention and minimisation of the damage (Garber, 2000).

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Visual Inspection
Visual assessment of the skin over bony prominences should include assessment for changes in Colour (red areas, discolouration, bruises) Texture (dryness, raised areas, cracks, scabs, blisters, rashes, shiny areas) Visual inspection needs to be conducted over all areas that have had potential pressure, shear or friction.
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Tactile inspection
Tactile inspection should be used to feel for areas of Warmth Wetness Swelling Hardness Softness.

Any changes to the skin could indicate the beginnings of a pressure ulcer, particularly if pressure continues to be applied.

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Self management of Skin Checks

Through education, people with SCI should be encouraged to assume responsibility of their skin care management. Paraplegia and some low level tetraplegia can be taught to self assess their skin with a mirror. Even if they are unable to perform their own skin assessment, it is important that the person learn to direct and monitor the inspection of their skin by others and be aware of the results of this assessment to direct appropriate courses of action.

Under a rehabilitation model, people with SCI need be taught how to self manage their skin, first during their initial and any subsequent hospitalisation, then after discharge to the community.
So remember to include the person in the assessment of their skin and encourage them to take charge.

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Frequency of skin checks

QSCIS recommends that skin inspection is conducted at least twice daily. This is generally conducted in the morning to ensure that nothing has occurred overnight in bed to cause changes to their skin, and at night on going to bed to ensure that nothing happened during the day while sitting in the chair. This allows for easy identification of potential sources/causes of skin trauma/damage. Skin inspection should also take place after each shower as this is a time of high risk for skin trauma.

Ideally an inspection of the skin is required after any change of position, especially for those people who are unwell or bed bound, and to all people with SCI as soon as possible after an event that may have caused trauma, i.e. bad transfer, lying/sitting on hard surface like xray or theatre tables. Remember: Frequent inspection is essential to detect early warning signs of impending skin breakdown (Garber, 2000).

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Common sites of pressure ulcer development in people with SCI

In the following positions, these areas are at risk of increased pressure lying on your back (supine) - occipital, sacrum and heels side lying lateral aspect of the greater trochanters (GT) sitting in a wheelchair - ischiums, posterior aspect of the GTs, sacrum and scapula using a shower commode posterior aspect of the GTs and sacrum, natal cleft and coccyx. This list is a guide and not conclusive. Many people with spinal cord injuries will sit and adopt postural deformities that place other less common bony prominences under increased pressure.

Area of pressure in different positions (Garber, 2000) QSCIS Education Series

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Chapter 4 Management of Skin Areas

Upon successful completion of this section the learner will be able to: Understand how to assess pressure ulcers. Demonstrate knowledge of the overall management (excluding wound dressings) required of a pressure area in people with spinal cord injury. Appreciate the nutritional needs in the prevention and management of pressure areas with people with spinal cord injury.

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Assessment of Pressure Ulcers

Accurate assessment of a pressure ulcer requires a standard measure that can be used by all health-care professionals involved in the management and care of people with pressure ulcers (Ousey, 2005). Pressure ulcer assessment requires many measurements to depict severity, including: stage size, depth, tissue health, exudate. All these need to be clearly documented and reviewed on a regular basis. This in turn directs the type of care required.

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Grading of a pressure ulcer

The first assessment of the pressure ulcer to be taken is its grade. Grading systems not only provide a base line for all health-care professionals to work with, they also allow for studies into incidence and prevalence of pressure ulcers (Ousey, 2005). The following grading system was proposed by Queensland Health (2004) as part of a recommendation by the National Pressure Ulcer Advisory Panel and documented in the Pressure ulcer prevention and management resource guidelines.

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Stage 1
Observable pressure-related alteration of intact skin whose indicators, as compared to adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues.
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Stage 2

Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

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Stage 3
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

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Stage 4
Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or support structures (e.g. tendon or joint capsule). Undermining and sinus tracts may also be associated with Stage 4 pressure ulcers.

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Location
The second most important part of assessing a pressure ulcer is clearly defining its location. This is generally documented in relation to the underlying bony structures. The easiest way to assess the location of a pressure ulcer on a patients buttock area is assess them in a lateral lying position i.e. lying on their side with hips flexed to 90 and knees flexed to 90. This mimics the position achieved when seated in their wheelchair, therefore giving a good impression of how the tissue lies over the underlying bony prominences whilst pressure would be applied during sitting. Palpating directly over the pressure ulcer is then required to determine which bony prominence it is associated with.

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The following bony prominences are the main areas to assess:

Ischiums The most inferior part of the pelvis. In the above described lateral position the ischiums are generally located about 5-6 cm lateral of the anus. Ischiums are generally 9-11cm apart in most people. Greater Trochanters (GT) Bony projections on the proximal end of the femur. In the above position the GTs are the most prominent bony structure in the hip region. If the wound is in this location then specific assessment needs to be made to determine which part of the GT the wound is over i.e. below or to the side of the GT. Palpate the wound: if it lies under the GT it is possible the area developed from sitting; if on the side, the area may have developed from side lying in bed. Sacrum / Coccyx The sacrum is formed from the fusion of the five sacral bones and forms part of the pelvis. The coccyx is formed from the fusion of the four bones at the base of the spine below the sacrum. Assessing the true location of this is important to determine if the pressure was coming from a seated position in a shower chair, wheelchair, or in bed.

Accurate assessment of the location of the area and possible cause of the pressure ulcer will assist in the assessment of future prevention strategies.
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Further pressure ulcer assessment

After staging and location of the pressure ulcer are completed, the following further assessments need to be made. Size/ depth measurement of width, length and depth (with wound probe) will allow you to track progress of wound and will indicate any changes in healing and the potential need for a change in management. Presence of sinus/tracking gentle probing with a wound probe by an experienced staff member and measurement and location of sinus needs to be conducted. Colour and type of tissue in wound bed distinguishes viable from non-viable tissue. Should be described in terms of: Black necrotic Yellow slough Green infection Red granulating Pink epithelialising Exudate and odour amount for consideration in the management. Condition of surrounding skin describing inflammation or maceration etc. to be considered in management. All this should be documented in the patients charts weekly (Princess Alexandra Hospital, 2003)
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Identify the cause

Determining the cause is one of the most important steps in the management of pressure ulcers. The cause needs to be determined so it can be removed to reduce further deterioration and potential reoccurrence.
Location of the wound will be your first clue. Ischial possible cause from sitting in wheelchair or other surface Lateral Great Trochanter (GT) possibly side lying Posterior GT possibly shower chair or sitting in wheelchair Sacral / Coccygeal (natal cleft) possibly sitting with head elevated in bed or shower chair Shape of the wound will also assist Rounded possibly due to pressure Elongated or irregular possibly shear or friction. History of any trauma is also important like a Fall Bad transfer, or Sitting longer than normal on a shower commode.

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Identify the cause - continued

This is not an exhaustive list, but only a guide for you to start your search for the cause of the wound. Once found every step possible needs to be taken to remove this cause through Equipment review Transfer/ technique review Self care review, i.e. how they are conducting skin checks Education on cause and how to avoid in the future.

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Management of Pressure Ulcers

People with pressure ulcers should be positioned so there is no direct pressure over the damaged tissue Pearson (1997). QSCIS has long regarded the principle of NO PRESSURE over the areas affected by pressure ulcers as standard practice. This means bed rest 24 hours a day, 7 days a week. This is easy to say, but can be hard in practice, particularly in the community.
FIRSTLY, an assessment needs to be made of the positions available to the person with SCI so that no pressure is applied to the pressure ulcer. SECONDLY, prioritisation of activities the person with SCI needs to perform. THIRDLY a review of the persons normal ADLs to see if any adjustments need to be made to accommodate the bed rest required FINIALLY, an assessment needs to be made of any other supports the person may require during this period of bed rest.

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Nutrition
A nutritionally balanced diet is a prime requisite for tissue repair and regeneration Carville (2005). Protein contains amino acids which are the components that make up collagen (the protein of connective tissue) Ascorbic Acid (Vitamin C) is also essential for collagen synthesis Zinc severe deficiency can lead to abnormal functioning white blood cells and lymphocytes, increasing susceptibility to infection and delayed wound healing (Sussman and Bates-Jensen, 2001)

The evidence is confusing and does not give any definite conclusion on how to base our practice, yet a few guidelines can be drawn Malnutrition can often lead to the increased susceptibility for pressure ulcer development. Protein supplements have been found to be beneficial in wound healing. Vitamin and mineral supplements have no ill effects as long as their given within RDI guidelines.

Therefore people with SCI should maintain a good nutritional intake; any person that develops a pressure ulcer should be reviewed with the possibility of the inclusion of dietary supplements under the guidance of a nutritionist.
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Chapter 5 Post Healing, Prevention and Patient Education

Upon successful completion of this section the learner will be able to: Understand the rationale for using seating programs in pressure area management. Understand protocols and the implementation of seating programs. Understand the need for pressure relieving equipment. Be familiar with the different categories relating to pressure relieving equipment. Understand prevention strategies related to pressure ulcers. Utilise patient education strategies within their work practice in regards to skin care management. Appreciate the importance of effective discharge planning with regard to skin care in people with SCI.

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Sitting programs
After healing of any pressure ulcer, whether that be through surgical or nonsurgical methods, consideration of a range of issues is essential to ensure the best outcome for the person with SCI. One component is the reintroduction of sitting.

QSCIC recommends a protocol of remobilisation to commence after 4 weeks uncomplicated healing. This allows for the area to increase in strength and ability to tolerate seating pressure and stretch over the scar tissue. The remobilisation should take place through a graduated sitting regime.
This picture shows the program utilised by QSCIS for inpatients postoperatively. This regime is designed to allow for an increase in skin sitting tolerance over gradually increasing periods of time, but also ensures that should a skin tolerance issue arise that it is identified and managed early keeping skin damage to a minimum.

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Sitting programs - continued

Sitting regimes times need to be strictly adhered to. Skin inspection both before and after sitting are needed to assess for the early signs of complications. Transfers into and out of bed using a hoist is recommended during the sitting regime to reduce the risk of trauma, this is to continue until clearance is given by the individuals physiotherapist for them to resume transfers if applicable. Returning to bed at the correct times allows for the best assessment of skin tolerance for that length of sitting time.

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Pressure relieving equipment

People with SCI may require several pieces of equipment to assist with their mobility and ADLs. These can include wheelchairs, cushions, hoists and slings, mattress and showering equipment. Pressure relieving devices can be divided into 1) comfort equipment, 2) static pressure-relieving devices, 3) dynamic or alternating pressure-relieving systems and 4) specialty beds (i.e. Engrit beds) (Carville, 2005).

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Prevention of pressure ulcers

Pressure ulcers in people with SCI are largely preventable, but still extremely common. Prevention is the best practice and this needs to start at the very beginning of rehabilitation and become a habit by the end of discharge, and throughout the individuals lifespan. Prevention comes in many forms, including regular skin checks ability to identify and solve problems when skin issues are found appropriate equipment maintained in good condition minimising risky behaviours e.g. poor transfers regular posture checks regular pressure relief diet, exercise, hygiene, non-smoking etc.

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Prevention Skin checks

Education on how to perform skin checks and manage these checks with carers if the person is unable to perform these independently it is their responsibility to oversee the checking and problem solving any skin issues
Education on what to look for when checking their skin Routine checking of their skin before they get out of bed, after they get into bed and after their shower commenced during rehabilitation to start forming a habit.

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Identify times when damage may have occurred i.e. after a bad transfer, and instill the importance of checking their skin as soon as possible after this.
Provision of suitable equipment to assist with skin checks if needed i.e. a mirror

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Prevention Problem solving of issues

The importance of total pressure relief off the area on identification of a skin problem
Simple management strategies for simple skin problems Liaison with community i.e. community nursing services, GP, SPOT, if the persons own management strategies are not working and/or the skin problem is not healing or getting worse Stressing the importance of asking for help early its much easer to fix a small problem.

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Prevention - Equipment
Ensure equipment is well maintained Appropriate adjustment of equipment i.e. cushion inflation, footplate height etc. Ability to identify when equipment is no longer appropriate or needs repair Information on how to obtain assistance with review and replacement of equipment Advice on time frames when equipment should be replaced and who is able to assist with this i.e. supplier, Medical Aid Assistance Scheme (MASS).

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Prevention Pressure relief

Problem solving the best strategies to obtain pressure relief over and above their pressure relieving equipment, depending on their functional level
Pressure lifts or shifts technique, frequency and positioning Tilt in space in power-drive wheelchairs for individuals with higher level injuries Symmetrical posture doing regular posture checks Encouragement, and explanation of benefits of prevention prior to discharge

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Prevention - other
Encouragement of a balanced diet
Information of weight gain/loss and its impact on the skin Adequate fluid intake

Stressing the impact of smoking and alcohol consumption on increasing the risk of skin problems Management of hygiene
Encouraging clean dry skin Ensuring incontinence is well managed and instilling the importance of prompt hygiene if accidents occur. All these prevention strategies are a part of an effective, holistic management program by the health professional of a person with SCI. Ensuring that the person with SCI is able to self manage these strategies before discharge is important.

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Patient Education Strategies

Rehabilitation is not only about ensuring the person with SCI is discharged with the highest level of ability they can achieve in all areas of their life, it is also about the person being informed about their injury and how to identify early and manage any potential complications they may face. Patient education during initial rehabilitation is recognized as the key by which patients effectively transition from hospital to community and guides the lifelong process of living with a disability. Patients need to be prepared to return to the community with the information and skills necessary for maintaining optimal health and wellbeing (May et al., 2006).
Motivation and readiness are two important components of adult education Motivation is the persons willingness to embrace the education Readiness is the term used to describe the level of motivation at a particular time (Redman, 2001) .

This is why time, patience, consistency of information to limit confusion and conflicting knowledge, and repetition of education at every opportunity is an essential component of a successful rehabilitation program.
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Every task you complete, assist in and decision you make needs to be explained to the person with SCI so they can accumulate the knowledge, skills, problem-solving skills and attitude needed for them to successfully assimilate back into their community.

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Discharge planning
The rehabilitation process assists the transition of the person back into the community and to a lifestyle as close as possible to their previous situation. Therefore discharge planning is one of the most important components of their rehabilitation. The discharge planning process, along with effective patient education, ensures that the potential risk for complications is minimised and the persons care needs are appropriately meet. A number of factors need to be considered in addition to functional ability. These factors included the persons individual roles, lifestyles, lifestyle demands and responsibilities, resources, travel, vocational and recreational issues.

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General discharge planning for a person with SCI

Personal care needs Does the person need assistance with ADLs? Do they need assistance from an outside agency? If care is unavailable is there someone within the persons support circle that can and is appropriate to fulfill this role? Co morbidities Are there other non SCI health concerns? Does the person need to be link with other community health services? Housing Is their home accessible? Are their other people in the home to consider? Can modifications be made or is alternative housing needed? How will this be funded?

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Mobility What are their equipment needs? Do they fit in with the above personal care and housing solutions? If they are a readmission do they need their equipment reviewed? Do they need new or additional items of equipment? How will this be funded? Patient education Is the person knowledgeable about their level of disability, their care requirements, where to go for help and how to monitor and identify any secondary complications early? If not what are the obstacles to this knowledge? What are your educational responsibilities as a professional? How will you engage the person in the learning experience? Travel How will the person physically get home? What does the person have to consider during travel?

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Specialised discharge planning for a person with skin issues

Cause of the skin area
Has this been identified? Has this risk been reduced?

Pressure relieving equipment

Is this appropriate for their risk of skin problems? Are they adequately educated in the care and maintenance of the equipment? Do they know where and when to seek help with their equipment? Do they have someone to set up any equipment (i.e. mattress) at home?

Skin care
Are they appropriately checking their skin morning, after shower and at night? Do they have the knowledge and resources to manage small areas appropriately if they happen? Do they need support in the management of their skin and has this referral been made? Do they need follow up review with the SIU? Have they been identified to TRP and SPOT as a potential risk for further skin issues so appropriate support can be provided? Is the team, the person and their carers/families in agreement with the discharge plans?
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Once one pressure ulcer has been experienced, the risk for more is increased. These groups of people need to be specifically targeted to ensure that all potential risks have been reduced as much as possible. This can require a change in their attitude towards skin care, changes within their home situation and with the equipment prescribed to reduce that risk.

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References
CALIRI, M. H. L. (2005) Spinal cord injury and pressure ulcers. Nursing Clinics of North America, 40, 337-347. CARVILLE, K. (2005) Wound Care Manual, Osbourne Park, Silver Chain Foundation.

COHEN, B. (2005) Memmler's The Human Body in Health and Disease, Philadelphia, Lippincott Williams and Wilkins
DORSETT, P. (2001) Spinal cord injury: How do people cope? School of Social Work and Social Policy. Brisbane, University of Queensland.

GARBER, S. L. (Ed.) (2000) Pressure ulcer prevention and treatment following spinal cord injury: A clinical practise guideline for health-care professionals, Paralyzed Veterans of America.
KRAUSE, J. S. (1998) Skin sores after spinal cord injury: relationship to life adjustment. Spinal Cord, 36, 51-56.

MIDDLETON, J. W., LIM, K., TAYLOR, L., SODEN, R. & RUTKOWSKI, S. (2004) Patterns of morbidity and rehospitalisation following spinal cord injury. Spinal Cord, 42, 359-367.

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OUSEY, K. (2005) Pressure Area Care, Oxford, Blackwell. PEARSON, A. (1997) Pressure sores - part II: Management of pressure related tissue damage. Best Practice: Evidence based practice information sheets for health professionals, 1, 2, 1-6. PERSHOUSE, K., COX, R. & DORSETT, P. (2000) Hospital readmissions in the first two years after initial rehabilitation for acute spinal cord injury. Topics of Spinal Cord Injury Rehabilitation, 6, 23-33. PRINCESS ALEXANDRA HOSPITAL (2003) Wound management policy. REDMAN, B. K. (2001) The practice of patient education, St Louis, Mosby. SOMERS, M. (2001) Spinal Cord Injury: Functional Rehabilitation, New Jersey, Prentice Hall. SUSSMAN, C. & BATES-JENSEN, B. (2001) Wound Care, Gaithersburg, Aspen. URQUHART, S., GRIFFITHS, L., KING, T., BAIRD, B. & DORSETT, P. (2004) Spinal cord injuries pressure readmissions project plan.
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