Stopping Pressure Injury Before It Begins

Posted by Nurse Linda in Life After Paralysis on June 23, 2021 # Health

A pressure injury is an issue for individuals with decreased sensation. The body tells the brain through the sensory nerves that we need an adjustment. These messages include that the blood vessels are becoming constricted due to the pressure of our body’s weight on them, that we have a muscle tiring, want some pressure relief, or that something is itching or uncomfortable. Thousands of indications of needing to change our position are provided to the brain. The brain processes all that information in nanoseconds. We then twitch or move a foot or lean a little more one way or even get up and move around to relieve the pressure. Most of the time, we are making thousands of small movements a day without even realizing it. This all happens automatically through the autonomic nervous system (ANS). Sometimes, we think, “I need to get up and move about.” That is a conscious decision initiated from information gathered by the ANS.

Those with sensation issues do not have the messages to move received or analyzed by the brain. The messages are still being sent but are interrupted along the way. Therefore, those little messages to twitch or to move are not carried out. Pressure is not relieved. This can cause damage to the blood vessels that are carrying the nutrients to feed the body and, in particular, the skin.

Blood pressure is the amount of force that is required for blood to circulate through the body. It is strongest coming right out of the heart and gradually decreases as it passes through the large arteries, to the smaller arteries (arterioles), makes the transition to capillaries, and then is least in the veins—the farther from the pump, the less pressure.

You can monitor your blood pressure through your arteries by measuring your blood pressure with a blood pressure monitor. After spinal cord injury, blood pressure naturally declines over time until your body stabilizes at a lower pressure. Blood vessels do not respond as quickly to changes in position, so you might become lightheaded when sitting up too quickly. These are the same issues that affect the blood pressure in your tiny arterioles and capillaries. You cannot measure the blood pressure in your arterioles and capillaries at home. Body pressure is being applied to these microscopic vessels, but the message to release the pressure when the brain is not receiving necessary. This can lead to damage to the vessels as blood is not able to pass through. Those vessels cannot deliver oxygen to their target, leading to damage to the vessels, muscles, and organs.

An accumulation of vessels that have been damaged by pressure leads to a deficit in the body. This is the start of a pressure injury. It begins inside the body where it is not seen and not felt. They start from the point of a bone pressing against internal tissue. By the time a change in pigmentation is seen on the surface of the skin, pressure injury is already developing within the body.

This damage can happen very quickly, in about 10-12 minutes or even much less time. That is fast. Skin that has a healed pressure injury has a scar. The scared tissue will be deep into the body as well, where you cannot see. Scars lack the elasticity of the skin, which makes the area more fragile in the future.

Since you cannot possibly know that a pressure injury has begun, you need to know that it is not necessarily a failure on your part. Pressure injuries occur for a variety of reasons, often even for reasons unknown. As individuals, we can only do our best. Often there is a physiological reason for a pressure injury that perhaps could have been prevented, but sometimes, not.

Pressure injury stages have been identified by the National Pressure Ulcer Advisory Panel and are documented as follows:

Pressure injury stages diagram

It is best to avoid a pressure injury from avoiding long-term consequences once the injury has occurred. The goal is to work toward never developing a pressure injury. Here are the steps you can take.

1. Avoiding internal damage is the goal of manual pressure releases. If you cannot automatically release pressure in your body, you need to perform manual releases. That means picking up your body and allowing blood to resume circulation through those tiny blood vessels prior to the damage occurring or before the body is unable to reopen those tiny vessels. This is a necessity in the prevention of pressure injury.


There is no exemption for pressure release, but there are supports you can use to help you. Pressure releases still need to be accomplished, but the following supports will help reduce the chance of a pressure injury from forming.


2. Surfaces that reduce pressure are necessary. Not all pressure-reducing surfaces are created equally. For instance, some think a pillow or craft foam will do because they are cushiony. However, these surfaces collapse with pressure, thereby creating a surface that adds pressure, making the situation worse. To reduce pressure on your skin, a surface that disperses pressure is needed. There is equipment that spreads the pressure from a central point, so it is not concentrated in one area.


There are many options for pressure dispersion. Bed overlays or specialty mattresses should be used. This can assist the individual in building up to two hours on one side prior to turning. Seating systems require more structure as all the upper body's weight rests on the bottom and upper thighs. In other words, more bodyweight is placed through a smaller surface amount of the body. Surfaces for bed and seating are based on the needs of the individual and their health status. Surfaces can include medical-grade foam that is designed to disperse pressure, gel-filled, air-filled systems that will alternate pressure areas. A pressure mapping device can temporarily be placed under your pressure points to ensure pressure dispersion and check that your system is working for you.


3. Eat a healthy diet. Nutrients need to reach every part of the body on a cellular level to provide power and life to the cells. If your diet does not contain the nutrients, the cells cannot obtain them. Eating a well-balanced diet that consists of fresh fruits and vegetables with little processed food is best.


4. Include fluid in your health plan. Drinking water is essential for cell function. Hydrate your body to provide the fluid needed for health. Avoiding excessive use of alcohol, sugar and caffeine will benefit your cells as these fluids can rob your body of the nutrients needed.


5. Check your skin often. You will be checking your skin frequently in the rehabilitation hospital. If someone is doing this for you, join in. It is your body. You need to know how your normal looks. Continue this at home. People often let this slide because they get in a routine and all is well, but this stability can change in an instant. Checking, using a mirror, documenting on your private camera will help you keep track.


6.Exercising your body will help keep joints supple as well as encourage blood flow through even the smallest of vessels. Exercise has many benefits to all parts of your body but especially the skin and blood vessels.

Most importantly, if you develop a change in pigmentation anywhere on your skin, stay off that area until totally resolved. In lightly pigmented individuals, a pressure injury will appear as a red spot. In those with darkly pigmented skin, an area will appear as a purple or ashy spot. Staying off the area is critical as the change in pigmentation is indicating that blood flow is not occurring in the capillaries at the surface of your skin. More damage has occurred inside where you cannot see it. Staying off the area until the change in pigmentation is resolved is absolute. One minute of applied pressure can negate hours of work you have put in by staying off the area. A few days or even a week of staying off a pressure injury is a shorter amount of time needed than if the pressure injury continues to develop and becomes worse.

Setting the stage to reduce pressure injury will help in the future. As we age, our skin becomes a bit more fragile and not as resilient. Blood vessels can weaken. Effects of long-term chronic issues come to the forefront. Starting a pressure injury prevention lifestyle will assist you as you live your best life. Nurse Linda

Pediatric Consideration:

Older children will be able to check their skin, but as a parent, you might want to, occasionally, just happen to be there when this occurs so you can check as well. Involve smaller children in the skin checking process as this can build their confidence in caring for themselves.

People often think baby skin is so healthy and resilient that pressure injury will not occur, yet it does. Be sure to turn and monitor children as the result of pressure injury is an area of skin that lacks elasticity for a lifetime. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

This project was supported, in part, by grant number 90PRRC0002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.