Reducing the Development of Pressure Injuries in Wheelchairs

Without adequate intervention, wheelchair pressure injuries can have serious, long-term implications. Learn more to prevent them from occurring.

Pressure injuries, otherwise known as pressure sores, pressure ulcers or decubitus ulcers, are caused when there is sustained, elevated pressure applied to one area of the body. This pressure reduces blood supply, causing the skin to become damaged or even die, leaving an injury in its place. The first sign of a pressure sore includes warm areas of red, spongy or hard skin, contributing to a physical break in the top layers of the skin itself. These sores are dangerous and can become life-threatening if untreated—especially for those who suffer from chronic health conditions.

Pressure injuries are most likely to develop on bonier areas of the body, such as the tailbone, hips, heels, ankles or shoulder blades. They progress over hours or days, as the cells die and the skin breaks down. Pressure sores are particularly risky and common among seniors, people with limited mobility, wheelchair users and those with severe or chronic health ailments and are considered a common, long-standing issue in the medical profession.

Pressure Sores: The 4 Stages of Pressure Sores

When it comes to developing pressure sores and ulcers in a wheelchair, The National Pressure Ulcer Advisory Panel describes the four stages of pressure injury development as follows.

Stage I – Non‐blanchable Erythema: "Intact skin with non‐blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate ‘at risk’ persons."

Stage 2 – Partial Thickness: "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough [dead tissue]. May also present as an intact or open/ruptured serum‐filled or sero‐sanguinous [serum and blood] filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising [bruising indicates deep tissue injury]. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration [damage through the skin being wet] or excoriation [damage through scratching/abrasion or burns]."

Stage 3 – Full Thickness Skin Loss: "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput [back of the head] and malleolus [ankle] do not have [adipose] subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable."

Stage 4 – Full Thickness Tissue Loss: "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar [scabbing] may be present. Often includes undermining and tunnelling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have [adipose] subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis [bone infection] or osteitis [inflammation of bone] likely to occur. Exposed bone/muscle is visible or directly palpable."

Who gets pressure sores?

Pressure injuries can happen to anyone who spends too much time sitting or lying down in one place. People who are most susceptible to pressure injuries include those that are:

• Overweight
• Disabled
• In bed or sitting most of the day with little movement
• Without full bowel or bladder control
• Chronically experiencing decreased feeling in certain areas of the body
• Are often stuck in one position for long periods of time
  
  

How do pressure injuries develop in a wheelchair?

There are many different reasons why pressure injuries may occur. Simply put, a pressure sore happens when force is applied to the surface of the skin, whether through constant or dragging pressure. Most commonly, sores develop because of repeated or sustained pressure on the same point.

While devices that involve stationary positioning, like wheelchairs, are frequently associated with pressure injuries, there are many other situations where sores are prone to develop. Other examples include spending too much time in bed, long-term hospital stays or lengthy surgical operations. Sores are most likely to occur when a person spends prolonged periods of time in the same position, without adequate repositioning.

Skin will require more advanced care and medical intervention once the pressure injury has formed, so it’s best to take as many proactive measures as possible to prevent the injury in advance. And the good news is, MSKTC states that 95% of pressure injuries are actually preventable.

How can pressure sores be prevented?

There are many proactive steps that can be taken to decrease and prevent pressure sores among those at risk of developing them. Here are some techniques.

1. Increase movement – Impaired mobility is the greatest contributor to pressure sore development, and increasing movement is the easiest way to prevent them. Repositioning the body redistributes pressure while minimizing the friction on the skin.
   
   
2. Use specialty bedding or materials – There are many kinds of mattresses that relieve pressure and redistribute weight more evenly, while also increasing airflow through the mattress to keep the patient’s underside cool and dry. Egg crate mattress toppers are an alternative that allows air to flow under the patient to prevent pressure injuries.
   
   Gliding sheets help to reposition a patient with more ease and care since pressure sores can also be caused by excess friction between the body and the sheets. Cornstarch can also be used to minimize friction.
   
   
3. Keep skin clean and dry – Maintaining healthy skin through regular cleansing and airflow—and keeping an existing sore clean using mild soap and warm water—will ensure that a pressure injury does not worsen.  
   
   
4. Maintain a healthy, well-rounded diet – It’s been recognized that people who are overweight are more likely to contract a pressure injury. Encourage a healthy, balanced diet with at least 8 cups of water a day.
   
   
5. Inspect skin regularly – Check the skin at least once a day, in the morning and before bed. Keep an eye out for common signs of pressure injuries, such as changes in skin color, blisters, bruises or cracked, scraped or dry skin. Common signs of skin breakdown also include skin feeling hard, swollen or warm.
   
   
6. Stop smoking – Smoking has a vasoconstrictive effect on the capillaries at the dermal level, which can slow the healing of a pressure injury. Refraining from smoking can have positive impacts on the healing process.
   
   
7. Keep as active as possible – Movement can reduce the frequency of pressure sores, so patients are encouraged to be as active as possible. Even if this only means being lifted and rotated more regularly or doing some exercises in the chair, any movement will minimize the impact of pressure injuries.
   
   
8. Shift body weight – Weight shifts allow the redistribution of weight onto different pressure points on the body. By relieving the pressure that comes from weight remaining in the same areas repeatedly, we can eliminate the likelihood of an injury.
   
   
9. Manage stress effectively – Stress has many impacts on the immune system. The cortisol levels associated with stress have been recognized to increase glucocorticoid levels, negatively impacting the production of wound-healing cytokines.

10. Use a pressure cushion – For wheelchair users, an air floatation cushion can move the air from areas of high pressure to low pressure, equalizing the force on the seat surface to other, less vulnerable areas of the body. These seat cushions are available in all different shapes and sizes and are easy to transport wherever your chair might go.

Equipment for relieving wheelchair pressure sores

XSENSOR’s wheelchair seating system offers an effective solution for clinicians designing seating solutions for preventing pressure injury for wheelchair users. Our ForeSite SS system is the most advanced pressure mapping technology on the market, combining top-tier sensor accuracy and high-resolution images with easy-to-use software. The result is a conformable, effective sensor pad that measures skin pressure, helping to manage existing injuries efficiently—or prevent them from developing in the first place.

The right equipment, combined with appropriate lifestyle changes, can help to alleviate, reduce and eliminate pressure injuries — especially for wheelchair users. To integrate XSENSOR’s dynamic sensing technology into your patient care, contact us today.