By the WoundSource Editors

Pressure injuries require complex care. They can be incredibly painful for patients, and they represent an enormous financial burden on the health care system. A subset of these patients includes those who are particularly prone to developing pressure ulcers as a result of comorbid conditions. This subset includes patients who may have cognitive disabilities, those who have a spinal injury or have undergone an amputation, and bariatric patients.

Pressure Injury Risk Factors in Special Populations

General risk factors for pressure injuries in any patient include immobility, a lack of sensory perception, poor nutrition and hydration, and the presence of any condition that affects blood flow.¹ Special populations often have circumstances that are marked by the presence of additional risk factors. Although these risk factors within each subset of the special population may vary, they generally include the following elements:

• Individuals with a spinal cord injury: These persons have an increased risk for pressure injuries secondary to immobility from sitting in a wheelchair. These injuries commonly occur on the sitting surfaces of the body.
• Medically fragile individuals: Pressure ulcers commonly occur in those who must receive long-term care. This group includes patients with cognitive disabilities (including pediatric patients), those with genetic malformations, and those with neurological deficits.²
• Bariatric patients: These patients have a higher risk because they bear additional weight on the surface that comes into contact with either the bed or the wheelchair.

In light of the increased risk that these patients face, it is crucial to understand how the risk of pressure injuries can be reduced or prevented.

Preventing Pressure Injuries in Special Populations

Pressure injuries can be prevented with prompt and thorough wound care strategies. Given the variety of risk factors faced by each subset within the special population group, there are different tactics in reducing the likelihood of pressure injury development. Prevention efforts generally focus on pressure redistribution, shear reduction, and microclimate control.³

Individuals With a Spinal Cord Injury
To prevent a wheelchair-related pressure injury, selection of the best equipment is imperative. This includes seating cushions that are high immersion and have a uniform loading distribution. When existing pressure injuries are present, the use of an alternating-pressure seating device may help when the benefits of offloading are greater than the potential for shear. Cushions should also allow for ventilation to optimize temperature and minimize moisture. When advanced pressure injuries are present, total bedrest may be necessary until the pressure injuries heal.³

Medically Fragile Individuals
Individuals with cognitive impairment, including pediatric patients and older adult patients with dementia, can potentially increase the risk for pressure injuries. This is particularly true for patients whose mobility is also affected or when there is a deterioration of neurophysiological subsystems associated with motor, sensory, autonomic, cognitive, or behavioral pathways.⁴ Prevention of pressure injuries in these patients requires that caregivers are vigilant in providing regular skin assessments, provide repositioning at appropriate intervals, assist with movement and exercise when possible, and optimize the environment in any other identifiable way that can reduce the likelihood that a pressure injury will develop.

Patients with an Amputated Limb
Patients with an amputation are at greater risk for experiencing skin problems, including pressure injuries. Approximately three-quarters of those with a lower extremity amputation who use a prosthesis experience skin problems, including pressure injuries.⁵ The residual limb is exposed to several conditions that can lead to the formation of pressure injuries, including elevated shear force, increased stress, increased humidity, and prolonged moist contact with the prosthesis. For these patients, monitoring for fit and comfort are vital to minimizing a breakdown of skin integrity and function. ⁵ Minor prosthetic adjustments or providing a new socket to be fitted can help improve conditions, although severe cases may require disuse of the prosthetic.⁵

Bariatric Patients
Bariatric patients also represent a patient population that is particularly susceptible to pressure injuries. In addition to increased risk, they heal more slowly because of decreased vascularity. Preventing pressure injuries in these patients often requires adequate repositioning and turning of the patient, proper skin cleaning, and proper nutrition and fluid intake.⁶ In addition to this, optimal equipment should be selected for these patients, including beds that support the weight of the individual and wheelchairs that are wide enough to accommodate the patient.³

Conclusion

Pressure injury prevention plans are not one size fits all; it is always important to consider each individual patient's situation and health factors that may contribute to their overall risk and plan interventions accordingly. The populations listed above are far from the only groups more prone to pressure injury development, so always do your own research and consider every possibility when planning for your patients.

References
1. Mayo Clinic. Bedsores (pressure ulcers). https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-cause…. Accessed September 17, 2019.
2. Rodriguez M. Appropriate treatment of pediatric pressure ulcers among the special needs population in the outpatient clinic: an introduction. Today’s Wound Clinic. 2016;10(5). https://www.todayswoundclinic.com/articles/appropriate-treatment-pediat…. Accessed October 8, 2019.
3. Cleveland S. Support surfaces do not replace good wound care: special populations. WoundSource. 2018. https://www.woundsource.com/blog/support-surfaces-do-not-replace-good-w…. Accessed September 17, 2019.
4. Jaul E, Meiron O. Dementia and pressure ulcers: is there a close pathophysiological interrelation? J Alzheimers Dis. 2017;56(3):861-866.
5. Highsmith, MJ, Kahle JT, Klenow TD, et al. Interventions to manage residual limb ulceration due to prosthetic use in individuals with lower extremity amputation: a systematic review of the literature. Technol Innov. 2017;18(2-3):115-123.
6. Swezey L. Top 5 ways to prevent skin breakdown in bariatric patients. WoundSource. 2015. https://www.woundsource.com/blog/top-5-ways-prevent-skin-breakdown-bari…. Accessed September 20, 2019.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.