How many times has it happened? An individual develops skin breakdown on the buttocks or hip and you are called in to provide a different kind of cushion, because, of course, it’s the cushion that is at fault. Well sometimes this might be true. Perhaps the cushion is worn out and no longer effective. Or perhaps the person’s needs have changed due to progression of disease or just plain age, and the current cushion is no longer the best option. However, there are many cases when we need to look beyond the cushion to other potential causes of skin breakdown.
When we think of the causes of skin breakdown, we most likely think of pressure and shear. Both result in reduction or blockage of the oxygen supply to the skin tissue and certainly can cause/contribute to damage. When these mechanisms are at fault, we typically do look to the wheelchair cushions to provide pressure redistribution and shear reduction with their numerous choices for shapes and materials. However, pressure and shear are not necessarily the only or primary cause of every breakdown. There are numerous other risk factors that even the best of cushions may or may not alleviate or eliminate.
One of the most common contributors to skin breakdown is inadequate nutrition. The cells that make up skin tissue require nutrients to survive and a diet that is inadequate or inappropriate will significantly increase the risk for damage and decrease the ability of the skin to heal once breakdown occurs. A poor diet is one that has insufficient intake and/or consists of the wrong types of foods, such as those with high sugar and fat content vs protein, vitamins and minerals. There are documented cases of chronic non-healing wounds that were unchanged by every type of cushion imaginable and only healed when adequate nutrition was provided. We must be sure to ask about nutrition and refer to the appropriate professional if the individual’s diet is questionable.
The elderly are at additional risk for skin breakdown due to the effects of normal aging, when the skin becomes thinner, less elastic and more fragile, as well as significantly drier. At this point, the skin may not be able to tolerate pressure or shear forces that were previously non-problematic. However, skin that is too moist is not the answer, either, since excessive moisture from incontinence or sweating can make the skin soft and fragile as well. The skin of any elderly person should be assessed by a clinician and proper care and education provided.
Anything that results in decreased mobility for the individual can also contribute to skin breakdown. This can include decreased muscle strength or paralysis, decreased coordination, compromised balance and stability, pain, and/or joint limitations. The lack of movement of the extremities compromises the circulation of the blood and may even cause blood to pool in the distal extremities. This impairs the flow of oxygen to the skin tissue, making it more vulnerable to breakdown. Appropriate mobility, both passive or active, should be encouraged.
Generalized deconditioning, decreased resistance or a compromised immune system due to disease, drugs, medications and/or other medical treatments can also be major factors in the inability to maintain good skin integrity. The skin of individuals with these compromises should be closely monitored.
OK, so if an individual has none of these other “intrinsic” risk factors that contribute to the skin breakdown, we can blame it on the cushion, right? Not so fast. What about all of the other surfaces that this person might be sitting on? How about that non-padded (or inadequately padded) commode, shower chair or tub bench that is being used for extended periods of time each day? Or how about the surface of the bed that the individual lies on for 8-10 hours a night, basically in the same position? Or consider the fact that he/she “sits up” in bed for several hours at a time, putting significant pressure on the sacrum. What about other seating surfaces such as the car seat, Lazy-boy recliner or couch? Any or all of these could be significant deterrents to good skin integrity. Even the method of transferring onto these surfaces can be a factor, especially if the skin breakdown appears to be from shear forces. Is the person dragging themselves (or being dragged) without adequate clearance over the transfer surfaces? Does the buttocks scrape over the bed, commode, tub bench, shower chair or rear wheel of the wheelchair as the individual transfers? Or does it scrape across the sheets as the person is being turned or lifted in bed? Questions regarding other surfaces/devices and observations of transfers are key to ruling these out as factors in skin breakdown.
We must also look at the efficacy and frequency of the individual’s method of weight shift. Is it effective in temporarily reducing pressure across vulnerable areas? Is it being performed frequently enough to relieve/redistribute pressure from at-risk areas? Is education needed to assist the person in adopting a new method and/or schedule for weight shifts?
No matter how effective and appropriate a wheelchair cushion might be its pressure-distributing and shear reduction qualities are severely diminished with any additional layers of material between the person’s skin and the cushion itself. This includes patient lift slings, incontinence pads, thick clothing, diapers, sheepskin, pillow cases, any cushion cover not specifically designed for that cushion, or anything else that is added on top of the cushion. Eliminating these added layers often involves education to the individual and/or well-meaning caregivers and family members regarding their detrimental effects.
And, finally we must look at the person’s position when in the wheelchair to determine if abnormal postures are creating peak pressures at vulnerable areas. If this is the case, we must identify the cause and select an appropriate solution to facilitate the most upright, neutral and midline posture possible, accommodate any fixed postures and prevent further deformity. This might involve providing support to make up for poor muscle strength, poor endurance, and/or compromised balance and stability. Or it could require specific shapes and angles to address range of motion limitations and contractures. This might be accomplished through the seating, but could also involve configuration and adjustments to the wheelchair itself such as the orientation of the frame, the seat to back angle, the hanger angle, or the wheelchair dimensions.
When a person develops a skin breakdown, it may in fact be due to an inappropriate or ineffective seat cushion. However, it may also be due to a combination of factors that have nothing to do with the ability of the cushion to redistribute pressure and reduce shear. We cannot jump to the conclusion that the cushion is to blame, change the cushion and expect resolution of the problem. We must look at every aspect of the person’s medical and physical status, current equipment, and daily activities to determine the cause of the breakdown. We must be good investigators to discover the actual cause of the problem before we can offer the most appropriate solution.