University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Circumstances Beyond Control

Although a person follows an active routine of methods to prevent pressure ulcers (which means the same thing as "pressure sores" or "bedsores"), including doing regular pressure reliefs, using custom-fitted equipment and cushions, and regularly inspecting their skin, sometimes a pressure ulcer can still develop 1. There are circumstances beyond an individual's control that can lead to a pressure ulcer. A chief example is a serious illness. A number of participants in our study, including Charlie, Chris, Odel, Rachel and Gary, developed pressure ulcers during their initial hospitalization following their spinal cord injury; in fact, studies show that between 20% and 60% of all people with spinal cord injuries develop a pressure ulcer during their first stay in the hospital 2. In many cases, this happens because the health of the patient is too fragile to allow for proper skin care procedures; in order to stabilize their condition and save their lives, paying attention to possible pressure ulcers became a lower priority.

For other participants, new injuries or medical conditions directly or indirectly caused a pressure ulcer, such as when Brenda broke her femur (thigh bone), or when a cast on Alley's broken leg rubbed a pressure ulcer on the skin beneath it. Alma, who received her spinal cord injury at the young age of 5, developed a pressure ulcer when her tailbone gradually shifted and grew "the wrong way;" the bone eventually broke through her skin and required surgery. Chris developed a bone growth on his hips called heterotopic ossification, which led to a pressure ulcer. Dave had rods in his spine that broke twice, requiring surgery to replace and causing pressure ulcers. Odel had leg spasms in his sleep that rubbed his foot along the sheets; he wasn't aware of these spasms until a pressure ulcer formed on his heel from the friction. In fact, the presence of other illnesses or conditions, including heterotopic ossification, are shown by medical studies to increase the risk of developing a pressure ulcer 3. And among all people with spinal cord injuries who reenter a hospital for any cause, between 7.5% 1 and 12.9% 4 get a pressure ulcer during their stay. Even people in a skilled nursing facility or a rehabilitation facility have about a one in four chance of forming a pressure ulcer 5.

Studies show that the risk of developing a pressure ulcer increases when skin is exposed for an extended period of time to urine or feces, which are highly acidic and sources of bacteria 3. Indeed, for a number of our participants, such conditions caused pressure ulcers, as it did for Brenda. Sometimes they spent too long in soiled clothing or diapers because a care attendant was not available to assist them, which is what happened to Robert, or the care attendant was neglectful, which happened to Rachel. Chris asked for a stronger adhesive tape to secure his condom catheter, but he was turned down by the insurance company because the tape was too expensive, resulting in leaking urine and skin breakdowns.

Sometimes larger circumstances of life can contribute to a pressure ulcer. Robert, for example, was in an airport when his flight was delayed, forcing him to remain up in his wheelchair for 19 hours; the result was a pressure ulcer. The sadness caused by the deaths of her father, aunt and boyfriend within a year's time, combined with her responsibilities to take care of their belongings after their passing, led to Helen's developing a pressure ulcer.

When what is happening in life is so overwhelming that you feel confused and without a sense of order or direction, that also increases the chances of getting a pressure ulcer, such as when Charlie had his wheelchair cushion stolen, then became homeless for a while, and was beaten and robbed while he was on the street. These awful events helped cause a pressure ulcer that became infected.

Other factors beyond a person's control can make pressure ulcers more likely. For example, people with complete spinal cord injuries are more likely to develop pressure ulcers than people with incomplete spinal cord injuries 3. As a person ages, the skin becomes more vulnerable to damage and less able to heal itself; although you can be aware that your skin is getting older, as Dave, Helen and Mitch learned, obviously you can't make your skin young again! A similar threat to the health of your skin that you can't control is damage from previous surgeries. A pressure ulcer can form along the scar line of a past operation, as happened to Ken, or on a "divot" or bump created from a previous surgery, which happened to Helen.

Past surgeries can cause other circumstances beyond your control that can create pressure ulcers. For example, Dave had so many muscle flap surgeries that he doesn't have a lot of the proper kind of muscle tissue left to provide for future surgeries. Both Helen and Chris got pressure ulcers in part because previous operations left their hips (and, in turn, their torsos) unbalanced.

Since pressure ulcers may start even when you are being cautious, the best defense is to remain extremely watchful for any changes in your skin. Doing frequent skin checks is a good idea; Odel and his mother (who is his caregiver) examine his skin twice a day. Although Steve had a number of risky behaviors and habits, he still avoided pressure ulcers by checking his skin every time he got in and out of his wheelchair. Remember: early detection is the key to saving your life, by stopping the pressure ulcer from growing. Reacting promptly to redness can also help stop a pressure ulcer, whether that means staying in bed with no pressure on the area, seeing a physician right away, or both. Even if there are circumstances beyond your control that can help form a pressure ulcer, you are in control of how you deal with it.

While it is true that pressure ulcers can occur for a number of reasons, some of which are just beyond a person's control 1, it's also true that they usually can be prevented by the best possible knowledge about pressure ulcers and a healthy lifestyle, including good nutrition, exercise, avoiding smoking or alcohol or recreational drugs, and doing daily self-care activities meant to avoid pressure ulcers (like skin checks, keeping clean and dry, and doing pressure reliefs) 6. Keep in mind that even if there are circumstances beyond your control that can help form a pressure ulcer, you are in control of how you deal with it. And research has shown that having a positive attitude and believing that you can make a difference helps you form those habits you need to avoid pressure ulcers in the first place, to recover sooner and to stay healthier after a pressure ulcer heals 7 8. Your choices about your health do count!

1 Witkowski, J. A., & Parish, L. C. (2000). The decubitus ulcer: Skin failure and destructive behavior. International Journal of Dermatology, 39, (12), 894-896.

2 Hammond, M. C., Bozzacco, V. A., Stiens, S. A., Buhrer, R., & Lyman, P. (1994). Pressure ulcer incidence on a spinal cord injury unit. Advances in Wound Care, 7, (6), 57-60.

3 Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington, DC: Paralyzed Veterans of America.

4 Thomas, D. R., Goode, P. S., Tarquine, P. H., & Allman, R. M. (1996). Hospital-acquired pressure ulcers and risk of death. Journal of the American Geriatrics Society, 44, (12), 1435-1440.

5 Baldwin, K. M., & Ziegler, S. M. (1998). Pressure ulcer risk following critical traumatic injury. Advances in Wound Care, 11, (4), 168-173.

6 Krause, J. S., & Broderick, L. (2004). Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors 5 or more years after onset. Archives of Physical Medicine and Rehabilitation, 85, 1257-1264.

7 Tenn, L., & Dewis, M. E. (1996). An evaluation of a Canadian peer-driving injury prevention programme for high-risk adolescents. Journal of Advanced Nursing, 23, (2), 329-337.

8 Wichowski, H. C., & Kubsch, S. M. (1997). The relationship of self-perception of illness and compliance with health care regimens. Journal of Advanced Nursing, 25, 548-553.