6.6 At-Risk Populations: Spinal Cord Injury, Stroke, Critical Care, and Cognitive Impairment

At-Risk Populations and Targeted Interventions

Objective 7.04 asks you to identify at-risk populations and appropriate interventions, naming spinal cord injury, stroke, intubation, cognitive impairment, limited mobility, and incontinence. The exam does not test whether you know these patients are at risk — that is obvious. It tests whether you know which site is at risk in which position, and which intervention is specific to that population rather than generic.

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1. Spinal Cord Injury

Patients with spinal cord injury (SCI) carry the highest lifetime prevalence of pressure injury of any population, and the injuries recur.

Why the risk is structural

• Complete sensory loss below the level of injury removes the discomfort signal that normally triggers unconscious position change.
• Motor paralysis removes the ability to act on it.
• Muscle atrophy below the lesion thins the soft tissue padding over bony prominences.
• Altered autonomic vascular tone reduces the reactive hyperemia that normally restores perfusion after pressure is relieved.
• Spasticity produces shear against surfaces and, in flexion patterns, skin-on-skin contact.

Position determines site

This is the most commonly tested distinction:

• Seated in a wheelchair — the ischial tuberosities bear the load and are the leading site.
• Supine in bed — the sacrum and heels predominate.
• Side-lying — the greater trochanters and lateral malleoli.

Targeted interventions

• Pressure mapping of the wheelchair seating interface, with a prescriptive cushion (air-cell, gel, hybrid, or contoured foam) selected from the map rather than by default.
• Weight shifts every 15 to 30 minutes while seated — forward lean, side lean, or push-up — held long enough for reperfusion (roughly 60 to 90 seconds).
• Tilt-in-space or reclining wheelchairs for patients who cannot perform an independent weight shift.
• Annual seating reassessment, and reassessment after any weight change, new spasticity, or new wound.
• Patient and caregiver education in daily skin inspection with a long-handled mirror over the ischia, sacrum, and heels.

Autonomic dysreflexia — the emergency you must recognize. In patients with an SCI at T6 or above, a noxious stimulus below the level of injury triggers unopposed sympathetic outflow: sudden severe hypertension, pounding headache, bradycardia, flushing and sweating above the lesion, and pallor and piloerection below it. A pressure injury, an occluded catheter, or an impacted bowel are common triggers. Management is to sit the patient upright, loosen constrictive clothing and devices, and find and remove the stimulus while treating the blood pressure. Untreated, it can cause stroke, seizure, or death. A wound care clinician who begins a painful debridement on such a patient must be alert to it.

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2. Stroke

Hemiparesis after stroke produces a distinctive and asymmetric risk pattern:

• Hemiplegia means the affected side is not repositioned spontaneously; the patient rolls onto the unaffected side and stays there, loading the affected shoulder, hip, and heel.
• Hemispatial neglect means the patient may not perceive or attend to the affected side at all, so self-inspection is unreliable and teaching must be directed to the caregiver.
• Dysphagia drives inadequate protein and fluid intake — screen and involve speech-language pathology and the dietitian.
• Aphasia removes the ability to report pain or discomfort; use a behavioral pain scale (section 1.6).
• Spasticity and contracture create skin-on-skin contact in a clenched hand, a flexed elbow, or adducted thighs, producing maceration and intertriginous injury. Palm protectors, splinting, and therapy referral are the targeted interventions.
• Shoulder subluxation on the flaccid side risks skin injury from poor handling and slings.
• Incontinence after stroke drives moisture-associated skin damage (section 6.2).

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3. The Intubated Critical Care Patient

In the ICU the mattress is often the least of the problem. The risk is devices and instability.

Device-related sites

Endotracheal tubes and their ties (lips, corners of the mouth, cheeks, ears), CPAP and BiPAP masks on the nasal bridge, high-flow nasal cannula on the columella and ears, cervical collars at the occiput, chin, and clavicles, pulse oximeter probes on digits and ears, nasogastric tubes on the nostril, arterial and central lines at their hubs, sequential compression devices, urinary catheters against the thigh or urethral meatus, and restraints at the wrists.

Prevention: correct sizing, prophylactic thin foam or hydrocolloid under the device, rotation of the device site where clinically permissible (alternate the ETT to the other corner of the mouth, alternate oximeter probes), and inspection of the skin under every device at least every shift.

Prone positioning

Prone ventilation shifts the entire pressure map anteriorly: forehead, cheeks, chin, chest, breasts, iliac crests, genitalia, knees, and dorsum of the feet. Prophylactic dressings, careful head repositioning on a schedule, and eye protection are standard.

Instability and vasopressors

Vasopressors reduce peripheral perfusion, so a given interface pressure causes more damage. Sedation and neuromuscular blockade abolish protective micro-movement. When a patient is too hemodynamically unstable to tolerate full turns, the correct action is small, frequent micro-shifts and incremental repositioning, with the clinical rationale documented — a documented modified schedule is defensible; an undocumented gap in repositioning is not.

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4. Cognitive Impairment and Dementia

• Cannot reliably report pain or discomfort — use PAINAD (section 1.6).
• May remove dressings, pull at tubes, or scratch. Tubular retention bandages, sleeves, and stockinette are preferable to restraints; mitts are a last resort with documented rationale.
• Poor oral intake and forgotten meals drive protein-calorie malnutrition.
• Wandering patients are paradoxically at lower pressure risk but higher risk of skin tears, falls, and friction injury.
• Repositioning must be approached rather than imposed — hurried or forceful turning in a resistant patient causes shear and distress. Consistent staff, familiar routine, and pre-emptive analgesia improve tolerance.

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5. Two More Populations Worth Knowing

Obesity. Pressure injury appears in atypical locations: within skin folds, beneath a pannus, between thighs, and where tubing or a limb rests on the body itself ("self-loading"). Adipose tissue is relatively poorly perfused. Intertriginous dermatitis and IAD are common. Bariatric equipment with adequate weight capacity and width is a safety requirement — an over-capacity surface bottoms out and delivers no redistribution at all.

End of life. Skin can fail as an organ despite optimal care. Recognize Kennedy terminal ulcers and unavoidable skin failure (section 1.8), and shift goals to comfort, odor, and exudate control (section 5.5).