Pressure Sores

Introduction

According to medical studies, pressure sores are a leading health care problem for people with spinal cord injury (SCI) and other forms of paralysis. A study in Iceland found that 58% of people who use a wheelchair have had a pressure sore. Another survey found that 17% had a pressure sore at the time of the survey.
Pulmonary disease, renal disease and autonomic dysreflexia were also linked to higher incidences of pressure sores. Further, the less mobile and less active, the higher the risk of developing pressure sores. Among those with traumatic spinal cord injury, over 70% had developed a pressure sore.
Like many illnesses pressure sores can take you by surprise. Many can be prevented, and in most cases, the sooner you begin treatment, the more complete the healing. Here are a few things I found out about pressure sores that may be helpful for you to know.

Pressure Sores

Pressure sores are areas of injured skin and tissue, at one or more stages depending on the level of injury. Technically, a pressure sore exists when there is any damage to the skin, though they are most commonly thought of in terms of sores being formed and with a breakdown in the skin. In more serious cases, the damage could be below the tissue and as far down as the muscle or bone.
Pressure sores may come in various forms. The mildest sores are simply areas where pressure has cut off the blood supply to the skin. These will usually be reddish areas in light-colored people. In all cases, they will be slightly warmer than the rest of the skin. As the damage is progressively worse, physical damage is caused to the skin, the tissue and the muscle. In extreme cases, damage may be caused to the bone itself.
If not treated and properly cleaned, infection could occur. Even when there is no cut in the skin layer, there may be damage to the tissue underneath, close to the bone.

Causes

Pressure sores are generally caused by sitting or lying on a hard surface for too long. In this context, a bed mattress would be considered a hard surface. That's why they are also known as bedsores. In most cases, the sore will develop near bony parts of the body, and be the result of slow breakdown. Just the pressure exerted on the area will limit the blood supply to the skin and tissue and weakens it's ability to resist further damage.
Sometimes the pressure or friction directly damages the skin or tissue. Dragging or rubbing against a hard object as well as stretching your skin, as in slipping down in your chair are other ways you may develop a pressure sore.
Indirectly, general health conditions may make it difficult to resist the development of pressure sores. Susceptibility increases with risk factors such as inactivity, immobility, age, weight, other diseases, alcoholism, smoking and corticosteriod use.

Prevention

Relief

An important key to prevention of pressure sores is the relief of pressure. Regular pressure relief could include regularly leaning from side to side, leaning forward or pushing up with your hands. Medical literature suggests you do pressure relief every 15 minutes, for at least 30 seconds. Frequent small body shifts are effective in relieving pressure on one particular area.

Wheelchair posture

Good posture is also important in even distribution of your body weight. For the SCI patient, many pressure sores are caused by the wheelchair. Maintain good posture in your wheelchair. You should sit straight and upright with your hips and knees level, and your legs spaced in line with your hips. A cushion between your knees and ankles will prevent them from rubbing together.
Keep your back straight to maintain good back muscular support and make it easier for you to move about. Bending over sluggishly can also increase the pressure at certain points on your lower body.

Pressure sores in bed

Pressure sores caused by lying in bed, are generally thought to be attributed to those that are confined to the bed, but sleeping habits can be a contributing factor in SCI patients as well. You should relieve pressure in bed by turning frequently. Other ways to minimize risks include sleeping prone (on your stomach). In any position, you will need to use cushions to relieve pressure points subject to breakdown.
Side lying, you must protect your hipbones, and between your legs at the heel and knee. You may also be careful with your shoulders. Lying on your back, your sacrum is the most likely to develop a pressure sore. Place a cushion under your calves to lesson pressure on your heels.
This is also very important if you often sit up in bed, or are propped up with pillows. Keep the sheets, blankets and sleeping clothes as wrinkle-free as possible. If you use a drainage bag, make sure you are not lying on the tubing. If confined to a bed, 30 degree rule is important. Do not elevate more than 30 degrees except for brief periods.

Cushions, Mattress

Using the proper bed mattress is important. It's our personal belief that a regular, plain ole, waterbed is the best thing to sleep on, but there are many other types of mattresses that provide support while limiting pressure points.
Other bed surfaces that you may consider include the accessory water mattress (placed on top of regular mattress), air or air-fluidized bed, alternating pressure mattress, or a convoluted foam pad. You can minimize pressure in the wheelchair using cushions made with high-density foam or plastic or silicone gel pads. No cushion uniformly distributes and relieves pressure entirely. Pillows and rubber rings are generally inadequate since they are easily compressed. The ROHO cushion is an air cushion that's popular and very effective when properly used.

Skin care

Your skin is the first defense against injury. Healthy skin is more likely to resist injury and an infection. One of the most important things you can do to improve the health of your skin is nutrition. That is covered in a separate section.
In addition, you should keep your skin clean and dry. Wash, rinse and dry your skin thoroughly every day. Use a mild soap like Dove or Oil of Olay and warm (not hot) water. Don't allow soap to dry on your skin.
Incontinence may be your skin's biggest enemy, so a bowel/bladder program that reduces the number of accidents is important to good hygiene.Aeration is also important. Sitting for long periods does not allow air to circulate in your groin area. This is particularly true if you sit with your legs close together. Padding, cushions, urine bags and sometimes clothing provide germs with the conditions they thrive in. Wash your groin area before going to bed for the night. At least once a day, get into a position where you can air out your groin area.
For dry skin areas, massage in lotion to soften it. Dry skin can crack and prevent healing. Avoid using lotion containing alcohol or other chemical that will allow your skin to dry out afterwards. Your skin needs to be resilient, but avoid allowing your skin to become so soft that it loses its resistance.
Excess moisture is often the result of incontinence or excessive perspiration and the inability to aerate the area.

Weight control

Obviously, weight has an impact on the likelihood of developing a pressure sore. You should maintain a weight that does not put unnecessary pressure on the bony parts of your body. This will vary depending on your build, and the amount of supporting tissue. It's obvious that excess weight will increase the pressure over parts of the body. On the other hand, being under weight, you will not have the "padding" needed to cushion yourself in those bony areas. If you are underweight, you are also more likely to be undernourished.
Regular personal exams . . . The key to quick recovery of a pressure sore is catching it before it gets worse. The longer you go before beginning treatment the more complicated the treatment will be. In addition to frequent pressure relief, people with sci should examine common sites for pressure sores frequently at least once a week, and preferably daily. This is especially important if you have a change of routine where the amount of time in the wheelchair or bed changes. Pressure sores are common on the buttocks, on the heels, ankles, knees, hips and shoulder blades.

Treatment

Half of the treatment for a pressure sore is preventing it from getting any worse, so preventive steps listed above should be continued where appropriate. Three things that are important to treatment, 1) Relieve pressure, pads, pillows, 2) Treating sores, 3) Improve the health of the body and skin through proper nutrition.

You should never lie on a pressure sore. Use cushions and pillows to take pressure off of the damaged area. In order for a pressure sore to heal, it must be kept clean, usually with a salt water solution.
When possible, dead tissue and scabs need to be removed in order to speed infection and avoid infection. Simply rinsing the area thoroughly whenever you change the dressing is usually sufficient for this.
Open pressure sores should be kept covered with a bandage or dressing. The hydrocolloid is a like a gel bandage, that's stuck to the skin like a patch and left for several days. DuoDERM is one brand name.
Another treatment is the use of a special spray to promote healing. Lightly massaging around the affected area will also help to increases body circulation to the area and speed natural healing.
In most cases, it's a good idea to massage the area to increase circulation and speed healing. This is especially true when using a topical treatment, such as a granulderm spray.
There may be other treatments for pressure sores when you get one, so ask around or consult a doctor. In 1997, Cleveland researchers were looking into the effects of electrical stimulation on pressure sores. In that announcement, it was written, "We know that electrical stimulation to paralyzed muscle will increase muscle bulk and create pressure variations that seem to reduce
pressure sore occurence."

Treating infected sores

If the pressure sore is not detected early or treated properly, it could lead to infection. An infected sore heals more slowly and the infection could spread throughout the body. Some signs of an infected sore include a think yellow or green pus, swelling and a bad smell from the sore. When the infection spreads, it could lead to fever or chills, weakness, increased heartbeat and confusion.

Nutrition

Nutrition is important for prevention as well as treatment. You will not see immediate results, but nutrition is one of the most crucial elements of care and treatment and prevention. Good nutrition promotes healthy skin and speeds healing.
It's important that your body gets the proper amount calories, protein and other nutrients. Patients at high risk of developing pressure sores should be given supplements with Vitamin C and zinc because they promote skin growth. Vitamin A and protein are also important.

In general you need 1500-1800 calories a day average depending on weight, for adequate nutrition. Your diet should follow guidelines from the food pyramid. A balanced diet would include 6-10 servings of bread/cereal, 3-5 servings of fruit and vegetables, 2-3 servings of meat and 2-3 servings of dairy products. While following the pyramid guide, try to include foods that are high in protein.

Fluids

Fluids are also an important part of your diet. For the average person, 8 - 8 oz glasses of fluids is recommended. If medications cause you to have dry mouth, you may need to include additional fluids. Additional fluids are also important during hot summer months to replace fluids lost there.
Fluids are important to prevent dehydration, keep kidneys and bladder flushed, and provide extra fluid if you have a wound that is draining. Fluids are also a necessity for most every other part of your body, from providing fluids for your skin, to facilitating the proper functioning of your lungs. Water, apple and cranberry juices are best

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