

                 Warren SKIN CARE FOR WHEELCHAIR USERS


Entered On Fri  0726-96At18:1
                     ==============================

Pressure ulcers are a dangerous complication for people with mobility
impairments.  Here's how to recognize and avoid them.

by Maricela Viehbeck, R.N., C.E.T.N; Catherine Britell, M.D., P.C.; C.
Andrew Salzberg, M.D.; Clemente D. Rodriguez, M.D.

People who have multiple sclerosis may develop disabilities that require
the use of a wheelchair or limit their ability to turn or position
themselves adequately in bed.  These people are at risk of developing
pressure ulcers, which can frustratingly limit a person's lifestyle, can
require hospitalization and surgery if they become severe, and can in
some cases be life-threatening.  Learning what causes pressure ulcers
can help you play an active role in their prevention, early detection,
and treatment.  To understand how pressure ulcers develop, it is
important to know the functions of the skin and the underlying tissues.

The Anatomy of the Skin

The four layers of the skin include:

1. Epidermis (outer layer):
   This is the major defense against infection.  It sheds continuously
   through the wear and tear of daily activities.

2. Dermis (middle layer):
   The dermis provides support and nutrients to the epidermis.  It
   contains the blood vessels, nerves, hair follicles and sweat glands.

3. Subcutaneous Layer (fat layer):
   This provides the insulation, absorbs shock, and provides a cushion
   for the layers above.

4. Muscle Layer:
   The muscles provide a cushion over bony structures and are the means
   to move the body.

5. Bone:
   Bones are the body's framework.

How Pressure Sores Develop
--------------------------

Pressure sores occur when the blood supply to the skin is squeezed or
plugged as a result of continuous pressure between a bony part and a
mattress or chair.  When the pressure is not relieved, the skin loses
oxygen and nutrients.  This damages and ultimately kills the tissues.
MS affects the nature and function of the skin in a number of ways.
First, the skin has  a great many sensory nerves, which enable you to
determine changes in temperature, pressure, pain and touch.  For
example, these sensory nerves tell you when you have been sitting or
lying in one place for too long and need to shift your weight, when you
are in danger of sustaining a burn of frostbite, or when your skin is
being pinched in some way.  When you have MS, part or all of the
sensation to the skin may be lost due to demyelination of the peripheral
sensory nerve pathways in the spinal cord, or the nerves in the brain.

Secondly, the nerves to the blood vessels in the skin are very important
in controlling blood pressure.  Many people with MS experience a drop in
their blood pressure when sitting for a long time due to the
demyelination of the nerve pathways controlling contraction of those
blood vessels.

Third, because of loss of use of the muscles, there is often wasting and
loss of muscle bulk.  This causes bony areas of the schism (hip) and
sacrum (tailbone) to become closer to the skin and increases risk of
pressure sore formation.

Fourth, the spasticity that occurs in many people with MS can lead to
poor positioning in the wheelchair or in the bed.

Prevention
----------

A number of things can predispose a person to developing pressure sores.
These may include loss of mobility, loss of bowel or bladder control,
poor nutrition, and reduced mental awareness.  Other factors, such as
smoking, traction on the skin, wetness, and extreme heat can make
pressure sores occur more readily.

In wheelchair users, sores occur most frequently over the ischial
tuberosities (the bony part of the bottom of the buttocks).  Other
locations at risk include the sacrum (tailbone area), shoulder blades,
behind the knee (popliteal area), and the heel of the foot.

Learning how to reduce your chances of developing pressure sores, how to
recognize the earliest signs of trouble, and what to do immediately to
relieve pressure is the best way you can avoid pressure sores.
Minimizing pressure is the key to avoiding pressure sores.  This can be
done in three ways.

Wheelchairs and adaptations

Your wheelchair must be prescribed especially for you by your health
care team based on your degree of mobility, body size, and weight.
There are many wheelchair features that will have a great deal of
impact on the comfort and safety of your seating.

Removable arm rests can help you avoid injury when transferring in and
out of your chair.  A seal belt is essential to maintain proper posture,
keep you from sliding out of the chair, and allow you to use your arms
more effectively without fear of falling.

Your footrest should be properly adjusted so the thigh is maintained
parallel to the floor to evenly distribute the weight between the
buttocks and the thigh.  If set too high, the footrest will produce
undue pressure under the thigh and cause swelling of the feet which
predisposes them to developing sores.

Cushion for pressure relief

Pressure reducing cushions are recommended for wheelchair users.  Your
therapist and physician should work together to prescribe a variety of
commercially available cushions made with foam, gel, air or a
combination of these substances.  Do not use doughnut type devices, as
they will cut off the circulation to the area you are trying to protect.
Chux, towels, or other materials between you and your cushion will
reduce its effectiveness.

Pressure relieving measures

Shifting body weight reduces pressure and improves circulation.  Several
maneuvers that can be performed while sitting are:

   Forward leaning.  This is accomplished by leaning forward with the
   chest close to the thighs.  This has been proven to be the most
   effective pressure relieving method.  It is a good choice for
   individuals who may not have upper body strength.

   Push ups.  Use the arm rests for support and lift the buttocks
   completely off the seat.  It is recommended that wheelchair users
   push up every 15 minutes and hold the position for at least 15
   seconds.

   Side to side.  Leaning from side to side may effectively shift the
   weight, if your balance is good enough to lean safely.

   Backwards tip or recline.  Tipping the wheelchair back 35 to 40
   degrees for 2 to 5 minutes every 30 minutes.  This can be performed
   by a family member, attendant/care giver, or by the patient if the
   wheelchair is equipped with a motorized recliner.

   Individuals who are unable to move must be repositioned, shifting the
   points of pressure at least every hour.  Positioning should include
   attention to posture alignment.

Skin assessment
---------------

Be on the lookout for pressure ulcers.  You should inspect your skin
twice a day, once before getting up in the morning and again before
going to bed.  Use a hand mirror for hard-to-see areas.  Areas of
special concern are sites of previous skin breakdowns and bony
prominences.  Look for redness and test to see if the redness goes away
when you push on the area with your finger.  It is a good sign if the
skin turns pale or white.  If redness persists 15 to 30 minutes after
pressure is relieved, this could be the beginning of a stage 1 ulcer.
The best approach is to keep pressure off the area.  Here are some
useful suggestions for skin care:

   Do not massage red areas.  Doing so will only cause damage to tiny
   blood vessels and make the situation worse.

   Routinely use moisturizing products.  Keeping the skin well hydrated
   prevents drying and cracking and helps reduce friction injuries.  If
   you can, avoid exposure to low humidity, cold air and extremely, hot
   temperatures.  Use water repellent ointments or liquid film products
   in the area around your anus and buttocks if there is excessive
   sweating or loss of bowel/bladder control.

   It is important to clean the skin as soon as it becomes soiled.  A
   soft cloth or sponge should be used to reduce skin injury.  Always
   check the water temperature before showering or bathing.  Dry your
   skin well after bathing.  Avoid hard rubbing with a towel and pay
   special attention to the groin area and between the toes.  shun
   topically applied alcohol-based products.  They can dry out your
   skin.

   Wear clothes that fit correctly.  Loose clothing creates wrinkles,
   and clothing that's too tight may constrict circulation.  Avoid wide
   seams and seams that do not bend.  Be leery of buttons, snaps, or
   carrying objects in your back pockets.

   Your shoes shouldn't be too tight.  New shoes should initially be
   worn for a short time.  Inspect your feet for any redness and then
   increase the wearing time.  Always wear socks under your shoes and
   keep your toenails trimmed.

   Be careful not to spill hot fluids on your skin and be alert to other
   potential heat hazards such as hot pipes or vinyl car seats in the
   summer.

Recognizing and characterizing pressure sores
---------------------------------------------

Initial signs of a pressure sore include sustained skin redness,
swelling, soreness, and abnormal warmth when you touch the spot.

Physicians and nurses use a staging scale to classify the degree of
tissue damage caused by pressure sores.  This classification aids in
deciding what treatment is needed to make the sore heal optimally.

Stage I:

There is a persistent, warm, pink or red area of unbroken skin.  It is
usually over a bony area, which may feel spongy or firm.

Stage II:

This involves epidermis and dermis.  The sore appears as a blister or a
superficial break in the skin, or a shallow crater.  The surrounding
area may be red.

Stage III:

This is a pressure sore that extends down to the fat layer. It may be
white or black in color, and have a foul smell or be draining.

Stage IV:

A stage IV sore extends to the muscles or bone.  This sore may be white
or black in color, and the surrounding tissues may be warm to the touch
and red in color.  Sometimes the ulcer will be much larger at its base
than on the surface, and there may be foul smelling drainage.

Treatment
---------

There are numerous approaches to treating pressure ulcers, pressure
relief being the first step.  With all pressure sores, it is imperative
that you relieve all pressure and absolutely avoid sitting or lying on
the area until the skin is back to normal.  Your cannot heal a sore
while sitting or lying on it.  If the skin is broken, the wound should be
cleansed twice daily with normal saline.  Solutions that contain soaps or
other chemicals may cause damage to the wound bed.  Keeping the wound
clean and moist will speed healing.  Products such as gels, film
dressings, hydrocolloids, and ointments will encourage the body's
natural wound healing capabilities.  You should talk with your doctor or
nurse and determine whether a visit is necessary.  A home visit will be
best if you need to see a health professional, since sitting up for a
trip to the doctor or clinic will often make the sore worse.

If the sore extends throughout the dermis and involves fat, muscle, or
bone, it is a serious problem and needs to be seen by a physician.  A
deep pressure sore can be life-threatening if it becomes significantly
infected.  Special X-ray studies and blood tests may become necessary to
determine the best method of treatment.  If there is dead tissue, it
needs to be cut away, and if the wound is large or deep, surgical
treatment by flap rotation is often the only effective way to get the
skin to close.  Because you're likely to lose a great deal of protein
with this kind of wound, you'll need to increase protein intake.

A brochure for treatment guidelines can be obtained by writing to:

      AHCPR Publications Clearinghouse
      P.O. Box 8547
      Silver Spring, MD 20907
      1-800-358-9295

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HandiNet Note:  This article was found in the August MS UPDATE, a
publication of the National Multiple Sclerosis Society, Hampton Roads
Chapter and is used with permission.



