NOTE: This message was originally in conference "INTERNET - E-MAIL AREA"
      and was copied here by Tom Mckeever.
From: Tom Walter 
To: Multiple recipients of list POLIO 
Date:         Fri, 26 Jul 1996 16:42:34 PST
Subject:      Skin Care for Wheelchair Users
 
The following article has been exerpted from MS UPDATE, newsletter of the
National Multiple Sclerosis Society, Hampton Roads Chapter, and is used
with their permission.
 
Although directed at people with MS, it contains useful information
for any of us who use wheelchairs and/or are bedridden.
----------
                  SKIN CARE FOR WHEELCHAIR USERS
                  ==============================
 
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 anda
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 
ying
 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 seat 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 
3
0
 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.  You 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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