The scourge of the plegias can be successfully tackled.
A resident of an independent living centre recently passed away from septicaemia and multiple organ failure as complications of a tiny but very deep pressure ulcer. This brought home to me that we cannot afford to be complacent in the prevention of these sores. I asked Dr Virginia Wilson of the Netcare Rehabilitation Hospital for advice on how best to go about preventing and managing this curse in the lives of persons with different types of plegias.
Q: What are the causes of pressure sores?
A: When someone cannot change their position to relieve discomfort because they are unable to do so themselves, for example, spinal cord-injured (SCI) individuals, their circulation becomes very poor. The skin also becomes thinner. So lack of movement, a thin skin and possibly poor nutrition all contribute to the development of pressure sores.
Q: Are there common spots where pressure sores develop or can they occur anywhere on the body?
A: There are definitely vulnerable areas: the back of the head and protruding areas such as the elbows; the most vulnerable are the buttock areas, the side of the hips, heels and the ankles.
Q: Beyond the discomfort, what are the dangers of pressure sores?
A: The most serious danger – the ultimate one – is death. When you get an increasing depth of the ulcer over a bony protuberance (where most pressure ulcers are located) you get infection into the bone (osteomyelitis) and infection into the bloodstream (septicaemia) and can lead to multiple organ failure; the kidneys, liver, heart and lungs all fail. And it’s not so much the length and width that is important, it is the depth.
Q: When a pressure sore heals, it heals from the sides to the centre. Do you sometimes get a situation where the skin grows closed but deep down the ulcer still exists?
A: Yes this sometimes happens. It all depends on how you manage the healing process. Many deep pressure sores have what is known as slough. This is a build-up of dead tissue (where bacteria thrive) and if you don’t remove the slough, either by scraping it off with a curette or by using a de-sloughing agent (a special paste or cream), or by using special dressings to make sure the wound is clean right down the base of the ulcer, you won’t get good healing. Deep dark holes are always worrying, because you don’t know what is happening inside.
Q: What should the carer of a person with an SCI do to prevent pressure sores?
A: Anybody who can do their own pressure relief should be doing it routinely. It should be an ingrained routine – like clockwork. For example a paraplegic with normal upper body function should relieve pressure areas three times an hour. Push yourself up with your arms and wiggle your backside for at least 20 seconds before sitting down again. This improves the circulation. If you are a quadriplegic, your carer must help, but if you have some upper body function, you can also drop your chest onto your knees and rock yourself from side to side, or lean from side to side.
Q: What about turning when in bed?
A: It is always a good idea to try and sleep prone – on your tummy, there are no real pressure points and this allows for a longer period of sleep without having to turn. It is also very good for spasticity: when you lie prone all the joints are moved in the opposite direction to when you are sitting, so it stretches all the muscles that were contracted and it relaxes the muscles that were stretched when you were sitting.
Q: How often should turning take place to prevent pressure sores?
A: In hospital we tend to turn every two hours but at home every three hours is fine.
Q: Are there any warning signs that a pressure sore is developing?
A: It is very important to do a top-to-toe examination at least once a day; for quads, twice a day. The first sign is usually a telltale redness that does not go away. But on darker skins this can be difficult to see and you must look for dark spots that do not go away. The minute you see a blister, treat it as a pressure sore.
Q: What about pain as a sign of pressure sores?
A: If you have complete absence of sensation below your lesion, you will not have pain. If you have an incomplete spinal cord lesion, you may have a warning pain or discomfort. However autonomic dysreflexia may be a sign of a pressure sore. If you feel nauseous or have a headache, check for pressure sores.
Q: When do we have to consider admitting someone with a pressure sore to hospital?
A: There are so many factors at play. If there are multiple pressure sores, caregivers will not cope and admission is essential. It also depends on the depth of the pressure sore – the type of dressings that are required. Some dressings cannot be done on an outpatient basis. Then there also are social issues. If the home environment is poor or the home is located in a rural area where home nursing is not always readily available, it is better to admit early.
Remember, though, that a dressing is worth nothing if the pressure is not taken off the affected area. The best way to heal a pressure sore is direct contact with air. Patients get cross with me. They show me their pressure sores and I tell them, “Go home and lie on your tummy.”
Q: Is fresh air a better dressing than a dressing itself?
A: Absolutely. If you don’t have access to dressings, leave it open to the air and keep the pressure off. And keep it clean with saline or even soap and water.
Q: What is the value of these really expensive ripple mattresses in the prevention and management of pressure sores?
A: They are useful in ICU situations, in hospice care and in the care of very emaciated patients, but they do not take the place of good care measures; keeping the pressure off, regular turning and regular inspection.
Our conclusion is: be aware of your skin and look after it. All your skin really needs is not to be compressed and to be exposed to fresh air. So now when I sleep it is bottoms up, punt in die wind, kaal gat and pressure sores se m**r…
Ida’s Corner is a regular column by George Louw, who qualified as a medical doctor, but, due to a progressing spastic paralysis, he chose a career in health administration. The column is named after Ida Hlongwa, who worked as caregiver for Ari Seirlis for 20 years. Her charm, smile, commitment, quality care and sacrifice set the bar incredibly high for the caregiving fraternity.
email: georgelou@medscheme.co.za
