I am making this a sticky and locking it here so that it can be easily accessed for the information in it . It is from the PRC website .



Skin Care

The death of Christopher Reeve last October was attributed to heart failure due to sepsis (also known as septicemia), an infection that spreads from a specific location (such as a skin sore or bladder infection) to the blood and other organs. What exactly happened to Christopher Reeve isn't known and may never be; there was no autopsy. Clearly, his death was related to pressure sores; at the time of his death Reeve had been battling more than one skin sore. He had even experienced life-threatening sepsis just weeks before he died.



Indeed, Reeve died as a result of heart failure, which was included in the death certificate. There were complicating factors, however.



According to Dana Reeve, speaking on national television, neither a pressure sore nor infection directly precipitated Reeve's coma and subsequent death. Despite what was reported at the time, Reeve's body almost certainly did not go into septic shock (a type of blood poisoning that can lead to organ failure and death). The most probable cause of death, Dana Reeve said, was a reaction to a drug Reeve was given to help treat a suspected infection. He had been given the drug on previous occasions, successfully. Reeve had a history of drug sensitivity. Shortly after getting an injection of the drug, Reeve's body went into shock (anaphylactic) resulting in coma and eventually, the shutting down of his organ systems. He never emerged from the coma and died less than 18 hours later.



Dana Reeve was very clear about the quality of care her husband received. She praised the medical staff and noted that their actions in the final hours were appropriate and unequivocal.



There may be lessons to be learned from the high profile life and death of Christopher Reeve. By all accounts Reeve's final days were totally normal; he was on the road making a speech, he was busy being a moviemaker, an advocate and a dad, basically doing the things he wanted to do. He never paid heed to the actuarial life-limits placed on his type of paralysis by statisticians (11.4 years).



Certainly, Reeve's medical staff urged him to heed the fundamental protocol for dealing with any level of pressure sore, that is, to get out of the wheelchair and let the wounds heal up. But Reeve chose to live his life fully and well and as much as possible on his own terms. He was not, as his wife explained, a man who was easily persuaded to slow down.



The primary lesson, of course, is to be especially aggressive with wounds. It may not be possible to prevent the occurrence of a pressure sore. With appropriate seating and sleeping equipment and attention to basic care, though, most people who are paralyzed can enjoy health and skin integrity for years to come.



While it may not have been a factor in Reeve's death, septicemia is a real possibility if a pressure sore gets out of control. This degree of infection is generally controllable, however.



What follows is a basic primer on skin health and pressure sore management.

Pressure sores are one of the leading complications across the lifespan of a person with paralysis. It is estimated, for example, that one in three people with spinal cord injury will develop a pressure sore during the early days after their injury and that between 50 percent and 80 percent will form pressure sores at some later point. Pressure sores are for the most part preventable but can occur even in people who have good care and proper equipment. These sores often take a good deal of time, money and care to heal; it is possible to be laid up for months because of a pressure sore, especially one that has resulted in surgery. All of this can cost thousands of dollars and mean valuable time away from your job, school or family.

Pressure sores, pressure ulcers, bed sores, decubiti, and decubitus ulcers are terms that define damage to an area of skin that has been exposed to excessive pressure or force. The condition is literally an injury to the skin and various tissues underneath.

The skin is the largest organ system in the body. It is tough and pliable and protects the underlying tissues against air, water, foreign substances, and bacteria. It is sensitive to injury and has remarkable self-repair capabilities. However, despite its resiliency, skin simply can not take prolonged pressure, excessive force or friction.

Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen. When skin is starved of blood for too long, the tissue dies and a pressure ulcer forms.

Skin damage from pressure usually begins on the body where the bones are close to the skin surface, such as the hip. These bony prominences apply pressure on the skin from within. If there is a hard surface on the outside too, the skin is pinched off from circulation. Because the rate of circulation is also reduced by paralysis, less oxygen gets to the skin, lowering the skin's resistance. The body tries to compensate by sending more blood to the area. This may result in swelling, putting even more pressure on the blood vessels and further compromising the health of the skin.

A skin sore can mean several weeks of hospitalization or bed rest in order for the sore to heal. Complex pressure sores may require surgery or skin grafting.

Who gets pressure sores? Anyone, including those with full mobility, can get a pressure sore if he or she remains in one position long enough to exert forceful pressure on a particular part of the body. People in wheelchairs or those who stay in bed are especially susceptible because they may have difficulty repositioning themselves or are unable to shift their weight without assistance. When limited mobility is coupled with impaired sensation, a person is more likely to develop a pressure sore due to the inability to sense when to make a weight shift in order to relieve pressure.

Lack of sensation is only part of the story. Paralysis related to trauma or disease affects the biochemistry of the skin itself. For example, there is a considerable loss of proteins such as collagen, which give skin its tensile strength; this makes the skin weaker and less elastic. The aging process also adds to the risk of skin breakdown. Older people generally have a higher risk of developing pressure sores.

Non-use of muscles around the bony prominences of the body (hips, heels and elbows, tailbone and ischium or seating area) leads to muscle loss (atrophy), adding to the risk of skin breakdown.

The force of friction or shearing-- the dragging movement of skin tissues across a surface, such as sliding in a bed or chair can cause blood vessels to stretch or bend, leading to pressure ulcers. An abrasion can occur when pulling across a surface instead of lifting. A bump or fall may cause damage to the skin that may not show up right away. Pressure sores can also be caused by clothing, braces, or hard objects that put pressure on your skin. Also, people with limited sensation are prone to skin injuries from burns.

Excessive moisture is also a factor for developing pressure sores in people with excess perspiration and/or incontinence.

Nutrition: Poor nutrition poses a serious threat to a person's overall health but also places a person with paralysis at a much higher risk for developing pressure sores with a much slower recovery period. The body demands various nutrients such as proteins and vitamins to keep the skin healthy, repair any damage and fight off any infections. A body that is depleted of nutrients is limited in its ability to ward off complications such as pressure sores.

Weight Problems: A person who is overweight is at higher risk for pressure sores; it is also quite possible for someone who is underweight to be at higher risk. For the overweight person, the extra pounds force the body increase pressure to the vulnerable skin areas. The lack of muscle and body mass - which you might think of as padding -- makes the skin less resilient to stress.

Other factors that increase the risk for pressure sores include poor health, dehydration, poor hygiene, smoking, anemia, chronic conditions such as diabetes, vascular disease, spasticity, poor equipment, substance abuse and depression. The medical literature suggests that people who are depressed are less likely to be vigilant with regard to important self-care issues such as skin health.

Types of Pressure Sores: Pressure sores have been categorized into four stages depending on their depth and size and to the severity of damage to the tissue layers. The stages are: Stage I (earliest signs), Stage II (blisters and sometimes openings or ulcers), Stage III (damage sets into the deep under tissue) and Stage IV (damage enters into the muscle and bone).

Stage I: A pressure sore almost always begins as a red area on the skin. This reddened area may feel hard and/or hot. For people with black or dark skin, the area may appear shiny or darker than usual. At this stage, the progression of tissue breakdown is reversible; the skin will return to normal as soon as the pressure is removed.

Care: Remove any source of pressure. Clean the affected area with warm water and keep dry. Allow the skin a chance for full recovery by keeping any pressure away from it as long as it is discolored. If the pressure sore is on the seat area, one must refrain from sitting as much as possible. Examine all seating and mattress support systems to access any contributing factors. Hydrate, rest and maintain a balanced and nutritious diet. Remember to keep the skin clean and dry. And check your skin often. If a pressure sore has not healed after a few days or has gotten worse, contact your physician.

Stage II: The pressure sore has formed a blister or scab and/or may have begun to open up at the surface of the skin possibly with some discharge. This means the tissue underneath has begun to die. If pressure is not relieved soon and care given to the skin area, the pressure sore can rapidly progress to a dangerous level where the infection can attack the bone and pose serious risks to your health.

Care: Again, remove all pressure from the area. Contact your physician. Keep the wound clean and dry and check skin often. Follow instructions from your health care provider, which typically will entail cleaning the affected area with a saline solution and applying a prescribed dressing in order to keep the area optimized for healing.

Stage III: By this stage of a pressure sore, a hole or ulcer has formed in the dead tissue. Damaged tissue extends to at least the subcutaneous or third layer of skin tissue, and may even extend to the bone.

Care: Follow the same initial procedure in Stages I and II. Generally, this stage requires specialized wound care; this often includes debridement, the surgical removal of dead tissues and foreign matter from a wound. Follow up care may include specialized packing agents, medicated creams, antibiotics and more appropriate seating or sleep surfaces to relieve pressure.

Stage IV: This is the worst stage of a pressure sore. The damage has extended into the muscle and quite possibly as far down as the bone. Drainage is almost always present. In severe cases excess puss may occur.

Care: If you have a fever, see green or yellow discharge and have a warmer temperature around your wound, you may have developed an infection. Whenever an infection forms within a pressure sore, all surrounding tissues are in danger of becoming infected too. If this should occur, then sepsis (a type of blood poisoning) becomes possible. Untreated, this can be fatal.

A skin sore at Stage IV may mean several weeks of hospitalized care followed by weeks of bed rest. Quite often, advanced pressure sores require surgery or skin grafting (skin is often taken from a leg and stitched to the area of the pressure sore). These operations can cost $100,000 or more and may require extended time away from everyday life.

Surgery may be avoidable altogether for an advanced ulcer because of dextranomer beads or newer hydrophilic polymers which can speed up healing without surgery. In fact, many new topical agents such as hydrophilic gels and many new dressings such as hydrocolloid dressings are becoming available to assist and speed up the healing process of pressure sores.

In addition, there are a few new kinds of treatments which are not yet widely used but have met with very good success. One of them is called vacuum-assisted closure therapy. The application of an air-tight foam dressing and a vacuum pump create a negative pressure around a wound which serves to stimulate blood flow and encourage healing. Another possibility you might look into is called electrotherapy. With this procedure, a very small electrical current is used to stimulate healing. As this is one of the newer forms of treatments for pressure sores, you may have to search for trained personnel with the correct equipment.

Basic Treatments:

Pressure Relief

Irrigating the wound with saline solution

Frequent shifting of weight

Special seat cushions and beds

Whirlpool used to remove tissue

Topical antibiotic ointments

Gel-foam bandages

Hydrocolloid dressings

Antibiotics

Debridement

Skin Grafting

Surgical Cleaning

Vacuum Assisted Closure Therapy

Electrotherapy

It is important to note that skin problems are almost always preventable with routine skin inspection, and with right equipment. A wide variety of pressure-relieving support surfaces, including special beds, mattresses, mattress overlays, or seat cushions, are available to support your body in bed or in a chair.

Prevention

The first line of defense is to be responsible for your skin care. People in danger of developing pressure sores need to create a skin-checking regimen which they adhere to daily. People with limited ability or those confined to bed rest must be assisted by caretakers with the daily checking; parents of children in wheelchairs need to check the skin of their children for potential trouble spots.

It is also important to regularly check your support surfaces to make sure they are in good condition. This means checking the seats of your wheelchair, toilet, auto transport and any other seat cushion you use during the day. Work with a trained seating specialist to investigate the many seat systems and cushions on the market. In addition, there are a wide variety of pressure-relieving sleep surfaces (mattresses and mattress overlays) which redistribute weight off of pressure sores.

A diet rich in vitamins and minerals is important in preventing any complication from pressure sores. A healthy diet will translate into healthy skin; healthy skin will be better able to stand up to the pressures and stress forces it is subjected to on a daily basis. Also, if a skin injury does occur, a healthy supply of nutrients in the blood will make for a much quicker recovery. Proteins and amino acids are essential to the body to keep skin, muscles and bones strong. And vitamins such as C and E assist with skin repair function.

People in wheelchairs need to change positions regularly. If one has use of the upper body, this can be done by lifting oneself up off the wheelchair seat for a few seconds in the same way a pushup is performed. This gives the skin in the seating area a much needed break in pressure.

For people who do not have upper body mobility, assistance is required. Some people may need to use tilt in space wheelchairs (seating position is maintained as the whole seat is tilted back).

A person in bed must be moved at least every one to two hours. Extra care should be given to make sure that the skin is not stretched when shifting the body of the individual.

Preventative Measures:

Skin stays healthy with good diet, good hygiene, and regular pressure relief. First, keep skin clean and dry. Skin which is moist from sweat or bodily discharges is more likely to break down.

Provide regular pressure relief throughout the day changing positions at least every two hours.

Check your skin at least once a day paying extra attention to any sensitive areas.

Eat a balanced diet that is rich in proteins, vitamins and minerals.

Check you support surfaces and equipment regularly for wear and tear.

Don't smoke. It narrows blood vessels which limits nutrients to the skin. Research has shown that heavy smokers are more prone to skin sores.

Daily exercise can add strength and vitality to your skin and overall health.

Change bedding and clothing frequently.

Use warm water and mild soaps to clean the skin. Hot water may hurt or damage it.

Maintain continence as much as possible and reduce moisture.

Attempt to avoid direct pressure to the "hot spots," any of the bony areas.

Use protective padding and items such as pillows which can help reduce pressure.

Drink plenty of fluids. A healing wound or sore can lose more than a quart of water each day. Drinking 8-12 cups of water a day might not be too much. Note: beer and wine do not count. Alcohol actually causes you to lose water or become dehydrated.

Avoid rapid gain or rapid loss of weight. Be sure to make any necessary readjustments to your equipment if you should go through a drastic change with your weight or body shape.

Watch weight, too. Being too thin causes you to lose the padding between your bones and your skin and makes it possible even small amounts of pressure to break down the skin. Getting too heavy is risky, too. More weight may mean more padding but it also means more pressure.

Continue to educate yourself on pressure sores and prevention.

Be active and enjoy your life.



Resources

Web Sites



Craig

Craig Hospital article: Skin It's Too Much Pressure


Spinal Cord Injury Information Network

Spinal Cord Injury Information Network
The Spinal Cord Injury Information Network website provides information on skin care and other topics relating to paralysis medicine, lifestyle and resources.



University of Washington School of Medicine 1

University of Washington School of Medicine 2

University of Washington School of Medicine 3

University of Washington School of Medicine
The University of Washington School of Medicine/Department of Rehabilitation maintains a very useful website with information on skin care, bowel and bladder management and other topics of concern to people with paralysis. See the above three pamphlets on pressure sores and skin care.



<A HREF="http://www.spinalcord.org/html/factsheets/pressure_sores.php" TARGET=_blank>NSCIA's Fact Sheet on pressure sores.
</A>

National Spinal Cord Injury Association's Fact Sheet on pressure sores.



<A HREF="http://www.spinalcord.org/html/factsheets/skin_care.php" TARGET=_blank>NSCIA's Fact Sheet on skin care.
</A>

National Spinal Cord Injury Association's Fact Sheet on skin care.



Health and Disability News

American Association on Health and Disability's Health and Disability News, Spring 2004 article "Preventing Pressure Sores".



MedlinePlus: Pressure Sores

MedlinePlus: Pressure Sores



Decubitus Ulcers

eMedicine: Decubitus Ulcers


Bedsores

Aetna Intelihealth: Bedsores (Decubitus Ulcers) What is it?

Gale Encyclopedia

Gale Encyclopedia of Medicine: Bedsores


Family Doctor

Family Doctor.org's Pressure Sores


Merck Manual

Merck Manual of Diagnosis and Therapy: Pressure Sores



Pressure Sores

Spinal Injury.net's Pressure Sores



<A HREF="http://www.sci-info-pages.com/skin_pres.html" TARGET=_blank>Skin and Pressure Sores
</A>

SCI-Info-Pages: Spinal Cord Injury: Skin and Pressure Sores



Wound Management

Kinetic Concepts Inc (KCI) Wound Management Reference Guide



VAC

Vacuum Assisted Closure (VAC) Therapy: An Advanced System for Wound Healing



Travis Roy Foundation

Travis Roy Foundation: Pressure Sores



Ulcer Advisory Panel

National Pressure Ulcer Advisory Panel



Decubitus

National Decubitus Foundation



Wound Care

Wound Care Information Network



Wound, Ostomy etc

Wound, Ostomy and Continence Nurses Society



Books



Consortium for Spinal Cord Medicine, Clinical Practice Guidelines. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America, 2002.


Decubitus Ulcers: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Health, 2004.


Hess, Cathy Thomas. Clinical Guide to Wound Care. Philadelphia: Lippincott, Williams & Wilkins, 2002.


Maklebust, JoAnn and Mary Sieggreen. Pressure Ulcers: Guidelines for Prevention and Management. Springhouse, PA: Springhouse Corporation, 2001.


Morison, Moya. Chronic Wound Care: A Problem-Based Learning Approach. Mosby-Year Book, 2004.


Morison, Moya. The Prevention and Treatment of Pressure Ulcers. C.V. Mosby, 2000.


Phillips, Jenny. Access to Clinical Education: Pressure Sores. New York, NY: Churchill Livingstone, 1997.


Pressure Sores: A Medical Dictionary, Biblography, and Annotated Research Guide to Internet References. San Diego, CA: Icon Health Publications, 2004.


U.S. Department of Health and Human Services. Treatment of Pressure Ulcers. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994.


Articles


Pressure Sores: Part I "An Incurable Malady?" PN (Paraplegia News). June 2002 pp13-17.



Pressure Sores: Part II "An Incurable Malady?" PN (Paraplegia News). July 2002 pp.33-38.



Pressure Ulcers. PN (Paraplegia News). January 2005 pp.45-6.



The Lurking Dangers of Pressure Sores

Muscular Dystrophy Association's Quest Feb. 1999 "The Lurking Dangers of Pressure Sores".



list of articles

JAMA & Archives list of articles on Pressure Ulcers





Videos


Mosby's Nursing Assistant Skills Video: Preventing and Treating Pressure Ulcers. C.V. Mosby, 2001.


Skin Care: Preventing Pressure Ulcers. Medlantic Research Institute. Can be ordered from PVA.


Taking Care of Your Wounds. Thin Air Productions. Taking Care of Your Wounds


CD-ROMs


21st Century Complete Medical Guide to Pressure Sores, Bedsores, Decubitus Ulcers: Authoritative Government Documents, Clinical References, and Practical Information for Patients and Physicians. Progressive Management, 2004.





Keyword Searching Terms:



Bedsores, Pressure sores, Pressure ulcers, Decubitus ulcers, Wound care, Skin breakdowns



The information contained in this message is presented for the purpose of educating and informing you about paralysis and its effects. Nothing contained in this message should be construed nor is intended to be used for medical diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified health care provider. Should you have any health care related questions, please call or see your physician or other qualified health care provider promptly. Always consult with your physician or other qualified health care provider before embarking on a new treatment, diet or fitness program. You should never disregard medical advice or delay in seeking it because of something you have read in this message

[This message was edited by dogger on 02-16-05 at 06:46 PM.]