64.15 A paraplegic’s skin

Bedsores occur in sensory paraplegia and occasionally in any very sick or very old patient who is left in the same position too long without being moved. You can prevent them completely, even in complete paraplegia and quadriplegia, but, only provided you turn a patient every 2 hours day and night.

Figure 64.18: MAKE A PARAPLEGIC’S LIFE AS COMFORTABLE AS POSSIBLE. If he can read, make sure he has a reading board and something to read. If he ever stops eating from the effects of misery and chronic infection, his death is near. Kindly contributed by Peter Bewes.

The cause of bedsores is clear. The pressure of the body on any part of the skin and subcutaneous tissue causes temporary ischaemia. In a normal person this causes mild discomfort, so that he turns about every 15 minutes to let another part of his anatomy bear his weight. Because a paraplegic patient cannot feel discomfort, or move, he cannot vary the skin on which he lies, so it remains ischaemic for hours at a time, it becomes necrotic, breaks down, and causes a bedsore. If only you can interrupt this period of ischaemia, you can prevent a sore forming. Explain the pathology of bedsores carefully to all your nurses, and to everybody who looks after paraplegic patients. Later, explain it to the patient too, so that he can play his part in preventing them. They are particularly likely to occur immediately after the injury, and during an intercurrent infection later.

Bedsores can only be prevented if prevention has a high priority in the surgical ward. So, put a chart at the foot of a patient’s bed, with the time marked on it every 2 hours. Ask the nurses to sign this chart each time they turn him, and to record the side onto which they have turned him—left side, back, front, etc. At least 2 people are needed, and three are better. During the night the nurse on duty will need help, any help, even that of a relative, a watchman, a porter, or another patient. Show them how to turn him gently, so that they don’t twist the patient’s injured spine and injure it further. This is especially important if his fracture is unstable, when he must be ’moved in one piece’. Happily, nurses very rarely injure a patient’s cord when they turn him.

The discipline of absolutely invariable 2 hourly turning is difficult to introduce because most nurses have seen paraplegics develop bedsores. Gloom and hopelessness thus pervades them all. So take the initiative yourself. Turn a patient yourself the first time, and next time, and perhaps the time after that. Ask a nurse to help you. If you show yourself prepared to get up a few times at 4 a.m. and help turn him (as some doctors have done), your nurses will play their part. Come early into the ward the next morning and inspect the pressure areas. If you find no redness (in a Caucasian) or blistering, congratulate the nurses, and help them with their plans for turning him during the rest of that day. Even offer to help them to turn him at night, if staff are short. If you are called, appear delighted, and conceal your distress!

Inspect the pressure areas on every ward round, and if they are healthy, congratulate the staff. At the slightest sign of redness or blistering, help the nurses to prepare an alternative routine of turning that will spare the red areas from pressure for a few days.

If any important person visits the hospital, show him the paraplegics. If he asks the inevitable question, "Why are there no bedsores?" ask him to ask the nurses. They will be only too ready to explain that it is because they are turning the patient every 2 hours. They will soon realize that they are becoming experts in this exacting field.

After a month or two, the patient, and his relative between them can begin to work out their own routine for turning him, and plan how to manage him at home. After a few months it becomes almost reflex for him to be turning himself in bed at home. Once he is able to do this himself, he need only be readmitted to be turned by the nurses if he has an intercurrent infection, such as pneumonia.

Try to get him into a wheel chair or calipers quickly. When he is in them, teach him how to avoid getting pressure sores, as described below.

If he is only partly paraplegic and wears calipers, he must inspect where they press, so that he does not get pressure sores there. Let him see other patients with bedsores, so that he knows what he is trying to avoid.

Dr NICKEL took over a chronic care hospital in California with the worst of reputations for poor nursing care. He made it a rule that at the begining of each shift, the new shift examined the back of each patient for pressure sores. If a bedsore developed, the senior nurse on the shift was dismissed. His hospital became a showplace. LESSON Good discipline can prevent pressure sores.

SKIN CARE FOR PARAPLEGIA

Turn a paraplegic patient every 2 hours. This is by far the most important treatment. Each time you turn him, put his joints through a full range of passive movement, concentrating on hip and knee extension and dorsiflexion of his ankles.

BED Place a door on an ordinary hospital bed. On it place two 10 cm foam mattresses covered with mattress ticking. Put soft pillows or foam rubber cushions between the patient’s legs and under his back.

If you have only a hard mattress, pad the pressure points with cotton wool, gauze, or pieces of fleece. Keep them in place with adhesive strapping, but watch these pads carefully. Don’t allow them to become creased. Remove them at least once a day and check the skin under them.

Try to keep the patient’s bottom sheet tight, dry, and free from creases, crumbs, and bits of food.

If his heels show any sign of pressure sores, put a pad under his ankles, or a ring pad around his heels.

PRESSURE POINTS Don’t pad pressure points—pad round them. Watch the skin over his sacrum, his iliac crests, his hips, the sides of his knees, his heels, and his malleoli, and his penis if a condom catheter is applied.

INCIPIENT SORES The first sign of a sore is redness of the skin. Treat any red areas by careful massage and then apply one of these solutions: (1) soap and water followed by careful drying and powder, (2) hypochlorite(’Eusol’), (3) borax in spirit, (4) 1% formaldehyde.

ESTABLISHED SORES Keep pressure off a sore until it has healed. Try to keep it clean. Use saline dressings or paraffin gauze. Honey and the fruit of the papaya (paw-paw) have also been used successfully. Small sores may heal slowly, if you keep them clean and protected.

If a skin lesion is obviously necrotic, toilet it and remove the necrotic tissue. You may find a much larger lesion under the surface. Large sores may need transposition, rotation, or myocutaneous flaps.

Keep the patient’s haemoglobin above 12 g/dl.