SKIN CARE

In The Wheelchair

Effective pressure sore prevention depends upon self-reliance. No wheelchair cushion allows its user to ignore the skin completely. Every individual must come to know the characteristic response of his/her body to excessive pressure. The skin must be inspected personally by the wheelchair user every morning and every night, using a mirror, where necessary, to ensure that no red areas are present. Tetraplegic may need assistance in positioning mirrors or other aids to check areas of the body, but the emphasis should rest upon the individualâ€™s being responsible for checking the condition of his own body.
An essential element of pressure sore prevention is weight relief. Every paralysed individual without full sensation should learn to relieve weight as a regular habit. A typical guideline is 20 seconds of weight relief from the seat every 20 minutes, followed by gentle restoration of full weight onto the buttocks. The activity does not necessitate a direct and conspicuous push-up in the wheelchair; leaning forward or from side to side can be just as effective. For many tetraplegics weight relief is difficult. Whilst some can achieve relief only with assistance, many learn ways of securely levering the body alternatively off each buttock to provide some restoration of circulation.
All wheelchair cushions have a limited life and need regular checking to provide a reliable degree of assistance in sore prevention.
A common habit amongst active wheelchair users is storing car keys and other items under the wheelchair cushion. This practice can lead to sores through migration of the items back under the cushion to areas susceptible to tissue damage. A safer way of carrying belongings is via a bag conveniently hung below or behind the seat.
Most clothing has not been designed with the paralysed person in mind. Stiff seams and pockets which cross over the ischial tuberosities, trochanters, or coccyx in sitting are common. These have led to sores in the past and should be eliminated wherever possible. A similar risk is associated with carrying objects in the back pockets of trousers while sitting.
Underwear can sometimes help to prevent sores by padding the skin against outer clothing. It is best to purchase underwear which has side seams rather than a seam that runs over the sacrum or ischial tuberosities. Natural fibres such as cotton, which absorbs perspiration, is preferable to man-made materials which will hold perspiration against the skin.
Correct positioning of the feet on the wheelchair footplates is also important to prevent foot-drop deformities of the feet and ankles, and the development of ulcers against the heels through pressure against the edges of the footplates, or the frame of the wheelchair. Special straps or heel loops often help in keeping the feet in place, especially in cases of spasm in the lower limbs.
Tetraplegics are often exposed to additional risks in wheelchairs. Special precautions must be taken in pushing wheel rims with insensitive hands, and protective gloves should therefore be worn. As many tetraplegics lean on arm rests, the elbows should also be watched and special elbow pads used where necessary.

In The Car

When sitting in a car the feet should be positioned to prevent injury, especially when driving on rough roads.
It is also important to check the temperature of the floorboard under the feet, particularly on long trips or in hot weather, to ensure that it is safe for contact with insensitive skin.
It is very easy to sustain burns when travelling by car, especially in hot weather. On long trips the sun shining through car windows can cause burns, and under these conditions most interior features of a car will become dangerously hot after parking in the sun for any period. Typical traps for paralysed driver or passenger are seat upholstery, seat belt buckle, and steering wheel, all of which should be checked before driving. Other hazards are associated with transferring in and out of a car, where accidental contact with a hot door frame or even the car exhaust is not unknown.
Cars can also be a source of severe burns under cold conditions. When travelling by car it is important for people with insensitive feet and legs to check that they are not in the direct airstream of convective heaters, which can cause severe burns.

In The Kitchen

Contact with hot food and liquid is a major cause of burns and scalds. The danger can be minimised by redesign of work areas to suit the wheelchair user. Useful rules are to avoid, where possible, lifting pots of boiling liquid and resting hot saucepans where they may be easily tipped over.
When using an oven the temptation always exists to balance hot objects on the wheelchair whilst closing the oven door. The problem can be avoided with a shelf at the right height next to the oven onto which objects can be immediately transferred.
Hot drinks or plates of food should never be balanced on the thighs whilst a wheelchair is being propelled, as there is always a risk of spillage, and the liquid or solid is often so much hotter than is imagined.
Tetraplegics should be careful to check that any item (e.g. a drinking mug) being lifted with the insides of the hands, is not hot enough to cause burns.

In The Bathroom

Transferring at anytime carries the risks of accidental bruising or grazing, particularly where wheelchairs or commode chairs with protruding metal fixtures (e.g. brake handles) are used. The risk can be minimised by ensuring that both surfaces involved are stable and will not suddenly shift under the moving body weight. The precaution is particularly important with mobile chairs in which every wheel cannot be locked to prevent rolling.
Cushions or additional padding should always be employed to protect the skin when in contact with any bathing or toileting appliances, such as commode chairs, baths, and bath seats.
Wet skin is always susceptible to pressure sores and other trauma than dry skin, so after washing or toileting, the skin must be dried thoroughly. Talcum powder must not be used excessively, as it can cause cracking of the skin and form hard lumps in contact with water.
Hot taps and pipes around the bath and beneath wash basins can also lead to burns if not checked.
The temperature of bath water should always be checked prior to transferring into it.

In The Bedroom

Along with the selection of an adequate wheelchair cushion, the use of a suitable mattress is vital to the successful prevention of pressure sores. The choice of mattress and the corresponding pressure tolerance period is a matter for individual assessment.
An additional aid which may prove useful in bed is a sheepskin.
Skin problems can also be avoided by ensuring that sheets are clean and smooth, without crumbs and wrinkles. Use of a suitable washing powder also aids in preventing chemical irritation of the skin.
Electric blankets and hot water bottles should not be used. Although electric blankets may seem to be only warm, after an extended period of contact, they can lead to severe burns, often over pressure-prone areas.

Outdoors

Paralysed individuals have reduced tolerance to extremes of heat and cold, so appropriate precautions should be taken. Great care is needed during exposure of insensitive skin to the sun and suitable sunscreen lotions should be applied where possible. It is particularly important for tetraplegics to wear a sun hat.
When at the beach, it is essential to check the temperature of the sand or blankets before sitting, particularly out in the open sun.
Exposure to the cold can also lead to skin problems. Since the risks of frostbite and severely reduced pressure tolerance are very real for paralysed individuals, all limbs should be warmly clothed and correctly fitted boots worn.

Choice of Clothing

Pressure problems can often be traced back to excessively tight or creased clothing, especially where footwear is concerned, as parts of the feet are very sensitive to pressure. A useful measure is to wear shoes which are one size larger than needed and have rigid soles to prevent footdrop. This is particularly important for men with large feet, which may overhang the footplates of standard wheelchairs.
Toe and heel sores are often a product of ill-fitting shoes, but they can also be caused by toes becoming wedged into the shoe if correct positioning of the foot is not checked. Elastic stockings may also constrict the blood supply to the feet and lead to foot ulcers.

Miscellaneous Problems

Indoor heaters, fires, and heating vents can be deceptive if feet are paralysed and temperature is sensed only by the face and hands. Indoors, burns to the feet can be avoided by sitting side on to direct sources of heat and keeping clear of hot-air ducts. Great care must be taken near outdoor fires and barbecues, especially when cooking, as hot fat can lead to serious burns.
Urinary drainage appliances must always be checked to ensure that urine drains freely and does not pool within an appliance. Any device must also be correctly fitted to avoid skin breakdown, particularly where a sheath drainage system is used.
Incontinence of urine and faeces is a complication of spinal injury. The spillage can lead to increased risk of pressure sores, as wet skin is liable to maceration, so wet clothing should be changed as soon as practicable, and all soiled skin washed thoroughly.
Smoking, amongst other things, can be a skin hazard. Tetraplegics often suffer burns due to cigarettes burning down to contact with the fingers, and therefore should use a suitable cigarette holder. A danger for all wheelchair users is the thin aluminium ashtray, which may cause burns if left resting on an insensitive thigh. Cigarette ash and matches also present cause for caution, as they can fall between clothing and the wheelchair cushion and cause damage to both. As in the case of all smokers, paralysed individuals should be discouraged from smoking alone in bed.

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