Decubiti, also called pressure sores or decubitus ulcers, are breaks in the skin caused by too much pressure over a period of time. They are only an occasional problem in people with MS, but they are considered a medical emergency when they do occur. If they are managed well when they first develop, they usually resolve without problem; if they are left to increase in size, they may become life-threatening.
Decubiti most commonly occur on the buttocks and other areas that are in constant contact with the surface of a bed or wheelchair. A person with decreased skin sensation does not perceive the discomfort that normally would indicate that he or she has been in one position for too long. Pressure sores frequently appear quietly, with little or no pain, and continue to enlarge, resulting in large holes in the skin that gradually expand into the underlying muscle. Additional factors that may contribute to this process include inadequate nutrition, dependency on certain medications, stool or urine incontinence, and a lack of education regarding prevention.
When pressure is applied to an area of skin over a bony prominence, blood flow to the area is obstructed. The body produces a rebound response of redness and heat when the pressure is relieved, and the skin and muscle below can recover. The skin and muscle below can recover if the pressure does not persist. This is called healing by first or primary intention. People with MS should know how to avoid stressing the skin to the point that it cannot recover. Several factors affect wound healing, including age, the presence of other medical problems, and nutritional state.
The key to managing decubiti is to avoid them! Avoidance means transferring weight off contact areas at frequent intervals without using pressure, shear, or friction to accomplish the move. It means using proper equipment to disperse the weight of the body over larger surface areas, such as foam pillows, air mattresses, water mattresses, and gels. Foam rubber pads and sheepskins placed under pressure areas such as the sacrum (tail area) and heels aid in dispersing pressure during movement. These "tools," plus proper positioning, relieve shear and friction. The skin must be frequently and carefully examined for areas of pressure and breakdown.
For the bedridden person, a special mattress that takes pressure off the stressed areas may replace the standard bed. It is important to turn once every two hours to avoid continuing pressure to any one area.
Immediate attention is essential if an ulcerated area does form. No pressure should be applied to the area. The good skin around the affected area must be preserved and toughened. Special "skinlike" bandages may be applied. Cleaning the area (debridement) may be necessary and should be performed by someone who is trained in this technique.
If all else fails, surgical closure of the wound may be necessary. Surgery allows for healing by secondary intention. The ulcer cavity (opening) with its surrounding scar tissue must be completely is to avoid them!
is to avoid them!
removed, the bony edge removed, and the wound covered with healthy skin.
Proper postsurgical management is critical for a favorable outcome. It should be obvious that care must be taken not to irritate the wound until it has healed. Further attention to prevention is even more important after the wound has healed because the area remains vulnerable to re-injury.
If careful attention is paid to the preventive measures described here, the chances of a pressure sore forming will be minimized. Prevention is the best strategy.
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