When traveling to a new country, some exchange participants with disabilities may find that the long flights, the change in routines and the stresses of an unfamiliar experience can trigger new pressure sores or make existing ones worse.  For those who first experience a pressure sore while abroad, or for those that may have had little education on these secondary conditions, the tipsheet may be helpful. It discusses what a pressure sore is, its risks, how to take steps to prevent it from happening while abroad, and how to recognize and treat a sore if it does develop.

What is a Pressure Sore? / Eight Tips to Prevent a Pressure Sore /

Low Cost Equipment / Practical Techniques for Pressure Relief /

What to Plan Before You Go / How to Tell if a Pressure Sore is Developing /

How to Treat a Pressure Sore / Healing of the Pressure Sore  / Quick Review

What is a Pressure Sore?

A pressure sore is known by many names, like pressure ulcer, decubitus ulcer, bed sore or skin sore. No matter what it is called, it is a serious problem that can take days, weeks, months or even longer to heal. A pressure sore is identified by any redness, darkness or break in the skin caused by too much pressure for too long a period of time. The result is dead or dying tissue due to a loss of blood flow to the area. It can begin in a number of ways. The most common type of pressure sore occurs when you rest in the same position on a bony area for a prolonged period of time.

Normally, the nerves send messages of pain or feelings of discomfort to your brain to let you know that you need to change position. However, people with spinal cord injuries, muscular dystrophy, spina bifida or other conditions that affect feeling or mobility, often don’t feel or are unable to respond to these pressure pains and move to a new position. 

Eight Tips to Prevent a Pressure Sore

 (Modified from http://www.spinalcord.uab.edu/show.asp?durki=21486)

1. Check your skin completely twice a day, once in the morning and once at night. Carefully look for skin damage, darkness or redness, especially on bony areas. If you have a low level of injury, you can use a mirror to inspect areas you cannot easily see. If your injury is at a higher level, have a family member or personal care attendant check your skin.
2. Know the places on your body that are more likely to get a pressure sore (See picture at left). The four most common areas for a pressure sore to develop are on the tailbone, the heel of the foot, the base of the buttocks and the bony areas of the foot. Hips can be at risk when lying down in bed.
3. 3. Keep skin clean and dry. Wet skin can become soft, inflamed and is less resistant to damage. Moisture weakens the skin and causes it to breakdown more quickly. Wash and dry skin right away after any bowel or bladder accident. Change clothes when they become wet. Pack an extra pair of pants in your travel day pack for times when you’re stuck in a sudden downpour or an accessible bathroom isn’t available.
4. Do not smoke. Smoking decreases oxygen to the skin and can make it more difficult for skin to heal. Do not abuse drugs or alcohol. Both can damage your skin and can also lead to other health problems.
5. Eat a well balanced diet. Foods high in protein, vitamins and minerals help your skin to stay healthy and heal more quickly; these include beans, lentils, eggs, meat, fish, and milk products. Drink the recommended amount of fluids to help your skin stay soft (at least 8 to 10 glasses of water per day). Limit the number of caffeinated drinks like coffee, tea and soft drinks.
6. Protect your skin from harm.  Avoid movement or activities that rub, scratch or cut your skin. Avoid clothes and shoes that are too loose or too tight fitting. Avoid clothes with thick seams, buttons or zippers located in areas where they put pressure on your skin.  Take special caution when doing transfers and participating in new activities or sports or on air flights.
7. Move often. Sitting or lying in the same position for too long causes the flow of blood to be cut off. Do weight shifts (pressure relief) at least every 15-20 minutes when sitting in your wheelchair. See the diagrams in the Practical Techniques for Pressure Relief below. 
8. Your seat cushion should fit your body and your wheelchair, and/or your leg braces should be properly adjusted to offer the best protection against pressure areas. Bring your seat cushion with you on long flights and remove your shoes/braces. Your mattress should provide proper support and protection too. While in bed, change position at least every two hours. Use pillows, rolled blankets or sheepskin to help protect areas of the body that get too much pressure. Bring this extra bedding with you overseas if necessary. Read the next section for creating or assessing a cushion.

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Low-Cost Equipment

(Modified from Disabled Village Children, by David Werner, http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00226.htm)

Special cushions are made with 'soft spots' of an almost-liquid 'silicone gel' in the areas of greatest pressure. However, these cushions are very expensive. Also, the gel may get too soft and liquid in hot weather.  Good cushions can also be made of 'microcell' rubber, which is fairly firm. It works best if cut and shaped to reduce pressure on bony areas.

A good, low-cost way to make a fitted cushion is to build a base out of many layers of thick cardboard glued together. Cover it with a 2 cm. or 3 cm.- thick layer of sponge rubber.

Wet the cardboard and sit on it wet for 2 hours so it forms to the shape of the buttocks. Make sure you relieve pressure regularly during this time and use a thin barrier that keeps the moisture away from the skin. Then let the cardboard dry, and varnish it.

Before making a specially-fitted cushion, you can make a 'mold' of the buttocks by sitting in a shallow container of soft clay, mud, or plaster. Note the bony hollows and form the seat to fit them.

Air cushions made from bicycle inner tubes are easily found overseas for prevention of pressure sores, and for bathing on a hard surface. Use 1, 2 or more tubes, depending on size of tube and your body size. 

Bind loops of the tubes together with thin straps of inner tube. Pump in enough air so that the whole buttocks is held up by air.

WARNING: For small areas such as heels, never use a ring or 'donut' of cloth to keep weight off the sore. This can cut off blood supply to the skin inside.

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Practical Techniques for Pressure Relief

(Modified from Disabled Village Children, by David Werner, http://www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00226.htm)

If you have strong arms, then lift up your whole body and hold it up for a minute or two. This lets the blood circulate in the buttocks.  

If your arms are weak. You can take the pressure off your buttocks by leaning your whole body over the armrest, first on one side, and then on the other.   

If your wheelchair has a low back, you can lean back and lift your hips off the seat.

If the chair has no armrests, or they can be removed, you can lie sideways over a pillow on a high bed and can rest for 15 to 30 minutes like this.  

If you have very little arm and body control, you can put your feet on the floor (with help if needed) and lean forward with your chest on your knees. This takes the pressure off your buttocks.  Or have someone tip your wheelchair backward for one minute or more.

For a longer 'nap' that rests the buttocks, someone can tip your wheelchair backward onto a cot.

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What to Plan for Before You Go

If you have had a pressure sore in the past, or have one before traveling, talk with your doctor and then your exchange coordinator about how to best manage this on the exchange program. Find out what the daily schedule will be and if you will be able to keep pressure off the area. Also make sure that you know your health insurance in case you need hospital visits or medications. It is also useful to read through the prevention tips above to know what materials to bring. Consider requesting a seat in business class on your flights, as this will give you more room to adjust during long trips.

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How to Tell if a Pressure Sore is Developing?  

(Modified from http://www.spinalcord.uab.edu/show.asp?durki=21486)

The most common sign of a pressure sore is the appearance of a red or dark area or spot on the skin. Ordinarily, darkness or redness clears within 30 minutes after the pressure is released. If the darkness or redness does not clear, a pressure sore is developing. The area may become light, dry, flaky, or ashy. Other signs indicating the beginning stages of a pressure sore are: an area of skin that is warmer than normal or a change in the skin's texture.

There are four stages to pressure sore development:

Stage 1 - Damage is limited to the top two layers of skin. The skin is not broken and the redness or darkness does not change when touched.

Stage 2 - Damage extends beyond the top two layers of the skin to the fat tissue. The skin is slightly broken. The sore appears to be an abrasion, blister or small crater.

Stage 3 - Damage extends through all the superficial layers of the skin, fat tissue, down to and including the muscle. The ulcer appears as a deep crater and damage to adjacent tissue may be present.

Stage 4 - Damage includes destruction of all soft tissue structures and involves bone or joint structures. Undermining of adjacent tissue and sinus tracts may be associated with these ulcers.
 
The kind of complications that can be caused by pressure sores include:  

• Prolonged bed rest or other conditions.
• Infections that spread to the blood, heart, bone.
• Amputations or death.

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How to Treat a Pressure Sore

(Modified from http://www.spinalinjury.net/html/_pressure_sores.html and from www.dinf.ne.jp/doc/english/global/david/dwe002/dwe00226.htm)

By the time you realize there is a problem, damage to the skin has already occurred. Once you see signs of a pressure sore, stay off the area and contact a doctor immediately for advice on treatment. You must keep weight off the area for it to heal. The treatment for a pressure sore can include extended bed rest.

Your doctor will determine the best type of treatment needed and instruct you on how to clean and dress the pressure sore. Cleaning helps to remove dead tissue, skin or fluid draining from the sore.  Wash the sore out well with soapy water. Use liquid surgical soap if possible. Then rinse with clean water (in some countries this may require boiling the water; just make sure it is not still hot when you use it). Remember to always wash your hands (or instruct the person who is changing the bandage to wash his/her hands) before cleaning the sore and changing the bandage. Watch for signs of infection. You need to seek help if any of the following occurs:

• You develop a fever.
• There is an increase in the size or drainage of the sore.
• There is increased redness around the sore or black areas starting to form.
• The sore starts smelling and/or the drainage becomes a greenish color.

If you are in a country where papaya grows, papaya has chemicals (enzymes) that can help soften the dead flesh in a pressure sore, and make it easier to remove. First clean and wash out a pressure sore. Then soak a sterile cloth or gauze with 'milk' from the trunk or green fruit of a papaya plant and pack this into the sore. Repeat cleaning and repacking 3 times a day until a pressure sore is free of dead flesh. Do not rub or massage areas where pressure sores might be forming. This could tear weakened flesh and make the sore inside bigger.

Once the pressure sore is free of dead flesh, your doctor may prescribe antibiotics. If medicine is not available, filling it 2 to 3 times a day with honey or sugar helps prevent infection and speeds healing. This treatment, used by the ancient Egyptians, and recently rediscovered by modern doctors, is now being used in some U.S. hospitals.

To make filling the sore easier, mix honey with ordinary sugar until it forms a thick paste. This can easily be pressed deep into the sore. Cover the sore with a thick gauze bandage. It is important to clean out and refill the sore at least two times a day. If the honey or sugar becomes too diluted with liquid from the sore, it will feed germs rather than kill them. Molasses can also be used. In Colombia, South America, doctors shave thin pieces off blocks of raw sugar and put these into the sore.

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Healing of the Pressure Sore and Reapplying Pressure

(Modified from http://www.spinalinjury.net/html/_pressure_sores.html)

The sore will get smaller when it begins to heal. Pinkish tissue usually starts forming along the edges of the sore and moves toward the center; you may notice either smooth or bumpy surfaces of new tissue. Some bleeding may be present. This shows that there is good blood circulation to the area, which helps healing.

Only when a pressure sore is completely healed can pressure be reapplied over the area. Complete healing means that the outer layer of skin is unbroken and normal coloring has returned to the area. Sometimes a scar may remain. 

The first time pressure is applied to a newly healed area, it must be for a very short time (15 minutes at most). Remove pressure from the area and inspect it for redness or darkness. If redness or darkness remains, observe it and time carefully how long it takes to fade to the color of the surrounding tissue. If fading occurs in 15 minutes or less, no damage has occurred. Wait at least one hour and repeat pressure application.

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Quick Review of Tips to Prevent Pressure Sores While Abroad 

1. Know your skin and what is normal.
2. Keep an eye on the trouble spot most prone to sores.
3. Keep the skin clean and dry.
4. Remove your seat cushion from your wheelchair and use it on flights and in other situations where you will be sitting for a while.
5. Protect your skin from damage.
6. Move often, shift positions and lift yourself off your seat for periods of time to relieve pressure.
7. Don’t smoke or abuse alcohol or drugs.
8. Eat a well balanced diet.