Recognizing and Treating Pressure Ulcers

Pressure ulcers, or bed sores, occur when pressure on the bony parts of the body reduces the blood supply to a particular area.  Circulating blood carries nutrients to the cells and carries out waste products.  When the blood supply is reduced, the cells are susceptible to damage and eventual death.


People who use wheelchairs, those who must stay in bed due to illness or injury, and those who have disabilities that make it difficult for them to move on their own are subject to pressure ulcers.  Conditions that affect blood circulation, like hardening of the arteries, make pressure sores more difficult to heal.

Symptoms of Pressure Ulcers

Pressure ulcers may hurt and may make it difficult for your loved one to sit or sleep comfortably.  Damaged skin may turn purple or red and may feel warm to the touch.  Pressure ulcers may be visible after a full-body examination of your loved one.  You may see pressure ulcers on the heels, around the knees, hip bones and other bony areas of the body.  The base of the spine, the shoulder blades, and the back of the head are also commonly seen sites for pressure ulcers.  These ulcers are usually found on weight-bearing areas of the body, or bony areas of the body such as hips and ankles.

The Two Hour Rule

Pressure ulcers can occur in a very short time on someone who is confined to a chair or a bed.  If left untreated, the skin can progress from red spots to open wounds.  Serious, painful infections may occur.  These ulcers can potentially be life threatening.  Pressure ulcers are  serious matter and they need to be properly cared for.  If you notice a pressure ulcer on your loved one, please consult your health care professional immediately.


While preventing bed sores may be difficult for someone who is bedridden, there are steps you can take to decrease the risk.  The most important step is to avoid prolonged pressure on any one part of the body.  Help your loved one move at least once every two hours.  Avoid putting pressure on existing sores.  Use soft pillows to prop your loved one up in bed, under their buttocks while sitting up in bed, or under their knees to elevate their legs a bit.  Other tips include:

• Keep Skin Dry - Keeping skin clean and dry may help prevent bedsores and other infections.  Use mild soap and apply moisturizer to prevent the skin from becoming dry and irritated.  Use a cornstarch-based powder after bathing to help keep areas dry without dehydrating the skin.  Examine your loved one's body every day and look for discolored skin or other signs of sores.
• Use Supports to Relieve Pressure - Use pillows and other props to relieve pressure.  For example, a pillow under the knees or feet will shift the pressure.  A rolled towel may be used to form a bridge under your loved one's bones or to lift the bed sheets off his feet.  Special pillows, mattresses, mattress covers, foam wedges, seat cushions, and other equipment may be available at medical equipment stores.  Ask your local pharmacist or other health care professional for ideas on where to locate these types of products.
• Sit in a Chair - Sitting up straight, rather than always lying down, may help reduce the pressure of the "sit bones" and allow your loved one to move more easily.  Changing positions every two hours if possible, may also help prevent bed sores.  Massaging your loved ones back and other weight-bearing areas to stimulate circulation may also help.

Treating Pressure Sores

Before treating a pressure sore, you should obtain advice from your physician, home health nurse, or other health care professional.  Do not attempt to diagnose a pressure sore yourself unless you are a certified professional.  However, some helpful tips for keeping sores clean may be applicable.


Changing the dressings (bandages) and keeping sores clean is important.  Ask a health professional to show you how to clean the sore and remove loose material, since changing dressings and removing dead tissue may be painful and requires particular care.  You may want to opt for a home health nurse to provide these bandage changes and wound cleanses for you.  Work with your loved one to determine the best time of day for both of you to change the dressing.  If it is too painful, ask the doctor if your loved one can take a pain reliever 30 minutes before you work on the sore.

Infected Pressure Sores

Infected sores heal slowly and the infection can spread to other parts of the body.  Fever or chills, mental confusion, difficulty concentrating, rapid heartbeat, and general weakness are signs that an infection may have spread.  Check for signs of infection each day.


More specific signs of infection include the following:

• Yellow or green pus
• Odor emanating from the sore
• Redness, or warmth around the sore
• Swelling or tenderness around the area.

If you notice any of these symptoms, contact your physician immediately.

Stroke - Part II

Treatment Team

Stroke treatment involves a multidisciplinary team.  Physicians are responsible for caring for the stroke survivor's general health and providing guidance aimed at preventing a second stroke.  Neurologists usually lead acute-care stroke teams and direct patient care during hospitalization.  The team may include a physiatrist (a specialist in rehabilitation, a rehabilitation nurse, a physical therapist, an occupational therapist, a speech-language pathologist, a social worker, a psychologist, and a vocational counselor.  Often there will also be a Home Health Nurse and a CNA or Personal Care Worker (PCW) to help the survivor once he returns home.

Emergency Treatment

Emergency treatment of stroke from a blood clot is aimed at dissolving the clot.  This "thrombolytic therapy" is currently performed most often with tissue plasminogen activator, or t-PA.  This t-PA must be administered within three hours of the stroke event.  Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of onset cannot be accurately determined.  The t-PA therapy has been shown to improve recovery and decrease long-term disability in selected patients.  The t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months.  Patients with clot-related (thrombotic or embolic stroke who are ineligible for t-PA treatment may be treated with heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases.

Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure.  Intravenous urea or mannitol plus hyperventilation are the most common treatments.  Corticosteroids may also be used.  Patients with reversible bleeding disorders such as those due to anticoagulant treatment should have these bleeding disorders reversed, if possible.

Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to allow access.  Ruptured vessels are closed off to prevent re-bleeding.  For aneurysms that are difficult to reach surgically, endovascular treatment may be used.  In this procedure, a catheter is guided from a larger artery up into the brain to reach the aneurysm.  Small coils of wire are discharged into the aneurysm, which plug it up and block off blood flow from the main artery.

Recovery and Rehabilitation

Rehabilitation refers to a comprehensive program designed to help the patient regain function as much as possible and compensate for permanent losses.  Approximately 10% of stroke survivors are without any significant disability and able to function independently.  Another 10% are so severely affected that they must remain institutionalized for severe disability.  The remaining 80% can return home with appropriate therapy, training, support and care services.

Rehabilitation is coordinated by a team that may include the services of a neurologist, a physiatrist, a physical therapist, an occupational therapist, a speech-language pathologist, a nutritionist, a mental health professional, and a social worker.  Rehabilitation services may be provided in a acute care hospital, rehabilitation hospital, long-term care facility, outpatient clinic and/or at home.

The rehabilitation program is based on the patient's individual deficits and strengths.  Strokes on the left side of the brain primarily affect the right half of the body, and vice versa.  In addition, in left-brain-dominant people who constitute a significant majority of the population, left-brain strokes usually lead to speech and language deficits, while right-brain strokes may affect spatial perception.  Patients with right-brain strokes may also deny their illness, neglect the affected side of their body, and behave impulsively.

Rehabilitation may be complicated by cognitive losses, including diminished ability to understand and follow directions.  Poor results are more likely in patients with significant or prolonged cognitive changes, sensory losses, language deficits, or incontinence.

Preventing Complications

Rehabilitation begins with prevention of stroke recurrence and other medical complications.  The risk of stroke recurrence may be reduced with many of the same measures used to prevent stroke, including quitting smoking and controlling blood pressure.

One of the most common medical complications following stroke is deep venous thrombosis, in which a clot forms within a limb immobilized by paralysis.  Clots that break free can often become lodged in a artery feeding the lungs.  This type of pulmonary embolism is a common cause of death in the weeks following a stroke.  Resuming activity within a day or two after the stroke is an important preventive measure, along with use of elastic stockings on the lower limbs.  Drugs that prevent clotting may be given, including intravenous heparin and oral warfarin.

Weakness and loss of coordination of the swallowing muscles may impair swallowing (dysphagia), and allow food to enter the lower airway.  This may lead to aspiration pneumonia, another common cause of death shortly after a stroke.  Dysphagia may be treated with retraining exercises and temporary use of pureed foods.

Depression occurs in 30-60% of stroke patients.  Antidepressants and psychotherapy may be used in combination.

Other medical complications include urinary tract infections, pressure ulcers, falls, and seizures.

Types of Rehabilitative Therapy

Brain tissue that dies in a stroke cannot regenerate.  In some cases, other brain regions may perform the functions of that tissue after a training period.  In other cases, compensatory actions may be developed to replace lost abilities.

Physical therapy is used to maintain and restore range of motion and strength in affected limbs, and to maximize mobility in walking, wheelchair use, and transferring (from wheelchair to toilet or from standing to sitting, or instance).  The physical therapist advises on mobility aids such as wheelchairs, braces, and canes.  In the recovery period, a stroke patient may develop muscle spasticity and contractures, or abnormal contractions.  Contractures may be treated with a combination of stretching and splinting.

swallowing skills.  When dysphagia is a problem, a nutritionist can advise alternative meals that provide adequate nutrition.

Mental health professionals may be involved in the treatment of depression or loss of thinking (cognitive) skills.  a social worker may help coordinate services and ease the transition out of the hospital back into the home.  Both social workers and mental health professionals may help counsel the patient and family during the difficult rehabilitation period.  Caring for a person affected with stroke requires learning a new set of skills and adapting to new demands and limitations.  Home caregivers may develop stress, anxiety, and depression.  Caring for the caregiver is an important part of the overall stroke treatment program.

Support groups can provide an important source of information, advice, and comfort or stroke patients and for caregivers.  Joining a support group can be one of the most important steps in the rehabilitation process.

Stroke - Part 1

Definition:  A stroke is the sudden death of  brain cells in a localized area due to inadequate blood flow.

Description: A stroke occurs when blood flow is interrupted to part of the brain.  Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die.  Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, a loss of memory and reasoning ability, coma, or death.  A stroke is also sometimes called a brain attack or a cerebrovascular accident (CVA).

Some important stroke statistics include:

• More than half a million people in the United States experience a new or recurrent stroke each year.
• Stroke is the third leading cause of death in the United States and the leading cause of disability.
• Stroke kills about 150,000 Americans each year, or almost one out of three stroke victims.
• Three million Americans are currently permanently disabled from stroke.
• In the United States, stroke costs about $30 billion per year in direct costs and loss of productivity.
• Two-thirds of strokes occur in people over the age of 65.
• Strokes affect men more often than women, although women are more likely to die from a stroke.
• Strokes affect blacks more often than whites, and are more likely to be fatal among blacks.

Stroke is a medical emergency requiring immediate treatment.  Prompt treatment improves the chances of survival and increases the degree of recovery that may be expected.  A person who may have suffered a stroke should be seen in a hospital emergency room without delay.  Treatment to break up a blood clot, the major cause of stroke, must begin within three hours of the stroke to be effective.  Improved medical treatment of all types of stroke has resulted in a dramatic decline in death rates in recent decades.  In 1950, nine in 10 people died from stroke, compared to slightly less than one in three today. 

Causes:  There are four main types of stroke.  Cerebral thrombosis and cerebral embolism are caused by blood clots that block an artery supplying the brain, either in the brain itself or in the neck.  These account for 70-80% of all strokes.  Subarachnoid hemorrhage and intracerebral hemorrhage occur when a blood vessel bursts around or in the brain.

Cerebral Thrombosis occurs when a blood clot, or thrombus, forms within the brain itself, blocking the flow of blood through the affected vessel.  Clots most often form due to "hardening" (atherosclerosis) of brain arteries.  Cerebral thrombosis occurs most often at night or early in the morning.  Cerebral thrombosis is often preceded by a transient ischemic attach (TIA), sometimes called a "mini-stroke".  In a TIA, blood flow is temporarily interrupted, causing short=lived stroke-like symptoms.  Recognizing the occurrence of a TIA and seeking immediate treatment are important steps in stroke prevention.

Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks free.  If it becomes lodged in an artery supplying the brain, either in the brain or in the neck, it can cause a stroke.  The most common cause of cerebral embolism is atrial fibrillation, a disorder of the heartbeat.  In atrial fibrillation, the upper chambers of the heart (atria) beat weakly and rapidly, instead of slowly and steadily.  Blood within the atria is not completely emptied.  This stagnant blood may form clots within the atria, which can then break off and enter the circulation.  Atrial fibrillation is a factor in about 15% of all strokes.  The risk of a stroke from atrial fibrillation can be dramatically reduced with daily use of anticoagulant medication.

Hemorrhage, or bleeding occurs when a blood vessel breaks, either from trauma or excess internal pressure.  The vessels most likely to break are those with preexisting defects such as an aneurysm.  An aneurysm is a "pouching out" of a blood vessel caused by a weak arterial wall.  Brain aneurysms are surprisingly common.  According to autopsy studies, about 6% of all Americans have them.  Aneurysms rarely cause symptoms until they burst.  Aneurysms are most likely to burst when blood pressure is highest, and controlling blood pressure is an important preventive strategy.

Intracerebral hemorrhage affect vessels within the brain itself, while subarachnoid hemorrhage affects arteries at the brain's surface, just below the protective arachnoid membrane.  Intracerebral hemorrhages represent about 10% of all strokes, while subarachnoid hemorrhages account for about 7%.  In addition to depriving affected tissues of blood supply, the accumulation of fluid within the inflexible skull creates excess pressure on brain tissue, which can quickly lead to death.  Nonetheless, recovery may be more complete for a person who survives hemorrhage than for one who survives a clot, because the blood deprivation effects are usually not as severe. 

Death of brain cells triggers a chain reaction in which toxic chemicals created by cell death affect other nearby cells.  This is one reason why prompt treatment can have such a dramatic effect on final recovery.

Risk Factors:  Risk factors for stroke involve age, sex, heredity, predisposing diseases or other medical conditions, and lifestyle choices including:

• Age and sex.   The risk of stroke increases with increasing age, doubling for each decade after age 55.  Men are more likely to have a stroke than women.
• Heredity.  Blacks, Asians, and Hispanics all have higher rates of stroke than do whites, related partly to higher blood pressure.  People with a family history of stroke are at greater risk.
• Diseases.  Stroke risk is increased for people with diabetes, heart disease (especially atrial fibrillation) high blood pressure, prior stroke, or TIA.  Risk of stroke increases tenfold for someone with one or more TIAs.
• Other medical conditions.  Stroke risk increases with obesity, high blood cholesterol level, or high red blood cell count.

Symptoms:  Symptoms of an embolic stroke usually come on quite suddenly and are at their most intense right from the start, while symptoms of a thrombotic stroke come on more gradually.  Symptoms  may include:

• blurring or decreased vision in one or both eyes
• severe headache
• weakness, numbness, or paralysis of the face, arm, or leg, usually confined to one side of the body
• dizziness, loss of balance or coordination, especially when combine with other symptoms

Diagnosis:  The diagnosis of stroke is begun with a careful medical history, especially concerning the onset and distribution of symptoms, presence of risk factors, and the exclusion of other possible causes.  A brief neurological exam is performed to identify the degree and location of any deficits such as weakness, loss of coordination, or visual losses.

Once stroke is suspected, a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction that guides therapy.  Blood and urine tests are done routinely to look for possible abnormalities.  Other investigations that may be performed to guide the treatment include an electrocardiogram, angiography, ultrasound, and electroencephalogram.