Hesperian Health Guides
Prevention of Pressure Sores
- Avoid staying in the same position for very long. When lying down, turn from side to side or front to back at least every 2 hours (or up to 4 hours if padding and cushioning are excellent). When sitting, lift body up and change position every 10 or 15 minutes.
- Use thick, soft padding, pillows, or other forms of cushion arranged so as to protect bony areas of the body (see cushion designs.)
- Use soft, clean, dry bed sheets. Try to avoid wrinkles. Change bedding or clothing every day and each time the bedding gets wet or dirtied. A person who stays wet gets pressure sores—especially if it is from urine.
- Bathe the child daily. Dry the skin well by patting, not rubbing. It is probably best not to use body creams or oils, or talc, except on the hands and feet to prevent cracking, as these soften the skin and make it weaker. Never use heat-producing oils, lotions, or alcohol.
- Examine the whole body carefully every day, checking especially those areas where sores are most likely to occur. If any redness or darkness is present, take added care to prevent all pressure over this area until the skin returns to normal.
- Good nutrition is important for preventing pressure sores. Be sure the child gets enough to eat. Give her plenty of fruits, vegetables, and foods with protein (beans, lentils, eggs, meat, fish, and milk products). If the child looks pale, check for signs of anemia and be sure she gets iron-rich foods (meat, eggs, and dark green leafy vegetables) or takes iron pills (ferrous sulphate) and vitamin C (oranges, lemons, tomatoes, etc.).
- As much as is possible, the child should learn to examine her own body for pressure sores every day and take responsibility for all the necessary preventive measures herself.
Other precautions
- To avoid pressure sores or other injuries on feet that do not feel, use well-fitted, well-padded sandals or shoes. These and other precautions are discussed under “Spina Bifida” and “Leprosy”.
- To avoid pressure sores when straightening limbs with casts, put extra padding over bony spots before casting and do not press on these spots as the cast hardens. Listen to the child when he says it hurts, and check where it hurts.
| If it hurts in these spots, it is probably the tight cord (tendon). A little pain is expected with stretching, but if it hurts a lot, examine it. |  |
If it hurts in one of the spots marked with an X, it may be a pressure sore. Remove the cast and see. |
Changing positions
| When a child has recently had a spinal cord injury, he must be turned regularly, taking great care not to bend his back. | As the child gets stronger, hang loops and provide other aids, if needed, so she can learn to turn herself. | |
| One good way is to roll him over using a sheet under him, like this. |  |
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At first it is important that the person turn, or be turned, at least every 2 hours, day and night. Later, if there are no signs of pressure sores, the time between turns can gradually be lengthened to 4 hours. To avoid sleeping through the night without turning, an alarm clock can be a big help.
When the child begins to sit or use a wheelchair, there is a new serious danger of pressure sores. The child must get into the habit of taking the pressure off his butt every few minutes.
| Juan has strong arms. He can lift up his whole body and hold it up for a minute or two. This lets the blood circulate in the butt. | Jose’s arms are weak. He takes the pressure off his butt by leaning his whole body over the armrest, first on one side, and then on the other. | ||
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When doing this, one buttock lifts in the air. |  |
| Carlota has a wheelchair with a low back, so she can lean back and lift her hips off the seat. | If the chair has no armrests, or they can be removed, the child can lie sideways over a pillow on a high bed. He can rest for 15 to 30 minutes like this. | ||
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| If he has very little arm and body control, he can put his feet on the floor (with help if needed) and lean forward with his chest on his knees. This takes the pressure off his butt. | Or have someone tip his chair backward for one minute or more. For a longer ‘nap’ that rests the butt, someone can tip his chair backward onto a cot. | ||
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A thick foam rubber mattress often works well. However, some foam is so spongy that it sinks completely down under weight. Then the bony area is not protected from the hard board. A firm sponge with very small air bubbles (microcell rubber) works well, but is expensive.
A "waterbed" (bag-like mattress filled with water) or air mattress also works well.
In some countries, an excellent mattress material is made of rubber-coated coconut fiber. Urine can be washed out by pouring water through it. Because this material is costly, a rehabilitation program in Bangladesh cuts a square out of a cheap mattress and fits in a square of the coconut fiber sponge.
- Careful placement of pillows, pads, or soft, folded blankets can also help prevent pressure sores. These are especially important in the first weeks or months after a spinal cord injury when the person must lie flat and be moved as little as possible. Pillows should be placed to avoid pressure on bony places, and to keep the person in a position that is healthy and that helps prevent contractures.
| BACK-LYING | SIDE-LYING |
 cotton sheet
absorbent pad to soak up urine
plastic or rubber sheet to prevent urine from soaking through |
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| See self-placement of pillows. | |
| BELLY-LYING | |
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| urine collection tube |
Chair and wheelchair cushions
All people with spinal cord injuries should use a good cushion. Sitting directly on a canvas or a poorly padded wood seat causes pressure sores.
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 be made of microcell rubber, which is fairly firm. It works best if it is 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 or 3 cm.-thick layer of sponge rubber. |
 Raised shelf here puts more pressure under thighs, less on butt. It also helps keep the hips from slipping forward.
Dip at back keeps hips from slipping forward.
Hollow in back keeps pressure off butt bones.
A ‘thigh separator’ can be included if needed
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 bottom curved to fit wheelchair seat |
| Wet the cardboard and sit on it wet for 2 hours, so it forms to the shape of the butt. Then let it dry, and varnish it. |
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Before making a specially-fitted cushion, you can make a ‘mold’ of the person’s butt by having him sit in a shallow container of soft clay, mud, or plaster. Note the bony hollows and form the seat to fit them. |
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 mold of butt |
Air cushions made from bicycle inner tubes are excellent for prevention of pressure sores, and for bathing on a hard surface. Use 1, 2 or more tubes, depending on size of tube and size of child.
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Bind loops of the tubes together with thin straps of inner tube. Pump in enough air so that the whole butt is held up by air. |
| (Idea from wheelchair rider-builders at Tahanan Walang Hagdanang (House With No Stairs), Quezon City, Philippines) |