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Pressure ulcers continue to constitute a health problem for people who are physically limited or bedridden, particularly among the elderly and victims of spinal cord injuries. The problem exists across the entire health framework, including hospitals, clinics, long-term care facilities and homes. The prevention of pressure ulcers is of prime importance, as most of them are preventable by means of a high level of awareness and by implementing preventive measures. These measures must be taken from the moment of admission or immobilization. Such preventive measures can save much suffering and expense to the family and the medical establishment alike. A pressure ulcer may develop in a matter of hours, whereas the cure takes many months, if at all. The complications of pressure ulcers are protean: they may serve as a conduit of pathogens, to prolong hospitalization, and to increase the risk of death. The diminution of the quality of life of the affected patient results from pain, discomfort, unpleasant odors from discharges, isolation and resultant depression. The prevention of pressure ulcers requires the involvement of a number of interventions, most of which have not undergone rigorous prospective randomized controlled studies. Recently, a systematic review has been undertaken to evaluate just such interventions. The preventive interventions that were reviewed include devices to relieve pressure, repositioning, exercise to assist bladder control, nutritional supplementation and moisturizing skin. The resultant recommendations appear in this review article.
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PMID:[Prevention of pressure ulcers--review of the evidence]. 1903 12

Chronic ulcers such as pressure, ischemic, and venous ulcers are common in long-term care (LTC) and frequently do not heal. A retrospective medical records review of all LTC residents referred to a wound consultative service between April 1999 and January 2007 was conducted to assess predictors of 6-month healing outcome. Variables abstracted and analyzed included wound, resident demographic, and laboratory values at diagnosis and comorbid medical illnesses. The average age of study participants (n = 397) was 78.1 years (+/- 11), 47% were men, 48% had more than one wound, and the most common wound diagnosis was pressure ulcer (n = 163). After 6 months, 66% of ulcers were not healed. The odds ratio for nonhealing was significantly higher in residents who had more wounds, a larger wound area, diabetes mellitus, or peripheral vascular disease and lower in residents with increased age and hemoglobin values and/or a history of stroke, depression, dementia, degenerative arthritis, peripheral neuropathy, and falls. After adjustment in the multivariate model, only the number of wounds and hemoglobin level remained significant predictors of healing status. A higher number of chronic ulcers and lower hemoglobin counts increased the risk of nonhealing after 6 months of care. Including these variables in LTC resident assessments may help clinicians ascertain expected outcomes of care.
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PMID:A retrospective cohort study of factors that affect healing in long-term care residents with chronic wounds. 1960 67

Physiological changes in old age: loss of muscle mass; reduction in bone mass; percentage of fat increased; lower amount of body water; lack of thirst; diminishing kidney function (caution: sufficient intake of fluids: 1.5-2 l and moderate intake of protein 8 g/kg body weight); reduced secretion of digestive enzymes, delayed emptying of stomach (which means premature feeling of repletion). Lack of fluids and nutrition is therefore likely. Daily intake of 1,500 kcal and 1.5-2 l fluids is necessary. An indicator for malnutrition is low body weight (defined for persons older than 65 years of age as BMI < 20) and a protein serum concentration < 35 g/l. Malnutrition carries an increased risk of infections, falling and fractures, bed sores, anemia, decompensation of chronic diseases. 10-20% of subjects over 80 years of age show signs of malnutrition, 40-60% of subjects in care institutions or hospitals. There are regressive changes in the locomotor and the nervous system of the elderly which have an effect on physical fitness. These changes reduce strength, endurance, proprioceptive capacity (e.g. coordination, balance) and mobility. Exercise in the old and very old should increase skeletal muscle strength in particular and improve coordination and balance. Regular physical exercise and moderate training has a positive effect on mobility and thereby improves independence and reduces falls. Moreover, it has a positive effect on cardiac output, maximum heart rate, stroke volume and the risk of a cardiovascular event and mortality can be reduced. Moreover, moderate physical exercise is often more effective in treating chronic disease than drug therapy e.g. heart failure, coronary heart disease, asthma/COPD, stroke, diabetes mellitus Type 2, degenerative diseases of the joints, depression and others. Examine cardiovascular risks in persons over the age of 50 before beginning physical exercise. Avoid maximum stress levels.
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PMID:Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors: Part D Basic conditions supporting drug treatment. 1947 91

The incidence of pressure ulcers in patients with psychiatric illness, especially with catatonia might be more than what is reported in the literature. We report a case of catatonia secondary to severe depression presenting with multiple pressure ulcers. Single case report - description and management. An 18 yrs old boy reported with a continuous course illness characterized by features of catatonia secondary to severe depression with multiple pressure ulcers over sacrum and heels. Ulcers were effectively managed by a multidisciplinary team of physiatrist, psychiatrist, and rehabilitation nurses. Immobility, reduced nocturnal movements, increased skin fragility, and poor nutrition contribute to the development of the pressure ulcer in bed-bound psychiatric patients. Efforts should be directed toward the prevention of pressure ulcers in these patients to reduce additional morbidity.
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PMID:Catatonia and multiple pressure ulcers: A rare complication in psychiatric setting. 1988 Oct 50

A static-led approach refers to the provision of high-specification foam mattresses for the whole of a population at risk of pressure damage. Such mattresses have been found to reduce the risk of pressure ulceration and cost less overall than standard mattresses, even in populations where only 1 in 100 patients develops a pressure ulcer. Reduced pressure ulcer prevalence and reduced costs resulting from decreased expenditure on dynamic mattresses following the implementation of a static-led approach have been reported. Pressure ulcers cause pain, a reduced quality of life, loss of independence, depression and social isolation for those in whom they develop. Organizations are increasingly having to pay out large sums of money following litigation surrounding pressure ulcers. This article explains why NHS healthcare providers and private care organizations need to work together to consider implementing a static-led approach to pressure ulcer prevention within care homes in order to reduce pressure ulcer incidence cost-effectively within their local populations.
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PMID:Should care homes adopt a static-led approach to pressure ulcer prevention? 2008 72

Purpose. To highlight research priorities of people with spinal cord injury (SCI), outline the current state of rehabilitation research and suggest potentially fruitful avenues for future inquiry. Method. Commentary. Results. People with SCI identify pain, depression, fatigue, pressure sores, spasticity and the management of bladder and bowel as research priorities. Research reveals multiple interconnections between these secondary problems, all of which negatively impact quality of life (QOL). However, despite a substantial volume of existing research, significant gaps in knowledge remain, duplications of research effort are apparent and few interventions have an adequate evidence base. Issues concerning community participation - another research priority - have only recently attracted researchers' attention. Conclusions. This commentary contends that research should: focus on issues and outcomes of relevance and importance to people living with SCI; address the complexities of secondary conditions and their inter-relationships; appraise environmental barriers to participation in meaningful living; be designed to identify and inform effective and relevant interventions. Innovative approaches to research partnerships, mixed methods and exploring variables usually omitted from quantitative studies might enhance the likelihood that the complexity of issues facing people living with SCI will be identified and addressed. Moreover, a governing focus on achieving lives experienced as hopeful, purposeful, satisfying and meaningful could contribute to enhancing QOL outcomes following SCI.
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PMID:Spinal cord injury rehabilitation research: patient priorities, current deficiencies and potential directions. 2013 45

Family physicians are often unfamiliar with the care of patients with spinal cord injuries because they may have only one such patient in their practice. Urinary tract infections, constipation, and decubitus ulcers are the most common problems, and autonomic dysreflexia the most serious emergency that family physicians treat in this population. This article addresses these areas, as well as spasticity, sexuality, depression, and the acute abdomen.
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PMID:Care of the spinal cord-injured patient. 2046 4

The Taiwan Join Commission on Hospital Accreditation identified pressure ulcers as an important clinical care indicator in 2011. Pressure ulcers are a particularly critical medical care issue in hospital intensive care units. Pressure ulcers can influence patient physiology in terms of greater perceived pain, elevated infection and sepsis incidence, increased unplanned surgical treatments, and reduced activities of daily living (ADL). Pressure ulcers can also affect psychology through induced depression, stress, and anxiety. They can also increase patient and societal costs and prolong hospital stay length. This article explores the prevention and management of pressure ulcer in serious illness patients and introduces effective assessment and management techniques. We hope this article raises clinical nurse awareness of this critical issue and helps decrease the incidence of pressure ulcer-related complications in order to enhance overall quality of care.
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PMID:[Prevention and management of pressure ulcers in critical patients]. 2285 91

A young woman with bipolar I disorder and comorbid catatonia on enteral nutrition from several months, developed a form of near-lethal catatonia with weight loss, pressure sores, muscle atrophy, electrolyte imbalance, and depression of vital signs. A compulsory treatment was necessary, and informed consent was obtained from her mother for electroconvulsive therapy (ECT). After 7 ECT sessions, the patient recovered and resumed feeding. ECT may save the life of a patient with catatonia provided that legal obstacles are overcome. Clinicians should carefully evaluate patients with near-lethal catatonia, taking into account the risk of pulmonary embolism and other fatal events. The medical-legal issues, which vary across state regulations, should be addressed in detail to avoid unnecessary and potentially harmful delay in intervention.
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PMID:Life-saving electroconvulsive therapy in a patient with near-lethal catatonia. 2316 Jan 14

A 22-year-old male sustained C-6 tetraplegia in 1992. In 1993, intravenous pyelography revealed normal kidneys. Suprapubic cystostomy was performed. He underwent open cystolithotomy in 2004 and 2008. In 2009, computed tomography revealed bilateral renal calculi. Coagulum pyelolithotomy of left kidney was performed. Pleura and peritoneum were opened. Peritoneum could not be closed. Following surgery, he developed pulmonary atelectasis; he required tracheostomy and mechanical ventilation. He did not tolerate nasogastric feeding. CT of abdomen revealed bilateral renal calculi and features of proximal small bowel obstruction. Laparotomy revealed small bowel obstruction due to dense inflammatory adhesions involving multiple small bowel loops which protruded through the defect in sigmoid mesocolon and fixed posteriorly over the area of previous intervention. All adhesions were divided. The wide defect in mesocolon was not closed. In 2010, this patient again developed vomiting and distension of abdomen. Laparotomy revealed multiple adhesions. He developed chest infection and required ventilatory support again. He developed pressure sores and depression. Later abdominal symptoms recurred. This patient's general condition deteriorated and he expired in 2011. Conclusion. Risk of postoperative complications could have been reduced if minimally invasive surgery had been performed instead of open surgery to remove stones from left kidney. Suprapubic cystostomy predisposed to repeated occurrence of stones in urinary bladder and kidneys. Spinal cord physicians should try to establish intermittent catheterisation regime in tetraplegic patients.
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PMID:Postoperative Complications Leading to Death after Coagulum Pyelolithotomy in a Tetraplegic Patient: Can We Prevent Prolonged Ileus, Recurrent Intestinal Obstruction due to Adhesions Requiring Laparotomies, Chest Infection Warranting Tracheostomy, and Mechanical Ventilation? 2353 31


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