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    Healing sores and using the toilet

    Has anyone had a pressure/shearing sore caused by their toilet seat?

    If so, how did you manage it? Were you able to continue to use the toilet while you were healing the sore? If so, what did you change to make it safer?

    My Dad slowly developed a sore on his left lower butt / upper inner thigh from his Activaid Comfortuff elevated toilet seat inner seat edge. To clean up, he scoots forward and leans towards the left, so that is why the sore is at that location. He can't clean up leaning to the other side because of an injury to that arm. We are trying to play with cushions/changing things to elevate and float that area when on the toilet, and to shorten the time on the toilet, but are having a hard time make it work.

    No doctor has seen the sore up close so far, and his physiatrist has not been as concerned as we would like. It is stage 2, Not traditional pressure sore - started as a shear injury - but now sensitive to pressure.

    A visiting home care nurse told us to put Remedy Nutrashield on it. She doesn't do much wound care and probably will only check it one more time. Previously we were using Silvadene on the open area and Proshield+. His physiatrist said not to put a dressing on it because of the sensitive./wrinkly location, and he thought a dressing would cause more problems than help.

    #2
    I do not recommend Silvadene. It is not even used in burn care anymore.

    Sad to say, if he keeps sitting on this seat for bowel care, it is likely to get worse, no matter what dressing is used. When trying to heal any pressure injury or shear injury on a sitting surface, we restricted bowel care to be done in bed, on your side.

    (KLD)
    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

    Comment


      #3
      Term is pressure injury. Sounds like pressure and shear and friction. How long does bowel program take? I agree with KLD-back to bed for program until healed is best.
      CWO
      The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

      Comment


        #4
        I appreciate your thoughts.

        His bowel program was taking 40-60 minutes, sometimes longer. He's been trying to speed things up, and now it is closer to 30-40 minutes. His bowels are actually moving pretty well, but he is very slow with the clean-up and sometimes there are multiple episodes that complicate the process.

        Do you have a favorite topical you would use in this situation? Everything also rubs off soon after application, of course.... The largest sore basically looks like road rash and is always pink/raw/wrinkled and it blanches. And the adjacent sore has an open center that is the most concerning currently. Deeper, likely getting re-opened daily on the toilet.

        I have been trying to warn him that he may have to take a break from the toilet. He hasn't tried to do bowels in bed since he was hospitalized 13 years ago. If you have any pointers for someone like him (or for me... the person who would be helping him...), we would appreciate hearing them. He doesn't respond to suppositories (T11-T12 fracture, functions now as L3 incomplete ASIA C). Usually he eats/has morning coffee, then goes onto the toilet, and uses straining/gravity (and rarely a bit of dig stim) to move things along.

        Unfortunately, he has a lot of other medical issues complicating the situation that may make bowels in bed difficult. He has a huge hiatal hernia and his stomach has herniated high up in his chest and presses on his heart and lungs. He gets severe attacks of chest pain due to twisting of the stomach (gastric volvulus) as well as severe reflux. Recently, he has been waking up with severe pain multiple times a night, so his stomach is in a particularly bad location (it moves/slides). It is exhausting. Anyway, he is never supposed to lie flat, and is not supposed to lie down after eating for hours(!). Right now he is sleeping in a position where he is nearly vertical.... He would love to be lying on his left side, which also relieves him of his chronic severe neuropathic pain, but he can't tolerate it because of his stomach.

        Well, any input is appreciated. Thanks again.

        Comment


          #5
          So this is inferior ischial bone? I am concerned that there is more damage deeper which is common in shear. I would put hydrocolloid AKA Duoderm (thin or thick which ever stays on best but I would recommend thick and since possible difficult to tape on I would wrap it around thigh if possible or even figure 8 around thigh and lower abdomen. The more cure it is the less shear/friction. What color is it? Open? 2 areas. I am sorry but this just doesn't sound like a Stage 2. I applaud his independence and 40 minutes or so is not bad but unfortunately any pressure especially on a toilet seat and if not covered, if not already, it will get infected. I highly suggest a wound specialist or a second opinion. A Wound Specialist Nurse? If it worsens, he will be be on bedrest possibly for months. We always worry about osteomyelitis. If he won't or can't do program in bed, then the toilet seat needs to be totally padded in that area, but I would do the whole thing. Even if it is just taping a '"custom" foam using the outline of the toilet seat but make sure no edges come in contact. If this sounds like rigging/homemade- it pretty much is. Would be okay to cover with plastic for washing it, disinfecting. Between the hydrocolloid and the padding this should help. A material store sells all different foams. Even the foam chairpads about one inch that you can get for very cheap would help. And vertical position puts more pressure on ischiums. Do weight shifts even if just change of lowering of upping 5-15 degrees will help. Has his cushion on wheelchair/chair been pressure mapped since he developed? Seating specialists are an awesome help. No sliding/scooting either. Hoping others can add to this. CWO
          The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

          Comment


            #6
            Originally posted by SCI-Nurse View Post
            So this is inferior ischial bone? I am concerned that there is more damage deeper which is common in shear. I would put hydrocolloid AKA Duoderm (thin or thick which ever stays on best but I would recommend thick and since possible difficult to tape on I would wrap it around thigh if possible or even figure 8 around thigh and lower abdomen. The more cure it is the less shear/friction. What color is it? Open? 2 areas. I am sorry but this just doesn't sound like a Stage 2. I applaud his independence and 40 minutes or so is not bad but unfortunately any pressure especially on a toilet seat and if not covered, if not already, it will get infected. I highly suggest a wound specialist or a second opinion. A Wound Specialist Nurse? If it worsens, he will be be on bedrest possibly for months. We always worry about osteomyelitis. If he won't or can't do program in bed, then the toilet seat needs to be totally padded in that area, but I would do the whole thing. Even if it is just taping a '"custom" foam using the outline of the toilet seat but make sure no edges come in contact. If this sounds like rigging/homemade- it pretty much is. Would be okay to cover with plastic for washing it, disinfecting. Between the hydrocolloid and the padding this should help. A material store sells all different foams. Even the foam chairpads about one inch that you can get for very cheap would help. And vertical position puts more pressure on ischiums. Do weight shifts even if just change of lowering of upping 5-15 degrees will help. Has his cushion on wheelchair/chair been pressure mapped since he developed? Seating specialists are an awesome help. No sliding/scooting either. Hoping others can add to this. CWO

            Thanks again for sharing your thoughts. He hasn't been seen by a doctor in person since February. No pressure mapping (has never done this). Sits mostly on ROHOs not in his wheelchair, but also lies on his side in bed, and on his tummy on a mat. He does change the surfaces where he sits many times a day, does a lot of stands for pressure relief, and very short walks. He tries to do a serious pressure relief every 20 minutes. The hardest mobility parts are getting up and into bed, and scooting into the middle of his bed. I have wondered whether we should have a lift... but also can't imagine how it would fit.

            My Dad had a telehealth visit with his doctor (SCI physiatrist) yesterday and I was shocked when the Doctor thought the sores looked pretty good. I couldn't believe he said that, considering we have been trying to cure them for almost 5 months and they have increased from 1 sore to two and are getting bigger. He thought he could continue to use the toilet, and just suggested putting a foam dressing (UrgoTul non-absorb non-border foam) on the sores to protect them when you go on the toilet, and take it off afterwards. Fortunately, I set up an appointment with a traveling wound care RN that will assess him on Monday ..... via telehealth.

            Tonight a new area, between the original sore, and the newer "open" sore, is breaking open. Not good. So I think my Dad will try doing bowels on his side, and getting off the toilet, He is very nervous about this....about not being able to do his bowels without gravity, and about making a mess.

            Does anyone have any pointers about doing bowels in bed, especially if you can do it independently? My Dad is an incomplete para. I will be helping when he needs it. He has terrible terrible hemorrhoids that bleed. Normally he eats/has coffee 40 minutes or so before getting on the toilet. He doesn't use suppositories (they don't work for him), and strains to go. Sometimes he will use a little digital stimulation, but not always. Any little pointers are appreciated. Or an explanation about tricks you have. Thanks.

            Comment


              #7
              Originally posted by hlh View Post

              Tonight a new area, between the original sore, and the newer "open" sore, is breaking open. Not good. So I think my Dad will try doing bowels on his side, and getting off the toilet, He is very nervous about this....about not being able to do his bowels without gravity, and about making a mess.

              Does anyone have any pointers about doing bowels in bed, especially if you can do it independently? My Dad is an incomplete para. I will be helping when he needs it. He has terrible terrible hemorrhoids that bleed. Normally he eats/has coffee 40 minutes or so before getting on the toilet. He doesn't use suppositories (they don't work for him), and strains to go. Sometimes he will use a little digital stimulation, but not always. Any little pointers are appreciated. Or an explanation about tricks you have. Thanks.
              This is going to get a lot worse before it gets better. You will have to get "creative". I had a shear wound right on the part of my crack where you can feel the tailbone through the skin. I went crazy to get it healed and it healed fast; but I was very disciplined in staying in bed. Like all day. A couple of benefits from doing this: decompressing my spine all of a sudden led to a sharp decrease in bladder spasms. I think when sitting most of the day, my lumbar puts a lot of undue pressure on some of the nerves that innervate my bladder. Also, my hemorrhoids mysteriously shrunk to near nothing and the "tennis ball in my ass" pain was gone. But, best of all, my sore healed in a couple of weeks. I still had tons of pain in the area, but it was mostly nerve pain. I thought I was losing my mind. Probably drove my PCP nuts. Went through the whole gamut of MRIs, CT scans, etc as I was convinced the bone was infected because that pain must have been coming from somewhere. It ended up being neuro pain, but I'm fine now. However, to this day, I still smear some petroleum jelly on that part of my crack before I get in the shower on my commode and do my bowel/shower. I also triple fold an extra fluffy towel to transfer onto in the shower so that I don't bust that tailbone open again.

              Sorry for the long-winded response, but all of this would have been pointless if I couldn't do my bowel care in bed. I live across the country on the East Coast half of the year alone, so I had to figure out how to do it. If you're interested in my precise technique, PM me. Your pops MUST stop using the commode or this will decrease his life expectancy. He might heal it, but from the sounds of what you have written so far, as soon as he heals it, he will tear it open again. Since he is in pain on his left side due to his stomach, I would suggest that you find which part of his left side hurts the most and see if you can decompress the area while he is on his left side with two large foam pads that you can place on his left hip and under his left armpit. Think of a bridge with the left side of his stomach "hanging" off the bridge.

              And convince him to use a suppository. I don't buy the "it doesn't work for me" routine. Grab a pack of Dulcolax bullet shaped suppositories from Walmart and have him stick one up there with some lube. It won't come back out. After about half an hour - especially if he's had coffee - he'll definitely need to go. This will definitely shorten his poopy time since the dulcolax will initiate the peristalysis (right now he has to initiate it with his fingers and that takes a while).

              But, you have to get him off of the commode. At least he can look forward to his hemorrhoids not acting up as much.

              No one ever became unsuccessful by helping others out

              Comment


                #8
                If he has 3? pressure wounds from shitting, I recommend bagging it!
                as in, colostomy. I've had one for 8 years and been injured 25. Wish I'd done it much earlier! What freedom and reliability I have now.
                69yo male T12 complete since 1995
                NW NJ

                Comment


                  #9
                  Originally posted by pfcs49 View Post
                  If he has 3? pressure wounds from shitting, I recommend bagging it!
                  as in, colostomy. I've had one for 8 years and been injured 25. Wish I'd done it much earlier! What freedom and reliability I have now.

                  I do really appreciate your input. Thanks for this! Honestly, I think he would appreciate the saved time, no more pain from hemorrhoids etc... Even he brought this up himself, because I have told him how many of you guys have had experiences. So this may be something discussed long term.... especially if the sores heal slowly, he can't find a safe way to use the toilet or he just dislikes bowels in bed. But today he's struggling with multiple other infections and his stomach issue that may require more urgent intervention.

                  Comment


                    #10
                    Originally posted by Tufelhunden View Post

                    This is going to get a lot worse before it gets better. You will have to get "creative". I had a shear wound right on the part of my crack where you can feel the tailbone through the skin. I went crazy to get it healed and it healed fast; but I was very disciplined in staying in bed. Like all day. A couple of benefits from doing this: decompressing my spine all of a sudden led to a sharp decrease in bladder spasms. I think when sitting most of the day, my lumbar puts a lot of undue pressure on some of the nerves that innervate my bladder. Also, my hemorrhoids mysteriously shrunk to near nothing and the "tennis ball in my ass" pain was gone. But, best of all, my sore healed in a couple of weeks. I still had tons of pain in the area, but it was mostly nerve pain. I thought I was losing my mind. Probably drove my PCP nuts. Went through the whole gamut of MRIs, CT scans, etc as I was convinced the bone was infected because that pain must have been coming from somewhere. It ended up being neuro pain, but I'm fine now. However, to this day, I still smear some petroleum jelly on that part of my crack before I get in the shower on my commode and do my bowel/shower. I also triple fold an extra fluffy towel to transfer onto in the shower so that I don't bust that tailbone open again.

                    Sorry for the long-winded response, but all of this would have been pointless if I couldn't do my bowel care in bed. I live across the country on the East Coast half of the year alone, so I had to figure out how to do it. If you're interested in my precise technique, PM me. Your pops MUST stop using the commode or this will decrease his life expectancy. He might heal it, but from the sounds of what you have written so far, as soon as he heals it, he will tear it open again. Since he is in pain on his left side due to his stomach, I would suggest that you find which part of his left side hurts the most and see if you can decompress the area while he is on his left side with two large foam pads that you can place on his left hip and under his left armpit. Think of a bridge with the left side of his stomach "hanging" off the bridge.

                    And convince him to use a suppository. I don't buy the "it doesn't work for me" routine. Grab a pack of Dulcolax bullet shaped suppositories from Walmart and have him stick one up there with some lube. It won't come back out. After about half an hour - especially if he's had coffee - he'll definitely need to go. This will definitely shorten his poopy time since the dulcolax will initiate the peristalysis (right now he has to initiate it with his fingers and that takes a while).

                    But, you have to get him off of the commode. At least he can look forward to his hemorrhoids not acting up as much.

                    Thanks so much for sharing all of this. It really helps.

                    I would be pleased to hear any other details you can share.

                    I agree that my Dad's right sided butt pain... which is awful.... is always better when he is in bed, on his left side. He will not be able to lie flat on his side... he has to be on a high wedge on his side, if you know what I mean. Do you think that would interfere with doing bowels in bed?

                    I think that suppositories don't work well for him because of his low level of injury. He has tried them multiple times over the years. But I will bring it up as a suggestion. Unfortunately, they also cause him pain, and leave him burning in his anus for hours, so that's a downside. He has crazy neuropathic pain down there that is easily activated.

                    Comment


                      #11
                      Not optimized- get a wound specialist if after staying off and doing bowel program in bed they do not heal. Did you shine a light on his wounds so the doctor could really see the wounds? If not, please do so for the wound nurse. High protein diet, extra Vitamin D and zinc. He seems to be mobile enough but I would suggest OFF the wound. LIft- there are portable ones that somewhat fold up and roll. I would definitely look in to that to prevent shearing/friction. I would get a wound specialist, they would probably scan, if looked infected start antibiotics and depending on that get Interventional radiology to do a bone biopsy. Osteomyelitis is very difficult to get rid of- minimally six weeks of IV antibiotics usually. Get a recommendation from Wound Care Nurse and make an appointment.
                      Bowels- he uses enemeez/docusol or what? Enemeez Plus has Docusate 283 mg with Benzocaine 20 mg rectal is the generic order. Suppositories (Bisacodyl) work by chemical irritant and stimulus is irritant. Enemeez (Docusate) is more natural and people do not complain of irritation and or mucous discharge after. www.enemeez.com- will usually send you free samples to try.
                      What is consistency of stool? Bristol Stool scale please. should be #4. If harder needs stool softener but sounds like time of 40 minutes is not out of norm. But doing in bed, he might need an adjustment.
                      Neuropathic pain- what is he on? Most (not always) true neuropathic pain is there no matter positioning. Tried Diclofenac gel- slather buttocks- may not help but won't hurt. Gabapentin? Cymbalta? Effexor? PMR doctor is SCI specialist? x-rays- could be NP and arthritis combined? Accupuncture?

                      Better to be safe than sorry and 5 months with newly developed pressure injury is concerning.
                      CWO
                      The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                      Comment


                        #12
                        Originally posted by SCI-Nurse View Post
                        Not optimized- get a wound specialist if after staying off and doing bowel program in bed they do not heal. Did you shine a light on his wounds so the doctor could really see the wounds? If not, please do so for the wound nurse. High protein diet, extra Vitamin D and zinc. He seems to be mobile enough but I would suggest OFF the wound. LIft- there are portable ones that somewhat fold up and roll. I would definitely look in to that to prevent shearing/friction. I would get a wound specialist, they would probably scan, if looked infected start antibiotics and depending on that get Interventional radiology to do a bone biopsy. Osteomyelitis is very difficult to get rid of- minimally six weeks of IV antibiotics usually. Get a recommendation from Wound Care Nurse and make an appointment.
                        Bowels- he uses enemeez/docusol or what? Enemeez Plus has Docusate 283 mg with Benzocaine 20 mg rectal is the generic order. Suppositories (Bisacodyl) work by chemical irritant and stimulus is irritant. Enemeez (Docusate) is more natural and people do not complain of irritation and or mucous discharge after. www.enemeez.com- will usually send you free samples to try.
                        What is consistency of stool? Bristol Stool scale please. should be #4. If harder needs stool softener but sounds like time of 40 minutes is not out of norm. But doing in bed, he might need an adjustment.
                        Neuropathic pain- what is he on? Most (not always) true neuropathic pain is there no matter positioning. Tried Diclofenac gel- slather buttocks- may not help but won't hurt. Gabapentin? Cymbalta? Effexor? PMR doctor is SCI specialist? x-rays- could be NP and arthritis combined? Accupuncture?

                        Better to be safe than sorry and 5 months with newly developed pressure injury is concerning.
                        CWO


                        Appreciate all of your input.

                        My Dad's recent UTIs, respiratory infections and debilitation from inactivity since the lock down have made him more vulnerable to skin changes/injury. He is also in his late 70's with a lot of atrophy of his butt muscle and with aging and weight loss from inactivity he is certainly at risk for skin injury.

                        He is always on a very high protein diet, good vitamin D supplements followed by his rheumatologist, and we just increased his Zinc gluconate to 50mg TID + the zinc in his supplements, plus Juven. Unfortunately, because of his terrible hiatal hernia associated gastric volulus/reflux/chest pain attacks he is on a low residue diet that has been cut back right now to try to get his nightly multiple chest pain episodes under control. He has decreased appetite during these periods of attacks because his stomach is likely getting twisted/compressed and literally has less space to expand.

                        His pain regimen is extensive and is monitored by his SCI PMR specialist and includes high dose gabapentin, cymbalta, opioids, mood medication, stretching/PT/cold packs/pressure release. He has tried a lot of topicals (anti-inflammatories/lidocaine/cannabis derived products) and none work well. It is pain in his right >>> left butt that is mostly neuropathic and some MUSK. Never tried accupuncture or a pain specialist.

                        Fortunately, his bowels move very well, and he usually goes within a few minutes of sitting on the toilet. As I mentioned, he does not use suppositories/enemeeze/enemas because they don't really work and usually cause prolonged pain afterwards and he goes so quickly that wouldn't be needed anyway. He sometimes will stick a finger in and do a little stim or manual evacuation. But most of the time it is gravity, having a regular daily routine of going at the same time, having a very regular and consistent diet and straining that has gotten his bowel program on track. And he strains/pushes, which is still bad for his hemorrhoids. He does take a lot of meds though - miralax twice a day as needed, misoprostol, and linzess, probiotic, lots of fluids, low fiber diet.

                        The wounds so far are not very deep, but they are spreading and not improving. They do not look infected and are not painful. His SCI physiatrist is not very impressed, but we are more concerned because the trajectory is clear. A wound care RN will take a look at them on Monday. If they don't go in the right direction soon, we will see the wound care doctor at his rehab hospital and I will call the plastic surgeon who did his surgeries after his accident who is excellent and has helped with wound care over the years.

                        A few questions...

                        What is that portable lift you recommend?

                        What dose of Zinc do you recommend, and for how long? It has long term risks of course.

                        Any specific recs for doing bowel care on your side in bed for someone like him? Low level injury L3 ASIA C. 78 years old

                        Comment


                          #13
                          You can buy the duoderm patch that text nurse mentioned on Amazon and it sticks fairly well.

                          Comment


                            #14
                            The generic is hydrocolloid- Duoderm is the original and brand. There is extra thin, thin and thick.
                            CWO
                            The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                            Comment


                              #15
                              So far his doctor has highly insisted not to put an adherent dressing on it. There are so many folds in the skin in this area that it couldn't adhere properly and would cause problems. I am hopeful that when the wound care nurse will see it remotely tomorrow they may help. If nocmt, I will upload a picture to see what you guys think.

                              Right now the total area that is abnormal is about 5cm x 5cm. There was only one open area of 1cm x 2cm until yesterday. Now there are 2 small open areas of that size (one less deep) and a surrounding area of pink that blanches.

                              CWO, if you could help with those questions I listed above, I would be grateful.

                              Comment

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