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Patient education

Doctors should emphasize with patients the

challenges of choosing monovision and bifocal contact
lenses to treat presbyopia. Doctors also should stress
that surgical procedures are not permanent, and that
patients may have to be retreated if regression occurs.

There is no known way to prevent presbyopia.

Management Online.

New Technologies Continue to Expand Options for
Treating Keratoconus, Myopia, Hyperopia. Primary
Care Optometry News.
Optometric Clinical Practice Guideline Care of the Patient
with Presbyopia. American Optometric Association

Mary Bekker

Prescription drug plan see Medicare prescription drug plan

Presenile dementia see Alzheimers disease


Ernest, J. Terry. Changes and Diseases of the Aging Eye.

In Geriatric Medicine, edited by Christine K. Cassel,
et al. New York: Springer, 1997.
Newell, Frank W. Optical Defects of the Eye. In Ophthalmology: Principles and Concepts. St. Louis, MO:
Mosby, 1996.

Gromacki, Susan J., and Eric Nilsen. Comparison of

Multifocal Contact Lens Performance to Monovision.
Contact Lens Spectrum 16, no. 5 (May 2001): 34-38.

American Academy of Ophthalmology. P.O. Box 7424, San

Francisco, CA 94120-7424. (415) 561-8500. http://
American Optometric Association. 243 N. Lindbergh
Boulevard, St. Louis, MO 63141. (314) 991-4100.
Contact Lens Association of Ophthalmologists, 721 Papworth Avenue, Suite 206, Metairie, LA 70005, (504)
Lighthouse National Center for Vision and Aging. 111 E.
59th Street, New York, NY 10022. (800) 334-5497.
National Eye Institute. 2020 Vision Place, Bethesda, MD
20892-3655. (301) 496-5248; Publications: (800) 8695248.

Glazier, Alan, O.D., F.A.A.O. Presbyopia Update: Helping Emerging Presbyopes. Optometric Management
asp?loc=articles/03062000115646am. html/.
Kattouf, Richard S., O.D. Achieving Maximum Efficiency
(Without Sacrificing Quality of Care). Optometric

Pressure sores
Pressure sores are also known as Bed sores, and
by the medical term (Latin) as decubitus. They are
ulcers, or sores, that develop on areas of the body that
have endured sustained stress or pressure for long
periods of time, such as suffered by people in wheelchairs or confined to bed rest. Such sores indicate
what is known as deep tissue, injury and can be a sign
of more serious underlying complications.

Pressure sores can range in stages from moderate
to severe. In appearance they can look as harmless as
any blister or discoloration on the skin, as in mild
bruises or scrapes. The National Pressure Ulcer Advisory Panel (NPUAP), with a concern for preventing
and treating pressure sores, has designated four categories, or stages in determining their severity.
According to the NPUAP, deep tissue injury can become first known by discolored skin that has a maroon or purplish tone, or the appearance of a bloodfilled blister. Sometimes skin spots will simply feel
painful to the touch, firmer or a different temperature
from the surrounding areas. In people with darker
skin tones, detecting deep tissue injury if often more
difficult than in lighter-skinned people. Due to evolution, a thin blister might actually develop over a
dark wound bed, according to the NPUAP. Further,
also due to what has developed through evolution, a
thin scab might cover the wound underneathwhile
that wound is growing deeper and more problematic.

Pressure sores

Nurses and assistants also prepare patients for

surgery by taking history, blood pressure and inserting
eyedrops. They also may be involved in preparing the
surgical areas, especially if surgery is performed in an
ambulatory surgery center. Ophthalmic nurses are
specially trained to assist in ocular surgeries.

Pressure sores

Stage I, of pressure sores are indicated first by a

red spot that itches or hurts, and might feel warm or
spongy when it is touched. Darker-skinned individuals such as those of African, Spanish, or Mediterranean descent might have skin that is blue or purple
in tone, or ashen, and easily flakes. If properly observed, and if the pressure source is relieved, this is
considered a superficial wound that can disappear in a
short period of time.
Stage II, is so designated because skin has probably already broken, and shows a wound bed that is
pinkish red in color. This can be at the epidermis or
outermost layer, or the dermis, the deeper layer of
skin. Sometimes it is actually a blister-like opening
and can be filled with liquid. Most likely, it will be
shiny if the skin is not already broken. Skin tears that
might result from bandage tape irritation, perineal
dermatitis, chafing, or other similar breakdown of
skin. At this stage pressure sores will also heal in a
short period of time if treated with proper care.
Stage III, ulcers indicate that the condition has
reached a critical stage, and that the damage runs to a
deeper layer of the skin, even though there is yet no
bone or tendon visible. NPUAP refers to this as full
thickness tissue loss, in which the fat under the skin
can be visible, but without the bone, tendon, or
muscle exposed. At this stage the wound is deep, with
a crater-like appearance.
Stage IV, is the most serious of the stages and
indicates severe loss of skin, affecting muscle, bone,
and even tendons and joints. These are the most
dangerous because of the depth of the open wound
making an individual subject to possible life-threatening infections. At this stage, the wounds, especially
in diabetics or people with other immune disorders,
are difficult to heal, and will probably require prolonged treatment.
The NPUAP has also determined that some
pressure sores are Unstageable. These are sores that
might be covered with dead tissue (slough) that can be
yellow, tan, gray, green, or brown; or, the pressure
sore might be covered over with a scab-covering, also
referred to as eschar, the color of tan, brown, or black.
In order to determine the stage of wound in this circumstance, the covering or scab would have to be
removed so the base of the wound can be examined.
Pressure sores develop wherever a person is most
likely to have sustained pressure. For someone in a
wheelchair, sores are likely to develop on the tailbone,
buttocks, should blades, spine, or on the backs of
arms and legs that might rest on or against the chair.
For those who are in bed for long periods of time due



How does diabetes affect my condition?

Will I have permanent scarring from pressure

to paralysis, coma, or recovery from an illness or

surgery, pressure sores might develop on the back or
sides of the head, along the rims of the ears, on the
shoulders or shoulder blades, the hipbones, tailbone,
or lower back, as well as on the heels of the feet, the
backs or sides of the knees, ankles or toes.

Anyone subject to long periods of inactivity, and
confined to a bed or a wheelchair is especially vulnerable to pressure sores. The highest incidence is
likely to occur in those individuals suffering from
spinal cord injuries, Due to the permanent nerve
damage often suffered due to the injuries, skin and
other tissues experience ongoing compression. Thinning or atrophied skin, decreased circulation
movement enables the flow of oxygen that helps to
keep skin from developing sores and other infectionsand no nerve signal to indicate discomfort due
to a prolonged position, all combine to make the
person with spinal cord injuries at the greatest risk for
pressure sores. Others at risk for this condition are
those over 70. With thinning skin, nutrition deficiencies, underweight, lower activity rates, the possibility
of developing pressure sores, and the problem of
healing them causes the increased risk to the older
adult. People with diabetes, and vascular diseases are
also at a greater risk than the general population
should the conditions comprising the dangers of
pressure sores arise. As with the other risk factors, the
lack of circulation and oxygen flow necessary to heal
wounds is compromised.
Other external factors that can cause an increased
risk of pressure sores include nursing home residence
due to the fact that people who have been hospitalized
or are in a nursing home are probably frail, and where
the volume of patients might create negligence in care;
a lack of pain perception; natural thinnes or weight
loss from illness or prolonged healing of such conditions as hip surgery; malnutrition; urinary or fecal
incontinence, with skin staying moist and thus more
vulnerable to breakdown; muscle spasms or

subcutaneousUnder the skin, or a layer of skin

epidermisThe outermost layer of skin
perinealPertaining to the area known as the
perineum, between the anus and the vulva in
women, and between the anus and scrotum in the

contracted joints that can make a person more vulnerable to repeated trauma from friction or shear

Causes and symptoms

Sustained pressure on vulnerable areas of the skin
is the first and foremost cause of pressure sores. When
anyone is in a position that is maintained without
shifting the pressure on a particular spot or spots, or
physical movement or activity is minimal, pressure
sores are likely to occur, especially in those who are
paralyzed, or have long illnesses that require them to
be immobile. Whether a person is underweight, or
overweight, pressure sores can developwith those
who are not cushioned by much fat or muscle over
areas just as a spine, tailbone, shoulder blade, hip,
heels, or elbows being especially vulnerable. With the
skin and underlying tissues caught between the bone
and the surface of something like a wheelchair or bed,
blood does not flow properly. Consequently, oxygen
and other nutrients necessary for proper healing and
maintenance are not available to the skin. When a
person is so confined, even clothing, bed linens, chair
or bed tilt, and perspiration can aggravate the skinit
softens under these circumstances and then is susceptible to injury. Even turning too frequently can be
harmful if it causes friction and irritation to the skin,
causing breakdown. Shear that arises when the skin
moves in one direction but the underlying bone moves
in anotheras in sliding down in a bed or chair (often
occurring in those who are lying in bed or sitting in a
wheelchair for long periods of time) or raising the
head of the bed more than 30 degreesstretches and
tears cell walls and the tiny blood vessels, and thus
causing skin breakdown.
Smokers have an increased risk of pressure sores
over non-smokers. Due to nicotine impairing circulation, and reducing the amount of oxygen flowing
through the blood, skin breakdown is more likely to
occur, and healing is likely to be more difficult. In

those with impaired mental facilities pressure sores

are a danger most often because they are less able to
care for nutrition, take proper medications, or take
other precautions that can prevent this condition.

Physicians, physician assistants, nurses, or other
medical professionals will diagnose pressure sores
even in their initial stages by simple visibility. Experienced professionals will be able to see immediately
that something is wrong. Diagnosis will extend to
various blood tests, urine analysis and culture, stool
culture, and in severe cases that are not healing despite aggressive treatment, a biopsy of the tissue will
be taken to determine a complete bacterial analysis.
In this case, a cancer biopsy might also be taken
because of the increased risk people have with wounds
that do not heal after a long period of time.

Because open wounds can take a long time to
close, treatment can be a slow and arduous process.
Due to damaged skin and tissues, even when wounds
are healed, evidence remains in scarring or fragile
skin. Because the problem of healing is complicated,
and often the individual is in fragile health already,
care is necessary for medical, emotional, and even
social aspects that arise with the condition. Primary
care physicians and nurses are the important first step
in diagnosis, and will assist in the process that might
involve social workers, physical therapists, urologists,
gastroenterologists, and for diabetics, endocrinologists if other than the primary physicians. When a
wound requires surgery for repair, a neurosurgeon,
orthopedic surgeon, and plastic surgeon might also be
involved. In a study reported by the Journal of the
American Geriatrics Society in August 2007, 52
nursing homes around the United States participated
in determining how best to treat pressure sores in
clients. Due to collaborative efforts by every department from the laundry to the hair salon, from the
kitchen staff to the health care professionals, severe
pressure sores that had been acquired within the
institutions themselves were reduced by 69 percent.
When the sores are classified as stage I or II sores,
treatment will involve nonsurgical measuresthe first
and most important being to remove the person from
the situation that can aggravate the sores or cause new
ones. These can include various options. One of them is
changing positions oftenevery 15 minutes for those
in wheelchairs, and every two hours for those who are
confined to bed, and using sheepskin or other padding

Pressure sores


Pressure sores

to protect the wound from friction caused by movement. Another would be using other pads and measures of support such as foam, air, or water-filled
mattresses or cushions to use while sitting or lying,
using care to avoid using pillows and rubber rings that
can cause compression. Physicians and health-care
professionals recommend low-air-loss beds or airfluidized beds. Inflatable pillows are used with low-airloss beds to provide support. Air-fluidized beds work
by suspending an individual on an air-permeable
mattress filled with millions of silicon-coated beads.
Whether a pressure sore involves an open wound,
or is only in stage I, regular cleaning is critical in order
to prevent infection. Stage I sores can be cleansed with
a mild soap and warm water. Open sores must be
cleaned with a saline (salt water) solution every time
the dressing is changed. A simple saline solution can be
prepared at home by boiling one teaspoon of salt in one
quart of water for five minutes, or can be purchased at
a drug store. The container in which it is stored must be
sterile if it is made at home, and should not be used
until it is cooled. Topical antiseptics such as hydrogen
peroxide and iodine should be avoided. These can
cause irritation and damage to the sensitive tissue and
in fact will likely delay healing. Because moisture on
the skin surrounding a wound will continue to aggravate the condition, incontinence is also a crucial issue
to address. If bladder or bowel problems exist, people
should consult a physician to help them address it
whether it involves a lifestyle change, behavioral programs, bed pads or adult care products, or medications.
Any dressings used to treat pressure sores must
provide protection of the wound in order to speed the
healing process. Usually stage I wounds will not require a dressing or bandage. Stage II sores are often
approached by using hydrocolloids which are transparent semipermeable dressings designed to hold in
the moisture and encourage skin cell growth.
Removal of damaged tissue, also known as debridement, can be accomplished through surgery.
More commonly it is done by using a nonsurgical
high-pressure device that causes the bodys enzymes to
break down dead tissue. Another form of debridement
is the application of topical debriding enzymes.
Hydrotherapy (using whirlpool baths) are helpful
with those who can tolerate them, as they clean the
wounds and assist in removing contaminated or dead
tissue. Relief from muscle spasms also helps to prevent and to treat pressure sores. In those instances, a
physician will prescribe skeletal muscle relaxants that
will serve as nerve blocking agents in the spine or in
the muscle cells.

When surgery is required to heal a pressure sore,

the first step is debridementthough more extensive
than the nonsurgical treatment form. Not only is the
dead tissue removed,but the fluid-filled sac and creates the gliding surface between the bone and the
muscle, is also eliminated, including any bone that is
diseased. Known as flap reconstruction, this type of
surgery is extremely complicated. Recovery takes a
long time and is difficult. Those who are considered
the best candidates for it will have a family or social
support system, excellent nutritional health, optimum
resources such as a pressure-release bed, and the
ability to participate actively and optimistically in
their own recovery.
As of 2008, other treatments were still being investigated for their success. These include the use of
hyperbaric oxygen chambers, electrotherapy, and the
topical use of human growth factorsthese proteins
that stimulate growth have been approved for diabetic
ulcers but not yet for pressure sores.
Health care professionals caution that massage
should not be used in treating pressure sores. Subcutaneous tissue is prone to damage in massage.

Nutrition/Dietetic concerns
A healthy diet that promotes healing would include Vitamin C and zinc, proven to promote the
healing of wounds. Physicians will often prescribe
Vitamin C and zinc supplements. These, in addition
to a nutrition plan that includes sufficient calories,
adequate protein, and a full range of fruits and
vegetables will provide crucial assistance in the process as well.

Physical therapy, including hydrotherapy, might
be necessary to assist in body movement either for
those with spinal cord injuries or paralysis, or after
someone has been immobile for a long period of time.
This might also assist in healing open wounds by
maximizing the amount of oxygen circulating
throughout a person's system.

The most difficult pressure sores to treat are those
in spinal cord patients, and thus the prognosis in such
cases is difficult at best but not impossible. Studies are
being conducted continually to find ways in which to
provide for optimal skin care that can heal and prevent
pressure sores. For anyone who is confined to bed or
wheelchair, is diabetic, or suffers chronic health care

In order to prevent pressure sores in highindividuals a number o measures help. Those include the
following: frequent position changestaking care to
move otherwise immobile patients at least every two
hours, or moving every 15 to 20 minutes if confined to
a chair or wheelchair; when lying on the hipbone on
one side, the angle should be 30 degrees, not flat;
providing proper leg support by placing a pillow or
foam pad under the legs from the middle of the calf to
the ankle, avoiding support pads directly behind the
kneea practice that can cause the flow of blood to
be restricted; not placing the head at an angle more
than 30 degrees; and using a pressurereducing mattress or bed. In addition to these, daily skin inspection
is essential in order to notice the first sign of a problematic skin issue that can lead to a pressure sore, or
one that has already developed. Once any sign of a
sore appears, seeking medical advice can be crucial.
Maintaining a good weight through proper nutrition
and adequate calorie intake is also essential in maintaining optimum skin health that will not provide an
environment for its breakdown that can result in
pressure sores.


Fighting Bedsores With a Team Approach. New York

Times. (February 19, 2008)
Lateral Decubitus Position Generates Discomfort and
Worsens Lung Function in Chronic Health Failure.
Chest Journal. (2005); 128:1511-1516).
Wall Street Journal Examines Hospital Efforts to Reduce
Pressure Sores. Medical News Today. (September 7,

Bedsores (Pressure Sores).

Pressure sores.
Pressure ulcer.
Pressure Ulcer, Definition and Stages.
Prevention of Pressure Sores through Skin Care. http://

National Decubitus Foundation, 4255 South Buckley Road,

#228, Aurora, CO, 80013, 3035949417, http://www.
National Pressure Ulcer Advisory Panel, 1255 Twenty
Third Street NW, Suite 200, Washington, D.C., 202
5216789, 2028333636,, http://

Jane Elizabeth Spehar

Caregiver concerns
When caring for someone who is at a high risk for
pressure sores, or might already have developed them,
a multidimensional approach is essential. Whether
or not the person is permanently immobile due to
paralysis, or recovering from or suffering a longterm
illness, the caregiver must serve as skin inspector,
body positioning aide, and nutritional guide even if
the person is participating in self-care. Infections can
be life-threatening and must be avoided, or treated for
optimal health.
Eat to heal

Eat smaller meals more often in order to maintain a

healthy weight

Eat larger meals at the time when hunger is at its

peak time

Limit fluids that prevent eating higher calorie foods

If swallowing is an issue, pureed food or liquid meals

can maximize calorie intake when necessary

Choose high protein foods that might be easier to

digest than meatcottage cheese, peanut butter,
yogurt, and custards


Priapism is a prolonged, sustained erection of the
penis that occurs in the absence of sexual excitation and
which may last hours to days, with or without pain.

The penis has two cavities, called the corpora
cavernosa, which run the length of the organ and are
filled with spongy tissue. Blood flows in and fills the
open spaces in the spongy tissue to create an erection.
Sexual desire commonly triggers erections. After an
erection, the penis returns to its original flaccid state
(detumescence). Priapism is the condition in which
erections persist for a long time without sexual excitement.
There are three types of priapism:

Ischemic priapism: This type is characterized by a

nonsexual, persistent erection that can last for hours


issues, success in treatment is possible even if challengingespecially if caught in the earlier stages.