Interface pressure distribution of elderly Japanese people in the sitting position.

AIM: To investigate the characteristics of elderly Japanese people sitting in a wheelchair using pressure mapping and an objective method to classify sitting patterns. METHOD: This descriptive observational study was conducted in a senior care facility and a geriatric hospital, with 107 elderly subjects (37 group A (house-bound), 34 group B (chair-bound) and 36 group C (bed-bound)) and 36 able-bodied. Maximum pressure, total support area, distance from backrest to coccyx and sitting pattern were collected by using a pressure mapping system. RESULTS: Maximum pressure was significantly lower for able-bodied than groups B and C (p < 0.001 and p = 0.024, respectively). Total support area was significantly larger for able-bodied than each elderly group (group A p = 0.014, group B p = 0.021, and group C p < 0.001). Distance from backrest to coccyx was significantly longer for group C than able-bodied (p < 0.001). The occurrence of proper sitting pattern significantly decreased as the degree of independence reduced (p < 0.001). CONCLUSION: Elderly people with disabilities have high interface pressure on a small support area, malposition, which is confirmed by longitudinal and lateral supporting balance indices, and imbalance in a wheelchair. The following concepts for developing cushions should be considered: low interface pressure with large support area, individual adjustment of sitting position and stability of body trunk.

Validation and determination of the sensing area of the KINOTEX sensor as part of development of a new mattress with an interface pressure-sensing system.

The purpose of the present study was to examine the validity of the KINOTEX sensor via comparison with an existing sensor and to determine the sensing areas for a new alternating-air mattress that incorporates an interface pressure-sensing system. The study design was an evaluation study to validate and determine the sensing area of the KINOTEX sensor in comparison with another sensor. Study participants were fifty-one healthy volunteers over eighteen years of age, and the two sensors were placed between participants and an alternating-air mattress. We measured the contact area, full weight load, and maximum pressure in the calcaneal region using two sensors and obtained a graphic pressure distribution of >40 mmHg in the lateral and supine positions. Correlation coefficients between sensors were r = 0.88 (p < 0.001) for the contact area, r = 0.89 (p < 0.001) for full weight load, and r = 0.72 (p < 0.001) at maximum pressure in the calcaneal region. Ninety-one percent of the pressure distribution was recorded in the central 50 cm of the bed, and 94.6% was recorded within an area 160 cm in length need the foot of the bed. We investigated the correlation between the KINOTEX sensor and an existing sensor and determined the necessary sensing area. Results suggested the feasibility of developing a new alternating-air mattress incorporating an interface pressure-sensing system to help prevent pressure ulcers.

Risk factors in the development of pressure ulcers in an intensive care unit in Pontianak, Indonesia.

The purpose of this study was to identify risk factors associated with the presence of pressure ulcer development in adult patients at an intensive care unit hospital in Indonesia. The prospective cohort design was conducted in this study. A total of 105 patients participated and a pressure ulcer developed in 35 patients. The initial analysis identified several variables as significant risk factors for pressure ulcer development (interface pressure, fecal incontinence, skin moisture, diastolic blood pressure, smoking and body temperature). However, when entered into a final multivariate analysis, four factors, interface pressure [odds ratio (OR) 17.6, 95% confidence interval (CI) 4.1, 74.3], skin moisture (OR 8.2, 95% CI 2.2, 30.9), smoking (12.7, 95% CI 2.8, 56.7) and body temperature (OR 102.0, 95% CI 7.7, 98.8) were found to be significant. The results suggest that interface pressure measured using a multipad pressure evaluator, skin moisture measured by a moisture checker, thermometer for body temperature and smoking status are adequate instruments for the prediction of pressure ulcer development.

Evaluation of a new pressure ulcer preventive dressing containing ceramide 2 with low frictional outer layer.

AIM: This paper is a report of an evaluation of the effectiveness of a newly developed dressing for preventing persistent erythema and pressure ulcer development and improving the water-holding capacity without increasing the skin pH in bedridden older patients. BACKGROUND: Shear forces and skin dryness play important roles in persistent erythema and pressure ulcer development. To eliminate these risks, we developed a dressing to reduce shear forces and improve the water-holding capacity. However, the effects of this dressing in clinical settings remain unknown. METHOD: An experimental bilateral comparison study was conducted at a hospital in Japan in 2004 with 37 bedridden older patients at risk of pressure ulcer development. The dressing was randomly applied to the right or left greater trochanter for 3 weeks. No dressing was applied to the opposite side as a control. The skin was monitored weekly during the 3-week application for persistent erythema and pressure ulcer development. Skin hydration and pH were also assessed during the intervention and for 1 week after dressing removal. FINDINGS: The incidence of persistent erythema was significantly lower in the intervention area than the control area [P = 0.007, RR 0.18 (95% CI: 0.05-0.73) and NNT 4.11 (2.50-11.63) ]. No pressure ulcers occurred in either the intervention or control area. Skin hydration increased significantly during dressing application and remained high after removal (P < 0.001) relative to the control area. Skin pH decreased significantly during the application (P < 0.001) but returned to control levels after removal (P = 0.38). CONCLUSION: This safe and effective dressing can be used for patients with highly prominent bones and dry skin to prevent pressure ulcers.

A study of the efficiency and convenience of an advanced portable Wound Measurement System (VISITRAK).

AIMS AND OBJECTIVES: A reduction of pressure ulcer wound area is one of the most important indicators of wound healing. A wound measurement system (VISITRAK), which calculates the area based on simple tracings of wounds, has been developed as a practical tool for assessing wound area at the bedside. However, its accuracy has remained to be clarified in a clinical setting. This study aimed to clarify the clinical accuracy of the VISITRAK system. DESIGN: A descriptive correlational study. METHODS: Intra- and inter-rater reliability of wound measuring techniques were calculated using an intraclass correlation coefficient (ICC) from 10 pressure ulcers. Concurrent validity was assessed, using 30 pressure ulcers, by comparing VISITRAK and digital planimetry. Assessment times for VISITRAK and digital planimetry were also compared for clinical practicality. RESULTS: The VISITRAK reliability results showed high (0.99) ICC values. For validity, a correlation coefficient between VISITRAK and digital planimetry was 0.99. The median time to take a measurement with VISITRAK was significantly shorter than that required for digital planimetry. CONCLUSIONS: Based on our results, VISITRAK was found to have high intra- and inter-rater reliability and high validity. RELEVANCE TO CLINICAL PRACTICE: The short measurement time with the VISITRAK system, and the ability to use it at the bedside, make it a useful, convenient device for clinical use.

Effect of vibration on skin blood flow in an in vivo microcirculatory model.

The effect of vibration on skin microcirculation was studied to investigate the possibility of clinical use of vibration to prevent and treat pressure ulcers. Vibrations at a vibrational intensity of 600, 800, or 1,000 mVpp with a fixed frequency of 47 Hz were applied horizontally to the ear of male hairless mice (n = 6 for each group) under inhalation anesthesia. The control group (n = 6) received no vibrations. Venular blood flow was measured by an intravital videomicroscope at the baseline and at 0, 5, and 15 min after the application of vibrations. A significant increase was observed in the 600 mVpp group 5 and 15 min after vibration in comparison to the control group (P = 0.002 and P = 0.046, respectively). We also detected increased blood flow in the 800 mVpp group (P = 0.028) and the 1,000 mVpp group (P = 0.012) 5 min after vibration; however, these increases attenuated after 15 min. These results indicate that direct skin vibration at a frequency of 47 Hz improves skin blood flow. The present study gives further support to the role of vibration on a short-term increase in skin blood flow.

Incontinence induces stratum corneum vulnerability and impairs the skin barrier function in the perianal region.

BACKGROUND: Incontinence leads to a reduced skin barrier function, while also increasing the risk of skin breakdown. AIM: To investigate the perianal skin barrier function of elderly patients with or without incontinence. METHODS: We compared the skin barrier function by investigating the skin hydration, the skin pH, the amount of ceramide and by making a dermatological skin inspection of the perianal region in patients with and without incontinence. RESULTS: Twenty-one incontinent patients (70.0%) showed a glossy skin, which indicates impairment of the skin barrier while none of the patients in the continence group did so. In the incontinence group, those who had a glossy skin showed a significantly greater skin pH and total amount of ceramide than those with a normal skin (p = 0.0099, p = 0.0179, respectively). CONCLUSIONS: These results demonstrate that a glossy skin may be a useful indicator of a reduced perianal skin barrier function.

Structured visualization of expert nursing: Prevention of pressure ulcers.

We made an algorithm by extracting the caring elements for the patients to develop a program for pressure ulcer prevention. The algorithm consisted of observation of the patient skin as a beginning point, extraction of the risk factors for pressure ulcer development, intervention to each risk factor, and evaluation. The expert panel identified this algorithm as adequate enough to adopt to the patients.

A prospective cohort study of lower-extremity pressure ulcer risk among bedfast older adults.

OBJECTIVE: To estimate the incidence and identify risk factors for lower-extremity pressure ulcers in bedfast older adult patients. DESIGN: Prospective cohort study. SETTING: A 500-bed long-term-care facility in Japan. PATIENTS: A total of 259 patients who were aged 65 years or older, confined to bed, and without lower-extremity pressure ulcers at enrollment participated in the study. MAIN OUTCOME MEASURES: Incidence of occurrence, wound characteristics, and risk factors for lower-extremity pressure ulcers. The incidence of lower-extremity pressure ulcers per 100 person-years was 16.8 (n = 33). The most common sites of lesions were the toes and heels. Cox regression analysis indicated that 3 factors were independently related to new lower-extremity pressure ulcer risk: low ankle-brachial index value (hazards ratio 0.075; 95% confidence interval [CI], 0.023-0.242), length of bedfast period (hazards ratio 1.010; 95% CI, 1.004-1.015), and male gender (hazards ratio 2.951; 95% CI, 1.450-6.009). Receiver operating characteristic curve analysis showed the area under the curve was 0.760 (95% CI, 0.675-0.844) for the ankle-brachial index. Therefore, an ankle-brachial index cutoff level of 0.8 provided high sensitivity and adequate specificity. CONCLUSION: Lower-extremity pressure ulcers are a significant problem in bedfast older adult patients aged 65 years or older. Bedfast older adult patients who developed lower-extremity pressure ulcers in this study were believed to have arteriosclerosis; the patients' ulcers exhibited features of ischemic ulcers. The findings of the present study suggest that bedfast older adult patients with a low ankle-brachial index value, a long bedfast period, or male gender should be closely monitored for lower-extremity pressure ulcer development on admission to long-term-care facilities. In particular, the ankle-brachial index is recommended as a screening tool in this practice setting.

A new instrument for predicting pressure ulcer risk in an intensive care unit.

The purpose of this study was to assess the utility of two instruments (the Braden scale and a multi-pad pressure evaluator) for predicting pressure ulcer development. A prospective cohort design was used and 105 intensive care unit patients participated in this study. The result was a 33% incidence of pressure ulcers. Both the Braden score and the multi-pad pressure evaluator instruments gave significant differences between patients who did and did not develop pressure ulcers. The predictive validity of these tools was calculated. The results indicated that the multi-pad pressure evaluator provided the best balance between sensitivity and specificity. We suggest that the multi-pad pressure evaluator may be better suited for assessing the risk of pressure ulcers in intensive care units.

Comparison of two pressure ulcer preventive dressings for reducing shear force on the heel.

OBJECTIVE: We compared the shear forces exerted over the heel between a pressure ulcer preventive dressing and a thin-film dressing in a clinical setting. Interface pressures were measured as well. DESIGN: Quasi-experimental clinical trial. SETTING AND SUBJECTS: Participants were 30 elderly patients (5 men, 25 women; mean age, 86.4 +/- 8.0 years) hospitalized in a geriatrics hospital in Japan; all had a Braden score of less than 14 (mean, 10.1 +/- 1.1). Informed consent was obtained from all the patients.A shear force and pressure sensor including a strain gauge, and an oval airbag-type pressure sensor were used. METHODS: The sensor was attached to one heel using double-sided tape; then the target dressing was applied over the sensor and on the opposite heel to avoid the influence of the opposite heel on the shear force measurement. Interface pressures were measured with the patient in a stationary supine position; shear force was then measured at 0.2-second intervals, while the sheet was manually pulled at a velocity of around 5 cm/second. Shear force was determined by averaging the stable shear force lasting for 10 measurement points. RESULTS: The mean interface pressures with the PPD and the film dressings were 70.7 +/- 16.5 and 70.2 +/- 15.2 mmHg, respectively; this difference was not statistically significant. The shear force produced during the pulling of the sheet was 2.2 +/- 1.4 and 11.7 +/- 5.8 N, respectively (P < .001, Wilcoxon signed-rank test). CONCLUSIONS: The results of this study suggest that a dressing with a low-friction external surface (such as the pressure ulcer preventive dressing) can significantly reduce shear force. However, results also suggest that external dressings do not significantly reduce interface pressures and cannot be used as a substitute for heel elevation in an immobile patient.

Measuring the pressure applied to the skin surrounding pressure ulcers while patients are nursed in the 30 degree position.

The 30 degree laterally inclined and 30 degree head elevated positions (hereafter referred as the 'rule of 30' unless otherwise specified) are widely used as a means of both primary and secondary prevention of pressure ulcers as a result of reductions in localised pressures over bony prominences. However, the authors observed that some some parts of the wound margin were thickened. These thickened edges may be caused by use of the rule of 30 positioning and may also be responsible for a delay in the healing process. This study included five bedbound elderly patients with pressure ulcers located at the sacrum and coccyx. The local pressure was measured at the thickened edges and normal edges of the subjects' wounds by a newly developed sensor while the subjects were positioned according to the rule of 30. The results showed the maximum pressure as well as the average pressure of the thickened edges to be significantly greater than that of the normal edges. Thus, it is suggested that higher pressure on different areas of the wound margin may be responsible for the thickened edges phenomenon, which may consequently delay the healing process. Clinical use of the rule of 30 for patients with pressure ulcers in the sacrum and coccyx regions should be reconsidered.

Randomised controlled trial to evaluate a new double-layer air-cell overlay for elderly patients requiring head elevation.

A clinical investigation was conducted concerning the effects of a newly designed double-layer air-cell overlay in preventing the onset of pressure ulcers for patients with a Braden scale score of < or = 16, and who require a head-elevated position of 45 degrees or higher. A randomised controlled trial was undertaken involving 82 patients from a general hospital ward using one of the following three support surfaces: a double-layer air-cell overlay, a single-layer air-cell overlay or a standard hospital mattress. A significantly lower percentage of patients using the double-layer air-cell overlay developed pressure ulcers (3.4%) compared to 19.2% and 37.0% for those patients using the single-layer air-cell overlay and standard mattress respectively. Based on these findings, a double-layer air-cell overlay should be more effective in preventing the onset of pressure ulcers than either a single-layer air-cell overlay or a standard hospital mattress for subjects requiring head elevation.