A Desriptive Evaluation of Pressure Reducing Cushions

7/25/2019 A Desriptive Evaluation of Pressure Reducing Cushions

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Clinical

A descriptive evaluation of

pressure-reducing cushions

Sylvia Banks, Jane Bridel

This article provides

a descriptive

evaluation of HNE

Hun tleigh s

Vaperm, Multitec

and Supatec

pressure-reducing

cushions in relation

to skin response,

comfort and posture

and their

effectiveness in an

overall pressure sore

prevention strategy.

Sylvia Banks is Practice

Devciopment Nurse and

Jane Bridel is Head of

Nursing Research and

Practice Development at St

Jam es s and Seacroft

University Hospitals,

Leeds

review of the literature reveals a

link between seating and the development

of pressure sores (Barbenel et al, 1977;

Barton and B arton, 1981; Geb hardt and

Bliss, 1994). A number of pressure-reduc-

ing cushions have been developed in an

attempt to reduce the risk of pressure-sore

development associated with sitting. In

1983, a national survey of the prevalence

of pressure sores highlighted the diversity

of pressure-reducing products available in

the NHS (David etal, 1983).

Figure la . The Vaperm pressure-reducing

cushion from the Seatec range.

Polyhedron-shaped channels

provide extra pressure relief

by helpirig reduce shear

lorces ol cushion and also

allow air lo circulate

throughout cushion

mnltl x cover provides:

1. 2-way slretch prevents

hammocking and shear

2.

42 vapour permeable

improves

s r

movement around

cushion

3. Waler-resistant prevents

foam Irom getting wet

Comfort layer of foam

takes up body contours

and provides comfort

The literature on pressure-reducin

cushions currently focuses mainly on th

measurement of interface pressures. I

1974, Souther et al examined a number o

these products and concluded that: N

cushion evaluated reduced mean pressu

below mean capillary pressure. How eve

the application of interface pressure me

surements to clinical practice was recent

challenged by Bridel (1993a), who ind

cated that at an individual level th

response to pressure varied widely. Th

reliability and validity of the tools used t

measure interface pressures have also bee

questioned (Clark, 1994), demonstratin

that these measurements cannot be used

an absolute indicator of the effectivene

of product.

Sitting is a dynamic, unstable postur

and the performance of pressure-reducin

cushion cannot be properly evaluated inde

pendently of the overall seating situatio

There is little information in the literatur

with regards to the effect of adding such

cushion to a seat, particularly in terms o

skin response. In view of th is, a descriptiv

study of the Vaperm, Multitec and Supate

cushions was undertaken.

Aims

The aims of the study w ere to:

1. D ete rm ine the effectiveness of th

Vaperm, Multitec and Supatec cushion

m relation to skin response

2. Assess the comfort of the cushions

3. Observe the effects of the cushions o

posture.

The Vaperm, Multitec and Supatec cush

ions form part of the Seatec range pro

duced by HN E Huntleigh.

The Vaperm cushion {Figure la ha

been designed to meet the needs of use


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Adescriptive ev aluation of pressure-reducing cushions

Breathable film covering

(Platilon)

Fire-reslsiant foam

walls take up

contours of patient's

to allow an even distribution of pressure.

The foam is vcntil.ucd to .illow .lir to cir-

culate through the cushion

{Figure

Ib .

The Multitec cushion

{Figure 2a

has

been designed to meet the needs of users

who are assessed to be at medium-high

risk of developing pressure sores, or as

part of the treatment for established sores

up to grade 2 or grade 3 healing (Torrance,

1983).

The centre of the cushion contains a

polyurethane envelope containing fluid

and a lattice of welds links the top and

bottom of the envelope to prevent exces-

sive fluid movement. The envelope is

housed in thin foam, allowing the patient

to sit into the fluid, while taking up the

contours of the body. If the patient shifts

his/her position, the fluid displaces accord-

ingly and redistributes the pressure over

the seating surface{Figure2b .

The Supatec cushion {Figure 3a has been

designed to meet the needs of users who are

assessed to be at a high-very high risk of

developing pressure sores, or as part of the

Figure 2a. The Mult i tec pressure-reduc ing


Choice o( outer cover

1. atchdogTerrtowelling

2. OmnHIeK'

Cotton cover to

strengthen foam

assembly

Fluid:

treatment for established sores up to grade

(Torrance, 1983). The Supatec contains mo

fluid than the M ultitec, allowing for better di

tribution of weight and pressure{Figure3b

The cushions used for evaluation were a

protected by a waterproof, vapou r-perm

able cover cal led Omnif lex. The cov

stretches two ways to reduce hammockin

and shear forces, and can be removed fo

laundering. The cushions used for evaluatio

had already been in use in the hospital for

months and no attempt was made to com

pare the performance of the cushions after

months with their performance when new.

Method

Sample

Patients admitted to a 32-bedded medic

ward and a 30-bedded elderly care war

were considered for entry into the stud

The ward nurses identified patients requi

ing a pressure-reducing cushion, by asses

ing the risk, skin quality and mobility of th

patients in accordance with the St James

University Hospital Trust (1993) pressur

area care policy. Patients were included i

the study if they met the following criteria:

1. The patient/carer was able to participat

in

a

simple, semi-structured interview

2. In the ward nurses clinical judgmen

the patient s mobility and conditio

were unlikely to alter during the 7-da

study period week

3.

On entry to the study, the patien t

Waterlow score (Waterlow, 1985) wa

5

or above.

A full explanation of the study wa

given and verbal consent to participate wa

obtained from all patients as determine

by the local ethics committee.

The cushions were allocated by the war

nurses according to the skin assessment

and the mobility of the patient describe

by the subscale contained within th

Braden scale (Braden and Bergstrom

1987). The guidelines for allocation ar

shown inTable 7.

Patients with dark pigmentation of th

skin were not considered for entry into th

study because of the difficulties associate

with the reliable identification of blanchin

and non-blanching areas of rednes

Patients assessed to have existing pressur

damage of grade 3 or worse (Torranc

1983) at the sacrum or ischial tuberositie

were also excluded from the study. It wa


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Adescriptive evaluation

of

pressure-reducing cushions

ultimately alter

the

dimensions

of the

ch.\ir.

In an

attempt

to

etisure that patients

were able

to

maintain their functional abil-

ity while sitting, the total scat height

of

the

chairs with the cushioninplace was chosen

to match the lengthof thepatient 'sleg

from the popliteal fossa to the floor. Where

a suitable chair height

was not

available,

aids such

as

foot-blocks were used

to

sup-

port the feet and maintain a 90 angle

at

the

hip and knee. All chairs used were covered

with polyvinyl chloride and had armrests.

Other pressure area care was determined

by ward staff who assessed the risk, skin and

mobihty

of the

patients

and

evaluation

of

skin response,

in

accordance with

the St

James's University Hospital Trust (1993)

pressure area care policy. Mattress allocation

and repositioning schedules while

in bed

therefore varied among the study sample.

Data collection

As well as demo graphic information,

descriptive data pertainingto theresponse

Figure

3a The

Supatec pressure-re ducing


2-way stretch cover ^^^^^k

Available in

Omn lilex'

or

^ ^ ^ ^ ^ ^ ^ ^ H

WatchdogTemiowelling ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ H

Extrafluidens ures that ^ ^ - - ^ ^ ^ ^ / ^ - ^ ^ i > I l ^

.y^

patients wtth fixed pelvic

^ --....y^

^^^^^^rr;^

displacement can use y' ^^ -^, ,,^ ^

j-

Supatee'

/

^ ~ ~ - - . ^ ^

Lattice work inside fluid modu le:

1.

Prevents user bonoming out on

cushion

Welds link outer layers of

polyurethane envelopes together:

1.

Allows moreofthe fluid to be

available to take up the body

of the skin were collected by thewa

nurses

and

were determined

by the

pre

ence

or

absence

of

redness. Skin

wa

assessed

at

the sacrum and ischial tubero

ties using

an

adapted version

of the

pre

sure sore classification described

b

Torrance (1983). These assessments wer

documented

on

entry

to the

study

and

each position change (24-hour clock)

for

7-day study period.

Additional information collected

by th

ward nurses

and

author included descri

tive data relating

to the

risk

of

pressu

sore development,

the

comfort

of th

cushions and posture.

Pressure sore risk was described

by ca

culation

of

the Waterlow score. Owing

t

the problems associated with interrate

reliability

of the

Waterlow score (Deale

1989; Bridel, 1993b),

the

documente

scores were used onlyas ageneral indic

tor

of

the level

of

risk

in

the description

the results

and no

attempt

was

made

t

improve the reliability among raters.

Data pertainingto thecomfort of th

cushions were collected by the auth

using a visual analogue scale and were sup

ported

by

descriptive inform ation fro

semi-stnictured interviews.

Ward nurses were given detailed expla

nations

of the

tools

and

data collectio

forms

to be

used. Since

the

focus

of th

evaluation was skin response, preparation

before data collection included interrate

reliability checksof skin assessments wi

level

registered ward nurses. A total

of

nurses (nine pairs) undertook skin assess

ments

on

four anatomical sites (buttoc

and heels)

of

18 patients, generating

a

to

of 72 paired assessments scores. There wa

92 absolute agreement

of

grades

{ ^yH

equating to aPearson product-mome

correlation

of .92

(P


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descriptive evaluation of pressure-reducing cushions

also defined. Transient skin changes refer

to the observation of skin redness (either

blanching or non-blanching) for less than

24 hours and persistent skin changes are

def ined as redne ss (ei ther blanch ing or

non-blanching) observed at the same site

for 24 hours or longer.

Ten of the 48 patients had superficial skin

loss (grade 2b) on entry to the study and a

further patient developed a pressure sore.

The per iod prevalence of pressure sores

was 22 .9 (11/48) and the inciden ce, i.e.

the proportion of subjects who first present

with a pressure sore, was 2.6 (1/38).

Vaperm

Sixteen patients were allocated a Vaperm

cushion; detai ls of the resul ts are sum-

marised in

Table 3

Eleven (69 ) had no

disco loration (grade 0) and five (31 ) had

reddened blanching areas on entry to the

study. Waterlow scores ranged from 15 to

23 (median 16) and mobility was recorded

as slightly limited for all patients (Braden

subscale 3). The total time spent sitting per

day rang ed from 4 to 11 ho urs (m ean 8

hours) and the length of time spent sitting

for any one per iod ra nged f rom 1.5 to

3 hours (mean 2.3).

Seven patients (44 ) had transient skin

changes during the study. Adjustments to

the indiv idu al r epo s i t ionin g schedules

were made by the ward nurses when red-

ness was observed and no persistent skin

changes occurred. Al l pat ients had skin

assessments of grade 0 at the end of the

study per iod.

Tab le I Gu idelines for alloca tion of cushions

Mobility

Multitec

Table 4 shows the results of the 16 patien

allocated a Multitec cushion. Nine patient

(56 ) had no disco loration (grade 0) and

seven (44 ) were classified as grade 1 on

entry to the study. Waterlow scores ranged

from 16 to 24 (median 22) and m obility wa

very l imited (Braden subscale 2) in al

patients. Tim e spent sitting varied w idely in

this group, ranging from 4 to 19 hours/day

(mean 8) for periods of1.5 3.5hours (mea

2.5 hours). Four patients experienced som

skin changes dur ing the study. Change

were made to their repositioning schedule

and no persistent changes occurred.

Skin status remained undamaged in al

nine patients with no discoloration on entry

to the study (grade 0) and resolved in 5 of

the 7 patients who were initially assessed a

grade 1. Th e skin cond i t ion of the tw o

remaining patients was unchanged, i.e. ini

tial skin changes were persistent. The lack of

improvement in these two patients could

not be explained by longer periods of sitting

(6 and 6.5 hou rs per day) than other patient

in the group or by their risk scores of23.

Supatec

The results of the 16 patients allocated a

Supatec cushion are shown in Table

Only one (6 ) had no d i scolora t ion

(grade 0) on entry to the study. The major

ity (6 3 ; 10/16) of the patients had super

ficial skin loss (grade 2) on either the

sacrum or the ischial tuberosities, and the

remainder had either non-blanching (n=l

or blanching (M=4) erythema.

I. Com pletely Immobile:

2

Very limited:

Doe s not make even Makes occasional

3. Slightly limite d:

4.

No limitations:

slight changes in body

or extremity position

without assistance

Skin assessment


or extremity position,

but unable to make

frequent or significant

changes independently

Makes frequen t though Makes major and


or extremity position

independently

frequent changes in

posit ion without

assistance

Grade 0:

no discoloration

Grade 1:

redness/blanching

Grade 2a:

redness/non-blanching

Supatec or

Multitec

Supatec or

Multitec

Supatec

Multitec

Multitec

Supatec

Vaperm

Vaperm

Multitec

Vaperm

Vaperm

Multitec


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descriptive evaluationofpressure-reducing cushions

All patients were either completely

immobile n

=5) ,

or their mobility was

severely limited n=l I). Risk of pressure

damage was high or very high in all cases

Waterlow score 18-34, median 25).

The total time spent sitting within this

group was less than that in the Vaperm and

Multitec groups, ranging from 3 to 7.5 hours

per day mean 5 hours). However, the

length of time sitting for any one period was

only slightly shorter than that in the othe

two groups range 1-2 hours, mean 1.7).

Table

2.

Characteristics

of

the patient population

i


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A descriptive evaiuation of pressure reducing cushions

Table 4.

Patient

no.

3

7

12

14

18

19

24

26

29

32

34

39

41

43

46

Multitec cushion results

Skinassessmentsa t

entry toevaluation

Ischial Sacnim

tuberosity

0

0

0

0

1

0

0

0

0

1

0

1

0

0

0

0

0

0

1

0

1

0

1

0

0

0

0

1

0

1

1

0

Skin assessments at

end of evaluation

Ischial Sacrum

tuberosity

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

1

0

0

0

0

0

0

0

0

0

Waterlow

score

21

21

23

16

24

19

23

18

24

24

20

24

17

23

23

19

Braden

mobility

1-4)

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

Mean time

sitting/day

hours)

19

4

6

I I

6

5

6.5

iO

8.5

7

5.5

9

6.5

8

8

13

Mean time

sitting/session

hours)

3

1.5

2

3

3

1.75

2.5

3.5

3

2

2.5

1.5

2.5

2

2.5

3.5

Table 5.

Patient

no .

2

5

9

10

15

17

20

22

27

30

33

35

37

42

Supatec cushion results

Skin assessments at

entry to evaluation

Ischial Sacrum

tuberosity

0

0

0

1

2b

2b

2a

0

0

0

0

0

0

2b

2b

2b

2b

2b

2a

2a

2a

2b

2b

2b

1

1

0

0

Skin assessments at

end o f evaluation

Ischial Sacrum

tuberosity

0

0

0

1

2b

2a

1

0

0

0

0

0

0

2b

2b

2b

2a

2b

2a

2a

1

2b

2b

2a

2a

1

0

0

Waterlow

score

25

26

28

27

34

32

28

26

25

24

21

22

18

20

Braden

mobility

1-4)

2

2

2

2

2

2

2

2

2

2

1

1

1

2

Mean tim e

sitting/day

hours)

3

4

5.5

6

3

5

5.5

6.5

4.5

5

5

4

7

5.5

Mean time

sitting/session

hours)

1

1.5

1.5

2

1.5

1.5

1.5

2

1.5

1.5

2.5

2

1.5


7/9

A descriptive evaiuation ofpressure-reducing cushions

On entry to

the

study the posture

of the patient was

observed when

the

patient was

initially

seated

and the

observation was

repeated a fter 1

hour.

All patients

were observed

to

maintaina9

angle

at

the

hip

and kn ee after 1

hour and feet

remained flat on

the floor

or

supported by

a

foot-block.

The

one

patient

in

this group

who had

no discolorat ion of skin on entry to the

s tudy did not experience persistent skin

changes during the study period,and skin

assessments of grade 0 were observed for

all areas

at the end of the

study.

Of the

tour patients with blanching redness,one

deter iorated

to

non-blanching (grade

2a)

but

did not

result

in

superficial loss

of the

e p i d e r m i s , and three per s i s t ed but

remained unchanged (grade

1).

One patientwasinitially assessed to have

non-blanching for all areas (grade 2a) on

entry

to the

evaluation

and

subsequent ly

developed a pressure sore (grade2b) at the

sacrum.At the end of the study, however,

improvement wasshown and skin assess-

mentsofgrade1were observedfor allareas.

Ten patients

(62%) had

skin assessments

of grade2b at one ormore sitesonentryto

t he s t udy . Of these , seven showed no

change over the study period.Theremain-

ing three patients entering the study with

skin assessments

of

grade

2b

s h o w e d

improvement, with assessmentsof grade2a

for all areasat the end of thestudy.

Comfort

Patients w ere askedtoratethecomfort of the

cushions on entry to the study and at the end of

the study period, using

a

horizontal 1 cm

visual analogue scale, where 0 cm represented

very unconrfoitable aiid

1

cm indicated ver}'

comfortable. Tlie visual arilo gue scores ranged

from6.2 to9.7 (mean 7.84).Asimilar rangeof

scores was ob tainedforeach cushion type .

Additional descriptive information relat-

ingto thecomfortof thecushionswas col-

lected during

a

semi-structured interview

with each patient. This information

sup-

ported

the

visual analogue scores.

A

selec-

tion

of

quotations from these interviews

are shown below:

*The cushion

is

more comfortable than

the cha ir.' (Vaperm)

'The chair makes

my

back ache,

but the

cushion's very comfortable.' (Multitec)

'(The cushion)

has

more give than others

I've used.' (Supatec)

Nine patients were unable to complete

the visual analogue scale. Five patientshad

i m pa i r ed senso r y pe r cep t i on and four

were unable

to

understand

the

concept

of

the scale. However, none

of the

patients

indicated that the cushions were uncom-

fortable when mterviewed.

init ially seated, and theobservat ion was

repeated after 1hour . All patients wer

observed

to

maintam

a 90

angle

at the hip

and knee after

1

hourand feet remained f

on

the

floor

or

supported

by a

foot-block.

Discussion

The period prevalence

of

22.9

and

pres

sure sore incidenceof 2,6% are compara

ble to those found in previous s tudies

Prevalence studies that include the mobil

ity levels of the patients surveyed enabl

the calculation of group-specific rates.For

exam pl e , for pat i en t s who have ver

res t r i c t ed mobi l i ty

or are

c o m p l e t e l

immobile,

a

point prevalence

of

21.7

can

be calculated from

the

study reported

by

Barbenel

et al

(1977)

and a

period preva

lence of 36.5% from tha t r ep or t e d by

Waterlow (1988).

O n l y G ebha r d t and Bliss (1994) hav

studied the association between pressur

sore incidenceand sitting.In a randomised

control led t r ial of 57 postopera t iv

or thopaedic pat ients, Gebhardt and Blis

(1994) found thatthepressure sore incidenc

was 63 among patients

who

were allowe

unl imited chair nursing

and 7%

am on

patients

who

were restricted

to

2 hours cha

nursing

per

session. Three differences

in

research aims

and

methodology' account

for

the lower incidenceofthis study.

First, thefocus of the study conducte

b y G e b h a r d t and Bliss (1994) was to

establish whether prolonged chair nursing

was detrimental , whereas theprimaryaim

of this studywas to evaluatethe effective

ness of three pressure-reducing cushion

in relationtoskin response.

Second,the chairs used during this evalu

ation were selected by the ward nurses to

suit the dimensions of the patients.The

importance

of

chair dimensions

and

desig

has been highlightedbyGilsdorfetal (1991

who repor t ed tha t a rmres t s suppor ted

between5% and 9% of thebody weighto

spinal cord-injured subjects,and by Lowr

(1992, 1993)whodescribed theproblemso

poor posture

and

seating provision

in

rel

tion

to

pressure sore developm ent.

Third, following a review of the liter

ture, Bridel (1993a) identified the impo

tance of recognising skin redness (reactiv

hyperaemia)as aprecursortopressure so

development. Consequent ly,a keyemph

sis

of the St

Jaines 's Un iversi ty Hosp i t


8/9

A descriptive evaiuation

o

pressure reducing cushions

/ /isgenerally

accepted that

visual n logue

sc lesare of most

value wherescores

are obtained

pre- an d post-

intervention from

the same

individual

...and/or used in

combination with

a qualitative

description of

the given

experience...The

combination of

data collected in

this studyin

relationto

comfort llowsthe

generalconclusion

that the three

cushionswere

ccept bleand

comfortable to

patients.

The ward n urses role in the implementa-

tion of thepolicy is of impor tance in the

interpretation

of

the results

of

this evalua-

tion, as they were responsibleforprescrib-

ing all nursing care, including seating and

mai t r css provi s ion and r epos i t i on i ng

schedules.Theward nurse s response to

skin redness is demonstrated by the adjust-

ments madeto repositioning schedulesfor

18 pa t i en t s when sk in change s we re

obse r ved . N one of the 18pat ients were

observedtohave persistent skin cha nges.

The skin response toVap erm, Mu ltitec

and Supatec cushions is described. H owev er,

the results

are

limited

by the

fact t ha t

no

attempt was madetocompare the perfor-

manceofthe cushions with thatofa control.

As reposit ioning schedules were adjusted

accordingto skin response,thevariationin

repositioning times supports the conclusion

drawnbyBndel (1993a) that,at anmdivid-

ual patient level,theresponseof the skin to

pressure varies widely

and is

likely

to be

dependent upon anumberoffactors.The

individual natureof skin tolerance isalso

demonstrated by thedifferent outc om es in

terms of skin changes for these patients.

Comfon

is an

abstract, multidimensional

concept which is difficult to defineand

measure (Redfern, 1976). The useofvisual

analogue scales

as a

measure

of

pa t i en t s

subjective experiences were discussedby

Ghapmanetal (1985) and Mag uire (1984)in

relation to pain. These studies highhghted

problems

of

poor sensitivity associated with

treatment effects and difficulties in compari-

so nofscores berween grou ps.Itis generally

accepted that visual analogue scalesare of

most value where scoresareobtained pre-

and post-intervention from thesame indi-

vidual (Maguire, 1984) and/or usedincom-

bination with a qualitative descriptionofthe

given experience (Redfern, 1976). The com-

bination of data collected in this studyin

relationto comfort allowsthegeneral con-

clusion that the three cushions were accept-

able and com fortable to patients.

Thi sis thef irst rep ort of theeffectof

cushions upon the postureofpatients. Th e

observation undertaken simply described

the pos ture of thepat ient whi le on the

cush i on

and the

i n forma t ion genera ted

that initial sitting posture wasmaintained

for periodsofu pto1 hour .It does, there-

fore, provide useful data.

Th e data were limited, however, as a com -

chairs for a

1-hour

per iod) .Theprecis

effectof the cushions on posture is therefor

u n k n o w n .

For

example,

was

po s t u r e

th

sameorimproved on the cushion comp are

with thechair? In view of this l imitation

addi t ional work wi th a different patien

population iscurrently being plannedin a

attempt to achieve the original aim.

Conclusion

This evaluation has shown that, irrespectiv

of thetotal timethepatient spends sittin

per day, the Vaperm, Multitec

and

Supate

cushionscan be used effectively asparto

an overall pressure sore prevention stra

egy, when careis planned accordingto th

skin responseof the individual andat ten

tion is paidtothe overall seating situation.

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DG

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Documents

A Desriptive Evaluation of Pressure Reducing Cushions