THE EFFECTS OF THE THIRTY-DEGREE TILT POSITION ON THE SHAPE OF PRESSURE ULCERS
Atsuko Kitagawa, Hiromi Sanada, Junko Sugama, Chizuko Konya and Mayumi Okuwa
School of Health Sciences, Faculty of Medicine, Kanazawa University, Japan

Introduction

In Japan, the 30-degree tilt position has been recommended as a technique for preventing and curing pressure ulcers since it avoids compression or friction on some particular sites on the body’s surface. However, it has been observed that this positioning sometimes leads to the exacerbation of pressure ulcers. This suggests that a change in body position can affect the shape of pressure ulcers. In this study, we examined the shape of pressure ulcers in relationship to changes in body position.

Method:

The subjects of this study were nine patients with pressure ulcers who gave informed consent to the study. Four patients had pressure ulcers in the coccyx region, three patients in the sacral region, and one patient in the posterior iliac region. Undermining had formed in six of the patients. According to NPUAP classification, two patients were Stage II, one patient was Stage III, and six patients were Stage IV.

Procedure:

The subjects were oriented in the 90-degree lateral position; we traced the wound’s visible perimeter as well as outlined the undermining area around the wound. We then transferred the tracing to a clear overhead projector sheet. Next, the subjects were oriented in the 30-degree tilt position; and repeated the same procedure. Changes in the surrounding skin, the wound’s surface area, shape, amount of dislocation (in the wound and undermining area) of the pressure ulcers were compared between the two positions. The differences were tested using the Mann-Whitney test.

Results:

Four of the nine patients showed a change in pressure ulcers shape, and compression at the wound edges. There was a significantly greater dislocation along the transverse plane (the amount of dislocation from the bilateral iliac bone side towards the wound edge) when these four patients assumed the 30-degree tilt position (P = 0.03) and a significantly smaller ratio of the cranial side and the distal side length of circumference of the wound (P = 0.03 and 0.04). Undermining dislocation was 6.87 mm for the patients with changes in wound shape and 1.45 mm for the patients who had no changes in wound shape.

Summary:

Compression of the wounds during the 30-degree tilt position attributes considerable changes in wound shape from the bilateral iliac bone sides towards the wound edge. This is probably an outcome of the pressure which pushed the buttock skin from the bed plane in the direction of the ceiling. In addition, the characteristically loose skin on the buttocks of elderly Japanese subjects probably leads the wound to close. The amount of undermining dislocation observed during the 30-degree tilt position is thought to delay the healing process due to the inability of granulation tissue to form. These results suggest that the 30-degree tilt position has limitations and is not recommended as a technique for orienting the bodies of patients who have pressure and loose buttock skin.

A CROSSOVER STUDY EVALUATING AN ADHESIVE FOAM DRESSING FOR HEEL ULCERS
Palsberg, I. 3, López-Jiménez E.1, Romero S.2, Hahn T.W.3
1 Hospital Universitario Reina Sofía, Córdoba, Spain.
2 Hospitales Universitarios Virgen del Rocío, Centro RNAL.Oncológico Duque del Infantado, Sevilla, Spain.
3 Coloplast A/S, Humlebaek, Denmark

Introduction:
Pressure ulcers are a significant health problem with at least 1.7 million people developing ulcers annually. Heel ulcers are difficult to dress with ordinarily shaped foam dressings. Two types of anatomically shaped dressings for moist wound healing of the heel are available on the market: Biatain Heel Dressing (Coloplast A/S) and Allevyn® Heel (Smith & Nephew). The two dressings are indicated for use in moderately to highly exuding ulcers.

The purpose of this study was to investigate the two dressings in relation to cost-in-use, health related quality of life (HRQoL) and patient/investigator preference in patients with stage 2 or 3 heel pressure ulcers.

Methods:

12 patients were included in this open, block-randomized, prospective, crossover study. At inclusion more than 50 % of the ulcer area was covered with granulation tissue. Each patient was treated with both dressings, i.e. the type of dressings was consecutively switched at each dressing change to avoid bias in exudates levels. Data was recorded on 10 dressing changes per patient.

Results:

73% of the patients preferred to use Biatain Heel Dressing and the investigator preferred Biatain Heel Dressing in 64% of the cases. Patients considered Biatain Heel Dressing to have a positive influence on wound pain in 88% of the cases; no negative influence was reported. In 98 % of the cases patients experienced no or mild pain during dressing application when using Biatain Heel Dressing.

Exudate handling capacity and pressure relieving effect were good for both dressings. Patients regarded the odour controlling ability of Biatain Heel Dressing to be superior to that of Allevyn® Heel.

The mean wear-time was 63.5 hrs for Biatain Heel Dressing and 57.1 hrs for Allevyn® Heel. Preliminary cost-in-use results estimate direct cost of treatment to _ 30.4 and _33.4 per week for Biatain Heel Dressing and Allevyn® Heel, respectively.

Summary:

The results indicate that both dressings perform well, however, both the majority of patients and health care professionals preferred to use Biatain Heel Dressing. Results on wear-time and the dressings’ apparent influence on pain may support this. Final study results are under preparation and will be presented.

NURSES’ PERCEPTIONS IN ASSESSMENT OF PRESSURE ULCER
Carina Bååth RN (doctoral student), Mona Wentzel RN (doctoral student), Marie-Louise Hall-Lord PhD, Bodil Wilde Larsson (Ass Prof.)
Karlstads University, Division for Health and Caring Sciences, Karlstad, Sweden. carina.baath@kau.se

Introduction:

Pressure ulcers are common in many healthcare settings. As most pressure ulcers could be prevented it is important to have prevention and educational strategies. EPUAP guidelines stress that risk assessment tool should be complementary to clinical judgement of pressure ulcers.

The aim of the study was to examine nurses’ perceptions of assessment of pressure ulcer, to what extent assessment tools are used and nurses’ perceptions regarding tools.

Method:

Data were collected with the use of questionnaire distributed to 89 nurses in communities (response rate 71%) and 116 nurses in three hospitals (response rate 65%), all in one county in Sweden.

Result:

An assessment in order to identify patients at risk for pressure ulcers was always made by 43% and occasionally by 56%. Less than one third of the nurses knew about assessment tools and very few used them. Perceived advantages with assessment tools were early discovery of risk patients and early interventions.They also supported nurses in carrying out a uniform assessment. Disadvantages mentioned were that they could be misleading and time-consuming. Regarding patients at risk nurses usually document the location of the pressure ulcers (99%), intact skin (58%) and patients’ perception of pressure ulcer 33%. More than half of the nurses (54%) said that there were no written guidelines.

Summary:

The findings of the study indicate that nurses do not always have a systematic, evidence based approach in pressure ulcer assessment. Even though assessment tools are rarely used, nurses could identify important advantages in using them in clinical care.

WHAT TYPES OF INSTITUTIONS SHOULD PARTICULARLY IMPROVE PRESSURE ULCER CARE IN LONG-TERM INSTITUTIONAL CARE (LTIC), IN FINLAND
U. Harriet Finne-Soveri, MD. PhD, senior researcher, STAKES, Anja Noro, PhD, senior researcher, STAKES,
PO Box 220 FIN-00531 Helsinki, Finland
e-mail: harriet.finne-soveri@stakes.fi

Pressure ulcers (PU) are an unwanted but persistent condition in long-term institutional care (LTIC) for the elderly. Prevalence of sores vary from 3 – 35 % depending on definition and time of assessment in relation to length of stay. In Finland, a voluntary collaborative project to implement Resident Assessment Instrument (RAI) in LTIC was launched in 2000. The aim of the project was to improve quality of care through individual care-planning, set national thresholds for quality of care and compare outcomes at ward level using internet. In 2002, nineteen communities with more than 200 wards participated. Assessments of 5456 individuals, mean age 82 years and females 74 %, were performed semi-annually. The sample comprised appr. 17% of the LTIC residents in Finland. All types of institutions participated. Prevalence for grade 1–4 pressure ulcers was determined in order to find out what types of institutions should most improve their performance in preventing and managing pressure ulcers.

Data collecting method was Minimum Data Set 2,0 (copyright interRAI). Statistical methods were chisquare for dichotomic and test for continuous variables. Logistic regression analysis for those variables significantly associated with PU was performed

Results:

PU were most often found in hospital based LTC caring residents with highest functional dependency, in nursing homes with medium functional dependency, the occurrence of PU was 9,9 % whereas in assisted living with lightest case-mix the corresponding figure was 7. Final regression analysis showed that diagnoses often seen in relation with PU stayed significant: Diabetes Mellitus (OR 1,33 95% CI 1,03–1,73), deep vein thrombosis (OR 1,89 95% CI 1,01–3,52) peripheral arterial disease (OR 2,18 95% CI 1,45–3,28) paraplegia (OR 10,2 95% CI 3,40–30,5) pneumonia (OR 3,43 95% CI 1,80–6,52). Increasing pain (OR 1,45 95% CI 1,29–1,63) together with increasing dependency (ADL=6, scale 0–6, where 6 = total dependency: OR 4,2 95% CI 2,09–8,50) were also associated with PU, whereas grades of dementia remained insignificant. Compared to hospital-based institutions, nursing-homes showed increased risk for PU (OR 1,39 95% CI 1,11–1,73) whereas assisted living remained not significant.

Summary:

The results demonstrate the particular need for nursing-homes, with medium-dependency residents, to focus on recognising and managing pressure ulcers.