VOL: 100, ISSUE: 20, PAGE NO: 77
Sinead Clarke-O’Neill, MSc, RN, is a research fellow, Department of Medicine, University College, London
The available evidence suggests that urine has a role in the development of pressure ulcers by over-hydration of the skin which leads to damage through a mixture of maceration, friction, and shearing forces (Zimmerer et al, 1986). Moisture on the skin is considered to be one of the extrinsic risk factors that may influence the development of pressure ulcers (RCN, 2001).
Maintenance of moisture-free skin is therefore an important issue for all individuals ‘at risk’ of pressure ulcers but it is particularly pertinent for those who also have continence problems. Absorbent pads are the principal method for managing incontinence and maintaining dry skin for those individuals with intractable incontinence. Yet very little is known about the interaction between these absorbent pads and pressure management products.
Pressure-relieving products and absorbent pads
A wide range of pressure management products is available and can be roughly divided into two categories: low-tech (static) incorporating standard foam mattresses and gel-filled mattresses; and high-tech (active) devices including alternating pressure and low-air-loss devices (Cullum et al, 2001).
The National Institute for Clinical Excellence guidelines (2003) underline the fact that the costs of prevention of pressure ulcers using pressure-relieving surfaces are high and that there is a need for robust evaluations to ensure that these devices are used appropriately and effectively.
However, there are some suggestions in the literature that absorbent pads have a negative impact on the efficacy of pressure management products. The RCN guidelines for pressure ulcer risk assessment and prevention (2001) advise practitioners that if the source of the moisture on the skin cannot be controlled then the use of moisture-absorbing continence aids could be considered. However, the guidelines then state that ‘the use of such aids should not interfere with any pressure redistributing surface an individual may be placed on’. There is no information given about the mechanism through which these aids do or do not interfere with the pressure-relieving surfaces.
The US clinical practice guidelines (Agency for Health Care Policy and Research, 1994) advise carers to follow the manufacturers’ guidelines when using air-fluidised and low-air-loss beds and avoid the use of adult incontinence briefs as they obstruct air-flow to the skin. However, the evidence for this recommendation is relatively low level (one randomised controlled trial or expert opinion) and no further details are given.
Some UK manufacturers of pressure management products recommend that patients lie or sit directly on the surface without the use of any product (such as a pad) in between. Again the research evidence for these guidelines is unclear.
As it is now recommended that any ‘at risk’ individual should be placed on an alternative to a standard foam mattress (RCN, 2001), the numbers of patients that will potentially be using both absorbent pads and pressure management mattresses is set to increase.
Impact on nursing care
Nurses caring for an individual with heavy incontinence have very few alternatives to an absorbent pad as a method for managing the condition (and hence maintaining moisture-free skin). We do not know to what extent nurses are aware of the guidelines that advise the avoidance of pads when using pressure-relieving devices. Furthermore, it is unknown which alternative continence products nurses opt to use if they do follow the guidelines. Nurses need further clarification of these guidelines in order to make informed decisions about optimal continence and pressure management care.
Establishing an evidence base
There is some evidence that absorbent pads do have a substantial adverse effect on the pressure redistribution properties of pressure management products. Fader (2003) used an instrumented articulated anthropometric phantom to measure the effects of absorbent incontinence pads on pressure management systems. The phantom had simulated soft body ‘tissues’ in the gluteal and sacral areas to measure the peak pressures over its sacral and ischial areas.
The results showed that there were substantial and significant differences in recorded peak pressures between naked buttocks and buttocks wearing a dry pad on three different pressure management mattresses (standard foam, visco-elastic foam, and surface-cut visco-elastic foam). These results are noteworthy but this was an exploratory study carried out using a limited range of pads from one manufacturer on low-tech pressure management products.
Further investigation of a wider range of pads and pressure management products is needed in order to establish whether the results are similar for all types of absorbent pads and a range of commonly used pressure management products. These issues will be addressed in the upcoming project by:
- Carrying out an in-depth review of the literature in the area of both tissue viability and incontinence to examine and explore the relationship between the two separate areas.
- Conducting a telephone survey of nurses to identify and explore current nursing practices and levels of awareness concerning guidelines related to the use of pressure-redistributing surfaces and absorbent continence products.
- Using an anthropometric phantom (Fig 1) to carry out laboratory testing of a wide range of pad types, designs, features, and materials. This will enable identification of the differences between the products in terms of the effects that they have on the pressure-relieving properties of commonly used pressure management surfaces.
- Examining a range of different pressure management mattresses, both static and active, to identify the effect that a reference group of pads have on their pressure relieving/distributing properties. Through this process an optimum pad will be identified.
- Carrying out a feasibility study of an optimum pad versus a standard pad in a clinical setting. This study will compare a pad identified as having features/ materials least likely to affect interface pressures with a standard pad that does not have these properties.
This approach will enable clarification of the current available evidence related to the use of absorbent pads and pressure management products. It will also describe what is currently occurring in clinical practice when a nurse is caring for a patient using both an absorbent pad and a pressure management mattress.
The in-depth laboratory testing will identify absorbent pads or features of absorbent pads that have the least disruptive effect on pressure management products. If successful, this will enable the development of absorbent products that are designed and recommended for use with specific pressure management products.