Management of night-time urinary incontinence in residential settings for older people: an investigation into the effects of different pad changing regimes on skin health

Absorbent pads are the main method of managing urinary incontinence in residential settings for older people. Improvements in technology have resulted in highly absorbent products which may be worn all night, but the effects of prolonged pad wearing on aged skin are unknown. The aim of this study was to examine the effects of two different pad changing regimes on skin health. A cross-over design was used. Subjects from residential settings were randomly allocated to one of two pad changing regimes: a frequent pad changing regime or a less frequent pad changing regime. Each regime lasted 4 weeks and was followed by the alternative regime. Skin measurements were taken twice during each regime using (i) the Diastron Erythema meter, (ii) a visual grading scale, (iii) the Servomed evaporimeter, and (iv) a pH meter. The primary outcome variable was the Diastron Erythema meter index. Eighty-one subjects completed the study. No significant differences were found in the severity of erythema, or skin pH, between regimes. Measurements of trans-epidermal water loss were significantly higher in the less frequent pad changing regime indicating that skin was 'wetter' (P = 0.01; 95% CI: 2.89-21.39). Five subjects developed grade 2 pressure ulcers (abrasions) during the less frequent pad changing regime, but none in the frequent pad changing regime; this result was not significant (P = 0.1; 95% CI: 0-1.09). No evidence was found that a less frequent pad changing regime has an effect on skin erythema or pH. There is evidence that skin is wetter which may make it more vulnerable to friction and abrasion. The statistically non-significant finding of greater incidence of grade 2 pressure ulcers is a cause for concern and merits further investigation because of the clinical significance of loss of skin integrity.     

Exploring the relationship between skin property and absorbent pad environment

Aim. The aim of this study is to identify the related factors of skin lesions found in the surrounding environment of absorbent pads by clinical investigation. Background. Most older patients with incontinence use absorbent products, therefore causing many patients to have skin lesion in the absorbent pad area. To prevent these skin lesions from occurring, it is necessary to examine the absorbent pad environment of clinical patients since there are many contributing factors that complicate the pathophysiology in this area. Design. A cross‐sectional design was used. Methods. One hundred older Japanese patients with faecal and/or urinary incontinence using diapers and absorbent pads participated. Excluding blanchable erythema, the presence of skin lesions in the absorbent pad area was confirmed. Skin pH, hydration level and bacterial cultures were used to assess the skin property. Absorbent pad environment and patient demographics were also investigated. Results. The overall prevalence of skin lesions was 36%. Forty percent of the skin lesions were contact dermatitis. Multivariate logistic regression analysis revealed that only the presence of diarrhoea independently affected contact dermatitis. Conclusion. There was a significant relationship between contact dermatitis and the use of absorbent pads when the patient had diarrhoea. Although the factors related to skin lesions in the absorbent pad area are complexly intertwined, this study was the first to be able to determine diarrhoea as one specific factor in clinical setting. Relevance to clinical practice. This finding suggests that the presence of diarrhoea is significantly related with contact dermatitis. Therefore, when a patient has diarrhoea, health‐care professionals should immediately implement a preventative care program which includes careful skin observation and improved skin care. It is also necessary to develop a more effective absorbent pad to protect the skin of incontinent patients who suffer from the irritating effects of liquid stool.     

Absorbent products for incontinence: 'treatment effects' and impact on quality of life

Abstract Aim. This study aimed to determine how the use and characteristics of absorbent products for incontinence impact on women's quality of life, and to examine the concept of ‘treatment effects’ in the context of pad use. Method. Key pad performance characteristics were identified from the literature and focus group work. Semi‐structured interviews with 99 women with light incontinence were used to investigate the impact of pad use on women's quality of life, including both positive and negative ‘treatment effects’, and to rank pad characteristics by their importance. Results. Achieving effective and discrete containment of urine was the dominant factor impacting on women's lives. Sub‐themes embraced physical effects, psychological impact and social functioning. The five pad characteristics ranked most important for day time use were: ‘to hold urine, to contain smell, to stay in place, discreteness, and comfort when wet. For night use discreteness was replaced by to keep skin dry’. High levels of reported anxiety were associated with perceived risk of poor pad performance, lack of discreteness and need for complex regimes for pad management. Conclusion. Insufficient attention has been paid to the balance between the beneficial and negative treatment effects of absorbent pads to date. Existing continence‐related quality of life measures are not designed for conditions where change in symptoms is not an outcome measure. The study findings provide the basis for developing a more sensitive, patient‐oriented, quality of life measure for pad‐users which can aid product selection, new product development and inform future evaluative comparisons between products/products and treatments. Relevance to clinical practice. This paper illustrates the complex influence on quality of life caused by using absorbent pads to contain incontinence. It raises awareness of the importance of careful selection of the most appropriate pad for each individual to minimize unfavourable side effects, and the need for a new quality of life measure designed for pad‐users.     

Optimum position of metatarsal pad in metatarsalgia for pressure relief

OBJECTIVES: To determine the optimum position of a metatarsal (MT) pad to treat metatarsalgia. DESIGN: We used a sensing mat with 16 x 16 sensors, 4.4 x 4.4 mm each, to measure plantar pressure in ten metatarsalgia patients walking with an MT pad in various positions. Peak pressures of the MT head and MT pad were analyzed. RESULTS: Walking without MT pads, the peak pressure of the MT head was 678 +/- 227 and 687 +/- 228 kPa in one proximal and one distal row of three sensors. Placement of the MT pad resulting in peak pressure two sensors proximal to the peak pressure of the MT head did not significantly reduce peak pressure on the MT head. In contrast, placement of the MT pad resulting in peak pressure just proximal to the peak pressures of the MT head reduced the proximal and distal peak pressures on the MT head to 427 +/- 97 and 431 +/- 92 kPa (P < 0.05). CONCLUSIONS: Optimum pressure reduction on the MT head is attained when the peak pressure generated by the MT pad is just proximal to the MT head.     

Collection and quantification of urine during anesthesia in small animals.

This note describes a simple method for collecting urine and quantification of urine production during anesthesia in small animals. It offers two advantages, especially important for procedures requiring lengthy anesthesia: 1) The animals are kept dry, and 2) fluid balance can be maintained more accurately. The method, which we have applied to rats, is to rest the animal on an absorbent pad of known weight and to weigh the pad after urine has been collected. The note describes the performance characteristics of a preferred pad type and contrasts them with those of other readily available types of absorbent pads. The preferred pad keeps the animal dry while facilitating quantification of urine production, a refinement of animal use.     

Effects of using a high-density foam pad versus a viscoelastic polymer pad on the incidence of pressure ulcer development during spinal surgery

The purpose of this study was to evaluate the effect of high-density foam (HDF) pads versus viscoelastic polymer (VP) pads in the prevention of pressure ulcer formation during spinal surgery and their cost-effectiveness. Subjects were 30 patients who underwent spinal surgery for more than 3 hr in a prone position. One side of the chest and iliac crest was padded with HDF pads and the other side was padded with VP pads. An Xsensor? pressure measuring sheet was placed between the pad and the patient. Bilateral chest and iliac crest points were observed for the presence of pressure ulcers at 30 min after the operation. Results showed that a pressure ulcer had occurred at 9 of 120 compression points (7.5% of the total), 30 min after the operation. Risk evaluation showed that female gender, weight <50 kg, and body mass index (BMI) <18 kg/m(2) as well as location (the iliac crest) were all risk factors for development of pressure ulcers. The most significant factor was BMI <18 kg/m(2). The average and peak pressures measured at the points padded with the VP pads were significantly lower than those padded with the HDF pads. However, there was no significant difference between the VP and the HDF pads regarding ulcer prevention. Because the cost of a VP pad is 250 times greater than that of an HDF pad of similar size, the VP pad should only be considered for use in high-risk patients.     

How to choose: nurses' judgements of the effectiveness of a range of currently marketed continence aids

• ? Continence is a costly health problem, both in terms of financial burden in continence aids, but also in terms of quality-of-life issues for the person who has continence problems.
• ? Manufacturers arc often perturbed as to why products specially designed to help continence problems are not popular, or do not appear to be applied as intended.
• ? This paper reports on a study involving a quantitative evaluation of a range of continence aids presently being marketed, as applied in a large elderly care centre.
• ? The evaluation used nursing judgements on a series of comfort and effectiveness criteria: amount of leakage around the pad, comfort to the client when the pad was cither wet or dry, skin integrity and snugness of fit, as well as whether the pad concealed well beneath clothing.
• ? Five body pads were evaluated two disposable and three washable and three bed wider-sheets.
• ? Effectiveness of pads was found to vary substantially according to sex of client and voiding type, that is whether the client had heavy or moderate incontinent episodes.

     

Evaluation of a simple approach to modify the supporting property of seating foam cushion for pressure relief

To provide pressure relief at the high pressure areas of the buttocks, small holes were drilled on the polyurethane (PU) foam cushion under the ischial tuberosities areas. This modification was done to locally lower the supporting property of the cushion. This approach could be easily implemented in the clinical setting. Measurements of interfacial pressures at the ischial tuberosities on such modified cushions for eight nondisabled subjects showed an average pressure 25% lower than those measured on foam cushions without modification (p < 0.01). The maximum pressure was 30% lower after modification (p < 0.01) The peak pressure gradient also showed a 38% decrease on modified foam compared to those measured on unmodified foam cushions (p < 0.01). Simple hole drilling could potentially provide an effective approach to enhance the pressure-relief characteristics of foam cushions.     

The prevalence of pressure sores within an area health authority

A point prevalence survey carried out to determine the number of pressure sores within the Nottingham Health Authority revealed that 5.3% patients were affected (132 patients out of 2513). The majority of patients were elderly (80.3% aged over 65), female (76.5%), and either categorized as immobile or having very limited mobility (77.2%). There were 233 pressure sores, 54.9% of which were on the buttocks or sacrum, and 24.9% of which were on or near the heels and ankles. Nine different cleansing agents were in use, 31 different preparations were applied to the sores and nine types of dressings were employed, with little standardization of use. The most popular aids used for the relief of pressure areas included synthetic sheepskin pads (supplied to 46.2% of the affected patients) and ripple mattresses (supplied to 28.8% of the affected patients). The prevalence of pressure sores within the health authority is indicated. These findings are similar to those of a previous study and may be applicable to other health areas.     

A Phantom-Based Method to Assess X-Ray Table Mattress Interface Pressures

BackgroundPressure redistribution performance of x-ray table mattresses can influence the development of pressure ulcers in at-risk populations. Interface pressure analysis, with human participants, is a common method to assess mattresses. This approach has limitations that relate to the lack of standardisation between and within humans.AimThis study aimed to develop and validate an anthropomorphic phantom-based method to assess x-ray table mattress interface pressures as an index of mattress performance.MethodsA three dimensional phantom simulating an adult’s head, pelvis, and heels was printed from x-ray computed tomography image data and attached to a metal frame 175 cm in length. Dry sand was added to the phantom head, pelvis, and heels to represent a range of human weights. Pressure distribution was assessed using XSensor. Phantom validation was achieved by comparing phantom mattress interface pressure characteristics, for five human equivalent weights, against 27 sets of human mattress interface pressure data.ResultsUsing the correlation coefficient R, phantom and human pressure data showed good correlation for the five phantom weights (R values: head = 0.993, pelvis = 0.997, and heels = 0.996).ConclusionA novel method to test x-ray mattresses for interface pressure was developed and validated. The method could have utility in the testing of x-ray mattresses that are in routine use and for new mattress development. Phantom interface pressure data could be provided by manufacturers to help inform procurement decisions when matching mattress characteristics to medical imaging demands and the underlying patient populations.     

Disposable pull-ups versus disposable nappies for children with a disability

Most children are expected to be dry by the age of three years (Lukeman, 1997). However, children with physical and/or learning disabilities may have difficulty achieving continence and will have an ongoing need for absorbent products. Historically these were disposable nappies. In recent years, the disposable pull-up style pad (Fig 1) has proved popular as an alternative design.     

Longitudinal study evaluating a seating system using a sacral pad and kneeblock for children with cerebral palsy

Purpose. Adaptive seating systems using sacral pads and kneeblocks are commonly used throughout the UK with children with complex motor disorders to improve their posture and stability in sitting. We sought to evaluate how effective these systems are for a group of children with cerebral palsy.

Method. A six-visit trial was performed to examine whether this combination controls pelvic and hip positioning. Twenty-three children with cerebral palsy aged 7 - 14 years participated (11 females and 12 males). The kneeblocks (active intervention) were removed for a period in the middle of the trial. Force exerted through the kneeblock, pressure exerted on the sacral pad and postural alignment was measured for change.

Results. Statistically significant differences before and after kneeblock removal were found for force at the kneeblock, but no difference was found in pressure at the sacral pad. No statistically significant correlations between force and pressure or posture were found.

Conclusion. The results indicate that seating systems using a sacral pad and kneeblock may not improve overall posture but may improve hip position in children with cerebral palsy.     

Supine interface pressure in children

The effectiveness of using 2-inch and 4-inch convoluted foam overlays to protect children from developing pressure sores was investigated in 13 healthy children ranging in age from ten weeks to 13.5 years. Interface pressures were measured under the occipital, sacral, and scapular areas of children as they lay on a standard mattress, then on 2-inch and 4-inch foam overlays. The differences in pressures between the occiput and scapula, occiput and sacrum, and scapula and sacrum were significant (p less than .001), with the highest pressures recorded under the occipital area. Occipital pressures decreased from 45.7mmHg on the standard mattress to 22.3mmHg on the 4-inch overlay in ages 0 to 2, 54.3mmHg to 30.5mmHg in ages 2 to 10, and 78.0mmHg to 42.4mmHg in ages 10 to 14. Sacral pressures were highest in older and larger children, increasing from 17mm Hg in ages 0 to 2 to 34mmHg in ages 10 to 14, and when body surface area was greater than 1m2. These results indicate that the site of greatest pressure changes with increasing age from the occipital area to the sacral area. Therefore, different pressure relief considerations are necessary in treating pediatric patients than in managing pressure under adults.     

Reduction of sitting pressures with custom contoured cushions

Previous research indicated that matching a cushion to the shape of the buttocks results in less tissue distortion and lower interface pressures. A system was developed to measure body contours and fabricate a cushion to match the measured contour. This project fabricated contoured foam cushions for 11 persons with spinal cord lesions (C5-L3). Mean pressures were compared on two flat and two contoured foams with different degrees of stiffness. Deflection characteristics on flat foam were compared to deflection on contoured foam in order to analyze loading differences. Material studies were determined by examining the load-deflection curves for flat foams of 1-, 2-, and 3-inch thicknesses. It was found that sitting on contoured foam resulted in a lower pressure distribution than sitting on flat foam (p less than 0.05), and sitting on a soft foam (ILD = 45) resulted in a lower pressure distribution than sitting on a stiffer foam (ILD = 55) (p less than 0.05). Results of the deflection measurements and compression tests were used to explain the loading differences at the seat interface of flat and contoured cushions. Loaded contoured foam demonstrated increased enveloping of the buttocks, decreased foam compression, and a more uniform pressure distribution. These attributes are typical of a safer sitting surface and may indicate less tissue distortion.     

Longitudinal study evaluating a seating system using a sacral pad and kneeblock for children with cerebral palsy

Purpose. Adaptive seating systems using sacral pads and kneeblocks are commonly used throughout the UK with children with complex motor disorders to improve their posture and stability in sitting. We sought to evaluate how effective these systems are for a group of children with cerebral palsy.

Method. A six-visit trial was performed to examine whether this combination controls pelvic and hip positioning. Twenty-three children with cerebral palsy aged 7 – 14 years participated (11 females and 12 males). The kneeblocks (active intervention) were removed for a period in the middle of the trial. Force exerted through the kneeblock, pressure exerted on the sacral pad and postural alignment was measured for change.

Results. Statistically significant differences before and after kneeblock removal were found for force at the kneeblock, but no difference was found in pressure at the sacral pad. No statistically significant correlations between force and pressure or posture were found.

Conclusion. The results indicate that seating systems using a sacral pad and kneeblock may not improve overall posture but may improve hip position in children with cerebral palsy.     

Urinary incontinence: a vibration alert system for detecting pad overflow

A sensor and electronics system is described that monitors the leakage of urine from continence pads into surrounding underwear. Urinary incontinence is involuntary loss of urine and occurs when the bladder muscles contract without warning or the sphincter muscles surrounding the urethra are too weak to prevent leakage. The system comprises a wetness sensor and electronics unit. The sensor is stitched into the underwear and detects overspills of urine from the pad. The electronics unit is attached to the underwear and responds by vibrating, signaling to the wearer that pad has failed. This system has application for individuals who use continence pads in the community, but it could also be used in care homes.     

The relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users

OBJECTIVE: To investigate the relation between pressure ulcer incidence and buttock-wheelchair seat cushion interface pressure measurements. DESIGN: Secondary analysis of data from a randomized clinical trial. SETTING: Skilled nursing facility. PATIENTS: Thirty-two elderly patients (age, > or = 65 yr), with Braden score < or = 18 and Braden mobility and activity subscale score < or = 5, who used wheelchairs > or = 6 hr/d, were free of existing sitting-induced pressure ulcers, and weighed < or = 250 lb. INTERVENTIONS: Generic foam seat cushion or pressure-reducing seat cushion. MAIN OUTCOME MEASURES: The incidence of sitting-induced pressure ulcers over a 1- to 12-month period was compared with pressure measured between patients' buttocks and wheelchair seat cushions. A flexible pad with a 15 x 15 pressure sensor array was used to measure interface pressure. RESULTS: Interface pressure measured on wheelchair seat cushions was higher (p < or = .01 for both peak pressure and average of highest 4 pressures) for patients who developed sitting-acquired pressure ulcers compared with those patients who did not. CONCLUSIONS: Results indicated that higher interface pressure measurements are associated with a higher incidence of sitting-acquired pressure ulcers for high-risk elderly people who use wheelchairs.     

Preventing pressure ulcers: an evaluation of four operating-table mattresses.

Pressure is a major factor in the development of pressure ulcers. This research focused on assessing the pressure-reducing effects of operating-table mattresses. Five mattresses were tested: a standard operating-table mattress, a foam mattress, a gel mattress, a visco-elastic polyether mattress, and a visco-elastic polyurethane mattress. Four intraoperative postures were evaluated: supine, lateral, fossa, and the Miles-Pauchet position. Interface pressure measurements were performed on 36 healthy volunteers. The foam mattress and the gel mattress seem to have little or no pressure-reducing effect; the polyurethane mattress and the polyether mattress reduce interface pressure significantly better (p < .001); but none of the mattresses reduce pressure sufficiently to prevent the occurrence of pressure ulcers.     

Reducing the leakage of body-worn incontinence pads

The aim of this research was to evaluate the effect of various absorbent materials (fluff pulp and superabsorbent) on the leakage performance of incontinence pads. A shaped pad-and-pant system was used as the basic design and four pad types made to different specifications were compared using a double-blind technique. Forty-five elderly hospital residents who were incontinent of urine used all four pad types in a randomly allocated order. Data were recorded on more than 5000 pads over a 2-month period. Leakage was reduced by adding a second layer of fluff pulp and, whilst the addition of a superabsorbent material tended to reduce leakage further, we found no clear relationship between the amount of superabsorbent and the reduction of leakage. Other data indicated the importance of securing the pad in place with the appropriate net pants and the leakage rates of pads in relation to the amount of urine they contained. This research suggests that superabsorbent materials have great potential for reducing the leakage rate of incontinence pads but that the way in which they are incorporated into the pad, the amount of fluff pulp and the design of the pad also play an important part.     

Attends Slip with S-form: a new design of an all-in-one product

Disposable absorbent containment products (continence pads) should only be used after a thorough assessment of the client's needs with regard to preference, independence, comfort and security. This article offers a list of criteria that can be used to examine the quality of products. It then looks at a new product using this criteria.