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Abstract Aims and objectives To measure the prevalence and severity of dry skin in the home care nursing setting in Germany and to determine demographic and health characteristics associated with skin dryness. Background Advanced age and skin care dependency are risk factors for the development of skin dryness. Dry skin has a negative impact on the quality of life and increases the risk for secondary cutaneous infections and other adverse skin conditions. The prevalence of dry skin in home care is unknown. Design A representative multicenter prevalence study was conducted in home care services in Germany during July 2015. Methods A random selection of home care services and clients was performed. Nurses, who were instructed how to perform the data collection using standardized forms, performed data collection. Demographic, functional and health variables were documented and analyzed. Results More than half of all participating clients (n = 923; median age 83 years (range 21–104)) were affected by dry skin (51.7 (95% CI 48.5 to 54.9). The most often affected skin areas were the distal extremities. Males and immobile clients were more often affected than females and mobile clients. In the adjusted analysis pruritus and the presence of incontinence-associated dermatitis were most strongly associated with dry skin. Conclusion Dry skin occurs widely in home care and is strongly associated with pruritus. Fundamental skin care is an easy but powerful nursing intervention to treat this condition successfully. Preventive skin care strategies need to be implemented in the home care setting to improve skin health and integrity either by nurses and/or informal caregivers. Highlights • More than half of all home care clients are affected by skin dryness. • The most often affected skin areas are the distal extremities. • Pruritus, incontinence-associated dermatitis and immobility are strongly associated with the presence of dry skin. • Being skin care dependent seems to increase the risk for dry skin. • Health care professionals should especially pay attention to dry skin at the distal extremities. [ABSTRACT FROM AUTHOR]

Background Pressure Ulcers (PUs) are a severe form of skin and soft tissue lesions, caused by sustained deformation. PU development is complex and depends on different factors. Skin structure and function change during prolonged loading on PU predilection sites and surfaces being in direct contact with skin are likely to have an impact as well. Little is known about the influence of fabrics on skin function under pressure conditions. Objectives To investigate skin responses to sustained loading in a sitting position and possible differences between two fabrics. Methods Under controlled conditions 6 healthy females (median age 65.0 (61.0–67.8) years) followed a standardized immobilization protocol of a sitting position for 45 min on a spacer and on a cotton fabric. Before and after the loading period skin surface temperature, stratum corneum hydration, transepidermal water loss (TEWL), erythema, skin elasticity and ’relative elastic recovery‘ were measured at the gluteal areas. Results A 45 min sitting period caused increases of skin surface temperature and erythema independent of the fabric. Loading on spacer fabric showed a two times higher increase of TEWL compared to cotton. Stratum corneum hydration showed slight changes after loading, skin elasticity and ’relative elastic recovery’ remained stable. Conclusions Sitting on a hard surface causes skin barrier changes at the gluteal skin in terms of stratum corneum hydration and TEWL. These changes are influenced by the fabric which is in direct contact to the skin. There seems to be a dynamic interaction between skin and fabric properties especially in terms of temperature and humidity accumulation and transport. [ABSTRACT FROM AUTHOR]

In this perspective paper, we discuss clinical and biomechanical viewpoints on pressure injury (or pressure ulcer) prevention research. We have selected to focus on the case of prophylactic dressings for pressure injury prevention, and the background of the historical context of pressure injury research, as an exemplar to illuminate some of the good and not so good in current biomechanical and clinical research in the wound prevention and care arena. Investigators who are conducting medical or clinical research in academia, in medical settings or in industry to determine the efficacy of wound prevention and care products could benefit from applying some basic principles that are detailed in this paper, and that should leverage the research outcomes, thereby contributing to setting higher standards in the field. [ABSTRACT FROM AUTHOR]

Purpose Pressure ulcers are localized injuries to the skin or underlying tissues over a bony prominence, as a result of pressure, or pressure in combination with shear. Ultrasound imaging techniques are widely applied to detect and to investigate pressure ulcer pathogenesis and healing, but due to missing structural alterations, very early signs of tissue alterations are not detectable. Ultrasound elastography was proposed as a new method to measure very early signs of pressure ulcer development but this was not investigated in humans so far. The aim of this study was to investigate for the first time whether US elastography is able to measure potential changes in dermal and subcutaneous tissue stiffness during prolonged loading. Materials and methods An exploratory study including nine healthy volunteers (mean age 70.1 (SD 4.8) years) was conducted. Study participants were requested to follow a standardized lying protocol, consisting of two loading phases of 90 and 150 min in supine position on a standard hospital mattress. Three pressure ulcer predilection sites (lateral heel over the calcaneus, sacral, and upper back area) were measured using B-mode and elastographic ultrasound system at baseline – immediately, after 90 min, and after 150 min loading. Results Mean baseline shear wave velocities were highest in the heel skin (2.7 m/s) and lowest in the upper back skin (1.9 m/s) indicating that heel skin was stiffest. Also the subcutaneous soft tissue stiffness was highest for the heel (2.7 m/s) and lowest for the upper back region (1.3 m/s). After 90 and 150 min loading there was a mean stiffness increase of the skin layers and a pronounced stiffness decrease of subcutaneous heel and sacral tissues. Conclusions Continuous loading of skin and underlying subcutaneous soft tissues leads to dynamic changes of tissue stiffness which are considered to play key roles in pressure ulcer development. Superficial skin and deep tissues seem to react differently. Elastography is able to quantify the dynamic of skin and subcutaneous soft tissue stiffness changes non-invasively in vivo . Shear wave velocity might serve as a new parameter for quantifying pressure ulcer damage risk in superficial and deeper tissues prone to pressure ulcer development. [ABSTRACT FROM AUTHOR]

Background Severe illness, disability and immobility increase the risk of pressure ulcer development. Pressure ulcers are localized injuries to the skin and/or underlying tissue as a result of long enduring pressure and shear. Little is known about the role of the stratum corneum and the upper skin layers in superficial pressure ulcer development. Objectives To investigate possible effects of long enduring loading on the skin barrier function under clinical conditions at two pressure ulcer predilection sites. Methods Under controlled conditions 20 healthy females (mean age 69.9 (3.4) years) followed a standardized immobilization protocol of 90 and 150 min in supine position wearing hospital nightshirts on a standard hospital mattress. Before and immediately after the loading periods skin surface temperature, stratum corneum hydration, transepidermal water loss and erythema were measured at the sacral and heel skin. Results Prolonged loading caused increases of skin surface temperature and erythema at the sacral and heel skin. Stratum corneum hydration remained stable. Transepidermal water loss increased substantially after loading at the heel but not at the sacral skin. Conclusions Skin functions change during prolonged loading at the sacral and heel skin in aged individuals. Accumulation of heat and hyperaemia seem to be primarily responsible for increasing skin temperature and erythema which are associated with pressure ulcer development. Increased transepidermal water loss at the heels indicate subclinical damages of the stratum corneum at the heel but not at the sacral skin during loading indicating distinct pathways of pressure ulcer development at both skin areas. [ABSTRACT FROM AUTHOR]

BACKGROUND: Deep tissue injuries are severe damages underneath the intact skin caused by long-endured, unrelieved pressure or shear forces. Empirical evidence regarding the magnitude of this health problem is limited. OBJECTIVE: Investigation of the prevalence, characteristics of persons affected and identification of the most affected body locations. DESIGN: Two cross-sectional studies in 2008 and 2009. SETTINGS: Nursing homes and hospitals throughout Germany. PARTICIPANTS: 6919 (year 2008) and 8451 (year 2009) hospital patients and nursing home residents. METHODS: Trained nurses conducted full skin assessments and collected demographic data based on written data collection forms. The Braden scale was used to measure pressure ulcer risk. RESULTS: Pressure ulcer prevalence including grades 1-4 and deep tissue injuries ranged from 4.3% (95% CI 3.8-4.9) in nursing homes to 7.1% (95% CI 6.2-8.0) in hospitals. Point prevalence rates of deep tissue injuries were 0.4% (95% CI 0.2-0.5) in hospitals and less than 0.1% in nursing homes. In total, 30 persons were affected by 38 deep tissue injuries. The mean age was 73.4 and the mean Braden scale sum score was 12.8. The most frequently affected anatomic sites were heels (n=24) and ischial tuberosities (n=6). CONCLUSIONS: Nurses must be aware that deep tissue injuries exist in clinical practice. Deep tissue injuries seem to be more common in hospitals than in nursing homes and heels are more prone to this kind of injuries than other body sites. Whenever such a lesion is suspected, optimal pressure relief is required to enable the affected tissue to heal. [ABSTRACT FROM AUTHOR]

BACKGROUND: The application of standardized pressure ulcer risk assessment scales is recommended in clinical practice. OBJECTIVES: The aims of this study were to compare the interrater reliabilities of the Braden and Waterlow scores and subjective pressure ulcer risk assessment and to determine the construct validity of these three assessment approaches. DESIGN: Observational. SETTINGS: Two intensive care units of a large University Hospital in Germany. PARTICIPANTS: 21 and 24 patients were assessed by 53 nurses. Patients' mean age was 69.7 (SD 8.3) and 67.2 (SD 11.3). METHODS: Two interrater reliability studies were conducted. Samples of patients were assessed independently by a sample of three nurses. A 10-cm visual analogue scale was applied to measure subjective pressure ulcer risk rating. Intraclass correlation coefficients (ICC) and standard errors of measurement (SEM) were used to determine interrater reliability and agreement of the item and sum scores. Pearson product moment correlation coefficients (r) were used to indicate the degree and direction of the relationships between the measures. RESULTS: The interrater reliability for the subjective pressure ulcer risk assessment was ICC(1,1)=0.51 (95% CI 0.26-0.74) and 0.71 (95% CI 0.53-0.85). Interrater reliability of Braden scale sum scores was ICC(1,1)=0.72 (95% CI 0.52-0.87) and 0.84 (95% CI 0.72-0.92) and for Waterlow scale sum scores ICC(1,1)=0.36 (95% CI 0.09-0.63) and 0.51 (95% CI 0.27-0.72). The absolute degree of correlation between the measures ranged from 0.51 to 0.77. CONCLUSIONS: Interrater reliability coefficients indicate a high degree of measurement error inherent in the scores. Compared to subjective risk assessment and the Waterlow scale scores the Braden scale performed best. However, measurement error is too high to draw valid inferences for individuals. Less than 26-59% of variances in scores of one scale were determined by scores of another scale indicating that all three instruments only partly measured the same construct. The use of the Braden-, Waterlow- and Visual Analogue scales for measuring pressure ulcer risk of intensive care unit patients is not recommended. [ABSTRACT FROM AUTHOR]

BACKGROUND: Measurement error can seriously affect the validity of pressure ulcer risk assessment and of pressure ulcer classification. OBJECTIVES: Determination of interrater reliability and agreement of pressure ulcer risk and pressure ulcers using the Braden scale and the EPUAP system. DESIGN AND SETTING: Duplicate assessments by trained nurses during two nationwide pressure ulcer prevalence surveys in the years 2007 and 2008 in The Netherlands in the home care setting. PARTICIPANTS: Home care clients which participated in 2007 (n=352) and 2008 (n=339) in the pressure ulcer prevalence surveys. METHODS: The Braden scale was used to assess pressure ulcer risk. Skin examination was conducted to detect pressure related tissue damages and to classify them according to the EPUAP. RESULTS: In 2007 and 2008, Intraclass Correlation Coefficients for Braden scale sum scores were 0.90 (95% CI: 0.88-0.92) and 0.88 (95% CI: 0.85-0.91) respectively, and corresponding Standard Errors of Measurement were 1.00 and 0.98. 95% limits of agreement were -2.8 to 2.8 and -2.7 to 2.7 respectively. The items 'moisture', 'sensory perception' and 'nutrition' contained largest amounts of measurement error. Proportions of agreement for the classification of pressure ulcers were 96% and interrater reliability was 0.81 and 0.79. Most disagreements were observed for the classification of grade 1 pressure ulcers. CONCLUSIONS: The standardized study procedure applied in the annual nationwide pressure ulcer prevalence surveys leads to reliable and reproducible results regarding pressure ulcer risk and pressure ulcer prevalence in the home care setting. Researchers and practitioners should be careful when drawing inferences from single pressure ulcer risk factors included in the Braden scale. Descriptions of the items 'moisture', 'sensory perception' and 'nutrition' should be made more clearly and unambiguous. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Waterlow scale is one of the pressure ulcer risk assessment scales which are frequently criticised for their low reliability. It is widely used in the United Kingdom, Europe and all over the world. OBJECTIVES: The study objectives were to systematically review and evaluate inter- and intrarater reliability and/or agreement of the whole Waterlow scale and its single items. The overall aim was to find out if the Waterlow scale is applicable to daily clinical practice. DESIGN: Systematic review. DATA SOURCES: MEDLINE (1985-June 2008), EMBASE (1985-June 2008), CINAHL (1985-June 2008) and World Wide Web. REVIEW METHODS: Selections of relevant studies, data extractions, recalculations of reliability and agreement coefficients, and study quality assessments were independently conducted by two researchers. Designs, methods and results of relevant studies were systematically described, compared and interpreted. RESULTS: Eight research reports were identified containing the results of nine inter- and intrarater reliability and agreement studies. Only three studies were considered as high quality studies. The Waterlow scale in clinical practice was examined in four studies. Interrater agreement for the total score varied between 0% and 57%. Taking into account any differences of up to two points the total score agreement increased to up to 86%. Median ranges of differences among raters scoring single items were high for 'poor nutrition', 'skin type', and 'mobility'. Recalculated intrarater reliability for one researcher was ICC(2,1)=0.97 (95% C.I. 0.94-0.98). CONCLUSIONS: Empirical evidence is rare regarding reliability and agreement among nurses when using the Waterlow scale in clinical practice. Interrater agreement for the total score is comparable to other pressure ulcer risk assessment scales. The interrater reliability has never been examined. Therefore, evaluation of reliability and agreement and evaluation of the applicability of the Waterlow scale to clinical practice are limited. It is very likely that the items 'poor nutrition', 'mobility', and 'skin type' are the most difficult items to rate. [ABSTRACT FROM AUTHOR]

Background Maintaining and improving skin health of patients and long-term care receivers is a widely agreed upon goal in health and nursing care. Care dependent and aged persons have a high predisposition to develop dry skin conditions. Objectives The aim of this study was to estimate the prevalence and severity of skin dryness in hospitals and nursing homes and to identify person- and health-related variables associated with this skin condition. Design The study was part of a bigger annual multicentre descriptive cross-sectional prevalence study of health problems. Settings/participants Fourteen nursing homes and six hospitals in Germany participated in this study in 2014. A total of 1710 subjects ( n = 1091 long-term care residents and n = 619 in-patients) were included. Methods Skin assessments were conducted and skin dryness was measured using the Overall Dry Skin Score. Mobility was measured using the respective item of the Care Dependency Scale. Demographic, functional and physiological parameters were compared between subjects with and without dry skin. A logistic regression model predicting skin dryness was created. Results The prevalence of skin dryness was 48.8% (95% CI 46.5–51.2). Nursing home residents were most often affected (52.6%; 95% CI 49.6–55.6) compared to in-patients (42.2%; 95% CI 38.3–46.1). The skin of feet and legs were most often affected by skin dryness (42.9%) compared to other skin areas. Being older (OR 1.01; 95% CI 1.01–1.02), having pruritus (OR 14.21; 95% CI 8.00–22.95), oncological (OR 1.95; 95% CI 1.30–2.91), musculoskeletal diseases (OR 1.31; 95% CI 1.04–1.64), being skin care independent (OR 0.48; 95% CI 0.32–0.70) were the strongest covariates for the presence of dry skin in the multivariate model. Conclusions Based on a large sample results indicate that approximately every second nursing home resident and hospital in-patient are affected by dry skin. Severe forms occur more often in hospital in-patients compared to nursing home residents. Skin care interventions to tackle dry skin are recommended particularly for hospital patients and nursing home residents who are affected by pruritus or oncological diseases, who are in need of washing/bathing assistance, and who have musculoskeletal diseases. [ABSTRACT FROM AUTHOR]

Background: Nurses' clinical judgement plays a vital role in pressure ulcer risk assessment, but evidence is lacking which patient characteristics are important for nurses' perception of patients' risk exposure. Objectives: To explore which patient characteristics nurses employ when assessing pressure ulcer risk without use of a risk assessment scale. Design: Mixed methods design triangulating observational data from the control group of a quasi-experimental trial and data from semi-structured interviews with nurses. Setting: Two traumatological wards at a university hospital. Participants: Quantitative data: A consecutive sample of 106 patients matching the eligibility criteria (age≥18 years, no pressure ulcers category ≥2 at admission and ≥5 days expected length of stay). Qualitative data: A purposive sample of 16 nurses. Methods: Quantitative data: Predictor variables for pressure ulcer risk were measured by study assistants at the bedside each second day. Concurrently, nurses documented their clinical judgement on patients' pressure ulcer risk by means of a 4-step global judgement scale. Bivariate correlations between predictor variables and nurses' risk estimates were established. Qualitative data: In interviews, nurses were asked to assess fictitious patients' pressure ulcer risk and to justify their risk estimates. Patient characteristics perceived as relevant for nurses' judements were thematically clustered. Triangulation: Firstly, predictors of nurses' risk estimates identified in bivariate analysis were cross-mapped with interview findings. Secondly, three models to predict nurses' risk estimates underwent multiple linear regression analysis. Results: Nurses consider multiple patient characteristics for pressure ulcer risk assess- ment, but regard some conditions more important than others. Triangulation showed that these are measures reflecting patients' exposure to pressure or overall care dependency. Qualitative data furthermore indicate that nurses are likely to trade off risk-enhancing conditions against conditions perceived to be protective. Here, patients' mental capabilities like willingness to engage in one owns care seem to be particularly important. Due to missing information on these variables in the quantitative data, they could not be incorporated into triangulation. [ABSTRACT FROM AUTHOR]

For decades various pressure ulcer risk assessment scales (PURAS) have been developed and implemented into nursing practice despite uncertainty whether use of these tools helps to prevent pressure ulcers. According to current methodological standards, randomised controlled trials (RCTs) are required to conclusively determine the clinical efficacy and safety of this risk assessment strategy. In these trials, PURAS-aided risk assessment has to be compared to nurses' clinical judgment alone in terms of its impact on pressure ulcer incidence and adverse outcomes. However, RCTs evaluating diagnostic procedures are prone to specific risks of bias and threats to the statistical power which may challenge their validity and feasibility. This discussion paper critically reflects on the rigour and feasibility of experimental research needed to substantiate the clinical efficacy of PURAS-aided risk assessment. Based on reflections of the methodological literature, a critical appraisal of available trials on this subject and an analysis of a protocol developed for a methodologically robust cluster-RCT, this paper arrives at the following conclusions: First, available trials do not provide reliable estimates of the impact of PURAS-aided risk assessment on pressure ulcer incidence compared to nurses' clinical judgement alone due to serious risks of bias and insufficient sample size. Second, it seems infeasible to assess this impact by means of rigorous experimental studies since sample size would become extremely high if likely threats to validity and power are properly taken into account. Third, means of evidence linkages seem to currently be the most promising approaches for evaluating the clinical efficacy and safety of PURAS-aided risk assessment. With this kind of secondary research, the downstream effect of use of PURAS on pressure ulcer incidence could be modelled by combining best available evidence for single parts of this pathway. However, to yield reliable modelling results, more robust experimental research evaluating specific parts of the pressure ulcer risk assessment-prevention pathway is needed. [ABSTRACT FROM AUTHOR]

In aged nursing care receivers, the prevalence of adverse skin conditions such as xerosis cutis, intertrigo, pressure ulcers or skin tears is high. Adequate skin care strategies are an effective method for maintaining and enhancing skin health and integrity in this population. The objective was to summarize the empirical evidence about the effects and effectiveness of non-drug topical skin care interventions to promote and to maintain skin integrity and skin barrier function in the aged, to identify outcome domains and outcome measurement instruments in this field. An update of a previous systematic review published in 2013 was conducted. Databases MEDLINE and EMBASE via OvidSP and CINAHL (original search January 1990 to August 2012, update September 2012 to May 2018) and reference lists were searched. Forward searches in Web of Science were conducted. A review protocol was registered in Prospero (CRD42018100792). Main inclusion criteria were primary intervention studies reporting treatment effects of basic skin care strategies in aged people with a lower limit of age range of 50 years and published between 1990 and 2018. Primary empirical studies were included with experimental study designs including randomized controlled trials and quasi-experimental designs. Methodological quality of included randomized controlled trials was evaluated using the Cochrane Collaboration's Tool for assessing risk of bias. Levels of evidence were assigned to all included studies. Sixty-three articles were included in the final analysis reporting effects of interventions to treat and/or to prevent skin dryness, pruritus, general skin barrier improvement, incontinence-associated dermatitis, skin tears and pressure ulcers. Skin cleansers containing syndets or amphotheric surfactants compared with standard soap and water improved skin dryness. Lipophilic leave-on products containing humectants decreased skin dryness and reduced pruritus. Products with pH 4 improved the skin barrier. Application of skin protectants and structured skin care protocols decreased the severity of incontinence-associated dermatitis. Formulations containing glycerin and petrolatum reduced the incidence of skin tears. Thirty-five outcome domains were identified with nearly 100 different outcome measurement instruments. Included studies showed substantial heterogeneity regarding design, interventions and outcomes. Basic skin care strategies including low-irritating cleansers and lipophilic humectant-containing leave-on products are helpful for treating dry skin and improving skin barrier in the aged. Lower pH of leave-on products improves the skin barrier. The number of different outcome domains was unexpectedly high. We recommend to identify critical outcome domains in the field of skin care to make trial results more comparable in the future and to measure possible performance differences between different skin care strategies and products. [ABSTRACT FROM AUTHOR]