Clinical

A descriptive evaluation of
pressure-reducing cushions
Sylvia Banks, Jane Bridel
This article provides
a descriptive
evaluation of HNE
Huntleigh'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
James'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 Barton, 1981; Gebhardt and
Bliss, 1994). A number of pressure-reducing 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 l a . 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

Omnltlex cover provides:

1. 2-way slretch prevents
hammocking and shear
2. 42% vapour permeable
improves sir movement around
cushion
3. Waler-resistant prevents
foam Irom getting wet
Comfort layer of foam
takes up body contours
and provides comfort

High density loam side walls:

1 Prevent irtner core toam rrom disintegrating
2 Asstsi patieni transfer

Higher density foam to prevent patient

from bottoming out after prolonged
usage. Provides stable base for user

Figure 1 b. Internal structure of the Vaperm cushion.

736

The literature on pressure-reducing

cushions currently focuses mainly on the
measurement of interface pressures. In
1974, Souther et al examined a number of
these products and concluded that: 'No
cushion evaluated reduced mean pressure
below mean capillary pressure.' However,
the application of interface pressure measurements to clinical practice was recently
challenged by Bridel (1993a), who indicated that at an individual level the
response to pressure varied widely. The
reliability and validity of the tools used to
measure interface pressures have also been
questioned (Clark, 1994), demonstrating
that these measurements cannot be used as
an absolute indicator of the effectiveness
of a product.
Sitting is a dynamic, unstable posture,
and the performance of a pressure-reducing
cushion cannot be properly evaluated independently of the overall seating situation.
There is little information in the literature
with regards to the effect of adding such a
cushion to a seat, particularly in terms of
skin response. In view of this, a descriptive
study of the Vaperm, Multitec and Supatec
cushions was undertaken.

Aims
The aims of the study were to:
1. Determine the effectiveness of the
Vaperm, Multitec and Supatec cushions
m relation to skin response
2. Assess the comfort of the cushions
3. Observe the effects of the cushions on
posture.
The Vaperm, Multitec and Supatec cushions form part of the Seatec range produced by HNE Huntleigh.
The Vaperm cushion {Figure la) has
been designed to meet the needs of users
who are assessed to have a low risk of
developing pressure sores, but who may
sit for prolonged periods. The cushion is
constructed from three densities of foam
British Journal of Nursing, 1995, Vol 4. No 13

A descriptive evaluation of pressure-reducing cushions

to allow an even distribution of pressure.
The foam is vcntil.ucd to .illow .lir to circulate 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 excessive 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 accordingly and redistributes the pressure over
the seating surface {Figure 2b).
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 Multitec pressure-reducing

cushion from the Seatec range.

Breathable film covering

(Platilon)

Fire-reslsiant foam
walls take up
contours of patient's
body

Choice o( outer cover

1. Watchdog Terrtowelling
2. OmnHIeK'"

Cotton cover to
strengthen foam
assembly
Fluid:
1. Provides pressure re 11 el
2. Takes up contours of patient's body
3. Oistnbutes patient's weight to
provide pressure relief

Welds to prevent
excessive fluid
movement

Figure 2b. Internal structure of the Multitec cushion.

738

treatment for established sores up to grade 5

(Torrance, 1983). The Supatec contains more
fluid than the Multitec, allowing for better distribution of weight and pressure {Figure 3b).
The cushions used for evaluation were all
protected by a waterproof, vapour-permeable cover called Omniflex. The cover
stretches two ways to reduce hammocking
and shear forces, and can be removed for
laundering. The cushions used for evaluation
had already been in use in the hospital for 6
months and no attempt was made to compare the performance of the cushions after 6
months with their performance when new.

Method
Sample
Patients admitted to a 32-bedded medical
ward and a 30-bedded elderly care ward
were considered for entry into the study.
The ward nurses identified patients requiring a pressure-reducing cushion, by assessing the risk, skin quality and mobility of the
patients in accordance with the St James's
University Hospital Trust (1993) pressure
area care policy. Patients were included in
the study if they met the following criteria:
1. The patient/carer was able to participate
in a simple, semi-structured interview
2. In the ward nurses' clinical judgment,
the patient's mobility and condition
were unlikely to alter during the 7-day
study period week
3. On entry to the study, the patient's
Waterlow score (Waterlow, 1985) was
15 or above.
A full explanation of the study was
given and verbal consent to participate was
obtained from all patients as determined
by the local ethics committee.
The cushions were allocated by the ward
nurses according to the skin assessments,
and the mobility of the patient described
by the subscale contained within the
Braden scale (Braden and Bergstrom,
1987). The guidelines for allocation are
shown in Table 7.
Patients with dark pigmentation of the
skin were not considered for entry into the
study because of the difficulties associated
with the reliable identification of blanching
and non-blanching areas of redness.
Patients assessed to have existing pressure
damage of grade 3 or worse (Torrance,
1983) at the sacrum or ischial tuberosities
were also excluded from the study. It was
felt that the dressings used for the management of the pressure sores would preclude
accurate skin assessments at that site.
The addition of any cushion to a seat will
British Journal of Nursing. 1995, Vol 4. No 13

A descriptive 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 ability while sitting, the total scat height of the
chairs with the cushion in place was chosen
to match the length of the patient's leg
from the popliteal fossa to the floor. Where
a suitable chair height was not available,
aids such as foot-blocks were used to support 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 demographic information,
descriptive data pertaining to the response

Figure 3a. The Supatec pressure-reducing

cushion from the Seatec range.

2-way stretch cover

Available in Omnlilex'" or
Watchdog Temiowelling ^.^^^

Extra fluid ensures that

patients wtth fixed pelvic
displacement can use
Supatee'"

^^^^^k
^^^^^^^^H
^^^^^^^^^^^H

^^--^^^
^ / ^ - ^ ^ i > I l ^ .y^
^""--....y^
^^^^^^rr;^
y'"^^-^,,,^^
j/
^~~--.^^
/
Lattice work inside fluid module:
1. Prevents user bonoming out on cushion
2. Movement of fluid conlrolled by lattice work
ensures stable surface lor user

Results

Welds link outer layers of

polyurethane envelopes together:
1. Allows more of the fluid to be
available to take up the body
contours
2. Distributes weight evenly

Figure 3b. The internal structure of the Supatec cushion.

740

of the skin were collected by the ward

nurses and were determined by the presence or absence of redness. Skin was
assessed at the sacrum and ischial tuberosities using an adapted version of the pressure sore classification described by
Torrance (1983). These assessments were
documented on entry to the study and at
each position change (24-hour clock) for a
7-day study period.
Additional information collected by the
ward nurses and author included descriptive data relating to the risk of pressure
sore development, the comfort of the
cushions and posture.
Pressure sore risk was described by calculation of the Waterlow score. Owing to
the problems associated with interrater
reliability of the Waterlow score (Dealey,
1989; Bridel, 1993b), the documented
scores were used only as a general indicator of the level of risk in the description of
the results and no attempt was made to
improve the reliability among raters.
Data pertaining to the comfort of the
cushions were collected by the author
using a visual analogue scale and were supported by descriptive information from
semi-stnictured interviews.
Ward nurses were given detailed explanations of the tools and data collection
forms to be used. Since the focus of the
evaluation was skin response, preparation
before data collection included interrater
reliability checks of skin assessments with
level 1 registered ward nurses. A total of 17
nurses (nine pairs) undertook skin assessments on four anatomical sites (buttocks
and heels) of 18 patients, generating a total
of 72 paired assessments scores. There was
92% absolute agreement of grades {(^yH),
equating to a Pearson product-moment
correlation of .92 (P<0.005) and a kappa
statistic of 0.77 (strength of agreemem='good') (Ahman, 1991).
Data were collected for 48 patients. For
convenience, 16 evaluations were completed for each cushion, with a maximum
data collection period of 7 days. The characteristics of the patient population
entered into the study are summarised in
Table 2 for each cushion.
For the purpose of the study, the term
'pressure sore' is defined as 'superficial
loss of skin epidermis', i.e. grade 2b.
However, since the focus of the evaluation
is skin response, the terms 'transient skin
changes' and 'persistent skin changes' are
British Journal of Nursing. 1995, Vol 4, No 13

A descriptive evaluation of pressure-reducing cushions

Multitec

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
defined as redness (either blanching 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 period prevalence of pressure sores
was 22.9% (11/48) and the incidence, i.e.
the proportion of subjects who first present
with a pressure sore, was 2.6% (1/38).

Table 4 shows the results of the 16 patients

allocated a Multitec cushion. Nine patients
(56%) had no discoloration (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 mobility was
very limited (Braden subscale 2) in all
patients. Time spent sitting varied widely in
this group, ranging from 4 to 19 hours/day
(mean 8) for periods of 1.5-3.5 hours (mean
2.5 hours). Four patients experienced some
skin changes during the study. Changes
were made to their repositioning schedules
and no persistent changes occurred.
Skin status remained undamaged in all
nine patients with no discoloration on entry
to the study (grade 0) and resolved in 5 of
the 7 patients who were initially assessed as
grade 1. The skin condition of the two
remaining patients was unchanged, i.e. initial 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 hours per day) than other patients
in the group or by their risk scores of 23.

Vaperm
Sixteen patients were allocated a Vaperm
cushion; details of the results are summarised in Table 3. Eleven (69%) had no
discoloration (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 ranged from 4 to 11 hours (mean 8
hours) and the length of time spent sitting
for any one period ranged from 1.5 to
3 hours (mean 2.3).
Seven patients (44%) had transient skin
changes during the study. Adjustments to
the individual repositioning schedules
were made by the ward nurses when redness was observed and no persistent skin
changes occurred. All patients had skin
assessments of grade 0 at the end of the
study period.

Supatec
The results of the 16 patients allocated a
Supatec cushion are shown in Table 5.
Only one (6%) had no discoloration
(grade 0) on entry to the study. The majority (63%; 10/16) of the patients had superficial 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.

Table I. Guidelines for allocation of cushions

Mobility
I. Completely Immobile: 2. Very limited:
Does not make even
Makes occasional

3. Slightly limited:
Makes frequent though
slight changes in body
or extremity position
independently

4. No limitations:
Makes major and
frequent changes in
position without
assistance

slight changes in body

or extremity position
without assistance

slight changes in body

or extremity position,
but unable to make
frequent or significant
changes independently

Grade 0:
no discoloration

Supatec or
Multitec

Multitec

Vaperm

Vaperm

Grade 1:
redness/blanching

Supatec or
Multitec

Multitec

Vaperm

Vaperm

Grade 2a:
redness/non-blanching

Supatec

Supatec

Multitec

Multitec

Grade 2b:
superficial damage,
broken or blistered

Supatec

Supatec

Supatec

Supatec

Skin assessment

Source; Torrance (1983); Braden and Bergstrom (1987)

742

British Journal o( Nursing. 1995. Voi 4. No 13

A descriptive evaluation of pressure-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

Table 2. Characteristics of the patient population

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 other
two groups (range 1-2 hours, mean 1.7).
i' <aiifiTTiirnif'~iiiT i n T

Vaperm

Multitec

Supatec

Number of patients
Sex {% female)

16
75%(=I2)

16
63%(n=I0)

16
56% {n=9)

Mean age (years)

(range)

69.4
(35-87)

71.8
(45-88)

72.7
(48-^8)

Cerebrovascular
accident

I3%(=2)

37% (=6)

50% (=8)

Chronic obstructive
airways disease

3\%{n=S)

I3%(=2)

I3%(=2)

Myocardial infarction

25% (=4)

6%(n=l)

Chest infection

3I%(=5)

25% (=4)

I3%(n=2)

Renal impairment

I9%(=3)

Main diagnosis {%)

Other

24% (n=4)

Waterlow score
median
(range)

22
(16-24)

16
(15-23)

25
(18-34)

Table 3. Vapernn cushion results

Skin assessments at
entry to evaluation

Skin assessments at
end of evaluation

Ischial
Sacrum
tuberosity

Ischial
Sacrum
tuberosity

II

Waterlow
score

Braden Mean time

mobility sitting/day
(1-^)
(hours)

Mean time
sitting/session
(hours)

15

17

2.5

16

9.5

2.5

20

8.5

13

23

1.5

16

18

21

18

23

15

10

25

15

28

16

2.5

31

16

36

22

1.5

38

21

40

16

10

45

15

II

48

16

Patient
no.

British Journai ol Nursing. 1995, Vol 4, No 13

II

743

A descriptive evaiuation of pressure-reducing cushions

Table 4. Multitec cushion results

Skin assessments at
entry to evaluation

Skin assessments at
end of evaluation

Patient Ischial
Sacnim
no.
tuberosity

Ischial
Sacrum
tuberosity

Waterlow
score

Braden Mean time Mean time

mobility sitting/day sitting/session
(hours)
(1-4)
(hours)
3

21

19

21

1.5

23

12

16

14

24

18

19

1.75

19

23

6.5

2.5

24

18

26

24

8.5

29

24

32

20

5.5

2.5

34

24

1.5

39

17

6.5

2.5

41

23

43

23

2.5

46

19

13

3.5

II

iO

3.5

Table 5. Supatec cushion results

Skin assessments at
entry to evaluation

Skin assessments at
end of evaluation

Patient Ischial
Sacrum
no.
tuberosity

Ischial
Sacrum
tuberosity

Waterlow
score

Braden Mean time Mean time

mobility sitting/day sitting/session
(1-4)
(hours)
(hours)

2b

2b

25

2b

2b

26

1.5

2b

2a

28

5.5

1.5

10

2b

2b

27

15

2b

2a

2b

2a

34

1.5

17

2b

2a

2a

2a

32

1.5

20

2a

2a

28

5.5

1.5

22

2b

2b

26

6.5

27

2b

2b

25

4.5

1.5

30

2b

2a

24

1.5

33

2a

21

35

22

2.5

37

18

42

2b

2b

20

5.5

1.5

44

19

7.5

47

21

1.5

744

British Journal of Nursing. 1995. Voi 4, No 13

A descriptive evaiuation of pressure-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 after 1
hour. All patients
were observed to
maintain a 90
angle at the hip
and knee 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 discoloration of skin on entry to the
study 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
deteriorated to non-blanching (grade 2a)
but did not result in superficial loss of the
epidermis, and three persisted but
remained unchanged (grade 1).
One patient was initially assessed to have
non-blanching for all areas (grade 2a) on
entry to the evaluation and subsequently
developed a pressure sore (grade 2b) at the
sacrum. At the end of the study, however,
improvement was shown and skin assessments of grade 1 were observed for all areas.
Ten patients (62%) had skin assessments
of grade 2b at one or more sites on entry to
the study. Of these, seven showed no
change over the study period. The remaining three patients entering the study with
skin assessments of grade 2b showed
improvement, with assessments of grade 2a
for all areas at the end of the study.

Comfort
Patients were asked to rate the comfort of the
cushions on entry to the study and at the end of
the study period, using a horizontal 10 cm
visual analogue scale, where 0 cm represented
very unconrfoitable aiid 10 cm indicated ver}'
comfortable. Tlie visual arilogue scores ranged
from 6.2 to 9.7 (mean 7.84). A similar range of
scores was obtained for each cushion type.
Additional descriptive information relating to the comfort of the cushions was collected during a semi-structured interview
with each patient. This information supported the visual analogue scores. A selection of quotations from these interviews
are shown below:
*The cushion is more comfortable than
the chair.' (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 patients had
impaired sensory perception and four
were unable to understand the concept of
the scale. However, none of the patients
indicated that the cushions were uncomfortable when mterviewed.

Posture
On entry to the study, the posture of the
patient was observed when the patient was
British Journal ol Nursing, 1995. Vol 4, No 13

initially seated, and the observation was

repeated after 1 hour. All patients were
observed to maintam a 90" angle at the hip
and knee after 1 hour and feet remained flat
on the floor or supported by a foot-block.

Discussion
The period prevalence of 22.9% and pressure sore incidence of 2,6% are comparable to those found in previous studies.
Prevalence studies that include the mobility levels of the patients surveyed enable
the calculation of group-specific rates. For
example, for patients who have very
restricted mobility or are completely
immobile, a point prevalence of 21.7% can
be calculated from the study reported by
Barbenel et al (1977) and a period prevalence of 36.5% from that reported by
Waterlow (1988).
Only Gebhardt and Bliss (1994) have
studied the association between pressure
sore incidence and sitting. In a randomised,
controlled trial of 57 postoperative
orthopaedic patients, Gebhardt and Bliss
(1994) found that the pressure sore incidence
was 63% among patients who were allowed
unlimited chair nursing and 7% among
patients who were restricted to 2 hours chair
nursing per session. Three differences in
research aims and methodology' account for
the lower incidence of this study.
First, the focus of the study conducted
by Gebhardt and Bliss (1994) was to
establish whether prolonged chair nursing
was detrimental, whereas the primary aim
of this study was to evaluate the effectiveness of three pressure-reducing cushions
in relation to skin response.
Second, the chairs used during this evaluation were selected by the ward nurses to
suit the dimensions of the patients. The
importance of chair dimensions and design
has been highlighted by Gilsdorf et al (1991)
who reported that armrests supported
between 5% and 9% of the body weight of
spinal cord-injured subjects, and by Lowry
(1992, 1993) who described the problems of
poor posture and seating provision in relation to pressure sore development.
Third, following a review of the literature, Bridel (1993a) identified the importance of recognising skin redness (reactive
hyperaemia) as a precursor to pressure sore
development. Consequently, a key emphasis of the St Jaines's University Hospital
Trust (1993) pressure area care policy is the
recognition of the importance of this physiological process when reviewing and considei'ing changes to planned care.

745

A descriptive evaiuation of pressure-reducing cushions

// is generally
accepted that
visual analogue
scales are of most
value where scores
are obtained
pre- and postintervention from
the same
individual
...and/or used in
combination with
a qualitative
description of
the given
experience...The
combination of
data collected in
this study in
relation to
comfort allows the
general conclusion
that the three
cushions were
acceptable and
comfortable to
patients.

746

The ward nurses' role in the implementation of the policy is of importance in the
interpretation of the results of this evaluation, as they were responsible for prescribing all nursing care, including seating and
maitrcss provision and repositioning
schedules. The ward nurses' response to
skin redness is demonstrated by the adjustments made to repositioning schedules for
18 patients when skin changes were
observed. None of the 18 patients were
observed to have persistent skin changes.
The skin response to Vaperm, Multitec
and Supatec cushions is described. However,
the results are limited by the fact that no
attempt was made to compare the performance of the cushions with that of a control.
As repositioning schedules were adjusted
according to skin response, the variation in
repositioning times supports the conclusion
drawn by Bndel (1993a) that, at an mdividual patient level, the response of the skin to
pressure varies widely and is likely to be
dependent upon a number of factors. The
individual nature of skin tolerance is also
demonstrated by the different outcomes in
terms of skin changes for these patients.
Comfon is an abstract, multidimensional
concept which is difficult to define and
measure (Redfern, 1976). The use of visual
analogue scales as a measure of patients'
subjective experiences were discussed by
Ghapman et al (1985) and Maguire (1984) in
relation to pain. These studies highhghted
problems of poor sensitivity associated with
treatment effects and difficulties in comparison of scores berween groups. It is generally
accepted that visual analogue scales are of
most value where scores are obtained preand post-intervention from the same individual (Maguire, 1984) and/or used in combination with a qualitative description of the
given experience (Redfern, 1976). The combination of data collected in this study in
relation to comfort allows the general conclusion that the three cushions were acceptable and comfortable to patients.
This is the first report of the effect of
cushions upon the posture of patients. The
observation undertaken simply described
the posture of the patient while on the
cushion and the information generated
that initial sitting posture was maintained
for periods of up to 1 hour. It does, therefore, provide useful data.
The data were limited, however, as a comparison of patients' posture with and without a pressure-relieving cushion was not
undertaken (because of the ethical dilemma
of sitting high-risk patients on standard

chairs for a 1-hour period). The precise

effect of the cushions on posture is therefore
unknown. For example, was posture the
same or improved on the cushion compared
with the chair? In view of this limitation,
additional work with a different patient
population is currently being planned in an
attempt to achieve the original aim.

Conclusion
This evaluation has shown that, irrespective
of the total time the patient spends sitting
per day, the Vaperm, Multitec and Supatec
cushions can be used effectively as part of
an overall pressure sore prevention strategy, when care is planned according to the
skin response of the individual and attention is paid to the overall seating situation.
Aliman DG (1991) Practical Statistics for Medical
Research. Chapman and Hall, London: 405-6
BarbencI JC, lordan MM, Nicol SM, Clark MO
(1977) Incid^cncc of pressure sore in the greater
Glasgow hcaith board area. Eaneet 2: 548-50
Barton A, Barton M (1981) The Management and
Prevention of Pressure Sores. Faber and Fabcr,
London
Braden BJ, Bergstrom NA (I 987) A conceptual
scheme for the study of the etiology of pressure
sores. RehabilNurs 12(1): 8-12, 16
Bridel J (1993a) The aetiology of pressure sores./
Wound Care 2(4): 230-8
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British Journal of Nursing. 1995. Vol 4. No 13