The role of sheepskins in preventing pressure ulcers in

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The role of sheepskins in preventing pressure
ulcers in elderly orthopaedic patients
Sunita McGowan RN MAppSc(Nurs) FRCNA
Ken Montgomery BSc PhD Leeds
Damien Jolley MSc London MSc LaTrobe
Robyn Wright RN BAppSc(Nurs) GDipAppSc(ISM)
A randomised controlled trial was undertaken in the orthopaedic ward at two hospitals to estimate the efficacy of a newly developed
Australian Medical Sheepskin overlay to prevent hospital acquired pressure ulcers relative to a standard hospital mattress or other low
technological constant pressure supports. A total of 297 patients aged 60 years and above were randomised to receive the sheepskin overlay
(experimental group) or the standard hospital mattress, with or without other low technological constant pressure supports (control group).
At risk status for developing an ulcer was assessed daily using the Braden Scale. Patients were assessed for evidence of a pressure ulcer on a
daily basis. The risk ratio for development of at least one pressure ulcer for the 155 patients in the experimental group and 142 control
group was 0.30 (95% confidence interval 0.17 to 0.52). The hazard ratio for time to development of first pressure ulcer in the experimental
group relative to control group was 0.31 (0.17 to 0.58). These results provide evidence that the Australian Medical Sheepskin is effective
in preventing pressure ulcers in elderly orthopaedic patients. A more comprehensive investigation, concentrating particularly on the effect
of the sheepskin on duration of stay in hospital, is indicated.
Sunita McGowan RN MAppSc(Nurs) FRCNA
Coordinator Nursing Research and Evaluation
Fremantle Hospital and Health Service, Alma St
Fremantle, WA 6959
Phone (08) 9431 2129, Fax (08) 9431 2443
Ken Montgomery BSc PhD Leeds
CSIRO Textile and Fibre Technology
Leather Research Centre
Private Bag 10, Clayton Sth MDC
Clayton, Vic 3169
Phone (03) 9545 2330, Fax (03) 9545 2363
Managing patients’ pressure areas is an important part of
nursing care. Despite the provision of nursing care aimed at
prevention, hospital acquired pressure ulcers occur frequently
and are responsible for untold suffering for patients. It has been
estimated that hospital acquired pressure ulcers cost the
Australian taxpayer up to $350 million per annum and they
reduce access to scarce bed space through unnecessary and
increased stays in hospital 1. Point prevalence studies undertaken
at Fremantle Hospital, a 400 bed teaching hospital in Western
Australia, have shown rates for hospital acquired pressure ulcers
Damien Jolley MSc London MSc LaTrobe
School of Health Sciences, Deakin University
221 Burwood Highway
Burwood, Vic 3121
Phone (03) 9251 7192, Fax 03) 9244 6017
as high as 12 patients per 100 (1994) and as low as 6.9 patients
Robyn Wright RN BAppSc(Nurs) GDipAppSc(ISM)
School of Postgraduate Nursing
University of Melbourne
243-249 Grattan St
Carlton Vic 3053
Phone (03) 9344 0774, Fax (03) 9347 4172
16 total hip replacements 4. Estimates of the cost of treating a
per 100 patients (1996) 2, 3.
Opportunity costs associated with pressure ulcers are
immense and it has been calculated that for each full thickness
sacral pressure ulcer that is prevented, it is possible to undertake
full-thickness pressure ulcer in Australia have been reported as
being about $61,000 5. Litigation regarding the development of
hospital acquired pressure ulcers is common in both the USA
and the UK and a precedent has already been set in NSW where
a damages claim for $632,500 has been reported 6.
Primary Intention
November 2000
In recent years, there has been a substantial increase in the
variety and cost of equipment available for nurses to choose
damp and can rapidly dissipate moisture 11 (a contributing factor
to pressure ulcer development) away from pressure points.
from to assist in the prevention and treatment of pressure ulcers.
Few studies have, however, been conducted to evaluate the
Most of this equipment, however, has not been reliably
merit of sheepskins in preventing or assisting in the treatment of
evaluated and nurses often have to rely upon information
pressure ulcers. Two small studies conducted in the 1960s to
provided by manufacturers as to the therapeutic value of their
evaluate sheepskin overlays and boots were not well designed
product .
and the results were generally inconclusive 12, 13. Other early
Constant low pressure supports in the form of high-
research into the effectiveness of sheepskins used patients as
specification foam or fibre filled mattresses are generally ‘first
their own controls and reported that sheepskins were
choice’ for prevention because of their relatively low cost,
advantageous in the prevention of pressure ulcers in bedridden
particularly when compared with the more expensive alternating
patients 14. Limitations of this study include a very small sample
pressure mattresses. These low pressure supports all have a
size and non-randomisation of patients.
common aim to reduce the point pressure by dispersing pressure
conducted in 1990 evaluated the effectiveness of sheepskins
over a greater body surface area.
Evidence from a few
with two patients using a single case design 15. Results did not
randomised controlled trials is sufficient to suggest that high
lend support to the theory that sheepskins reduce pressure
specification foam is superior to the standard hospital mattress
in preventing pressure ulcers 8.
A further study in 1993 compared the use of a genuine
Many hospitals, however, cannot afford to replace the
Another study
sheepskin with a synthetic pile product 16. The study group was
comprised of 64 residents of a long-term institution who were
alternatives, particularly since their durability is often unknown.
randomly placed on a genuine sheepskin. A control group was
The durability and pressure relieving qualities of the overlay
selected by conducting a retrospective audit of the medical
mattresses are generally dependent upon their usage.
records of 44 long-term care residents placed on the synthetic
hospitals have limited supplies of alternative mattresses for use
product. At the end of a 2 month period, results for the study
with patients assessed at low or medium risk of developing
group showed 63 per cent of residents maintained skin integrity
pressure ulcers and therefore they are in constant use. Overlay
compared with 41 per cent in the control group. The authors
mattresses require regular inspection and testing to ensure that
concluded that the genuine sheepskin is more effective in the
the fibre or foam has not deteriorated, collapsed or ‘bottomed
prevention and treatment of pressure ulcers than the synthetic
out’ thus eliminating the pressure relieving qualities.
product. To date, there are limited studies undertaken with
hospitals have mattress inspection protocols and busy nurses
sheepskins. Those that have been conducted lack rigour and the
rarely have time to unzip covers to check the condition of the
outcomes are inconclusive.
Until recently, there has been no reliable standard
Sheepskins are claimed to be of value in the prevention of
regarding the quality of sheepskins used in hospitals for
pressure ulcers . Their therapeutic value is believed to be due
pressure relief.
to the pressure reducing and distributing properties of the high
products are often purchased in an effort to reduce health
density, soft, springy but resilient wool fibres. In a simulated
costs and inappropriate laundering results in rendering the
comparison , objective measurement of peak pressure beneath
leather backing hard, making them unsafe for patient use. The
an electropneumatic sensor placed either directly on a hospital
CSIRO Leather Research Centre addressed these problems by
mattress or onto an Australian Medical Sheepskin on the same
facilitating the development of an Australian Standard for
mattress, indicates that medical sheepskins reduce peak pressure
Medical Sheepskins, AS 4480.1-1998. The standard defines
from 95 mm Hg on the mattress to 27 mm Hg on the sheepskin
the high performance requirements by specifying leather
(CSIRO, unpublished work). The fibres have a low friction
quality, wool type and length as well as laundry procedure to
coefficient that reduces the strain on skin and alleviates shearing
ensure its capacity to be washed with selected chemicals
forces on the underlying tissues. Wool can also also absorb up
through commercial laundries at a temperature of 800C for
to 33 per cent of its dry weight in moisture without feeling
high level thermal disinfection. To confirm compliance with
Primary Intention
November 2000
Cheap substandard sheepskins or synthetic
the Australian Standard, a permanent label must be bonded to
Sample size
the leather side of the sheepskin.
Laboratory testing has
Based on data obtained from this casemix of patients during
shown that these skins retain their characteristics after at least
annual point prevalence studies at Fremantle Hospital, a
50 wash cycles.
The Mercy Private Hospital laundry in
prevalence rate of 20 per cent was estimated. Assuming an
Victoria has successfully washed the skins up to 65 times with
average duration of 5 days, the approximate background
no deterioration of the leather or wool.
incidence rate of pressure ulcers is thus about 40 per 1000
person-days. The number of events required in the control
group to detect a rate ratio of RR=0.5 at the 5 per cent level
The objective of this investigation was to estimate the relative
with 90 per cent power is 63 17. The target number of person-
incidence of hospital acquired pressure ulcers among elderly
days exposure in the control group was therefore 1575. From
orthopaedic patients nursed on a standard hospital mattress
casemix data from these hospitals, the average length of stay of
plus an Australian Medical Sheepskin overlay, compared to
elderly orthopaedic patients is about 10 days and so the number
those nursed on either a standard mattress alone or a standard
of patients required in each group was about 150.
mattress with other low technology constant pressure
Inclusion criteria
Patients who met the following criteria were enrolled in the study:
The null hypothesis addressed by this study was that patients
• age 60 years or greater;
nursed on a standard hospital mattress plus an Australian
• admitted with an orthopaedic diagnosis;
Medical Sheepskin overlay have the same incidence of hospital
• assessed at low or moderate risk of developing a pressure
acquired pressure ulcers as patients nursed with standard
ulcer based on the Braden Pressure Ulcer Risk Assessment
hospital care.
Scale 18;
This may or may not include other low
technological constant pressure supports.
• patient or significant other (relative or legal guardian) able
to give informed consent.
Study design
The study design was a two arm parallel group, open label
Exclusion criteria
randomised controlled trial. Blinded outcome assessments were
Patients were excluded from the study if one of the following
not possible because the support surfaces could not be disguised
was present:
and patients could not be moved off the bed for assessment of
Sheepskin in use.
their pressure areas.
Study setting
The study was conducted in two Western Australian hospitals;
Fremantle Hospital, a 400 bed teaching hospital and
Hollywood Hospital, a 360 bed private hospital. Over a 13
week period, patients (emergency and elective) admitted to two
orthopaedic wards (62 beds) at Fremantle Hospital and two
orthopaedic wards (61 beds) at Hollywood Private Hospital
were assessed within 24 hours of admission for suitability for
inclusion in the trial.
Two registered nurses were employed as research nurses to
obtain patient consent, undertake randomisation and to
complete daily assessments of the patients’ skin condition and
their risk status for developing pressure ulcers.
Primary Intention
November 2000
• patients assessed as no risk (requiring no intervention) or
high risk (requiring more complex interventions) for
developing pressure ulcers;
• patients with a pre-existing pressure ulcer;
• non-English speaking patients (unless an interpreter was
• patients with an anticipated stay of less than 48 hours;
• coloured skin patients where stage 1 ulcer detection is
Approval to conduct the study was obtained from the
participating hospitals’ Ethics Committees.
Subject to the
inclusion and exclusion criteria and following consent, patients
were randomly allocated (using sealed envelopes) by research
nurses to receive one of two interventions:
• Standard hospital mattress and sheet with or without other
low technological constant pressure relieving devices as
determined by ward nursing staff (control group).
with lower scores indicating greater risk. Good reliability of the
tool (r=0.99) has been reported when used by registered nurses 18.
Training in the identification of pressure ulcers and in the
use of the Braden Scale was provided for the research nurses.
Patients were assessed daily by these nurses, using operational
definitions recommended by the Agency for Health Care Policy
and Research 20 for evidence of pressure ulcers (Figure 1).
One of the investigators undertook regular inter-rater
comparisons (Intraclass correlation coefficient 0.93). Where a
Stage 2 pressure ulcer (broken skin) occurred in either group,
nursing staff on the ward were informed and determined what
treatment was required. All patients who were able to
comprehend English and had normal cognitive function were
asked prior to discharge to rate the comfort of the bed surface
on a 10 point scale where 1 indicated ‘very uncomfortable’ and
10 ‘very comfortable’. Patient’s comments regarding
satisfaction with the support surfaces were also noted.
Education sessions were held on each ward to inform nursing staff
of the purpose of the trial. To reduce the occurrence of control
• Standard hospital mattress and sheet plus an Australian
Medical Sheepskin overlay.
Sheepskin heel and elbow
Figure 1.
Classification of stage of pressure ulcers.
protectors were also provided by the research nurses where
Stage 1
the clinical condition indicated these were required
Non-blanching erythema or erythema not resolving within
(experimental group).
thirty (30) minutes of pressure relief. Epidermis remains
intact. Reversible with intervention.
Baseline data regarding demographics, surgical procedure,
Stage 2
medications or treatments that could increase the risk of
Partial thickness loss of skin layers involving epidermis and
developing pressure ulcers (for example epidural local
possibly penetrating into but not through dermis. May
anaesthetic post-operatively ) were collected.
present as blistering with erythema and/or induration;
Patients admitted on the day of surgery, considered likely to
wound base moist and pink; painful; free of necrotic tissue.
be at risk of developing pressure ulcers post-operatively because
of the planned procedure, were enrolled in a pre-admission
Stage 3
clinic. Consent was obtained at this time and randomisation
Full thickness tissue loss extending through dermis to
usually occurred on the day of surgery.
involve subcutaneous tissue.
This enabled the
Presents as shallow crater
sheepskins to be placed on beds (for experimental patients) prior
unless covered by eschar.
to the patient’s return from the operating theatre. At risk status
undermining, sinus tract formation, exudate, and/or
was re-confirmed once the patient had returned from surgery.
infection. Wound base is usually not painful. If wound
Patients randomised to the experimental group were provided
involves necrotic tissue, staging cannot be confirmed,
with Australian medical sheepskins on top of the standard hospital
mattress for the duration of their hospital stay.
May include necrotic tissue,
therefore classified as Stage 4.
randomised to the control group were nursed on a standard
hospital mattress and received other pressure relieving equipment
based on availability and as determined by the ward nursing staff.
At risk status for developing a pressure ulcer was assessed on a daily
basis for patients in both groups by research nurses using the
Braden Pressure Ulcer Risk Scale. Total scores on six sub-scales
reflecting critical determinants of pressure range from 6 to 23,
Stage 4
Deep tissue destruction extending through subcutaneous
tissue to fascia and may involve muscle layers, joint and/or
Presents as a deep crater.
May include necrotic
tissue, undermining, sinus tract formation, exudate, and/or
infection. Wound base is usually not painful.
Primary Intention
November 2000
patients being given the experimental sheepskin (a problem at
commencement of the trial) posters were developed and displayed
A total of 297 patients were enrolled in the trial. Of these, 142
where the sheepskins were stored to remind staff that sheepskins
(48 per cent) were randomised to the control group and 155
were allocated to patients by the research nurses. Additional notices
(52 per cent) to the experimental group. Table 1 compares the
were placed in the experimental patients’ nursing notes asking staff
baseline characteristics of both groups. There were more males
to provide patients with a clean sheepskin when wet or dirty
in the experimental group and more patients in this group were
sheepskins were removed. The research nurses were responsible for
admitted for total knee replacement, compared to the control
checking sheepskins daily and changing them when the wool pile
group. The mean Braden Score and assessed risk status on
required rejuvenation, generally every 3-4 days.
admission or post-operatively were almost identical in the two
groups. The average ages of the control and experimental
Study end point
groups were 74 and 73.6 years, respectively.
The end point of the trial was discharge from hospital or transfer
to a rehabilitation ward.
Of the 297 patients enrolled in the trial, two patients (one in
Clinical response to preventive
each group) withdrew prior to data collection. Six patients in the
interventions was based upon the presence or absence of a
experimental group withdrew before completion of data
pressure ulcer. Incidence and severity of pressure ulcers were
collection because the sheepskin caused an irritation, was too hot
recorded during the period of hospitalisation. The day of risk
or uncomfortable. An additional seven patients in the control
that the ulcer first occurred, the site of the ulcer, subsequent
group and three in the experimental group were also withdrawn
severity and the type of preventive intervention in situ were
due to protocol violations (sheepskins given to control group by
recorded. Patients whose clinical condition resulted in at risk
mistake, sheepskins not replaced for >12 hours and additional
status increasing to high continued in the trial if their at risk
pressure relieving equipment provided in experimental group).
status reverted to moderate or low after 48 hours.
Data collected for patients up until the time of withdrawal has
collection ceased for any patient still identified as high risk after
been included in the analysis with the exception of five controls
48 hours. Data prior to and including the 48 hours at high risk
and two patients from the experimental group for whom study
are included in the analysis.
participation time was not available.
A total of 43 (30.3 per cent) of the 142 patients in the
control group developed a pressure ulcer compared with 14 (9
Cumulative incidence of pressure ulcers was computed in each
per cent) of the 155 patients in the experimental group. The
group and compared using a standard risk ratio with 95 per cent
cumulative incidence risk ratio was 0.30 (95 per cent confidence
confidence intervals. Incidence density was computed using
interval: 0.17 to 0.52). The 40 control patients with valid data
person-time of exposure and rate ratios were formed with
developed a total of 67 pressure ulcers (rate= 46.9 per 1000
confidence intervals.
patient-days) whilst the 14 patients in the experimental group
Primary Intention
November 2000
with valid data developed a total of 21 pressure ulcers (13.1 per
ulcer that progressed beyond Stage 1. The most common sites
1000 patient-days). The rate ratio for sheepskins relative to
for pressure ulcers in the control group were the sacrum and
standard treatment was 0.28 (95 per cent confidence interval:
elbows and for the experimental group the elbows (Table 2).
0.16. to 0.46).
A total of 268 patients (124 control and 144 experimental)
Figure 2 displays Kaplan-Meier survival curves for the ulcer-
were able to complete the rating scale on the level of comfort of
free experience of the experimental group compared to the
the bed surface.
control group. A log-rank test of the 40 patients with ulcers
comfort significantly higher than the control group (Mann-
observed in the control group and the 14 seen in the
Whitney U, Z=-7.74, P<0.0001). No significant differences in
experimental group was statistically significant (χ2 = 15.75 on 1
comfort levels were observed between control patients nursed
df, P < 0.0001).
on the standard hospital mattress or patients nursed on a foam
Twenty five (58.1 per cent) of the 43 patients in the control
Patients in the experimental group rated
or Spenco overlay mattress.
group had one pressure ulcer, seven (16.3 per cent) had two and
Sixteen patients (11.4 per cent) in the experimental group and
11 patients (25.6 per cent) developed three pressure ulcers. In
seven (5.5 per cent) in the control group provided additional
four of the patients, the pressure ulcers progressed to Stage 2
responses regarding the bed surface. Patients in the experimental
(broken skin) and one patient developed Stage 4 pressure ulcers
group commented that the sheepskins were hot, curled up when
on both heels. This compared with seven (50 per cent) of the
in bed, the full length sheepskin provided comfort for feet, should
14 patients in the experimental group who had one pressure
be larger to cover the length of the bed and was very comfortable
ulcer and seven (50 per cent) who developed two pressure
particularly on first day. Comments from patients in the control
ulcers. No patient in the experimental group had a pressure
group all related to the hardness of the beds.
Table 1.
Baseline characteristics of control and experimental groups.
Age (years)
• Mean
• Median
• Min.
• Max.
• Std Dev
• Male
• Female
Admission type
• Emergency
• Elective
Admission diagnosis
• Total knee replacement
• Total hip replacement
• # femur (neck & shaft)
• # lower leg/patella
• Shoulder/arm surgery
• Laminectomy
• # pelvis
• Wound infection hip/leg
• Tibial osteotomy
• Hip/knee pain
• Dislocated THR
• Removal of screws ankle
• Hip arthrotomy
• Total ankle replacement
• Bone graft lower leg
Braden Score on admission or post-operatively
• Mean
• Median
• Min.
• Max.
• Std Dev
Assessed risk status at admission or post-operatively
• Low (scores 15-18)
32 23%
27 17%
• Moderate (scores 13-14)
99 70% 120 77%
• High (score 12 or less)
• Missing
Low scores on admission or post-operatively (=1 or
• Sensory
• Moisture
• Activity
137 96% 153
• Mobility
134 94% 152
• Nutrition
105 74% 107
• Friction
140 99% 152
At risk status high for >48 hrs
Epidural post-operative
Primary Intention
November 2000
At commencement, at 6 weeks and on completion of the
The sheepskins were not wide enough to provide protection
trial, thermal disinfection of the sheepskins was confirmed by
for the elbows and none of the experimental patients with
measuring median colony counts on three of the sheepskins.
pressure ulcers on their elbows had elbow protectors in situ at
Satisfactory results were obtained on all three occasions.
the time of ulcer development. Only when a pressure ulcer
developed were some patients in the experimental group
prepared to persevere with the elbow protectors because of the
Findings from this study show that patients nursed on the
relief from pain that they provided. Of the 15 pressure ulcers
Australian Medical Sheepskin had fewer pressure ulcers. The
on the elbows, three patients (20 per cent) tried the elbow
results also show that the number of days free from pressure
ulcers was significantly higher for patients nursed on the
sheepskin. Where pressure ulcers did develop, they were less
severe. Of the 142 patients in the control group, 43 (30.3 per
cent) developed a pressure ulcer, compared with 14 (9 per cent)
of the 155 patients in the experimental group. Patients in the
control group developed a total of 72 ulcers, with 28 (39 per
cent) of the ulcers occurring on the heels.
In comparison,
patients in the experimental group developed 21 pressure ulcers
with 15 (71 per cent) of the ulcers occurring on the elbows.
protectors and their pressure ulcers resolved prior to discharge.
Comfort is an important factor for patients and when asked
to rate the level of comfort of the bed surface, patients nursed
on the Australian Medical Sheepskin indicated a significantly
higher level of comfort than those nursed on the hospital
mattress alone. There is no definition of what constitutes a
standard hospital mattress and little information was available
on the age or the composition of the standard foam hospital
mattress used in this study. It is likely that, depending upon the
age of the bed, mattresses of different foam composition are in
use throughout the hospital.
The pressure reducing foam
The sheepskin booties and elbow protectors were of limited
overlay mattresses used were 4” Dunlop high density flexifoam.
value with this group of patients because they were difficult to
The condition of the foam overlay mattresses at the time of the
keep in place, particularly once the patient started to mobilise.
trial was unknown and, since mattress longevity is also not
Pressure ulcers on the heels occur because of pressure applied to
known, foam collapse cannot be ruled out in many of them.
a bony prominence over a prolonged period of time or friction
and shearing as a result of patients attempting to move around
in bed. Where booties could not be kept in place, a second
There are several limitations to this study. First, the study was
sheepskin was placed on the bottom of the bed to minimise
conducted with elderly orthopaedic patients which limits the
friction and shearing forces on the heels and thus the
generalisability of the results to a similar population.
development of pressure ulcers.
research is required to investigate the efficacy of the sheepskins with
at risk patients of other ages and with other medical conditions.
Figure 2.
Kaplan-Meier survival curve comparing ulcerfree survival of experimental to control groups.
Second, patients were only followed for the acute period of
their hospital stay. It is possible that those patients who were
transferred to a rehabilitation ward may have developed pressure
ulcers after transfer.
Third, although nurses appeared impressed with the new
sheepskins, it is possible that they provided more regular
turning and re-positioning for patients in the experimental
group. Blinded outcome assessments were not possible, so a
Table 2. Site of pressure ulcers.
• Sacrum
• Heels
Control Group
Experimental Group
22 (30.5%)
4 (19%)
28 (39%)
2 (10%)
• Elbows
22 (30.5%)
15 (71%)
• Total
72 (100%)
21 (100%)
Primary Intention
November 2000
bias cannot be excluded. Standardisation of the management of
protectors, Bill Gardiner (Textile Consultant) for laundry
pressure areas is not possible because of nursing workloads and
the peaks and troughs of activity in acute care areas. A more
microbiological testing, research nurses Lois Hensley and Janet
comprehensive study to address some of the above issues is
Power and Mark Hickey and Joanne Parsons of CSIRO Leather
Research Centre for technical help.
Pressure ulcer prevention is generally recognised as a nursing
Klei M, MacLellan L & MacLellan D. Bottoms up! – avoiding the horrors of
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Intention 1996; 4(1):9-16.
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Ford G. Sydney Morning Herald, 1994 (September 24); 10.
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make it impossible to implement them. Alternatives such as low
information about the therapeutic value of the product and how
often turning and re-positioning regimes can be implemented
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supports surfaces (e.g. foam or fibre filled mattresses) can be
used on beds, chairs and trolleys for patients at risk of
developing hospital acquired pressure ulcers.
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at least 50 washes and it is easy to identify any deterioration.
Whilst pressure relieving equipment can never replace skilled
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The authors wish to acknowledge funding received from the Sir
pressure ulcer risk: a multisite study of the predictive validity of the Braden
Edward Dunlop Medical Research Foundation and the Nurses
Scale. Nursing Research 1998; 47:5:261-269.
Memorial Centre (Inc) Western Australia, that enabled the
undertaking of this study.
Also the support from Nola
Cruickshank for coordinating the Hollywood hospital
collaboration, Mayall Australia for supply of Hitemp Medical
Sheepskins, Fleececraft Industries for supply of heel and elbow
19. Bliss M & Simini B. When are the seeds of post-operative pressure sores
sown? [editorial] BMJ 1999; 319:863-864. Retrieved 22nd March 2000
from <>.
20. Agency for Health Care Policy and Research. Clinical guidelines: how to
predict and prevent pressure ulcers. American Journal of Nursing, July 1992;
Primary Intention
November 2000

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