Integrating Nursing with Biomedical Engineering: A Multidisciplinary Integrative Innovative Approach to Home-Base Care for Aging Society in Thailand

Pressure Ulcers (PUs), also known as pressure sores or bedsores are an important healthcare problem throughout the world [1-3], especially in Thailand where the prevalence of pressure ulcers in the public tertiary care hospital is about 1.7 per 1,000 persons-years [4]. Home-Acquired Pressure Ulcers (HAPU) are an often suffer and serious issue that provides to increased morbidness and mortality among adults in home-based care [5-8]. PUs is complications that are found to occur frequently in elderly and immobilized patients whom physicians release for home-base care [9]. It thus falls to family caregivers to assume the responsibility of looking after the patient. In many research were found that the most commonly perceived barriers to pressure-ulcer prevention are the patient's condition, a lack of time, personnel, agreed-on routines, pressure-redistribution surfaces and inadequate knowledge [10,11]. Included also is the fear that turning will cause the patient to discomfort, pain or risk of imminent danger [11]. Also, caregivers risk causing musculoskeletal injury [12,13]. Additionally, when combined with correctly positioning and turning, this task becomes quite difficult, as it involves numerous steps that must be taken and creates a troublesome situation for the caregivers. It may dissuade the caregivers from placing a high priority on properly positioning or turning. It could thus become Pus development when they stay at home [12].

The design and construction of innovative beds that can turn person that will reduce the forces imposed on the human tissues and skin (mechanical loading). The beds will be designed to adjust the head level upward and to adapt to the knee joint to allow it to bend. It must especially be capable of adjusting the position into 30 tilt lateral, as the pressure ulcer prevention guidelines [14-17].

This article revealed the development of innovations that employ an integrated blend of knowledge and science drawn from medical, nursing, the engineering sciences and an analytical review of evidence-based practice. These innovations will be devised for the construction of innovative repositioning beds that employ techniques in the management of mechanical loading.

A literature review is conducted using the databases CINAHL, MEDLINE, DYNAMED, Web of Science, ISI and PubMed that focuses on pressure injury-related mechanical loading in each setting. Keywords are: pressure ulcer; innovation; bed and loadings and targeted studies published in English from January 2010 to December 2017.

Mechanical Loading: interface pressure, shearing force and friction/surface resistance are significant causes of PUs [11,18-22]. When mechanical loading impinges upon the body continuously over an extended period of time, it causes an insufficiency of skin microcirculation, ischemia, and tissue injury. Shearing force constitutes restraining force acting between layers of skin whenever the patient slides the body while in a sitting or lying position. It causes a tearing of the tissues which then develops into wounds and blockage of the subcutaneous blood capillaries. The result is that circulation of the blood in the area of skin subject to interface pressure is reduced, and the reduction in blood leads to subsequent tissue death. A friction/surface-resistance force is generated by sliding the patient on his bed or by the patient himself sliding along the bed. Consequently, the superficial layers of skin become torn and breakdown. Likewise, the subcutaneous blood capillaries are injured, pressure injures will occur. 

Repositioning is considered to be an important strategy and is absolutely essential in the prevention of pressure ulcer of elderly patient [23]. In a systematic review, it was suggested that repositioning must be performed at least every two hours [12], but the duration may vary according to the condition of the patient. Patients who are at high risk for developing PUs can be repositioned more frequently than every two hours if red marks have been found on the skin. In a study conducted by Bergstrom [15], it was found that there was no difference incidence over three weeks of observation between those turned at 2-, 3-, or 4-hour intervals in patients using high-density foam mattresses.

In a previous empirical-evidence analysis, it was discovered that the factor affecting the development of PUs is mechanical loading. Mechanical loading impacts microcirculation in ways that differ according to supine position. For instance, in lying position, a weight-bearing point is the occiput, which becomes subject to a pressure of 58-60 millimeters of mercury (mmHg). Another such point is the scapula, which comes under a pressure of 28-36 mmHg. Yet another is the sacrum, under a pressure of 120 mmHg; and yet another is the heel of the foot, under a pressure of 65-80 mmHg. When positioned on the lateral position, the weight-bearing points bearing the greatest pressure loads are the ear lobe, the shoulder, the ribs, the femur, the thigh and the ankle. As for the sitting position with the back straight, and knees bent at a 90-degree angle, the weight-bearing point is at the back of the thigh; but, if the body is slithering down with the knees further bent and the hip joint at more than 90-degrees, the weight-bearing point is shifted downward to the pelvic bone and the coccyx. Consequently, properly repositioning can reduce and redistribute the mechanical loading being sustained and thereby help to prevent occurrences of Pus [10].

Lying positioning leads to minimum contact pressure upon the skin. Head elevating should not over than 30-degrees, with both knees raised of 0-30 degrees, as well as using a pillow to support the heels, help to prevent PUs, reduce problems from shearing and avoids muscular contraction and tension of the joints [15,24]. In lateral positioning, patients should be turned at a 30-degree lateral tilt. This position will reduce pressure on the coccyx and the shoulders, and will allow oxygen to nourish the tissues in the region of greater trochanter more effectively than when positioned to lie at angle of 60 or 90 degrees [22,24].

Accordingly, innovative repositioning beds that turn a patient on his side have been developed. These beds are capable of managing the mechanical loading that affects human tissues and skin; their function is to forestall occurrences of PUs and to lessen the burden being borne by caregivers. Use of these beds thus continues to improve the quality of life of both patient and caregiver, by applying physiological concepts to the development of pressure-injuries and managing interface pressures by properly repositioning.

Innovative repositioning beds, the In RB, were built and developed by researchers from beds that turned position by use of a remote control. The In RB, a new innovative structural steel bed, has 30-degrees of head-bed level, 30-45 degrees for the knee level, and 30-degrees lateral tilt to redistribute mechanical loadings on the bony prominences [15]. They conducted pilot research studies on enhancing the quality of care for patients who are stoke victims through the use of beds that can turn someone, and the caregivers’ satisfaction. The goal is promoting the proper patients positioning, to reduce and distribute the interface pressure and to stimulate the blood flow so that the tissues can receive nourishment and oxygen. It is thus intended to help prevent and reduce the occurrences of PUs in the high risk of developing PUs when at home and also decreased workload of caregivers. Statistically significant results from the study have shown that this bed, which has been built to turn a patient by use of a manual crank, is safe and can prevent PUs. Also, care givers have a high level of satisfaction in the use of a bed that can turn the patient. Continued development has thus been directed toward achieving greater efficiency and effectiveness in the prevention of PUs. The quality of the instruments was sought through a proposal presented to five qualified specialists, among them a professor of medicine with expertise in the care of patients with injuries, a skilled nurse with experience in the care of injured patients (Advanced Practitional Nurse: APN) and a professor of mechanical engineering, to test for safety, sturdiness and functionality according to the objective, design and suitability of the invented product.