incontinence associated dermatitis by prof dr mikel gray

IncontinenceIncontinenceAssociated DermatitisAssociated Dermatitis

Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANMikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANProfessor & Nurse PractitionerProfessor & Nurse Practitioner

University of Virginia Department of UrologyUniversity of Virginia Department of Urology

Anatomy & PhysiologyAnatomy & Physiology

Largest organ (6 pounds or 3,000 sq inches); itsLargest organ (6 pounds or 3,000 sq inches); itsthickness varies from 0.5mm thickness varies from 0.5mm –– 6 mm 6 mm

Functions:Functions:–– BarrierBarrier: against toxins in external environment and for: against toxins in external environment and for

the prevention of excessive fluid & electrolyte lossthe prevention of excessive fluid & electrolyte lossfrom internal environmentfrom internal environment

–– ThermoregulationThermoregulation–– Sensory organ/ communicationSensory organ/ communication–– Immune functionsImmune functions–– Vitamin D metabolismVitamin D metabolism

Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell ScienceBurns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science

Moisture barrier of the skinMoisture barrier of the skin

–– Stratum corneum: Stratum corneum: deaddeadkeratinocytes or corneocyteskeratinocytes or corneocytes

–– Lipid matrixLipid matrix: slows: slowsmovement of water &movement of water &electrolyteselectrolytes

–– WaterWater: hydrates corneocytes: hydrates corneocytes–– pHpH: (usually 5.0-5.9) forms: (usually 5.0-5.9) forms

an acid mantlean acid mantle–– Bacterial floraBacterial flora: competes: competes

with pathogens to preventwith pathogens to preventinfectioninfection

–– TemperatureTemperature: regulates: regulatespermeabilitypermeability

How do Clinicians & ResearchersHow do Clinicians & ResearchersMeasure the skinMeasure the skin’’s Moisture Barrier?s Moisture Barrier?

No clinical test for measuringNo clinical test for measuringmoisture barriermoisture barrier

Researchers measureResearchers measureTransepidermal water lossTransepidermal water loss (TEWL); (TEWL);which is the rate of which is the rate of passive diffusionpassive diffusionof Hof H220 from internal environment 0 from internal environment totoexternal environment (differs fromexternal environment (differs fromperspiration)perspiration)

The perineal skin and scrotum haveThe perineal skin and scrotum havethe highest TEWL os any surfaces ofthe highest TEWL os any surfaces ofthe body, skin over back is thethe body, skin over back is thelowestlowest

Loffler H, Loffler H, HautarztHautarzt. 50(11):769-78, 1999. 50(11):769-78, 1999

Perineal Skin at thePerineal Skin at theExtremes of LifeExtremes of Life

Barrier function in the neonateBarrier function in the neonate–– Less robust than adults, Less robust than adults, particularlyparticularly premature infants premature infants

Higher TEWLHigher TEWL Higher rates of percutaneous absorptionHigher rates of percutaneous absorption Greater risk for erosion, stripping, pressure injuryGreater risk for erosion, stripping, pressure injury

–– Cornification of skin begins about GW 20Cornification of skin begins about GW 20–– VernixVernix contains FFA, cholesterol & ceramides, thus acting as contains FFA, cholesterol & ceramides, thus acting as

proxy while skin developsproxy while skin develops–– Full-term skin contains 10-20 layers of stratum corneum, skinFull-term skin contains 10-20 layers of stratum corneum, skin

in premature baby has 2-3in premature baby has 2-3

Lund C et al. JOGNN 1999; 28(3): 241.Lund C et al. JOGNN 1999; 28(3): 241.

Perineal Skin at thePerineal Skin at theExtremes of LifeExtremes of Life

Aging Skin: gradual declineAging Skin: gradual declinein barrier functionin barrier function–– ↑↑ TEWLTEWL–– Overall thickness declinesOverall thickness declines–– ↓↓ Collagen & elastinCollagen & elastin–– Local changes in capillaryLocal changes in capillary

beds reflect systemicbeds reflect systemicchanges inchanges inmicrocirculationmicrocirculation

GhadiallyGhadially R. American J Contact Dermatitis 1998; 9(3): 162. R. American J Contact Dermatitis 1998; 9(3): 162.

Searching for an appropriate name:Searching for an appropriate name:Perineal Dermatitis?Perineal Dermatitis?

PerineumPerineum: region between the thighs, in the female: region between the thighs, in the femalebetween the vulva and the anus, in males, between thebetween the vulva and the anus, in males, between thescrotum and the anusscrotum and the anus11

DermatitisDermatitis: inflammation of the skin: inflammation of the skin11, itself a broad term, itself a broad termmay be divided intomay be divided into22

–– Atopic (eczema)Atopic (eczema)–– AllergicAllergic–– IrritantIrritant

–– Multiple other terms used, dermatoses used to describeMultiple other terms used, dermatoses used to describe““well defined endogenous skin dysfunctionwell defined endogenous skin dysfunction””22

1. Online Medical Dictionary, 1. Online Medical Dictionary, http://cancerweb.ncl.ac.uk/cgi-bin/omd?actionhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?action==Home&queryHome&query

2. Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science.2. Burns T et al. Textbook of Dermatology, 2004. Mass: Blackwell Science.

Searching for an appropriate name:Searching for an appropriate name:Diaper or Nappy Dermatitis?Diaper or Nappy Dermatitis?

StrengthsStrengths–– Clearly associated with incontinence and use ofClearly associated with incontinence and use of

one type of containment device, infant diaperone type of containment device, infant diaper(often called nappy in UK) or adult(often called nappy in UK) or adultcontainment briefcontainment brief

LimitationsLimitations–– Unfairly blames one type of containmentUnfairly blames one type of containment

device as cause of the problem itselfdevice as cause of the problem itself–– Possible pejorative interpretation when appliedPossible pejorative interpretation when applied

to adultsto adults

Searching for an appropriate name:Searching for an appropriate name:Incontinence Associated DermatitisIncontinence Associated Dermatitis

Name selected from alternatives at Name selected from alternatives atconsensus conference held in Chicago,consensus conference held in Chicago,IL summer of 2005, results of conferenceIL summer of 2005, results of conferencepublished in JWOCN, 2007published in JWOCN, 200711

Describes etiology and outcome ofDescribes etiology and outcome ofconditioncondition

* Supported by unrestricted educational grand from SAGE, Inc.* Supported by unrestricted educational grand from SAGE, Inc.

1. Gray M, Bliss DZ, Doughty DB< 1. Gray M, Bliss DZ, Doughty DB< Ermer-SeltunErmer-Seltun K, Kennedy-Evans KL, Palmer MH. JWOCN K, Kennedy-Evans KL, Palmer MH. JWOCN34(1): 57-69.34(1): 57-69.

Moisture Associated Skin DamageMoisture Associated Skin Damage(MASD)(MASD)

IAD is part of larger etiological frameworkIAD is part of larger etiological frameworkcalled MASDcalled MASD–– IntertrigoIntertrigo: inflammation in skin folds related to: inflammation in skin folds related to

perspiration, friction and bacterial/ fungalperspiration, friction and bacterial/ fungalbioburdenbioburden

–– Periwound macerationPeriwound maceration: skin breakdown from: skin breakdown fromwound exudate, related to volume, constituentswound exudate, related to volume, constituentsor exudate & bacterial bioburdenor exudate & bacterial bioburden

–– IADIAD: urine, stool, containment device, secondary: urine, stool, containment device, secondarycutaneous infection cutaneous infection –– typically fungal typically fungal

Epidemiology of IADEpidemiology of IAD

Long-term care literature reportsLong-term care literature reports–– Prevalence of 5.6%-50%Prevalence of 5.6%-50%–– Incidence of 3.4%-25%Incidence of 3.4%-25%

Acute-careAcute-care–– Incontinence prevalence: 20%Incontinence prevalence: 20%–– IAD prevalence was 10.9% of the generalIAD prevalence was 10.9% of the general

hospital populationhospital population–– IAD prevalence was 54% in IAD prevalence was 54% in incontinentincontinent

patients in 3 acute-care hospitalspatients in 3 acute-care hospitalsLyder, et al., 1992; Bale, et al., 2004; Bliss, et al., 2005; Junkin, More-Lisi, Lyder, et al., 1992; Bale, et al., 2004; Bliss, et al., 2005; Junkin, More-Lisi, SelekofSelekof, 2005, 2005

2005 IAD Prevalence Study2005 IAD Prevalence Study

976 Total number of

patients surveyed

35% had Foley catheter

(deemed continent)

20.3% (198) prevalence of incontinenceurine or stool

• 27% had IAD• 33% had a pressure

ulcer• 18% had a probable

fungal Infection

21% had more than 1 type of injury

Junkin J, Junkin J, SelekofSelekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN. J. IAD prevalence in acute care. WOCN National Conference, June 2006 Minneapolis, MN.

IAD: Effect of Urine on SkinIAD: Effect of Urine on Skin

WaterWater: decreases skin: decreases skinhardness, renders it morehardness, renders it moresusceptible to friction andsusceptible to friction anderosionerosion

AmmoniaAmmonia: raises pH,: raises pH,promotes pathogenicpromotes pathogenicgrowth, disrupts acidgrowth, disrupts acidmantle, activates fecalmantle, activates fecalenzymes, alters normalenzymes, alters normalflora of skinflora of skin

Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9Gray M. Journal of WOC Nursing 2004; 31(1 Suppl):S2-9 .

Impact of Stool on SkinImpact of Stool on Skin

Intestinal colonization acts as a reservoir forIntestinal colonization acts as a reservoir forpotential pathogenic substancespotential pathogenic substances11

–– VREVRE–– MRSAMRSA–– Clostridium difficileClostridium difficile–– Antibiotic resistant Antibiotic resistant Staphylococcus aureusStaphylococcus aureus–– Multiple other antimicrobial resistant gram-Multiple other antimicrobial resistant gram-

negative bacillinegative bacilli

SteifelSteifel & & DoskeyDoskey, 2004; Current Infectious Disease Report 2004; 6:420., 2004; Current Infectious Disease Report 2004; 6:420.


Disruption of the usual microflora providesDisruption of the usual microflora providesopportunity for pathogenic colonizationopportunity for pathogenic colonization11

–– Normal colon: 10Normal colon: 101212 CFU per Gm with obligate CFU per Gm with obligateanaerobe counts exceeding parasitic organismsanaerobe counts exceeding parasitic organisms~~1000:1; important defense against pathogens1000:1; important defense against pathogens

–– Antimicrobials that are excreted into the intestinalAntimicrobials that are excreted into the intestinaltract disrupt this balancetract disrupt this balance

–– Result in skin contamination in 83% andResult in skin contamination in 83% andenvironmental surface contamination in 67%,environmental surface contamination in 67%,diarrhea and fecal incontinence magnify riskdiarrhea and fecal incontinence magnify risk22

1.1. SteifelSteifel & & DoskeyDoskey, 2004; Current Infectious Disease Report 2004; 6:420., 2004; Current Infectious Disease Report 2004; 6:420.2.2. DonskeyDonskey et al. NEJM 2000; 343: 1925. et al. NEJM 2000; 343: 1925.


Disruption of gastric acid content in stomachDisruption of gastric acid content in stomach–– Healthy individual: >99% of coliform bacteriaHealthy individual: >99% of coliform bacteria

ingested killed within 30 minutes because ofingested killed within 30 minutes because ofgastric acid secretiongastric acid secretion11

–– Use of medications that inhibit stomach acidUse of medications that inhibit stomach acidproduction associated with production associated with C. difficileC. difficile, , S. aureusS. aureus,,VRE and antibiotic resistant gam negativeVRE and antibiotic resistant gam negativeinfectionsinfections22

1.Donskey, Clinical infectious Disease 2004; 39: 219.1.Donskey, Clinical infectious Disease 2004; 39: 219.2. Cunningham et al., J. Hospital Infection 2003; 36: 149.2. Cunningham et al., J. Hospital Infection 2003; 36: 149.

PathophysiologyPathophysiology

Use of absorptive containment devicesUse of absorptive containment devices–– Exacerbate overhydration by promoting perspirationExacerbate overhydration by promoting perspiration

& retaining urine and stool; & retaining urine and stool; with padding alonewith padding alone:: TEWL increases 3-4 fold within daysTEWL increases 3-4 fold within days COCO22 emission increases > 4 fold emission increases > 4 fold pH increases from 4.4 to 7.1 (pH increases from 4.4 to 7.1 (withoutwithout incontinence) incontinence)

–– Emerging data supports direct role in PU riskEmerging data supports direct role in PU risk……

1. Grove GL et al. Clinical Problems in Dermatology 1998; 26:1831. Grove GL et al. Clinical Problems in Dermatology 1998; 26:1832. 2. ZimmererZimmerer RE et al. Pediatric Dermatology 1986; 3: 95. RE et al. Pediatric Dermatology 1986; 3: 95.3. 3. ZhaiZhai H et al. Skin Research & Technology 2002; 8:13. H et al. Skin Research & Technology 2002; 8:13.

IAD & Pressure UlcerationIAD & Pressure Ulceration

Precise nature of association not understoodPrecise nature of association not understood Fecal incontinence strongly associated with PUFecal incontinence strongly associated with PU

risk, UI is notrisk, UI is not1-41-4

Analysis rarely based on PU stage, few articles Analysis rarely based on PU stage, few articlesthat use stage associate FI/ UI with stage I & IIthat use stage associate FI/ UI with stage I & II33

Both FI & UI associated with increased time andBoth FI & UI associated with increased time andcost to wound healingcost to wound healing55

1. 1. MaklebustMaklebust J & Magnan MA Advances in Wound Care 1994; 7(6): 25. J & Magnan MA Advances in Wound Care 1994; 7(6): 25.2. 2. GunninbergGunninberg L. Journal of Wound Care 2004; 13(7): 286. L. Journal of Wound Care 2004; 13(7): 286.3. Fader M et al. Journal of Clinical Nursing 2003; 12(3):374.3. Fader M et al. Journal of Clinical Nursing 2003; 12(3):374.4. 4. BerlowitzBerlowitz DR et al. Journal of the American Geriatrics Society 2001; 49(7):866-71. DR et al. Journal of the American Geriatrics Society 2001; 49(7):866-71.5. NarayanNarayan S et al. S et al. JounalJounal of WOCN 2005; 32(3): 163. of WOCN 2005; 32(3): 163.

IAD & Pressure UlcerationIAD & Pressure Ulceration

Does FI or UI Does FI or UI indirectlyindirectly contribute to pressure contribute to pressureulcer risk?ulcer risk?–– Skin wetted with synthetic urine or water shows aSkin wetted with synthetic urine or water shows a

significant decrease in hardness, temperature, andsignificant decrease in hardness, temperature, andblood flow during pressure load when compared toblood flow during pressure load when compared todry sitesdry sites11

–– Absorbent products may Absorbent products may enhanceenhance the risk for the risk forpressure ulceration by creating areas of increasedpressure ulceration by creating areas of increasedinterface pressure, even when used in conjunctioninterface pressure, even when used in conjunctionwith a pressure reducing or relieving devicewith a pressure reducing or relieving device22

1. 1. MayrovitzMayrovitz HN, Sims N Adv Skin Wound Care 2001;14(6):302. HN, Sims N Adv Skin Wound Care 2001;14(6):302.

2. Fader M et al. Journal of Advanced Nursing 2004; 48(6): 569.2. Fader M et al. Journal of Advanced Nursing 2004; 48(6): 569.

PathophysiologyPathophysiology

Epidermis

Dermis

Hypodermis

Normal skin

Irritants PerspirationUrine

Stool (especially liquid)Exudate / Effluent

Penetration of irritants

ElevatedTEWL

Altered pH

Inflammation

Redness

Swelling

Release ofcytokines

Inflammation

Cracking ofskin

Denudation

Erosion (denudation)of skin

Screen for Redness, InflammationScreen for Redness, Inflammation

IAD: DiagnosisIAD: Diagnosis


Inspect the skin forInspect the skin forerythema, redness,erythema, redness,cracking, swelling,cracking, swelling,vesiclesvesicles

Determine locationDetermine locationof skin damage of skin damage ––does it lie in skindoes it lie in skinfold or over bonyfold or over bonyprominence,prominence,underneathunderneathcontainmentcontainmentdevice?device?


Look in Skin FoldsLook in Skin Folds–– Opposing skin surfaces trapOpposing skin surfaces trap

moisturemoisture–– Warm moist environmentWarm moist environment

encourages bacterial andencourages bacterial andfungal colonization,fungal colonization,overgrowth and infectionovergrowth and infection

–– Friction created as skin foldsFriction created as skin foldsrub against one anotherrub against one another


Look for erosion ofLook for erosion ofskinskin

Partial thicknessPartial thicknesserosion commonerosion common

Full thickness woundFull thickness woundimplies pressure orimplies pressure orshear and pressureshear and pressureulcerationulceration


Look for secondaryLook for secondarycutaneous infection,cutaneous infection,especially candidiasisespecially candidiasis–– Opportunistic infectionOpportunistic infection

with with candida albicanscandida albicans–– Thrives in warm, moistThrives in warm, moist

environment & damagesenvironment & damagesstratum corneumstratum corneum

–– Seen in 18% of one groupSeen in 18% of one groupof 976 acute careof 976 acute careinpatientsinpatients11

1. Junkin J, 1. Junkin J, SelekofSelekof J. IAD prevalence in acute care. WOCN National Conference, June 2006 J. IAD prevalence in acute care. WOCN National Conference, June 2006Minneapolis, MN.Minneapolis, MN.

Differentiate MASD fromDifferentiate MASD fromPressure UlcerationPressure Ulceration

Gray M et al. JWOCN 2007; 34(2):.Gray M et al. JWOCN 2007; 34(2):.

What type of skin damage?What type of skin damage?

IAD: PreventionIAD: Prevention

Principles of Prevention: 1) cleanse, 2)Principles of Prevention: 1) cleanse, 2)moisturize, 3) protectmoisturize, 3) protect–– Gentle cleansing: Gentle cleansing: NO scrubbingNO scrubbing–– Select a cleanserSelect a cleanser with acceptable pHwith acceptable pH

& no irritants& no irritants–– Moisturize dried areas to maximizeMoisturize dried areas to maximize

lipid barrierlipid barrier–– Apply moisture barrier as indicatedApply moisture barrier as indicated

HospitalHospitalWashclothWashcloth Vs.Vs.

DisposableDisposableWashclothWashcloth

Basin Sage

Preventive Skin Care:Preventive Skin Care:CleanseCleanse

Soap & WaterSoap & Water–– What is the clinical evidence for soap &What is the clinical evidence for soap &

water as a perineal skin cleanserwater as a perineal skin cleanser alkaline pH raises pH more than cleansing withalkaline pH raises pH more than cleansing with

pH pH ‘‘balancedbalanced’’ cleansers; alkaline pH associated cleansers; alkaline pH associatedwith skin irritation and severity of IADwith skin irritation and severity of IAD11

cleansing requires significantly more time thancleansing requires significantly more time thanwith cleanserswith cleansers1,21,2

2 small RCT have not demonstrated greater risk 2 small RCT have not demonstrated greater riskfor dermatitis in frail elder patientsfor dermatitis in frail elder patients1,21,2

1. Byers et al. JWOCN, 1995, 187.1. Byers et al. JWOCN, 1995, 187.2. Lewis-Byers et al. OWM, 2002, 44.2. Lewis-Byers et al. OWM, 2002, 44.

Preventive Skin Care:Preventive Skin Care:CleanseCleanse

Incontinence skin cleansersIncontinence skin cleansers–– ‘‘pH BalancedpH Balanced’’ designed to maintain the designed to maintain the

acid mantle of perineal skinacid mantle of perineal skin–– Many described as Many described as ““no rinseno rinse”” (no water (no water

required)required)–– Require Require significantly less timesignificantly less time than than

traditional cleansing with soap and watertraditional cleansing with soap and water–– Many contain emollients (skin softeners) orMany contain emollients (skin softeners) or

moisturizers to preserve lipid barrier, thusmoisturizers to preserve lipid barrier, thuscombining 2 steps into a single actioncombining 2 steps into a single action

Preventive Skin Care:Preventive Skin Care:Perineal Skin CleansersPerineal Skin Cleansers

Humectant acts asHumectant acts asmoisture barriermoisture barrier

Cleanser, moisturizer,Cleanser, moisturizer,humectanthumectant

CavilonCavilon Cleanser Cleanser

Labeled as Labeled as ““SkinSkincare lotioncare lotion””

Cleanser, moisturizer*,Cleanser, moisturizer*,emollient, moisture barrieremollient, moisture barrier

CavilonCavilon 1-step 1-step

No scents, noNo scents, nopreservativespreservatives

Cleanser, emollient,Cleanser, emollient,moisturizermoisturizer

SensiSensi-care-care

3-n-1 adds3-n-1 addsemollient, lemonemollient, lemonscentedscented

Cleanser, moisturizer* (aloeCleanser, moisturizer* (aloevera), emollientvera), emollient

Aloe-Vesta 2-n-1Aloe-Vesta 2-n-1and 3- n-1and 3- n-1

NotesNotesKey ComponentsKey ComponentsProductProduct



Wash has Wash has ““herbalherbal””fragrance, AB hasfragrance, AB has““deodorizerdeodorizer””

P Wash: cleanser, vit. E,P Wash: cleanser, vit. E,moisturizer*,moisturizer*,antibacterial in oneantibacterial in onepreparationpreparation

Provon PerinealProvon PerinealWash &Wash &AntibacterialAntibacterial

No alcohol, fragrances,No alcohol, fragrances,preservatives, dyespreservatives, dyes

Cleanser, moisturizerCleanser, moisturizerPerigenePerigene

““Fresh fruitFresh fruit”” fragrance fragranceCleanser, moisturizer*Cleanser, moisturizer*Peri-FreshPeri-Fresh

Advocates use asAdvocates use asshampoo as wellshampoo as well

Cleanser, moisturizerCleanser, moisturizerDermaRiteDermaRite 3 in 1 3 in 1



Antiseptic, fragranceAntiseptic, fragrance(deodorizer)(deodorizer)

Cleanser, benzethoniumCleanser, benzethoniumchloridechloride

Peri-wash IIPeri-wash II

Dispensed as foam, mildDispensed as foam, mildfragrancefragrance

Cleanser, moisturizerCleanser, moisturizerCarafoamCarafoam skin & skin &perineal cleanserperineal cleanser

3-n-1 product with3-n-1 product withantimicrobial agentantimicrobial agent

Cleanser, moisturizer,Cleanser, moisturizer,emollient, benzalkoniumemollient, benzalkoniumchloridechloride

Remedy 4-n-1Remedy 4-n-1antimicrobialantimicrobialcleansercleanser

3-n-1 product3-n-1 productCleanser, moisturizer,Cleanser, moisturizer,emollientemollient

Restore Clean &Restore Clean &MoistMoist

Preventive Skin Care andPreventive Skin Care andContemporary AssessmentContemporary Assessment

Comfort Bath:Comfort Bath:cleanser &cleanser &moisturizermoisturizer

Deodorant ComfortDeodorant ComfortBath: cleanser,Bath: cleanser,moisturizer &moisturizer &deodorizing agentdeodorizing agent((ExopherylExopheryl™™))

Preventive Skin CarePreventive Skin Care

Typical ProtocolTypical Protocol–– Routine daily cleansing forRoutine daily cleansing for

everyoneeveryone–– Cleanse & moisturize withCleanse & moisturize with

each major incontinenteach major incontinentepisodeepisode

–– Apply moisture barrier forApply moisture barrier forsignificant UI, fecal or doublesignificant UI, fecal or doubleincontinenceincontinence

–– Comfort Shield: cleanser,Comfort Shield: cleanser,moisturizer, 3% moisturizer, 3% dimethiconedimethiconeskin skin protectantprotectant

Risk FactorsRisk Factorsfor Pressure Ulcer Developmentfor Pressure Ulcer Development

JoAnn Maklebust, MSN, RN, CS, NP and Morris A. Magnan, MSN, RN,“Risk Factors Associated with Having a Pressure Ulcer: A Secondary Data Analysis”, Advances in Wound Care, November 1994

“…The odds of having a pressure ulcer were

22 times greater for hospitalized adult patients

with fecal incontinence compared to hospitalized

patients without fecal incontinence…and 37.5 times

greater in patients who had both impaired mobility

and fecal incontinence”

Facts About Pressure UlcersFacts About Pressure Ulcers

80% of pressure ulcers in hospital are Stage I or Stage II.80% of pressure ulcers in hospital are Stage I or Stage II.11

Almost half of all pressure ulcers form on the sacrum (36.9%) andAlmost half of all pressure ulcers form on the sacrum (36.9%) andischium (8.0%).ischium (8.0%).22

A healthcare facility will spend between $400K and $700KA healthcare facility will spend between $400K and $700Kannually on pressure ulcer treatment.annually on pressure ulcer treatment.33

JACHO lists prevention of health care associated pressure ulcersJACHO lists prevention of health care associated pressure ulcersas a patient safety goal.as a patient safety goal.44

1. Whittington KT, Briones R, “National Prevalence and Incidence Study: 6-Year Sequential Acute Care Data,” Adv Skin Wound Care.2004 Nov/Dec;17(9):490-4. 2. Amlung SR, Miller WL, Bosley LM, Adv. Skin Wound Care. 2001 Nov/Dec; 14(6): 297-301. 3.Robinson, C; Gioekner, M; Bush, S; Copas, J; et al. Determining the efficacy of a pressure ulcer prevention program by collectingprevalence and incidence data: a unit-based effort. Ostomy Wound Manage. 2003. May: 49(5):44-6. 48-51. 4.http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_ltc_npsgs.htm

“Evaluating the Efficacy of a Uniquely Delivered Skin Protectantand Its Effect on the Formation of Sacral/Buttock Pressure Ulcers”*

*Comfort Shield® was used on all incontinent patients and was the only variable changed from the control period.

Clever et al. - Pressure Ulcer StudyClever et al. - Pressure Ulcer Study

Average Monthly Incidence of Sacral/Buttock Pressure Ulcers

Old Standard of Care

7/00 – 3/01

New Standard of Care

5/01 – 7/01

2/02 – 4/02

Old standard of care vs.using Comfort Shield®

as preventative in newstandard of care

Reduction in IncidenceOf sacral/buttock pressure

ulcers0.5%

4.7%

Clever K, Smith G, Bowser C, Monroe KLong-Term Care Unit, Fulton County Medical Center, McConnellsburg, PA, Ostomy/Wound Management. Dec 2002;48(12):60-7.

Group AGroup A = Cleansing spray, washcloths, skin barrier = Cleansing spray, washcloths, skin barrier (multi- step process and the current practice). (multi- step process and the current practice). Group BGroup B = Shield Barrier Cloths. = Shield Barrier Cloths. Group CGroup C = Disposable washcloth without dimethicone. = Disposable washcloth without dimethicone.

““The Development of Cost-EffectiveThe Development of Cost-EffectiveQuality Care for the Patient withQuality Care for the Patient withIncontinenceIncontinence””

Dieter L, Drolshagen C, Blum K, Cost-effective, quality care for the patient with incontinence. Research Poster Abstract presented atWOCN , Minneapolis, MN June 2006

http://www.sageproducts.com/education/shSymposiaPres.asp

Results:• Group A = $6.13 per patient per day; 10% skin breakdown.• Group B = $5.40 per patient per day; 8% skin breakdown.• Group C = Discontinued in week 4 due to 29% skin breakdown.• 2003 72 consults due to IAD and 2004 10 consults due to IAD.

Program, guidelines and algorithm for clinicalProgram, guidelines and algorithm for clinicaldecision making to include: Protection, Treatmentdecision making to include: Protection, Treatmentand Containment devices.and Containment devices.

33% of hospitalized patients have fecal incontinence.33% of hospitalized patients have fecal incontinence. Fecal Incontinence increases PU risk 22 times andFecal Incontinence increases PU risk 22 times and

30% if immobile.30% if immobile. Shield Barrier cloths for prevention of IAD;Shield Barrier cloths for prevention of IAD;

Xenaderm for Treatment of IAD and guidelines forXenaderm for Treatment of IAD and guidelines forexternal and internal fecal containment devicesexternal and internal fecal containment devices..

““Developing a Comprehensive FecalDeveloping a Comprehensive FecalIncontinence Management ProgramIncontinence Management Program……(for IAD)(for IAD)””

Gray DP, Developing a comprehensive fecal incontinence management program.Practice Innovation Poster Abstract presented at WOCN, Minneapolis, MN June 2006.

http://www.sageproducts.com/education/shSymposiaPres.asp

Treat Underlying IncontinenceTreat Underlying Incontinence

Consider Diversion ofConsider Diversion ofStool When IndicatedStool When Indicated

Anal PouchAnal Pouch–– Synthetic, adhesiveSynthetic, adhesive

skin barrier attached toskin barrier attached topouchpouch

Bowel ManagementBowel ManagementSystemSystem–– ZassiZassi BMS or BMS or FlexisealFlexiseal

Nasal TrumpetNasal Trumpet–– Off label useOff label use

Treat Underlying IncontinenceTreat Underlying Incontinence

Temporary Diversion for UI:Temporary Diversion for UI:Indwelling CatheterIndwelling Catheter–– IndicationsIndications

UI complicated by urinary retention,UI complicated by urinary retention,obstruction & only when CIC not feasibleobstruction & only when CIC not feasible

Stage 3-4 PU for transient diversion onlyStage 3-4 PU for transient diversion only

–– Selection criteriaSelection criteria Silicone or LubricathSilicone or Lubricath Smaller French sizeSmaller French size

SluserSluser Study Study –– Consistent Treatment Consistent Treatment

IAD: TreatmentIAD: Treatment

GoalsGoals–– Establish or continue cleansing/Establish or continue cleansing/

moisturization/ skin barrier programmoisturization/ skin barrier program–– Restore epidermal integrityRestore epidermal integrity–– Minimize exposure to irritants (ManageMinimize exposure to irritants (Manage

UI or Fecal incontinence)UI or Fecal incontinence)–– Treat secondary cutaneous infectionsTreat secondary cutaneous infections–– Create environment for wound healingCreate environment for wound healing


Inert Skin BarriersInert Skin Barriers–– Deflect drainage andDeflect drainage and

provides moistureprovides moisturebarrierbarrier

Most commonMost commoncontaincontain–– PetrolatumPetrolatum–– DimethiconeDimethicone–– Zinc oxideZinc oxide


Inert moisture barriersInert moisture barriers–– No evidence base couldNo evidence base could

be identified supportingbe identified supportingefficacy for existing IADefficacy for existing IAD

–– Ample anecdotalAmple anecdotalevidence supports role inevidence supports role inmild to moderate cases inmild to moderate cases inoutpatient/ home settingoutpatient/ home setting

–– Disadvantages includeDisadvantages includeremoval (zinc oxide inremoval (zinc oxide inparticular)particular)


Topical DressingsTopical Dressings–– HydrocolloidsHydrocolloids–– Thin film dressingsThin film dressings

Act as barrier to urine &Act as barrier to urine &stoolstool

Promote moist environmentPromote moist environmentfor wound healingfor wound healing

Can be combined withCan be combined withtopical treatmentstopical treatments


Topical DressingsTopical Dressings–– Maintaining adherenceMaintaining adherence

significant challengesignificant challenge–– Skin surfaces complexSkin surfaces complex–– Borders often roll whenBorders often roll when

ointments orointments ormoisturizing productsmoisturizing productshave been appliedhave been applied

–– Undermining of urineUndermining of urineor stool may occuror stool may occur


BCT agentsBCT agents BCT Ointment (Xenaderm)BCT Ointment (Xenaderm)

–– Balsam Peru, Castor Oil, Trypsin inBalsam Peru, Castor Oil, Trypsin inointment baseointment base

–– Applied to dermatitis twice daily or withApplied to dermatitis twice daily or withmajor cleansingmajor cleansing

BCT gel (BCT gel (OptaseOptase)) NOTENOTE: FDA has ruled out further: FDA has ruled out further

reimbursement pending documentationreimbursement pending documentationof efficacyof efficacy

IAD Treatment:IAD Treatment:Secondary ComplicationsSecondary Complications

CandidiasisCandidiasis–– Topical antifungals are effective for theTopical antifungals are effective for the

treatment of cutaneous infectionstreatment of cutaneous infections–– Effective agents include the polyeneEffective agents include the polyene

antibiotics, azoles and the allylaminesantibiotics, azoles and the allylamines11

–– Resistance to antifungals is emerging,Resistance to antifungals is emerging,careful monitoring of research literature iscareful monitoring of research literature isessentialessential

1. Evans & Gray, JWOCN, 30(1), 20031. Evans & Gray, JWOCN, 30(1), 2003

IAD and IHI as it relates to SageIAD and IHI as it relates to Sage

Facilities need to follow the Six ElementsFacilities need to follow the Six Elementsof Pressure Ulcer Prevention (from IHI)of Pressure Ulcer Prevention (from IHI)–– AsssessAsssess the skin upon admission the skin upon admission–– Reassess the skin dailyReassess the skin daily–– Inspect the skin dailyInspect the skin daily–– Manage moistureManage moisture–– Optimize nutrition and hydrationOptimize nutrition and hydration–– Minimize pressureMinimize pressure

Provide supplies at the Provide supplies at the bedside bedside of each at-risk patient who isof each at-risk patient who isincontinent. This provides the staff with the supplies that they need toincontinent. This provides the staff with the supplies that they need toimmediately clean, dry, and protect the patientimmediately clean, dry, and protect the patient’’s skin after eachs skin after eachepisode of incontinence.episode of incontinence.

Provide under-padsProvide under-pads that pull the moisture away from the skin, and that pull the moisture away from the skin, andlimit the use of disposable briefslimit the use of disposable briefs or containment garments if at all or containment garments if at allpossiblepossible..

Provide Provide pre-moistened, disposable barrier wipespre-moistened, disposable barrier wipes to help cleanse, to help cleanse,moisturize, deodorize, and protect patients from moisturize, deodorize, and protect patients from perinealperineal dermatitis dermatitisdue to incontinence.due to incontinence.

Summary: Manage Moisture: Summary: Manage Moisture: Keep Keepthe Patient Drythe Patient Dry and Moisturize Skinand Moisturize Skin

http://www.ihi.org/IHI/Programs/Campaign/

incontinence associated dermatitis by prof dr mikel gray

Health & Medicine