What We Have Learned Over the Last Decade

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Maurice Walton
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1 What We Have Learned Over the Last Decade

2 IAD: A Relatively New Concept For many years, moisture/incontinence considered simply as a contributing factor to pressure ulcer development In 2007, consensus conference held to discuss issue of skin breakdown caused by exposure to stool and urine Term IAD introduced (now has widespread acceptance) Contributed to increased awareness that trunk wounds are caused by a variety of etiologic factors Top down superficial wounds usually caused by moisture and friction Deep bottom up wounds usually caused by pressure and shear Impact Increased recognition of IAD as separate from pressure ulcer Increasing number of studies into pathology, prevention and management IAD one type of Moisture Associated Skin Damage (MASD): another new concept

3 IAD and MASD Moisture Associated Skin Damage: skin damage caused primarily by exposure to moisture 4 main types identified to date: Incontinence Associated Dermatitis Intertriginous Dermatitis PeristomalMASD Periwound MASD Concept of moisture +??? Moisture makes skin more vulnerable Breakdown caused by irritants, pathogens, friction Gray M et al. (2011). MASD: Overview. JWOCN 38(3): 33-41

4 Definition of IAD IAD: inflammation of the skin caused by chronic or repeated exposure to urine or stool or both (external moisture source) Subcategory of Moisture Associated Skin Damage IAD, ITD, Peristomal MASD, Periwound MASD IAD and ITD IAD: inflammation 2 o exposure to stool and/or urine (and possibly friction) ITD: skin damage 2 o moisture trapped between skin folds, i.e., diaphoresis (and possibly friction)

5 Prevalence of IAD Common!!! 10 35% community dwelling adults (UI) 50% community dwelling adults with fecal incontinence LTC: up to 65% of patients with UI/FI 83% of ICU patients with incontinence IAD Best Practice Document; WOCN, 2011.

6 Significance of IAD Painful (and usually preventable!) Increases risk for friction damage (impact of overhydrated skin) Increases risk for pressure/shear damage

Pathology of IAD Overhydration(moisture): reduced tensile strength/ increased fragility and increased drag against sheets Repeated cleansing: loss of skin oils (impact) andprogressive removal

7 Pathology of IAD Overhydration(moisture): reduced tensile strength/ increased fragility and increased drag against sheets Repeated cleansing: loss of skin oils (impact) andprogressive removal skin cells Irritants and bacteria enter through gaps and cause inflammatory response Change in ph Impact of friction Gray M et al. (2012) IAD: Comprehensive Review & Update. JWOCN 39 (1):

8 Pathology of IAD Think of moisture (maceration) as the set-up guy: makes skin more vulnerable + factors cause actual skin loss: Mechanical trauma (cleansing/friction) Penetration by irritants/enzymes in stool and urine Invasion by fungal or bacterial agents

9 Risk Factors for IAD Frequent or prolonged exposure to stool (liquid versus solid) with or without urine Fragile skin (elderly patient, malnourished patient, patient on steroids, patient with multiple comorbidities) Functional/cognitive function Fever and diaphoresis Inappropriate use of absorptive products (occlusion) Aggressive cleansing/inappropriate care protocol Nix DH. Perineal Assessment Tool; OWM 2002: 48(2):

occlusion Avoid aggressive cleansing Replace lost

10 Prevention Program Goals: Keep skin healthy (dry, acidic, supple)/ maintain intact barrier Avoid occlusion Avoid aggressive cleansing Replace lost lipids Prevent or minimize contact between skin and urine/ stool

11 Goal # 1: Maintain Healthy Skin/ Intact Barrier Prevent maceration Use absorptive products only when essential Select products that wick (polymers) Avoid occlusion keep open when possible! Use moisture barrier to keep skin dry Change promptly

12 Goal # 1: Maintain Healthy Skin/ Intact Barrier: Cleanse correctly Assure gentle cleansing No scrubbing No picking Soft cloths versus standard wash cloths For fragile skin, think baby skin when providing care

13 Goal # 1: Maintain Intact Barrier: Moisturize Routinely Replace/maintain intercellular lipids (skin oils) ph-balanced cleansers Moisturizers/ emollients (oils, dimethicone, petrolatum, etc.)

ambulatory with assistance Perianal pouches or internal

14 Goal # 2: Minimize Contact Between Skin and Stool/Urine Toileting programs for pt who can respond to cues/is ambulatory with assistance Perianal pouches or internal bowel management systems for patient with high volume liquid stool

15 Goal # 2: Minimize Contact Between Skin and Stool/Urine Routine Use of Moisture Barriers (make skin more waterproof) Desirable characteristics: resistant to urine and stool; transparent; atraumaticapplication and removal; cost effective Major types: Petrolatum Dimethicone Zinc oxide Combinations Liquid barrier films

16 Types of Moisture Barriers Petrolatum-based products Moisturizer so contributes to intact skin barrier Good protection against urine & solid stool Less effective against liquid stool Atraumatic application and removal Transparent Occlusive/may transfer to absorptive product and block uptake of urine (importance thin vs thick layer) May not adhere to damaged skin (unless mixed with absorptive powders) Zehrer et al. Assessment of diaper-clogging potential of petrolatum moisture Barriers. Ostomy Wound Management 2005: 51(12),

17 Types of Moisture Barriers Dimethicone-based Products Moisturizer so contributes to intact skin barrier Effective against urine and solid stool Ineffective against liquid stool Nonocclusive/Non-greasy/Does not transfer to absorptive products Transparent Atraumatic removal Not intended as treatment for damaged skin

18 Types of Moisture Barriers Zinc-oxide based products Does not moisturize so does not contribute to intact barrier Effective against liquid stool Effective for damaged skin when combined with absorptive powder Most are thick/sticky/opaque can t assess skin status without removing product Difficult to apply and remove without causing trauma (use perineal cleanser) Practice tips: zinc-oxide impregnated gauze strips vs paste + clear thin cover dressing or combination products

19 Types of Moisture Barriers Combination Products (used to maximize advantages and minimize disadvantages): petrolatum-zinc oxide Petrolatum makes it easier to apply and remove the product (reduces trauma to damaged skin) Zinc oxide provides higher level protection

20 Types of Moisture Barriers Liquid barrier films (alcohol-free) Effective against urine and solid stool limited protection against liquid stool Less frequent application needed (lower cost) Clear so easy to assess skin Atraumatic fast application no removal required If skin damaged, must use in conjunction with absorptive powder (dust on powder; blot or spray with liquid barrier film) Can use in conjunction with ointments for protection against liquid stool (liquid film as base followed by ointment)

21 Summarizing Prevention Toileting/containment when feasible Use absorptive products selectively Avoid occlusive environment Change promptly following incontinent episode

22 Summarizing Prevention Skin Care Critical elements Gentle cleansing with ph-balanced cleanser ( cc ) Moisturizer(to replace skin lipids), especially when skin dry and fragile ( cc ) Use of moisture barrier(to water-proof skin) ( cc ) Frequency: limited evidence that Q 6 hr(& PRN) application protectants more effective than Q 12 hr (& PRN) Conley et al. (2014). Does skin care frequency affect severity of IAD in critically ill patients? Nursing 44(12):

23 Management IAD Mild moderate irritant dermatitis Severe irritant dermatitis Yeast dermatitis (candidiasis)

24 Management IAD Mild Irritant Dermatitis Indicators: Mild to moderate erythema Mild to moderate tenderness NO SKIN LOSS (inflammation of intact skin)

25 Management Mild IAD Goals: Reduce inflammation Prevent breakdown Strategies Initiate prevention If prevention protocol in effect, reevaluate! Effective products: liquid barrier films; petrolatum; combination products e.g., petrolatum + dimethicone

26 Management Severe IAD Characteristics: Severe erythema and tenderness Vesicle formation Epidermal loss Goals Promote healing Eliminate contact with irritants

27 Management Severe IAD Strategies Eliminate use of absorptive products if possible/strictly avoid occlusion Gentlecleansing High-level moisture barrier protection Zinc oxide usually best (careful removal) Liquid barrier film + powder + moisture barrier ointment

28 Management Severe IAD Alternative: BC ointment (balsam of peruand castor oil in ointment base): indicated for partial thickness skin loss/severe IAD Narayanan et al. Pressure ulcer treatment in LTC facilities, JWOCN 2005: 32(3),

29 Management Candidiasis Characteristics Maculopapular rash that is solid in center with distinct satellite lesions Typically pruritic and tender Goals Eradicate infection Promote healing

30 Management Candidiasis Strategies Moisture control (no occlusion; check & change Q 2h) ph-balanced cleanser Moisture barrier with antifungal (e.g., azole agent), OR crusting with antifungal powder + non-washable liquid barrier film OR antifungal powder + moisture barrier ointment

31 Selling the Program Increased focus: IAD is painful & preventable! Simple protocols/ combination products keys to consistency in care; e.g.,soft cloth impregnated with cleanser, moisturizer, moisture barrier = 1-step prevention Clever et al. Evaluating efficacy of uniquely delivered protectanton sacral/buttock pressure ulcers. Ostomy Wd Mgmt 48 (12), 2002.

32 Simple Protocol Considerations in formulary/protocol development: Minimize products: ph-balanced cleanser (or impregnated wipes) liquid barrier film or moisturizer-moisture barrier combination for routine protection; zinc oxide product for severe IAD antifungal for candidiasis Keep protocols SIMPLE!

33 Sample Protocol Cleanse with using GENTLE technique Apply appropriate barrier product: Skin intact: Clear Barrier Ointment daily and PRN (dimethicone/petrolatum?) Denuded skin (severe IAD): Ostomy powder + liquid barrier film daily and/or Zinc oxide ointment Q 6 12 hours and PRN Candidiasis:_ Antifungal powder + liquid barrier film Mon Wed Fri or Antifungal moisture barrier ointment daily and PRN Gray et al. IAD: Consensus. JWOCN 34(1), 2007 Doughty D et al. IAD consensus statements, guidelines, challenges. JWOCN 2012:

34 IAD vs ITD (Intertriginous Dermatitis) Definition ITD: skin damage caused by trapped perspiration and frictional forces between opposing skin surfaces Basic mechanism of injury: overhydrationof the skin leading to reduced tensile strength; friction or stretch leading to skin loss Damage involves skin layers and is top down Black J et al. MASD Part 2: IAD and ITD: Consensus. WOCN 2011: 38 (4):

35 Characteristics ITD Location: base of body folds (natal cleft; groin creases; etc) Risk factor/exposure: trapped moisture (perspiration) Depth/contours: linear break vs kissing lesions Surrounding skin macerated

technique when cleansing/inspecting skin at base of folds Black

36 ITD: Prevention Use of product that wicks moisture and separates skin folds Support surface with low volume air flow GENTLE technique when cleansing/inspecting skin at base of folds Black J et al. MASD Part 2: IAD and ITD: consensus. JWOCN 38(4): , 2011.

37 ITD: Management Moisture management Dressing that maintains moist wound surface and separation of opposing skin surfaces Adhesive foam Hydrocolloid Zinc oxide ointment + soft folded gauze to provide separation

IAD vs Pressure Ulcer Definition: Localized injury to skin and/or underlying tissue, usually over a bony prominence, as result of pressure and/ or shear Mechanism(s) of injury

38 IAD vs Pressure Ulcer Definition: Localized injury to skin and/or underlying tissue, usually over a bony prominence, as result of pressure and/ or shear Mechanism(s) of injury Ischemia/reperfusion injury Primary disruption muscle cells Current evidence: bottom-up injury EPUAP/NPUAP: Pressure Ulcer Guidelines, Bryant R Nix D: Acute and Chronic Wounds, Elsevier Mosby, 2012.

Characteristics Pressure Ulcers Location:

39 Characteristics Pressure Ulcers Location: Over bony prominences Under medical devices Fleshy prominences (?) Risk Factors/ History: Immobility/inactivity Sensory loss/sedation Depth: usuallyfull thickness lesions (damage begins in deep tissue layers)

etiology pressure + shear Wound Bed: necrotic tissue common

40 Characteristics Pressure Ulcers Contours/Edges Defined edges Round/oval if etiology pressure alone Elongated with undermining if etiology pressure + shear Wound Bed: necrotic tissue common (ischemic pathology) Bryant R Nix D. Acute and Chronic Wounds, Elsevier Mosby, 2012.

41 Summary Keys to Success in IAD Prevention and Management Appropriate products (not too many!) Clear simple protocols Ongoing staff education and consciousness raising Bowel/Bladder champions?

Clinical Aspects of Microclimate

Clinical Aspects of Microclimate Margaret Goldberg, MSN, RN, CWOCN 2016 National Pressure Ulcer Advisory Panel www.npuap.org 1 Microclimate Local temperature and moisture at body/ support surface interface