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Practical Issues in Wound, Skin and Ostomy Management
By: Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA
Maggot therapy is the controlled, therapeutic application of maggots to a wound. Simple to use, it provides rapid, precise, safe, and powerful debridement. Many wound care professionals don’t provide maggot therapy (also called wound myiasis) because they lack training. But having maggot therapy technology available for patients adds to your capabilities as a wound care provider. (more…)
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Aspirin inhibits wound healing A study in the Journal of Experimental Medicine describes how aspirin inhibits wound healing and paves the way for the development of new drugs to promote healing. The authors of “12-hydroxyheptadecatrienoic (12-HHT) acid promotes epidermal wound healing by accelerating keratinocyte migration via the BLT2 receptor” report that aspirin reduced 12-HHT production, which resulted in delayed wound…
Be sure you’re familiar with these valuable resources for you and your patients. Colorectal cancer resources Fight Colorectal Cancer has a comprehensive resource library for patients, including: a link to “My Colon Cancer Coach,” which provides a personalized report to help guide patients in making treatment decisions archives of webinars (past topics include healthy changes that may reduce recurrence, highlights…
By Pam Bowers, RN, and Liz Ferron, MSW, LICSW Conflict in the workplace is a fact of life, and dealing with it is never easy. Sometimes it seems easier to ignore it and hope it will take care of itself. But in healthcare organizations, that’s not a good strategy. Unresolved conflict almost always leads to poor communications, avoidance behavior, and…
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN The development of a care plan related to skin integrity can be challenging for any clinician. It takes a strong understanding of skin integrity risk factors and knowledge of how to modify, stabilize, and eliminate those risk factors. This article provides tips for the care-planning process.
By Jennifer Oakley, BS, RN, WCC, DWC, OMS It’s time again for annual staff education, and you, the certified wound clinician, need to teach the staff at your organization. You dream of staff entering a state-of-the-art classroom with computers at each station, mannequins, wound anatomy models, and enough products for each student to do hands-on demonstrations. But when you open…
By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS A medical device–related pressure ulcer (MDRPU) is defined as a localized injury to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace; splint; cast; respiratory mask or tubing; tracheostomy tube, collar, or strap; feeding tube; or a negative-pressure wound therapy device. The golden rule…
By Judy Bearden, MSN/ED, RN Changes in healthcare policy and reimbursement are pushing treatment from the hospital to the community. This shift is likely to result in a higher number of complex wounds being treated in the home, which can create stress for patients and families. Education plays a key role in reducing this stress. This article focuses on education…
By Yolanda G. Smith, MSN, RN, CCRN Are you able to relax, have fun, and enjoy the simple pleasures of life? Or do you: have trouble falling or staying asleep? smoke, drink, or eat to reduce tension? have headaches, back pain, or stomach problems? get irritated or upset over insignificant things? have too much to do and too little time…
By: Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA Maggot therapy is the controlled, therapeutic application of maggots to a wound. Simple to use, it provides rapid, precise, safe, and powerful debridement. Many wound care professionals don’t provide maggot therapy (also called wound myiasis) because they lack training. But having maggot therapy technology available for patients…
By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Transparent film dressings are thin sheets of transparent polyurethane (polymer) coated with an adhesive. These dressings are available in a variety of sizes and shapes.
By Debra Clair, PhD, APRN, WOCN, WCC, DWC Providing wound care requires a great deal of knowledge and skill. To become a wound care nurse entails taking classes, gaining and maintaining certifications, and acquiring on-the-job experience. But despite your education, knowledge, skills, and certifications, you may encounter problems when wound care requires you to touch the patient in a sensitive or…
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By Joanne Aspiras Jovero, BSEd, BSN, RN; Hussam Al-Nusair, MSc Critical Care, ANP, RN; and Marilou Manarang, BSN, RN
A common problem in long-term care facilities, pressure ulcers are linked to prolonged hospitalization, pain, social isolation, sepsis, and death. This article explains how a Middle East rehabilitation facility battles pressure ulcers with the latest evidence-based practices, continual staff education, and policy and procedure updates. Sultan Bin Abdulaziz Humanitarian City (SBAHC) in Riyadh, Saudi Arabia, uses an interdisciplinary approach to address pressure-ulcer prevention and management. This article describes the programs, strategies, and preventive measures that have reduced pressure-ulcer incidence. (more…)
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By Kulbir Dhillon, MSN, FNP, APNP, WCC
Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic.
Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency (CVI) causes hypertension in the venous system of the legs, leading to various pathologies that involve pain, swelling, edema, skin changes, stasis dermatitis, and ulcers. An estimated 1% of the U.S. population suffers from venous stasis ulcers (VSUs). Causes of VSUs include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Preventing VSUs is the most important aspect of CVI management. (more…)
Read MoreGreet the new year by tapping into some new resources.
GI Buddy is a free tool from the Crohn’s & Colitis Foundation of America that patients can use to stay on top of managing their Crohn’s Disease or ulcerative colitis symptoms. Patients can record what they eat, track their treatment and well-being, and access detailed reports. Patients also can access a video of tips for using GI Buddy, which is available online and as an iPhone app. (more…)
Read MoreDermatologic difficulties: Skin problems in patients with chronic venous insufficiency and phlebolymphedema By Nancy Chatham, RN, MSN, ANP-BC, CWOCN, CWS; Lori Thomas, MS, OTR/L, CLT-LANA; and Michael Molyneaux, MD
Skin problems associated with chronic venous insufficiency (CVI) and phlebolymphedema are common and often difficult to treat. The CVI cycle of skin and soft tissue injury from chronic disease processes can be unrelenting. If not properly identified and treated, these skin problems can impede the prompt treatment of lymphedema and reduce a patient’s quality of life.
This article reviews skin problems that occur in patients with CVI and phlebolymphedema and discusses the importance of using a multidisciplinary team approach to manage these patients. (more…)
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By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS
Collagen, the protein that gives the skin its tensile strength, plays a key role
in each phase of wound healing. It attracts cells, such as fibroblasts and keratinocytes, to the wound, which encourages debridement, angiogenesis, and reepithelialization. In addition, collagen provides a natural scaffold or substrate for new tissue growth. (more…)
By Ronnel Alumia, BSN, RN, WCC, CWCN, OMS
Achieving excellent wound care outcomes can be challenging, given the growing number of high-risk patients admitted to healthcare facilities today. Many of these patients have comorbidities, such as obesity, diabetes, renal disease, smoking, chronic obstructive pulmonary disease, and poor nutritional status. These conditions reduce wound-healing ability. (more…)
Read MoreBy Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP
Quality patient education is essential for comprehensive health care and will become reimbursable under healthcare reform in 2014. However, it’s difficult to provide effective education when time for patient interactions is limited. You can enhance your instruction time—and make your teaching more memorable—by using the techniques of analogy and metaphor. (more…)
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Each month, Apple Bites brings you a tool you can apply in your daily practice.
Xerosis, an abnormal dryness of the skin, is one of the most common skin conditions among patients with type 2 diabetes. While assessing for predictors of foot lesions in patients with diabetes, the authors of one study found that 82.1% of these patients had skin with dryness, cracks, or fissures. An unpublished survey of 105 consecutive patients with diabetes revealed that 75% had clinical manifestations of dry skin. (more…)
Read MoreAssessing moisture and pressure risk in elderly patients continues to be a focus for clinicians in all settings, particularly long-term care. Ongoing research challenges our ideas about and practices for cleansing and protecting damaged skin. Until recently, most wound care clinicians have cleansed long-term care patients’ skin with mild soap and water. But several studies have shown pH-balanced cleansers are more efficient than soap and water for cleansing the skin of incontinent patients.
Various terms are used to describe skin breakdown related to moisture—incontinence-associated dermatitis, perineal dermatitis, diaper rash, intertriginal dermatitis, intertrigo, moisture-related skin damage, moisture-associated skin damage, and even periwound dermatitis. This article uses moisture-associated skin damage (MASD) because it encompasses many causes of skin breakdown related to moisture. Regardless of what we call the condition, we must do everything possible to prevent this painful and costly problem.
Start with an overall assessment of the patient’s skin. Consider the texture and note dryness, flaking, redness, lesions, macerated areas, excoriation, denudement, and other color changes. (See Identifying pressure and moisture characteristics by clicking the PDF icon above.)
A patient’s risk of MASD can be assessed in several ways. Two of the most widely used pressure-ulcer risk scales, the Norton and Braden scales, address moisture risk. The Norton and Braden subscales should drive your plan for preventing skin breakdown related to moisture or pressure. The cause of breakdown (moisture, pressure, or shear/friction) must be identified, because treatment varies with the cause.
Both the Norton and Braden scales capture activity, mobility, and moisture scores. The Braden scale addresses sensory perception, whereas the Norton scale identifies mental condition. (See Subscales identifying pressure, shear, and moisture risk by clicking the PDF icon above.) Also, be aware that two scales have been published for perineal risk, but neither has been used widely.
You must differentiate pressure- and moisture-related conditions to determine correct treatment. Patients who are repositioned by caregivers are at risk for friction or shear. Also, know that agencies report pressure-ulcer prevalence. Care providers no longer classify mucous-membrane pressure areas in skin prevalence surveys; mucous membranes aren’t skin and don’t have the same tissue layers. Furthermore, don’t report skin denudement from moisture (unless pressure is present) in prevalence surveys.
Skin has two major layers—epidermis and dermis. The epidermis itself has five layers: The outermost is the stratum corneum; it contains flattened, keratin protein–containing cells, which aid water absorption. These cells contain water-soluble compounds called natural moisturizing factor (NMF), which are surrounded by a lipid layer to keep NMF within the cell. When skin is exposed to moisture, its temperature decreases, the barrier function weakens, and skin is more susceptible to pressure and friction/shear injury. Also, when urea in urine breaks down into ammonia, an alkaline pH results, which may reactivate proteolytic and lipolytic enzymes in the stool. (See Picturing moisture and pressure effects by clicking the PDF icon above.)
The standard of care for moisture-related skin breakdown includes four major components: cleanse, moisturize, protect, and contain. Specific products used for each component vary with the facility’s product formulary.
Gently wash the area using a no-rinse cleanser with a pH below 7.0. Don’t rub the skin. Pat dry.
Use creams containing emollients or humectants. Humectants attract water to skin cells and help hold water in the cells; don’t use these products if the skin is overhydrated. Emollients slow water loss from skin and replace intracellular lipids.
Options for skin protectants include:
• liquid film-forming acrylate sprays or wipes
• ointments with a petroleum, zinc oxide, or dimethicone base
• skin pastes. Don’t remove these products totally at each cleansing, but do remove stool, urine, or drainage from the surface and apply additional paste afterward. Every other day, remove the paste down to the bare skin using a no-rinse cleanser or mineral oil.
Be sure to separate skinfolds and use products that wick moisture rather than trap it. These may include:
• commercial moisture-wicking products
• a light dusting with powder containing refined cornstarch or zinc oxide—not cornstarch from the kitchen or powder with talc as the only active ingredient
• abdominal pads.
To keep moisture away from skin, use absorbent underpads with wicking properties, condom catheters (for males), fecal incontinence collectors, fecal tubes (which require a healthcare provider order), or adult briefs with wicking or gel properties. Call a certified ostomy or wound care nurse for tips on applying and increasing wear time for fecal incontinence collectors.
If 4″ × 4″ gauze pads or ABD pads are saturated more frequently than every 2 hours, consider applying an ostomy or specially designed wound pouch to the area. Collecting drainage allows measurement and protects skin from the constant wetness of a saturated pad.
Don’t neglect the basics, for example, know that wet skin is more susceptible to breakdown. Turn the patient and change his or her position on schedule. Change linens and underpads when damp, and consider using a low-air-loss mattress or bed or mattress with microclimate technology.
Also, be aware that fungal rashes should be treated with appropriate medications. If the patient’s skin isn’t too moist, consider creams that absorb into the skin; a skin-protecting agent can be used as a barrier over the cream. Besides reviewing and using the standards of care, you may refer to the Incontinence-Associated Dermatitis Intervention Tool, which has categories related to skin damage. See the “Incontinence-Associated Dermatitis Intervention Tool” (IADIT).
To help prevent skin breakdown related to moisture, assess patients’ skin appropriately, determine treatment using evidence-based guidelines, and implement an appropriate plan of care.
Selected references
Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.
Borchert K, Bliss DZ, Savik K, Radosevich DM. The incontinence-associated dermatitis and its severity instrument: development and validation. J Wound Ostomy Continence Nurs. 2010;37(5):527-35.
Doughty D. Differential assessment of trunk wounds: pressure ulceration versus incontinence-associated dermatitis versus intertriginous dermatitis. Ostomy Wound Manage. 2012;58(4):20-2.
Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-15.
Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;
39(1):61-74.
Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233-41.
Langemo D, Hanson D, Hunter S, Thompson P, Oh IE. Incontinence and incontinence-associated dermatitis. Adv Skin Wound Care. 2011;24(3):126-40.
National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline.Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: superficial skin changes & Deep Pressure Ulcer Framework©. Adv Skin Wound Care. 2011;24(12):571-80.
Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.
Wound, Ostomy and Continence Nurses Society. Incontinence-Associated Dermatitis: Best Practice for Clinicians. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2011.
Zulkowski K. Diagnosing and treating moisture-associated skin damage. Adv Skin Wound Care. 2012;25(5):231-6.
Patricia A. Slachta is an instructor at the Technical College of the Lowcountry in Beaufort, South Carolina.
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Here are resources that can help you in your busy clinical practice by giving you information quickly.
The International Affairs & Best Practice Guidelines has released “Assessment and Management of Foot Ulcers for People with Diabetes, Second Edition,” published by the Registered Nurses’ Association of Ontario.
The guidelines include recommendations for practice, education, policy, and future resource. Strategies for implementation are given, as well as several useful appendices, such as:
• Debridement Decision-Making Algorithm
• A Guide to Dressing Foot Wounds
• PEDIS: Diabetes Foot Ulcer Classification System
• Offloading Devices
• Optimal Treatment Modalities.
The guidelines also recommend that clinicians refer to “Toolkit: Implementation of Best Practice Guidelines, Second Edition.”
PREPARE is a useful and patient-friendly website designed to help prepare people to make complex medical decisions. The website was developed by clinical researchers from the San Francisco VA Medical Center; the University of California, San Francisco; and NCIRE—The Veterans Health Research Institute.
PREPARE uses videos to provide concrete examples of how to identify what is most important in life; how to communicate that with family, friends, and doctors; and how to make informed medical decisions when the time comes. Users can also download a PDF of a PREPARE pamphlet.
Download two free implementation guides for infection prevention from the Association for Professionals in Infection Control and Epidemiology (APIC):
2013 Guide to Preventing Clostridium difficile Infections
This revised guide contains strategies for prevention, considerations for specific patient populations, evolving practices, and how to incorporate current regulations.
Topics include:
• C. difficile in pediatrics and skilled nursing facilities
• pathogenesis and changing epidemiology of C. difficile infection diagnosis
• environmental control
• new and emerging technologies
• tools and examples to help apply preventative measures, such as hand hygiene monitoring, environmental cleaning, and isolation compliance.
2013 Guide to Infection Prevention in Emergency Medical Services
This guide includes infection-prevention standards, regulations, and best practices, as well as instructions, examples, and tools to conduct surveillance and risk assessments.
“Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices,” from the Agency for Healthcare Research and Quality, covers several topics of interest, such as preventing in-facility pressure ulcers, promoting a culture of safety, and human factors and ergonomics. The report lists 22 patient-safety strategies that are ready for adoption. You can access more information about these strategies, read a related special supplement from the Annals of Internal Medicine, and read a thoughtful commentary about the report, “Treat the system, not the error: Patient safety in 2013.”
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