Moisture lesions. Sara-jane Kray Clinical Nurse Specialist (Honorary contract KCHT)
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1 Moisture lesions Sara-jane Kray Clinical Nurse Specialist (Honorary contract KCHT)
2 Aim To differentiate between moisture lesions and pressure ulcers. To understand the effects of urine and faeces on skin integrity. To relate Best Practice Guidelines to moisture lesions and incontinence.
3 Pressure Ulcers Skin Moisture Lesions
4 Moisture Lesions A moisture lesion as reactive responses of the skin to chronic exposure to urine and faecal matter, which could be observed as an inflammation and erythema with or without erosion (Gray et al, 2007) Typically there is loss of the epidermis and the skin appears macerated, red broken and painful (Cooper et al, 2006; Gray et al, 2007).
5 Moisture lesions Different terminology: Incontinence associate dermatitis (IAD s) Moisture lesions Moisture ulcers Perineal dermatitis Diaper / nappy dermatitis All refer to skin damage caused by excessive moisture
6 Diagnosis of Moisture Lesions and Pressure Ulcers The diagnosis of the moisture lesions and / or pressure ulcers is more difficult than one assumes There is often confusion between a pressure ulcer and a moisture lesion The treatment strategies vary and the consequences of the outcome for the patient are of paramount importance Tissue Viability Society. Achieving Consensus in Pressure Ulcer Reporting. JTV 2012
7 Understanding the differences between Moisture Lesions and PUs To prevent pressure damage, the most important factor is to reduce or relieve pressure To prevent moisture damage, the most important factor is keeping the skin clean, dry and well hydrated Correct identification is critical to ensure the correct treatment and prevention is put in place. Tissue Viability Society. Achieving Consensus in Pressure Ulcer Reporting. JTV 2012
8 So What is a Pressure Ulcer & What Is a Moisture Lesion?
9 Moisture Lesions Moisture Lesions develop where moisture is present; incontinence, perspiration, exudate. Excoriation varies from mild to severe. Slough may be present but necrosis and eschar will not.
10 Pressure and Pressure Ulcers Pressure A perpendicular load or force (such as a patient s bodyweight) exerted on a unit of area (such as the sacrum) Bennett and Lee (1986) Pressure Ulcer A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be Clarified (EPUAP)
11 So what are the differences between the two?
12 Cause Pressure Ulcers Moisture Lesions Pressure and or Shear Moisture present Incontinence Perspiration Exudate
13 Location Pressure Ulcers Moisture lesions Normally over a bony prominence Can occur when soft tissue is compressed by external forces (e.g. nasal cannula s, urinary catheters etc) Also occasionally soft tissue on soft tissue. Anal cleft Perianal area Skin folds Sacrum (due to severe incontinence NOT pressure)
14 Shape Pressure Ulcers Circular / regular shape Tear drop Excludes friction injuries Moisture Lesions Diffuse different superficial spots Kissing (copy lesions) Linear wounds
15 Depth Pressure Ulcers Moisture Lesions Dependent on category of pressure ulcer From superficial - to - Extensive destruction Superficial wounds Can be deeper if infection is present
16 Necrosis Pressure Ulcer Moisture Lesion Depends upon category of ulcer: black necrotic scab or escar maybe present. No necrosis or escar present May also present as a a black/blue shimmer under the skin that may evolve.
17 Edges Pressure Ulcer Moisture Lesion Distinct / defined edges Diffused edges / irregular lesions
18 Colour Pressure Ulcers Moisture Lesions Non- Blanching erythema (cat 1) Epithelisation Granulation Slough Necrosis Bone/ tendon etc. Red but not uniformly distributed Pink or white surrounding skin (maceration / excoriation)
19 N.B. Moisture / Pressure & Shear may be present simultaneously This is known as a combined lesion. Tissue Viability Society. Achieving Consensus in Pressure Ulcer Reporting. JTV 2012
20 Do we Grade Moisture Damage?
21
22 Moisture lesions / Incontinence associate dermatitis (IAD s)
23 Aetiology of moisture lesions can be complex and multifactorial. When the skin is exposed to urine, faeces, double incontinence and/or requires frequent cleansing, the permeability of the skin increases and the natural barrier function of the skin is reduced
24 Incontinence Issues Changes in the skin ph ph of normal skin is 5.5 (acidic) Normal ph of urine is 6.5 7pH in the morning and becoming more alkaline by the evening ph Normal faecal ph is pH Therefore if urine and faeces are in contact with the skin an immediate change in ph will occur, thus increasing protease and lipase activity.
25 Urine, faeces and urinary ammonia cause: Increased irritation Increased moisture leading to maceration of the skin Breakdown of vulnerable skin, due to an increased friction Increased risk of bacterial colonisation and infection most often with Candida albicans and Staphylococcus from the perineal skin and the gastrointestinal tract
26 Urinary incontinence alone can cause moisture damage, however, it is exacerbated when combined with faecal incontinence. Extrinsic factors may exacerbate the problem, for instance, the side effect of some medications includes diarrhoea (Nix and Haugen, 2010).
27 Moisture damage Excessive exposure to moisture causes the skin to become damp, soggy and clammy and eventually saturated. If the skins permeability is breached, there is an increased risk of a combined lesion, resulting from physical damage (friction, shear and /or pressure)
28
29 Prevention: Best Practice Recommendations Moisture lesions forms part of pressure ulcer protocols: Risk assessment - Waterlow /Braden Level of risk based upon protocols Structured skin care regime Gentle cleansing and moisturising Skin protection / moisture barrier Regular skin inspections Pressure repositioning strategies Nutrition
30 Best Practice Recommendations For the very young and elderly experiencing incontinence and effects of irritation it is important to avoid aggravating this further through inappropriate methods of cleansing.
31 Best Practice Recommends Soap & water should NOT be used when cleansing following episodes of incontinence Most soaps increase the skin s ph to an alkaline level Puts the skin s surface at risk of the effects of dehydration Alters the normal bacterial flora of the skin Allows colonisation with more pathogenic species Best practice recommends a ph balanced foam cleanser as part of a cleansing regime post episodes of incontinence.
32 Best Practice Recommends A protective barrier should also be used to prevent sore skin from breaking down further
33 Skin Protectants / barriers There are many skin barriers available: Petroleum (oil) based products Ineffective Clogs under garments Zinc based products Opaque can t visualise skin Very hard to remove requires excess force Dimethicone based products Dimethicone is a very good barrier Keeping it on the skin can be the challenge
34 Best Practice Recommends Patients with incontinence should undergo a full holistic nursing assessment that includes questions regarding bladder and/or bowel function/habit. Advice on assessment and appropriate products to aid management of incontinence should be sought from your local continence advisor. Reassessment should be regularly undertaken depending upon the patients condition, as changes in incontinence (incontinence pattern, cleansing regimen and continence aids used) can contribute to the development of skin breakdown. BEST PRACTICE STATEMENT: CARE OF THE OLDER PERSON S SKIN (2ND EDITION) 2012
35 Incontinence UK prevalence Older people are more prone to incontinence Statistics show 29% of older people in nursing homes were incontinent of urine, 65% doubly incontinent and 6% catheterised Urinary continence 31% of older women 23% of older men Between 30% and 85% of residents in nursing homes Faecal incontinence between 1 10% of adults are affected 40-60% of patients who have experienced a stroke and are admitted to hospital can experience incontinence related problems BEST PRACTICE STATEMENT: CARE OF THE OLDER PERSON S SKIN (2ND EDITION) 2012
36 Costs to the patient and carers Urinary / faecal Incontinence is distressing and socially disruptive May be the cause of personal health and hygiene problems May restrict employment and educational or leisure opportunities May lead to embarrassment and exclusion Reason for breakdown of relationships leading to nursing home admission Financial costs to patients and carers, may be considerable i.e. products, laundry
37 Remember : Urine and faeces on the skin = increased moisture Resulting in maceration and excoriate of the area (Moisture lesions) This is avoidable!!
38 Key Points Good Skin Hygiene is fundamental to preventing / treating moisture lesions Use a ph balanced foam cleanser post episodes of incontinence. Protect the skin with an effective skin protectant / barrier.
39 Recommendation for further training on PU s and IAD s
40
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42 References Best Practice Statement: Care Of The Older Person s Skin (2nd Edition) 2012 Wounds UK, London. Trudy Young (2012) The causes and clinical presentation of moisture lesions. The identification and management of moisture lesions. Wounds UK, London. Cooper P, Clark M, Bale S (2006) Best Practice Statement: care of the older person s skin. Wounds UK, London Gray M, Bliss D, Doughty D, Ermer-Seltum J, Kennedy-Evans K, Palmer M (2007) Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs 34: Nix D, Haugen V (2010) Prevention and management of incontinenceassociated dermatitis. Drugs Aging 27(6): Pressure Ulcer Classification Tool : European Pressure Ulcer Advisory Panel (2013) Tissue Viability Society. Achieving Consensus in Pressure Ulcer Reporting. JTV 2012
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NHS Continuing Healthcare
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epuap Trustees of the European Pressure Ulcer Advisory Panel EUROPEAN PRESSURE ULCER ADVISORY PANEL
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THERAPY FOR THE SKIN Non-allergenic and Non-sensitizing
THERAPY FOR THE SKIN Non-allergenic and Non-sensitizing FOR CLINICAL INFORMATION ABOUT OUR PRODUCTS, CALL 877.611.0081. TO ORDER, VISIT MMS.MCKESSON.COM OR CALL YOUR MCKESSON MEDICAL-SURGICAL ACCOUNT MANAGER.
Nursing college, Second stage Microbiology Dr.Nada Khazal K. Hendi L14: Hospital acquired infection, nosocomial infection
L14: Hospital acquired infection, nosocomial infection Definition A hospital acquired infection, also called a nosocomial infection, is an infection that first appears between 48 hours and four days after