Differentiating Deep Tissue Pressure Injury (DTPI) From Other Causes of Purpura in the Sacrococcygeal Area: A Multiple Case Series

BACKGROUND

Recent revisions to the pressure injury staging system include guidance on differential diagnoses for deep tissue pressure injury (DTPI). Accurately identifying DTPI is critical; however, purpura in the setting of vascular disorders and systemic infectious processes can share similar features confounding diagnosis.

CASES

In this three-case series, we describe suspected DTPI with an uncharacteristic shape or occurring in the presence of additional lesions distributed outside of typical pressure areas prompted further evaluation.

CONCLUSIONS

The interdisciplinary approach we adapted was useful in determining the cause of purpura when the DTPI was ruled out by the certified wound care nurse.

The role of dressings in the prevention of pressure ulcers

Pressure ulceration is a significant global healthcare problem and represents a considerable burden on healthcare resources. Within the literature an increasing number of studies have examined the role prophylactic dressings play in redistributing pressure and helping to protect the skin from the effects of friction and shear. The use of dressings to prevent pressure ulcers may be considered a controversial issue, as previous opinion has been that dressings do not reduce the effects of pressure. This article will critically evaluate the literature to examine the role dressings play in the prevention of pressure ulceration.

Developing a critical care bowel management assessment tool to manage faecal incontinence

BACKGROUND

Critical care patients with faecal incontinence are at high risk of developing moisture lesions, pressure ulcers and secondary infection.

AIMS

The aims of this quality improvement programme were to identify the level of harm caused by faecal incontinence in critical care, and to review current critical care nursing practice on the use of bowel management systems, with the intent to implement changes to prevent delayed insertion.

THE IMPROVEMENT PROGRAMME

A four-step approach was used to guide the improvement programme. A total of seven case studies across three critical care units were reviewed and information was collected on stool type and frequency, duration of diarrhoea and skin integrity prior to bowel management system insertion.

DISCUSSION

Critical care nurses may not always use a consistent approach to the assessment of patients at risk of moisture or pressure damage due to faecal incontinence. Lack of knowledge about the maintenance of bowel management systems was viewed as a likely reason for the inconsistent approach. A Critical Care Bowel Management Assessment Tool was created, to contribute towards a more standardised approach to bowel assessment and management.

CONCLUSIONS

Inadequate assessment and management of faecal incontinence may have implications for critically ill patients. Further evaluation is required in order to demonstrate over time whether the changes made, as a result of this quality improvement programme, have led to sustainable improvement.

Expert Recommendations for Managing Acute Faecal Incontinence with Diarrhoea in the Intensive Care Unit

Acute faecal incontinence with diarrhoea (AFId) has been reported to affect up to 40% of patients in the intensive care unit (ICU). The clinical challenges of AFId include the risk of perineal skin breakdown and cross-contamination with nosocomial infections, such as Clostridium difficile. In addition, the management of AFId is a burden on nursing time and hospital resources. Despite these challenges, there is currently no standard way of managing AFId. To address this problem, an international panel of intensive care specialists was convened to discuss AFId management recommendations. The collective knowledge of the specialists combined with literature searches from online medical databases were used to create a set of guidelines together with an accompanying management algorithm to aid healthcare providers in deciding the most appropriate care for patients with AFId in the ICU. These guidelines have been specifically designed to take into account patient severity of illness and comorbidities, which coupled with common AFId-associated clinical complications, can influence management choices. A comprehensive review of current AFId management strategies, taking into account the spectrum of patients and hospital economic limitations, has been included as a reference guide. It is hoped that the wider adoption of these recommendations will be a step forward in improving the current management of AFId in the ICU.

Moisture-associated skin damage: an overview for community nurses

The harmful effects of excessive moisture on the skin are well documented. Although traditionally this has been considered as being a specific problem of continence care, it is a common problem encountered in many different patient groups. As a consequence the umbrella term moisture-associated skin damage (MASD) has been introduced to describe the spectrum of damage that occurs in response to the prolonged exposure of a patient's skin to perspiration, urine, faeces or wound exudate etc. It is generally accepted that MASD consists of four distinct conditions, each having slightly different aetiologies, namely: incontinence-associated dermatitis; intertrigo; peristomal moisture-associated dermatitis; and periwound moisture-associated dermatitis. Careful assessment can help distinguish between the four and enable appropriate prevention and management interventions to be implemented. Whatever causes the excessive moisture, effective interventions should consist of the adoption of a structured skin care regime to cleanse and protect, and methods to keep the skin dry, controlling the source of the excessive moisture and treating any secondary infection.

Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.

Issues related to accurate classification of buttocks wounds

PURPOSE

This study was designed to determine the level of agreement among wound care nurses when asked to classify the etiology of 9 wounds located on the buttocks and within the intergluteal cleft.

SUBJECTS

Study subjects were 100 wound care nurses who responded to an invitation placed on the WOCN Society's wound care forum and to an e-mail sent to members of the WOCN Iowa Affiliate.

METHODS

Respondents were asked to view 9 unique wound photos and to determine whether the primary etiologic factor was pressure, moisture, incontinence-associated dermatitis, or skin tear. Subjects were given no background information regarding the patients but were allowed to add comments.

RESULTS

The overall κ analysis of the 9 photos combined was 0.1708 (99% confidence interval, 0.1630-0.1786). The testing of the overall κ for the 9 photos equaling "0" or mere chance produced a P < .0001. Analyses revealed that the agreement between the 100 respondents for the 9 photos was only 17% better than chance alone. In summary, our study revealed only "Slight Agreement" between wound care nurses' classifications of photo subgroups or for all 9 photos analyzed together.

IMPLICATIONS

Accurate wound classification impacts not only treatment decisions but also reimbursement, risk of litigation, and accuracy of data regarding prevalence and incidence of pressure ulcers. It is, therefore, critical for professional societies such as the WOCN to begin development of consensus definitions and guidelines to ensure consistency and accuracy in wound classification.

Maintaining skin integrity bariatric patients

The skin is the largest organ in the body, accounting for 16% of total body weight. Individuals who are obese face particular dermatological challenges, and health professionals working in the community setting should be alert to these risks. Skin assessment should be undertaken by a competent practitioner within a holistic framework. If assessment and treatment is not undertaken in a timely manner there is risk of tissue damage with associated cost and care implications. This article discusses aspects of skin care that apply particularly to bariatric patients, and draws on best practice guidance from the literature to help nurses ensure that the patient is appropriately managed in relation to their skin care, wound treatment and body dynamics.

Aging enhances maceration-induced ultrastructural alteration of the epidermis and impairment of skin barrier function

BACKGROUND

Skin maceration is recognized as a risk factor for the development of certain skin lesions. In health care settings, incontinence-associated skin maceration is highly prevalent in the elderly. However, the effect of senescence on maceration has not been fully elucidated.

OBJECTIVE

To reveal the enhancement of the maceration-induced ultrastructural alteration and barrier function of the epidermis by aging.

METHODS

Skin maceration was reproduced by exposure to agarose gel in human and rat. The ultrastructural alterations in human and rat tissue were observed by transmission electron microscopy. The skin barrier function was evaluated by noninvasive methods in human, and by the transdermal penetration of small- and large-fluorescent molecules in rat. In order to reveal the effect of aging on the skin maceration, we compared these parameters between young and aged rats.

RESULTS

In macerated skin, we observed expansion of the interstices of the stratum corneum, spinosum, and basale of the epidermis; disruption of the intercellular lipid structure in the stratum corneum; a decreased number of cell processes in the stratum spinosum and basale. The transdermal penetration test in the rat using two types of fluorescein indicated that maceration disrupted skin barrier function. Furthermore, senescence-enhanced ultrastructural and functional alterations were revealed in the rodent studies.

CONCLUSION

This study demonstrates that aging enhances skin maceration. Considering that maceration is a risk factor for the skin damage, the development of technology to promote skin barrier recovery after maceration in the elderly is warranted.