moisture associated skin damage pathway

2
Moisture Associated Skin Damage Pathway PRODUCTS BIBLIOGRAPHY 3M, Tegaderm and Cavilon are trademarks of 3M Company. © 3M 2013 GF35 3M Health Care Limited 3M House Morley Street Loughborough Leicestershire, LE11 1EP Telephone: (01509) 611611 Facsimile: (01509) 237288 www.3M.co.uk/healthcare 3M Ireland The Iveagh Building The Park Carrickmines Dublin 18 Ireland Telephone: 00 353 (01) 2803555 Facsimile: 00 353 (01) 2803509 Please contact your local 3M representative for further information on educating your nursing team on the MASD pathway. Alternatively, please contact us at www.cavilon.co.uk Beeckman D, Schoonhoven L,Fletcher J, et al (2007) EPUAP classification system for pressure ulcers: European reliability study. J AdvNurs 60(6): 682–91 Black JM, Gray M, Bliss DZ, et al (2011) MASD part 2: incontinence associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ost Continence Nurs 38(4):359–70 Colwell JC, Ratliff CR, Goldburg M,et al (2009) MASD part 3: perisotimal moisture-associated dermatitis and periwound moisture-associated dermatitis: a consensus. J Wound Ostomy Continence Nurse 38(5): 233-241. Defloor T, Schoonhoven L, Fletcher J, et al (2005) Pressure Ulcer Classification differentiation between pressure ulcers and moisture lesions. European Pressure Ulcer Advisory Panel. Available from: http://www.epuap <http://www.epuap/> . org/archived_reviews/EPUAP_Rev6.3.pdf Grey M, Black JM, Baharestani MM, et al (2011) Moisture associated skin damage: an overview and pathophysiology. J Wound Ostomy Continence Nurse 38(3): 233–41 National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel (2011) Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. 2009. NGC:008145 Rees J, Pagnamenta F (2009) Best practice guidelines for the prevention and management of incontinence-associated dermatitis. Nursing Times 105(36):24-6 Romanelli M, Vowden K, Weir D (2010). Effective exudate management made easy. Wounds International 1(2). Voegeli D (2012) Moisture-associated skin damage: aetiology, prevention and treatment. Br J Nurs 21(9):517–21 White RJ, Cutting KD (2003) Interventions to avoid maceration of the skin and wound bed. Br J Nurs 12(20): 1186-203 Produced in collaboration with Caroline Dowsett PhD, MSc, BSc (Hons), Dip N, D.N, RGN Nurse Consultant in Tissue Viability

Upload: hoangnguyet

Post on 12-Jan-2017

230 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: Moisture Associated Skin Damage Pathway

Moisture Associated Skin Damage Pathway

PRODUCTS

BiBliOgRAPhy

3M, Tegaderm and Cavilon are trademarks of 3M Company. © 3M 2013

gF35

3M Health Care Limited 3M house Morley Street loughborough leicestershire, lE11 1EP

Telephone: (01509) 611611 Facsimile: (01509) 237288 www.3M.co.uk/healthcare

3M Ireland The iveagh Building The Park Carrickmines Dublin 18 ireland

Telephone: 00 353 (01) 2803555 Facsimile: 00 353 (01) 2803509

Please contact your local 3M representative for further information on educating your nursing team on the MASD pathway. Alternatively, please contact us at www.cavilon.co.uk

Beeckman D, Schoonhoven l,Fletcher J, et al (2007) EPUAP classification

system for pressure ulcers: European reliability study. J AdvNurs 60(6): 682–91

Black JM, gray M, Bliss DZ, et al (2011) MASD part 2: incontinence associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ost

Continence Nurs 38(4):359–70

Colwell JC, Ratliff CR, goldburg M,et al (2009) MASD part 3: perisotimal moisture-associated dermatitis and periwound moisture-associated dermatitis: a consensus. J Wound Ostomy Continence Nurse 38(5): 233-241.

Defloor T, Schoonhoven l, Fletcher J, et al (2005) Pressure Ulcer

Classification differentiation between pressure ulcers and moisture lesions.

European Pressure Ulcer Advisory Panel. Available from: http://www.epuap <http://www.epuap/> .

org/archived_reviews/EPUAP_Rev6.3.pdf

grey M, Black JM, Baharestani MM, et al (2011) Moisture associated skin damage: an overview and pathophysiology. J Wound Ostomy Continence

Nurse 38(3): 233–41

National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel (2011) Pressure ulcer prevention recommendations. in: Prevention and treatment of pressure ulcers: clinical practice guideline. 2009. NgC:008145

Rees J, Pagnamenta F (2009) Best practice guidelines for the prevention and management of incontinence-associated dermatitis. Nursing Times 105(36):24-6

Romanelli M, Vowden K, Weir D (2010). Effective exudate management made easy. Wounds international 1(2).

Voegeli D (2012) Moisture-associated skin damage: aetiology, prevention and treatment. Br J Nurs 21(9):517–21

White RJ, Cutting KD (2003) interventions to avoid maceration of the skin and wound bed. Br J Nurs 12(20): 1186-203

Produced in collaboration with Caroline Dowsett PhD, MSc, BSc (hons), Dip N, D.N, RgN Nurse Consultant in Tissue Viability

Page 2: Moisture Associated Skin Damage Pathway

gENE

RAl

CRiT

ERiA

•Nu

tritio

nals

tatu

s•

Mob

ility

•Pr

evio

uss

kin

diso

rder

•Al

lerg

ies

•Pa

tient

bat

hing

/ski

n ca

re ro

utin

e

MAS

D SP

ECiF

iC•

Urin

eor

faec

alin

cont

inen

ce

Exce

ssive

sw

eatin

g

•Ex

cess

ivew

ound

exu

date

•St

oma

leak

age

iS T

hE S

KiN

DAM

AgE

CAUS

ED B

y:

Urin

e or

faec

al m

atte

r Ex

cess

ive m

oist

ure

from

sw

eatin

g

Wou

nd e

xuda

te

Stom

a le

akag

e

Excl

ude

pres

sure

dam

age

as a

cau

se (3

M D

iffer

entia

tion

guid

e*)

ASSE

SSM

ENT

DiFF

EREN

TiAl

DiA

gNO

SiS

Moi

stur

e As

soci

ated

Ski

n Da

mag

e Pa

thw

ay

MAN

AgEM

ENT

iMPl

EMEN

T SK

iN C

ARE

REgi

MEN

REAS

SESS

MEN

T &

EVAl

UATi

ON:

REC

ORD

OUT

COM

ES

SKiN

iS iN

TACT

BUT

REg

UlAR

REA

SSES

SMEN

T RE

qUiR

EDTh

ERE

iS E

ViDE

NCE

OF S

KiN

BREA

KDOW

N

iNCO

NTiN

ENCE

ASS

OCiA

TED

DERM

ATiT

iS (i

AD)

Sour

ce o

f MAS

DUr

ine

or li

quid

faec

es

Eryt

hem

a &

infla

mm

atio

n of

the

skin

, er

osio

n &

denu

datio

n ca

n oc

cur a

s re

sult

of e

xpos

ure

to u

rine

and

faec

es

iNTE

RTRi

giNO

US D

ERM

ATiT

iS

(MAS

D W

iThi

N SK

iN F

OlDS

)

Sour

ce o

f MAS

DPe

rspi

ratio

n

Mild

, mirr

or im

age

eryt

hem

a on

eac

h si

de o

f the

ski

n fo

ld. M

ay h

ave

eros

ion

& de

nuda

tion

as re

sult

of e

xpos

ure

to c

hron

ic

pers

pira

tion

PERi

WOU

ND D

ERM

ATiT

iS

Sour

ce o

f MAS

DEx

udat

e, a

dhes

ive s

tripp

ing

or in

fect

ion

Eryt

hem

a &

infla

mm

atio

n of

ski

n w

ithin

4c

m o

f wou

nd e

dge,

may

sho

w

denu

datio

n or

ero

sion

PERi

STOM

Al M

OiST

URE

ASSO

CiAT

ED D

ERM

ATiT

iS

Sour

ce o

f MAS

DUr

ine

or fa

eces

see

page

infla

mm

atio

n &

eros

ion

of s

kin

rela

ted

to

moi

stur

e fro

m s

tool

, urin

e, &

per

spira

tion,

ex

tend

ing

outw

ard

from

sto

ma

site

iNCO

NTiN

ENCE

ASS

OCiA

TED

DERM

ATiT

iS (i

AD)

•Ap

ply

barri

erfi

lmp

rodu

ct,3

M™

Ca

vilon

™ N

o St

ing

Barri

er F

ilm

or a

ski

n pr

otec

tant

•Tr

eata

reas

ofc

utan

eous

can

didi

asis

(th

rush

) with

app

ropr

iate

ant

ifung

al

treat

men

t

•Co

nsid

erth

eus

eof

app

ropr

iate

de

vices

to d

ivert

urin

e or

sto

ol

•Ke

eps

kin

clea

nan

ddr

y

iNTE

RTRi

giNO

US D

ERM

ATiT

iS

(MAS

D W

iThi

N SK

iN F

OlDS

)

•Ex

amin

een

tire

area

oft

hes

kin

fold

s,

incl

udin

g th

e ba

se

•En

lista

ssis

tanc

ein

ord

erto

gen

tly

lift t

he fo

ld w

ithou

t cre

atin

g or

ex

acer

batin

g tra

ctio

n an

d fis

sure

fo

rmat

ion

•Co

nsid

erti

ssue

type

and

trea

tmen

taim

w

hen

sele

ctin

g tre

atm

ent

•Av

oid

prod

ucts

con

tain

ing

chlo

rhex

idin

egl

ucon

ate,

alc

ohol

, or p

erfu

mes

as

thes

e ca

n be

abs

orbe

d by

dam

aged

sk

in

•M

easu

res

toe

nsur

eth

eco

ntin

ued

dryin

g of

the

skin

fold

mus

t be

a pr

imar

y tre

atm

ent s

trate

gy

•Pr

otec

taffe

cted

are

afro

mfu

rther

br

eakd

own

or m

acer

atio

n (3

M™

Ca

vilon

™ N

o St

ing

Barri

er F

ilm)

PERi

WOU

ND D

ERM

ATiT

iS

•Ba

sed

ress

ing

choi

ceo

nex

udat

ele

vels

(3

M E

xuda

te P

athw

ay)

•So

me

area

sm

ayb

ech

alle

ngin

gto

dr

ess,

util

ise

sacr

al a

nd h

eel s

hape

s (3

M™

Teg

ader

m™

hyd

roco

lloid

, Foa

m

Adhe

sive

, Abs

orbe

nt D

ress

ings

)

•Co

nsid

erth

epo

tent

ialf

orw

ound

in

fect

ion

•If

the

wou

ndis

not

hea

ling

or

prog

ress

ing,

furth

er in

vest

igat

ion

may

be

requ

ired

to e

stab

lish

co-m

orbi

ditie

s

•M

anag

ene

crot

ica

nds

loug

hyti

ssue

us

ing

dres

sing

s w

ith a

utol

ytic

qua

litie

s.

This

may

be

cont

rain

dica

ted

in c

erta

in

cond

ition

s su

ch a

s di

abet

es a

nd th

ose

with

arte

rial d

isea

se

•If

bone

ise

xpos

edc

onsi

dert

heri

sk

of o

steo

mye

litis

and

refe

r to

suita

ble

heal

th c

are

prof

essi

onal

•Pr

otec

tper

iwou

nda

rea

from

furth

er

brea

kdow

n an

d m

acer

atio

n (3

M™

Ca

vilon

™ N

o St

ing

Barri

er F

ilm)

PERi

STOM

Al M

OiST

URE

ASSO

CiAT

ED D

ERM

ATiT

iS

•Co

nsul

tSto

ma

Nurs

esp

ecia

listf

or

guid

ance

on

appl

ianc

es

•Pr

otec

tper

isto

mal

are

afro

mfu

rther

br

eakd

own

and

mac

erat

ion

(3M

Cavil

on™

No

Stin

g Ba

rrier

Film

)

Ensu

re p

atien

t con

sent

to a

ny s

kin c

are

prac

tice

and

treat

men

t•

Cont

rol s

ympt

oms

and

treat

the

unde

rlyin

g ca

use

Utilis

e di

spos

able

was

h ba

sins

to re

duce

cro

ss in

fect

ion ri

sk•

Mois

turis

e an

d pr

otec

t usin

g ap

prop

riate

bar

rier p

rodu

ct(s)

, eg

•3M

™ C

avilo

n™ S

kin C

are

Rang

e

Educ

ate

all c

are

prov

ider

s on

pre

ferre

d m

etho

d of

skin

car

e•

Adop

t a m

ultid

iscip

linar

y app

roac

h•

Rem

ove

irrita

nts

from

skin

and

pro

tect

from

furth

er e

xpos

ure

Clea

nse

skin

with

ph

neut

ral w

ipes

/clea

nser

Chec

k sk

in fo

lds

for r

esid

ual f

aece

s/ur

ine

Use

devic

es/p

rodu

cts

to w

ick m

oistu

re fr

om a

ffect

ed s

kin•

if no

impr

ovem

ent o

r det

erio

ratio

n in

con

ditio

n, re

fer t

o TV

N &/

or c

ontin

ence

CNS

incl

ude

patie

nt in

all

desc

isio

ns re

latin

g to

trea

tmen

t Co

mpl

ete

an a

sses

smen

t and

car

e pl

an in

all

inst

ance

s