Sarah Sage Clinical Nurse Consultant-Wound Management

Susan Leenaars Clinical Nurse Consultant-Continence Management

Royal Melbourne Hospital

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*Seen in infants (usually with cloth nappies)

*Type of contact

dermatitis

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*Mentioned in the EPUAP definitions:

*Often confused with a stage 2 pressure injury

*Proper diagnosis is to remove/manage the

moisture of the skin, if the break is still there-

consider moisture lesions.

*Can appear in skin folds NOT just perineum

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Incontinence Associated Dermatitis (IAD) is “skin inflammation

manifested as redness with or without blistering, erosion, or

the loss of skin barrier function that occurs as a consequence

of chronic or repeated exposure of the skin to urine or fecal

matter” (Grey 2007)

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* Is a break in integrity

* Is part of the body’s

response to continuing

insults

* Is a type of contact

dermatitis

*Best treated with topical

anti-inflammatory and

removal/control of

injuring substance

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*Works to help people with

incontinence overcome the

incontinence

* Provide people with the tools

to maintain social continence

* This includes but is not

limited to: medication, diet,

exercises, counselling etc

*Works to provide optimal healing environment for wounded tissue.

* E.g.. Overcome biofilm, improve nutritition, manage oedema etc

* This includes but is not limited to: compression, diet, medication, dressings, exercises, counselling etc

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*Shared quality project MH and Hartmann’s support

*Pre-learning

*Pre-event knowledge and collaboration survey

*1 day event to have open discussion about Victorian CNC (wound and continence) regarding expert opinion on IAD

*Objective to discover current practices and understanding of IAD

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*What were other CNCs doing in Victoria?

*What was considered best practice?

*Decided to run a 1 day scoping event

*For senior wound and continence CNVs in

Victoria in tertiary referral centres

*Hoped to play match-maker

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*4 articles

*Mainly from WCON literature

*Minimal literature in wound or continence

circles e.g. CFA brochure was approx. 10 years

old

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*Identified gaps:

*40% identified that they referred to their

counterparts, (60% less than 5 times)

*Clinicians indentified that IAD was a factor in

pressure injury development, but did not have

confidence in ward staff management

*Most clinicians felt confident in their won

understanding of IAD

*Not targeted education on IAD prevention

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*Brief theory to set the tone of the day

*Hands-on practice with both wound and continence products (clinicians are encouraged to ‘play’

*Workshop in small groups re: policy

*Clinicians not to sit with their ‘friends’

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*Many of the participating clinicians realised

that they have policies pertaining to skin

management of people with incontinence

*Policies were usually embedded inn aged

care/continence polices

*Not part of everyday practice or acute hospital

knowledge

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*50% of residents in care are incontinent

*80% of immobile are incontinent

*1/3 0f patients admitted to Royal Park are

known to be continent on admission (excludes

the hidden majority)

*Expectation that incontinence is a normal part

of aging (its not)

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*Summary of what policy is:

*Key points are:

*pH appropriate skin care (4.5-5.5)

*Active toileting

*Promoting continence (NOT managing incontinence)

*Barrier cream for all (with pads)

*Skin checks

*Skin Hygiene

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*Urine is composed of 95% H2O 5% organic solutes, primary urea.

*Normal skin has a pH of 5.4 to 5.9 (acid environment) this has an antibacterial effect limiting pathogenic organisms.

*Urinary urea decomposes on the skin to form ammonium hydroxide which is an alkaline substance and raises the skins pH, which favours bacterial proliferation.

Faeces contains enzymes including:

*Proteases (Any of various enzymes that bring about the breakdown of proteins into peptides or amino acids)

*Lipases (Any of a class of enzymes that break down fats, produced by the liver, pancreas, and other digestive organs or by certain plants)

*50% made up of microorganisms

Faeces degrade the skin barrier function

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*Continence and skin care is seen a something

that ward nurses can own

*Responsibility is being taken

*However, concern that each speciality is adding

layers of complexity to the ward nurses role

and increasing the list of tasks that have to be

done

*IAD, skin care and continence is on the

executive agenda

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*Nurse Rounding

*Advancement of technology (e.g.. Cloth vs. disposable pads, visible vs. invisible barrier creams)

*Evolution of own practice and understanding of concepts

*Looking to have follow-up day on IAD

*Looking to other professional groups for engagement (WOCN)

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*Decision to take nursing education ‘back to

basics’

*Improve all nursing care, then continence, and

skin care will improve, reduces falls

*Empower patients and carers to be involved

and speak up about care and nursing needs

*Nurse rounding is a philosophy NOT a task, and

Susan is working to engage nurses to embrace

this nursing concept

*When Rounding?

PositioningMaking sure the patient

is comfortable and assessing the risk of

pressure ulcers

Personal needsScheduling trips to the

bathroom to avoid risk of falls

PainAsking patients to describe

pain level on a scale of 0 - 10

PlacementMaking sure the items a patient

needs are within easy reach

Four Ps Intentional rounding

key elements

*The Evidence

*Decrease buzzer usage 40-50%

*Patient falls reduced by 33%

*Hospital-acquired pressure ulcer cases reduced by 56%

*Overall patient satisfaction has increased by 71 percentile

points

Best Practise: Sacred Heart Hospital Pensacola, Florida (2007 Studer Group)

sarah.sage@mh.org.au

susan.leenaars@mh.org.au

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*Apply a barrier cream (article)

*Don’t wait for redness or signs of incontinence associated dermatitis

*Think of it like sunscreen-you wouldn’t expose skin to the sun on a hot day without protection

*Don’t expose skin to urine or faeces without protection!

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*List participants

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*Continence Foundation of Australia

*Australian Wound Management Association of

Australia

*Wound, Ostomy and Continence association