Skin/WoundIssuesWhyThingsGoWrong

Dane De LucaRN BSN WOCN

SkinIssueTopics

O IncontinenceO Leakage from tubesO Products available to protect

the skinO Management of tube leakage

IncontinenceAssociatedDermatitis(IAD)

O Definition: an inflammation of theskin in the genital, buttock or innerthigh areas that occurs when urineand/or stool comes in contact withthe skin.

IncontinenceAssociatedDermatitis

Skin can be:O painfulO weepyO erythematous (redness)O edema (raised or swollen)O itchy

Themostchallengingskinissuesresultfromdiarrheaorfrequentstooling

O Some common causes of diarrhea are:O Hyperosmolar or rapidly delivered tube

feedsO Atrophy of the intestinal liningO Ischemic bowelO Short bowel syndromeO Pseudomembranous colitisO Infection

O Treating Incontinence AssociatedDermatitis may include medical and/orsurgical intervention based on the cause.

O The role of the CWOCN is to prevent skinbreakdown by minimizing exposure tostool or urine and providing anenvironment that maintains skin integrityand promotes wound healing to preventinfection.

OA key to preventing skinbreakdown is a defined skin careregimen that includes gentlycleansing, moisturizing andapplying a skin protectant orbarrier ointment.

O Cleansing with soap and water is very appropriate with awell functioning tube or with patients who are diapered andnot experiencing any skin issues.

O If there are skin issues, then cleansing with a perinealcleanser is beneficial. These products have a pH range thatreflects the acid mantle of healthy skin (ph between 5.4-5.9)A higher skin pH enhances the risk of skin colonization bymicroorganisms.

O Cleansers emulsify dirt and microorganisms on the skinsurface so that they can be easily removed.

O No rinse cleansers combine detergents and surfactants toloosen and remove dirt or irritants and many contain amoisturizer.

SkinProtectantsO This category of product aims to prevent skin

breakdown by providing an impermeable orsemipermeable barrier on the skin, thuspreventing penetration of water and irritantsfound in stool and urine.

O Skin protectants include petrolatum basedointments, dimethicone-based ointments, zincoxide creams and oils.

Skin Protectant Paste

O The same products to protect and treatskin irritation from stool or urine are usedfor irritation around a gastrostomy orjejunostomy tube.

O The management of unstable G or Jtubes that leak effluent around theinsertion site present significantchallenges to the Doctors, nurses, familymembers, and the patient.

ProblemswithTubesO DislodgementO MigrationO CloggingO Stomal enlargementO LeakageO Skin breakdownO Hypergranulation tissue

ClearPegTube

ThecauseoftheleakagemustbeidentifiedandeliminatedifpossibleSiteleakageandsubsequentskinbreakdownisthemostcommoncomplicationofGtubes.

Monlycke Mepilex Foam Dressing

MepilexFoamDressing

Polymem Dressing

O Hypergranulation tissue is tissue that forms aroundthe insertion site of the tube, it’s appearance isbeefy red and forms a spongy mat above the skinlevel.

O Excessive tube motion can cause or increase thegranulation tissue formation.

O A common cause of leakage around the tube ishypergranulation tissue formation.

O The tissue can bleed easily and secrete ayellowish exudate.

O Treatment includes silver nitrate (cauterizing thehyergranulation tissue) and/or improved securingof the tube.

HypergranulationTissue

Coloplast Protective Sheet

ColoplastProtectiveSheet

GastricStomaO The stomach lining can actually migrate up the

tube and mature at the skin level as a gastricstoma.

O This situation can cause major leakage problemsand challenges stabilizing the tube.

O Treatment options include: tube holders, pouchingof tube site with or without the tube in place,surgical, cauterization or surgical relocation of thetube.

GastricStoma

GastricStoma

Granuloma

HollisterTube

Holder

HollisterTubeHolder

Convatec FlexiTrak Tube

Holder

Enlarged Insertion Site with Leakage Issues

Severe Skin Irritation from Leakage

Aquacel Ag (Silver)

PouchingaTubeSite

Pouching the Leaking Site and Threading the Tube through a Tube Holder

ConclusionO There are many over the counter ointments and

skin protectants available.O Reimbursement of many of the products

mentioned in this presentation is dependent onyour insurance and home care coverage.

O Samples are available in the back of the roomfrom calmoseptine, coloplast and hollister.

O Special thanks to Laurie Reyen and Valerie DeLuca.