Collection of Practical Guides of Wounds of the Servizo Galego de Saúde
Practical Guide for Moisture Associated Skin Damages. Guide No. 7
COLLECTION OF PRACTICAL GUIDES OF WOUNDS OF THE SERVIZO GALEGO DE SAÚDE PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES Guide No. 7
Xunta de Galicia Consellería de Sanidade Servizo Galego de Saúde Dirección Xeral de Asistencia Sanitaria 2016 Publisher: Xunta de Galicia Consellería de Sanidade Servizo Galego de Saúde Dirección Xeral de Asistencia Sanitaria Graphic design and layout: Versal Comunicación, S.L. Year: 2016
Licence: Creative Commons Attribution-ShareAlike 4.0 International Licence (CC BY-SA 4.0) http://creativecommons.org/licenses/by-sa/4.0/ 01 COLLECTION OF PRACTICAL GUIDES OF WOUNDS OF THE SERVIZO GALEGO DE SAÚDE
— No. 1 Pressure Ulcers — No. 2 Ulcers of the Lower Limb — No. 3 Ulcers of the Diabetic Foot — No. 4 Neoplastic Skin Lesions — No. 5 Burn Injuries — No. 6 Acute Surgical Wound — NO. 7 SKIN LESIONS ASSOCIATED WITH MOISTURE — No. 8 Traumatic Wounds
Úlceras Fóra Programme. Servizo Galego de Saúde, 2016
evidence toachieveanimprovementinthepatient’s qualityofcareandsafety. by ulcersandwounds,oratriskofsuffering them, in ordertoincorporatethebestavailable to patientsaffectedapproach practice inthecareandcomprehensive improve theirclinical Saúde That is why this in theclinicalvariabilityforthistypeoflesions. reduction ofcriteriaandacorresponding etc.) which allowustomovetowardsthestandardisation establish preventivemeasures,treatments, use of products, monitoring,registration, objectives proposedwastosetcommoncarecriteria(toidentifytherisk,assesslesions, strategic lines inthe approach of everything relatedto ulcers andwounds,oneof the basic Through the the careactivityarisingfromthisprocess. systematise and to trynormalise required, conditions and the structure,resources to improve andtreatmentofthistypelesions;soforseveralyearswehavebeenworking the prevention Department, thereisanawarenessof the importanceandimpactof a propermanagement of through theHealthCare Integration Innovation and Organisational for CareManagement From theServizoGalegodeSaúde,andmoreintensivelyfromGeneralSub-Directorate professionals. also bytheworkloadandclinicalvariabilitythattheircarerepresentsforhealthcare carers, and and families to theimpactthatithasontheir in patients,due of life the lossofquality magnitude due to the extra financial cost it means for sustainability of the health system, due to of great a healthproblem to ulcersandwoundsimplies Everyone knowsthattheapproach PRESENTATION , describestheeffort(doctors andnurses)to of manyprofessionals and enthusiasm Úlceras Fóra Programme Collection of Practical Guides for Wounds from the Servizo Galego de the reference frameworkto develop and establish GeneralDirectoroftheHealth Assistance Department Servizo GalegodeSaúde Jorge Aboal Viñas Jorge Aboal
7 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 8 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES or healthcentrewheretheyareintendedtobeapplied. at available the time of the sanitary attentionandinthe regulations establishedby the institution resources the particular; in patient each of preferences and needs specific the as well as time; of the practices the bestclinical them and applies who care professional of thehealth evidence) variation of the recommendations set forth herein, shallbebasedonclinicaljudgement(internal out. to becarried care thatisintended or treatmentfortheintegral procedure or Any amendment a in followed be to conduct of course single a define not do therefore and nature general a of are in thisguide that areincluded on evidence practice based for clinical The recommendations Sergas. for Care ManagementandOrganisationalInnovation Directionof Sanitary Assistance of and scientific institutions at national level, under the coordination of the General Sub-Directorate and hospitalcareof the ServizoGalegodeSaúde(Sergas)andreviewedby expert professionals with theparticipationof health professionalsinprimarycare This PracticeGuidewasdeveloped PREFACE IMPLEMENTATION and disseminationontheInternetthroughofficialwebsiteofSergas. SergasHealthcare in the institutions all public Network, the dissemination in of an official statement to the presentation media, its official disclosure in scientific the events Galicia, de Xunta The diffusionof de Sanidadethe processentailsaceremonialpresentationat the Consellería Innovation, ofSergas. Department, of the General Sub-Directorate Generalfor Care ManagementandOrganisational Management of Fora Programme;that the Úlceras is to say, by theHealthCareIntegration Collection of Practical GuidesonWounds of Sergas, shallbeco-ordinatedthroughthe Technical strategy ofthispracticalguide;aswellas,theentire andimplementation The dissemination DISSEMINATION AND
9 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 10
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES of care. categorisation whichmay lead to a clinical risk of safety for the patient and/ or affect the quality modify its of evidence if anyoftherecommendations performed beforetheendofthisperiod can be Its updating after 3yearsfromthedateofitspublication. be reviewed should The guide
VALIDITYUPDATE AND DECLARATION OF CONFLICTS OF INTEREST AND EDITORIAL INDEPENDENCE
The authors of this practical guide declare to have made an effort to ensure that the information contained herein is complete and up to date, and state that they have not been influenced by conflicts of interest that could change the results or contents during the preparation stage and its development. Likewise, the authors of the guide assume responsibility for the content expressed, which includes evidence and recommendations.
The editors of the Collection of Practical Guides for Wounds of the Servizo Galego de Saúde declare that there is editorial independence regarding the decisions taken by the technical management and the coordinators of the working group. PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
11 ASSESSMENT AND CLASSIFICATION OF THE EVIDENCE
The scientific evidence and recommendations set forth in this Practical Guide were the result of the assessment and analysis of the sources of information consulted as bibliographic reference (clinical practice guides, guides based on the best evidence, other documents based on evidence, systematic reviews and original articles); the critical reading method and consensus by nominal group between authors and panel of experts was used to prepare it.
The classification of the level of evidence and grading of the recommendations hasbeen maintained while respecting the original source consulted and the scale of evidence that has been used. The method that CENETEC (National Centre of Technological Excellence in Health) of Mexico in the development of their clinical practice guidelines (GPC) has been used for this: • Classify with the symbol [E] that evidence which is published in any GPC, followed by its alphanumeric classification (quality of the study, if it is referenced) and bibliographic citation. • Categorise with the symbol [R] those recommendations identified by any GPC, followed by their strength of recommendation (by A-B-C-D levels, in descending order according to clinical importance, or by their grading in high-moderate-low evidence). • Identify with the symbol [GP] those actions and / or activities considered as good practices, which are not referenced or supported by any GPC, but that appear in other documents based on the evidence (guides to good clinical practice, clinical pathways, protocols based on evidence, etc. ) and whose evidence has been obtained through systematic reviews, meta-analyses, clinical trials, etc.
The scales on the level of evidence and degree of recommendations that are described in the contents of this practical guide can be consulted through the bibliographic sources referenced in the summary table of recommendations / evidence. PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
12 of theServizoGalegodeSaúde Collection ofPracticalGuidesWounds PRACTICAL GUIDENº7 DAMAGES MOISTURE ASSOCIATEDSKIN PRACTICAL GUIDEFOR 01
PREFACIO
13 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES
INDEX
01. RELATIONSHIP OF AUTHORS, COORDINATORS AND REVIEWERS | 16 |
02. INTRODUCTION | 18 | 2.1. Justification | 18 | 2.2. Scope and Objectives | 18 | 2.3. Questions to be Answered by this Practical Guide | 19 |
03. DEFINITION | 20 |
04. EPIDEMIOLOGY | 21 |
05. ETIOPATHOGENESIS. PREDISPOSING FACTORS | 22 |
06. PATHOPHYSIOLOGY CLINICAL MANIFESTATIONS | 27 |
07. DIAGNOSTIC ASSESSMENT. CLASSIFICATION AND CLINICAL DIFFERENTIATION | 31 | 7.1. Scales of assessment of the risk of lesion due to moisture | 18 | 7.2. Classification of the MASD | 18 | 7.3. Characteristics of differentiation between MASD AND PU | 19 |
08. GENERAL GUIDELINES ON PREVENTION AND TREATMENT | 27 | 8.1. Determine the cause of the lesion | 18 | 8.2. Risk assessment | 18 | 8.3. Skin care | 19 | 8.4. Skin protection | 18 | 8.5. General cleaning and hygiene measures | 18 | 8.6. Decision algorithm for the prevention of MASD | 18 | 8.7. Health education | 18 | 8.8. Prevention and treatment model | 18 |
09. SUMMARY OF EVIDENCE RECOMMENDATIONS | 42 |
10. LITERATURE | 45 |
11. ANNEXES | 49 | PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
15 01 RELATIONSHIP OF AUTHORS, COORDINATORS AND REVIEWERS
TECHNICAL MANAGEMENT
Úlceras Fóra Programme Health Care Integration Department. General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). [email protected]
WORKING GROUP
AUTHORS OF THE GUIDE José María Rumbo Prieto Supervisor for Care, Research and Innovation. University Hospital Complex of Ferrol Organisational Structure of Integrated Management of Ferrol. Luis Arantón Areosa Director of Nursing Processes. University Hospital Complex of Ferrol Organisational Structure of Integrated Management of Ferrol. Ramón López de los Reyes Specialist Doctor Attached to the General Surgery and Digestive System Department. University Hospital Complex of Ferrol Organisational Structure of Integrated Management of Ferrol. Eulalia Vives Rodríguez Specialist Doctor Attached to the General Surgery and Digestive System Department. University Hospital Complex of Ferrol Organisational Structure of Integrated Management of Ferrol.
COORDINATORS OF THE COLLECTION OF GUIDES José María Rumbo Prieto Supervisor for Care, Research and Innovation. University Hospital Complex of Ferrol Integrated Management Structure of Ferrol. Camilo Daniel Raña Lama Nurse Labañou Health Centre Integrated Management Structure of A Coruña. María Blanca Cimadevila Head of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). Ana Isabel Calvo Pérez Technician of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). Josefa Fernández Segade
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL Technician of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas). 16 REVIEWERS Panel of experts • Group of Trainers and Guides in Wounds for the Úlceras Forá Programme of SERGAS • Carmen Outón Dosil Nurse. University Hospital Complex of A Coruña Integrated Management of A Coruña. • Estela María Souto Fernández Nurse. University Hospital Complex of A Coruña Integrated Management of A Coruña. • Rocío Sanmartín Castrillón Nurse. University Hospital Complex of Ferrol Integrated Management Area of Ferrol. • Juan Santiago Cortizas Rey Nurse Supervisor of Nosocomial Infection. University Hospital Complex of Ferrol Integrated Management Area of Ferrol. • Pedro Pita Miño Nurse Surgery Supervisor University Hospital Complex of Ferrol Integrated Management Area of Ferrol. • Federico Palomar Llatas Nurse Director of the Hartmann Chair for Skin Care Catholic University of Valencia. • Ana Isabel Calvo Pérez Technician of the Health Care Integration Department General Sub-Directorate for Care Management and Organisational Innovation. Directorate General of Health Care. Servizo Galego de Saúde (Sergas).
Scientific Institutions and Societies • Asociación Nacional de Enfermería Dermatológica e Investigación del Deterioro de la Integridad Cutánea (ANEDIDIC) • Sociedad Gallega de Heridas (SGH) • Academia de Enfermería de Galicia • Colegio Oficial de Enfermería de Lugo • Colegio Oficial de Enfermería de A Coruña • Colegio Oficial de Enfermería de Ourense • Colegio Oficial de Enfermería de Pontevedra
HOW TO QUOTE THE DOCUMENT
Rumbo-Prieto J. M., Arantón-Areosa L., López-de los Reyes R., Vives-Rodríguez E. Practical Guide for Moisture Associated Skin Damages. [Practical Guide No. 7]. In: Rumbo-Prieto, J. M.; Raña-Lama, C. D.; Cimadevila-Álvarez, M. B.; Calvo-Pérez, A. I.; Fernández-Segade, J., editores. Collection of Practical Guides for Wounds of the Servizo Galego de Saúde. Santiago de Compostela (A Coruña): Xunta de Galicia. Consellería de Sanidade. Servizo Galego de Saúde; 2016. PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
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PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES practice based onevidenceand; to attainafewquality careindicatorsforthe careand from theGalician healthandsocio-health caresystembased ontherecommendations of achieve greateroptimisation inthemanagementofhumanandeconomic resourcesavailable uncertainty, reducetheprevalence andincidenceofthishealthprobleminsociety, aswell is tocontributethewelfare ofpeople,reducethevariabilitytreatments andprofessional and treatment,whichskin lesionsassociatedtomoistureposeasahealth problem. The aim referral detection, prevention, of actions specific perform factors, risk identify to reference The aim of the Guide is to provide guidelines and/or standardised criteria to serve as a Primary HealthCare,HospitalCareandSocio-Health Care. associated skindamages,inanyofthethreehealth carelevelsintheCommunityofGalicia: professionals withdirectorindirectresponsibility fortheintegralapproachofmoisture The scopeoftheGuideisaddressedtopeople affected, informalcarersandallhealth 2.2. SCOPE AND OBJECTIVES suffering fromthem;accordingtotheclinicalpractice basedonthemostcurrentevidence. or atriskof skin damages for thecareofadultswithmoistureassociated practices available This guide isthereforemeant as a synthesisof the best interventions andpreventiveor therapeutic Public healthattheserviceofpatients. Health System2010,aswellas,withSERGASStrategy2014: Quality PlanfortheNational Practice), ofthe Clinical with strategyNo.10(Improving in line is aligned such aCollection, Innovation. Inturn, andOrganisational forCareManagement Sub-Directorate by theGeneral with the strategies andlinesof action promotedthroughthe Úlceras Fora Programme coordinated ofPracticalGuidesWoundsinto theCollection Health Service;inaccordance oftheGalician This same clinicalandpathology. to patientswiththe in relation or patientandeveninasameprofessional the sameproblem when facing in techniques,tests, and diagnosticskills,clinicaljudgementdecision-making decides. who person of theprofessionals the performance in disparity to agreat rise This gives and the available on thetime,information based of decisions variability causes aconsiderable turn in which etc.) guides, protocols, evidence, scientific patient, the of preferences experience, data, professional sources (clinical from avarietyofinformation into accountseveralalternatives professionals. healthcare taking requires its approach regarding Therefore, thedecision-making to take onthepreventionandcaring),alsobyworkloadthat their carerepresentsfor in life of quality of many caseshave in carers (which and their families to theimpactthatithason patients, due loss the to due systems, health the for means it cost financial extra the to due of greatmagnitude a healthproblem implies tochroniculcersandwounds The approach 2.1. JUSTIFICATION 02 INTRODUCTION Practical GuideforMoisture Associated SkinDamages (PracticalGuideNo.7)isintegrated safety of patients that shall allow for greater efficiency of the process between the different care levels.
2.3. QUESTIONS TO BE ANSWERED BY THIS PRACTICAL GUIDE
• What are moisture associated skin damages (MASD) and how are they defined? • What is their epidemiology and etiopathogenesis, what type are they and how are they classified? • What are the most frequent locations? • How to diagnose and/or differentiate a MASD lesion? • What treatments and/or therapeutic measures are most appropriate? • What complications can occur? • What prevention recommendations are the most indicated? • What treatment recommendations are best? • What therapeutic guidelines and health education should patients, informal carers and professionals follow to facilitate their care? PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
19 03 DEFINITION
The term moisture associated skin damages (MASD)1 is a general concept which includes in its definition the effect of moisture with other aggressive agents and their effect on the skin. Recently the term has been the subject of a discussion of consensus to redefine the concept, to identify sources of moisture and differentiate this type of lesion from others that are not.1-10
The Grupo Nacional para el Estudio y Asesoramiento en Úlceras Por Presión y Heridas Crónicas (National Group for the Study and Advice on Pressure Ulcers and Chronic Wounds )(GNEAUPP), in its document No. II; proposes as a MASD definition:3 “The lesion located on the skin (usually does not affect underlying tissues) that is presented as an inflammation (erythema) and/or erosion of it, caused by the prolonged exposure (continuous or almost continuous) to various sources of moisture with potential irritation to the skin (for example: urine, faeces, exudates from wounds, effluents of stomata or fistulas, sweat, saliva or mucus)”.
In this way, we can understand MASD as: a deterioration of the integrity of the skin caused by prolonged exposure to various sources of moisture, with associated physical or chemical irritation, characterised by a type of dermatitis and/or eczema with inflammation and erythema, with or without excoriation of the epidermis and usually accompanied by maceration, which is located mainly at the level of the integumentary folds, in perilesional and/or periestomal tissue, and perianal or perigenital area (figure 1).
©Teresa Segovia
Figure 1. Moisture associated skin damage in the perianal and perigenital area PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
20 amount ofprecipitatingfactorssuchasthepresenceexudates,irritants,etc. an enormous omitting this group, in recognised (IAD) was dermatitis associated incontinence by of their aetiology(moisture),buttraditionallyonly MASD isconditioned The epidemiology diaper) werethemostaffected,due to dermatitisassociatedwithincontinence. mainlybyinjuries of the (areas genitals and areas gluteal the the location, on %. Depending centres 5.25 sanitary care, the prevalence of MASD in PrimaryCarewas3.7 %; in hospitalcentres8.1 % andinsocio- % of combined injurieswasdetermined:pressureand/ora shearing + moisture. By levels of associated skindamages(MASD)represent6.5%of the total. In addition, the existence of 16 In the 4 body’s naturaldefence. pressure orshearing,aggravatestheeffectsnon-relieved of thesebecauseitdecreasesthe a riskfactorfortheonset ofpressureulcers(PU), above, isconsidered of the or acombination type, faecal urinary either with incontinence, associated The moisture and withthepresenceofcomorbidpathologies(ascommoninwomenasmen). in socio-sanitarycentres;anincidentthat increases withage elderly andthoseinstitutionalised in is veryfrequent,particularly incontinence of faecalandurinary the coexistence because aetiology, this identifying specifically into delving when increase will they that prevalence of In our environment,theMASD is epidemiological still littlestudiedbut it is noted injuries). preventable of casesareconsidered number of life andinalarge the person,theirquality (they affectpainful and the mostfrequent to IADare MASD related of state ofhealth thegeneral 04 EPIDEMIOLOGY th National PrevalenceStudy for PU inSpain, 18 according to the aetiology, moisture 14-17 which combined with whichcombined 1, 2,6,7 11-14 especially
21 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 22
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES its barriereffect andthatinturninteractbecomemorepowerful amongsteachother: the skinandreducing factors thatactbydeteriorating general The MASDoccurduetothreemajor 05 ETIOPATHOGENESIS. 2. 1. 3. exudates…) solutions...) irritation) Due totheactionof irritating chemicalagents (cosmeticproductsof topical application, The effect of an excessof moisture onthe skin (incontinence, sweating,exogenous Due to the activity resulting from an excessive and repeated cleaning and hygiene (physical and hygiene cleaning Due totheactivityresultingfromanexcessiveand repeated PREDISPOSING FACTORS (figure 4) (figure 2) (figure 3) Figura 3. Figura 2. . ©Teresa Segovia © FedericoPalomar . . Incontinence associateddermatitis(IAD) Dermatitis withtopicalproductremainsandfaecalincontinence
13, 14,19,22 Figura 2. Incontinence associateddermatitis(IAD) etc. present intheskin,patient’smicro-organisms pathogenic potential healthstatus,age, skin), themechanicalfactors like theforcesof friction andshearing,thepresenceof of the (integrity of theirritant,skinconditions amount of theirritant,volumeand duration amount, content, type andthe intensity of the irritant(substancethat causes themoisture), volume, (duration), exposure factors suchasprolonged by othercontributing determined a lesionwillalsobe of producing produce alesionontheskin(dermatitis),probability to cause sufficient not is moisture of sources various the to exposure hand, other the On (pressure ulcers). lesions with pressurecanresult indeeper since, aswesaidabove,iftheyarecombined These lesionsdueto moisture inturn, need to be addressed earlyandsatisfactorily, treated properly, can leadto chronic lesionsassociatedtomoisture(damagedskin) and detected not is it if which, skin) (complete erythema and inflammation with of The this consequences skin lesionaretheof initial appearance dermatitis and/ or eczema (figures 6and7) Figura 5. Figura 4. ©Teresa Segovia ©Teresa Segovia . Dermatitis resulting Dermatitis and repeated cleaning from excessive and hygiene Deterioration oftheskinintegrityduetoexcessmoisture (figure 5) .
23 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 24
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES Figure 6. CUTANEOUS INJURY FRICTION HUMIDITY (LESCAH) ASSOCIATED WITH SWEATING MOISTURE EXCESS MUCUS SALIVA Classification oftheMASDaccordingtotheiretiopathogenesis Cleaning -hygiene By YATROGENIA By PRODUCTS REST OF TOPICS HUMIDITY CHEMICAL IRRITATION • >SKININFECTIONRISK • •
Figure 7. Multicausal aetiological model of MASD
In the following scale, regarding the different types of irritating substances, the intensity of affectation that a prolonged excessive contact can cause on the skin is reflected from lowest to highest.
TYPE OF IRRITATING SUBSTANCE INTENSITY OF AFFECTATION Water (hot / cold). + Sweat. + Saliva. + Mucus. + Urine. ++ Topical irritating products. ++ Exudate. ++ Formed faeces. +++ Urine and faeces. ++++ Soft faeces with or without urine. ++++ Liquid faeces with or without . +++++ PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
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PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES The mainphysiopathologicalprocessesandclinicalmanifestationsinvolvedinMASDare: of theskintomoisture. by thefrictionofexternalforcesassociatedwithexcessiveexposure integrity andtissuecaused layer,of thedermolipid alteration skin alkalinisation, of theskin deterioration andconsequent with (dermatitis), process inflammatory an of establishment the to due because, characterised it is that itdeteriorates; theprobability increasing of theskinmakesit more vulnerable, barrier of the activitiesof the patient. hygiene, toiletormobilisations This alterationof the protective well asbythephysicalirritationthatcouldresultfromrepeatedfrictionexertedduring and/or to the chemicalirritationproducedbyactionof the urine, faecesorexudates,as Generally, the skinofpersonaffected byMASDbecomesfragileduetoexcessivemoisture MANIFESTATIONS 06 PATHOPHYSIOLOGY CLINICAL PROCESS (Dermatitis) INFLAMMATORY PROCESSES PHYSIOPATHOLOGICAL
sweat... faeces, exudates, – Presenceof urine, area. of theexposed repeated washing – Continuousor – Excessmoisture. INVOLVED ELEMENTS – Excessivehumiditycaninjuretheskinby CLINICAL MANIFESTATIONS exudation, scabs,itchingandpain. oedema, erythema,maceration,tissueexcoriation, in thepermeabilityofskintopotentiallyproduce become morechronic,withtheconsequentincrease dermatitis. The resultingskineczematendsto skin thatifmaintainedorincreasedcanleadto improper dryingcanresultinasofteningofthe – Prolongedexposuretomoisture,aswell exposed togreaterriskofinjury. can besaturatedandfavourthattheskinis (products forincontinence,dressings,etc.),which – Improperuseofprolongedocclusionproducts prolonged exposuretomoisture). macerating it(softeningandbreakageasaresultof 13,14,19-22
INTEGRITY THE SKIN AND TISSUE DETERIORATION OF ALTERATION DERMOLIPID SKIN ALKALINISATION area. of theexposed repeated washing or – Continuous moisture. – Excess moisture. – Excess area. of theexposed repeated washing or – Continuous sweat... faeces, exudates, – Presenceof urine, area. of theexposed repeated washing – Continuousor – Excessmoisture. into irritation,inflammationandinfectionoftheskin. proliferation ofbacteriaandinturncandegenerate urea inammoniumhydroxide),whichfavoursthe environment (duetothedecompositionofurinary – The presenceofurinecreatesanalkaline deterioration intheskin. produce harmfuleffects whichincreasetheriskof urine andfaecalenzymescancauseirritation to moistureandirritatingsubstancescontainedin breaking down.Repeated,prolongedexposure prevents theexistingbalancewithnormalflora guarantees theexistenceofanacidmantlethat – NormalskinpHvariesbetween4.8-5.6which skin andthemicrobialactivityincrease. makes theenzymaticactivity, thepermeabilityof skin losesitsbarriereffect duetodehydration. This stratum canincreaseupto5timesitssizeandthe corneal stratumfixingtotheproteins. The corneal – The waterpenetratestheintracellularspacesof and/or necrosis(stageIIulcer). local ischemicprocesswith theconsequentinjury maintained, althoughnotexcessive, giverisetoa tolerance, mayleadtothe fact thatpressures integumentary folds,associatedwithalowerskin in theintergluteal,perianal,perigenitalareaand – The forcesoffrictionandshearing,fundamentally favour dermatitis excess ofmoisturethatifmaintainedorincreasedwill type lesions. An inadequatedryingmayresultinan out frictioninthedryingandpossiblemechanical Repeated cleaningactivitiesalsoinvolvecarrying coefficient, causingtheskintocrackorfissure. – Excess moisture canincreasethefriction contact dermatitis. release proinflammatorysubstancesthatresultin hygiene withsensitisingcomponentsthatwould increased bytheuseofcertainproductsforwashing/ cutaneous elasticity(skinxerosis). This can be water isacceleratedwiththeconsequentlossof the skinlipidsareremovedandlossofepidermal the functionofprotectivebarrierskinas – oftheaffectedFrequent washing skin,canchange
27 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 28
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES to planandcarryoutthemostappropriatetreatment: be ableto moisture associatedskindamagesandconsequently adopt the necessary measures There arevariousscalesorinstrumentstobeablemakeacorrectassessmentoftherisk to planandcarryoutthemostappropriatetreatment: be ableto moisture associatedskindamagesandconsequently adopt the necessary measures There arevariousscalesorinstrumentstobeablemakeacorrectassessmentoftherisk MOISTURE 7.1. SCALES OF ASSESSMENT OF THE RISK OF LESION DUE TO of thistypelesionandpreventitsevolutiontomorecomplexclinicalstages. the earlydetectionandtreatment therefore ithastobeoneofthepriorityobjectivesachieve and irritants isessential, to skin to moistureand/or exposed of theskin assessment The proper DIFFERENTIATION 07 DIAGNOSTIC ASSESSMENT. b) a) f) e) d) c)
Palomar, GNEAUPP. Iconographic scale ofDiaperRash caused byMoisture(DPH) Visual Scale of the Erythema(EVE) Severity scaleof skin lesions due to incontinence (ESLCI) IAD, Incontinence Skin Condition Associated Dermatitis ToolAssessment Grading Scale Perineal Dermatitis PAT, Perineal ToolAssessment et al. associateddermatitis duetoincontinence impairment Developed by Kennedy andLutz factorsasaresultofnursingintervention and thechangesinthese (IAD), dermatitis associated severity oftheincontinence the scopeand items thatassess between 0and3points the sum of obtaining the scoresthroughassessmentof four sub-sections with values colour and the degree of skin affectation. This scale classifies the severity of the lesion the of severity the classifies scale affectation.This skin of degree the and colour assessment degreesoferythema colorimetric contact dermatitis lesion due to incontinence intheperinealarea duetoincontinence lesion by moisturein6types CLASSIFICATIONCLINICAL AND 29 It is a scale of 0 to 12 points (0 = intact healthy skin, 12 = severely damaged skin), damaged (0 =intacthealthyskin,12 =severely of 0to12points Itisascale 25 fromtheEVEscale.Consistsofavisualscalethatassesseserythema 1 It is a scalethat consists of 4 itemsor factors that assess the risk of skin 24 . Consists of a numeric scale of 0 to 4, which determines up to five to up determines which 4, to 0 of scale numeric a of Consists . (annex 2) (annex 6) 28 . consists of three items that assess thedegreeof skin . : Originally developed by Nix, developed : Originally : Created by Brown and Sears. and by Brown : Created : Designed by Fader : Designed (annex 1) (annex 3) (annex 5) . . 23 fromtheQuinnscalefor : byRuedaJ. Developed . (annex 4) 26 27
and adapted by andadapted It is a scale of 4 Itisascale : Designed by : Designed .
:
Table No.1 lesion suffered bytheskintissueassociatedwithmoisture: Additionally, the GNEAUPP on the proposes classifyingMASD into two categories, depending are classifiedinto6types Based onthestudyby Torra iBouetal. 7.2. CLASSIFICATION OFMASD exudatation associated with dermatitis Perilesional perspiration dermatitis by dermatitis or Intertriginous (DAI) incontinence associated with Dermatitis TYPE OFMASD g) subcategories: two into classified be can this excoriation and/or erosion of degree the on depending and edges. perilesional macerated with yellowish-white bed, usually pink At thesametime, of reddish- be lossofthicknessthedermisinformsurfacelesion There would Category II:Erythemawithlossofskinintegrity subclasses: subjected tomoisture. on theerythema,therearetwo At thesametime,anddepending area, usually ornot)ofalocalised (blanchable skin withredness be integral There would Category I:Erythemawithoutlossofskinintegrity
Moisture Sub-scale of the Braden Scale exposure level of the skin tomoisture exposure leveloftheskin refers to moisture as a risk factor. one of which sixsub-scales, it includes ulcers; the riskof pressure is usedtopredict . ClassificationoftheMASD 2B • Category 2 • Category • 1 • Category
Category 1B lesion. the perilesionalskin with exudationfrom prolonged contact related tothe Skin affection on cutaneousfolds. contact withsweat to theprolonged Skin affection related products. and absorbent mixed incontinence urinary, fecalor substances by contact withirritant to theprolonged Skin affection related DESCRIPTION A A : Mild-to-moderate (erosion <50%ofthetotalerythema). : Mild-to-moderate(erosion (pinkskin). : Mild-to-moderateerythema : Intense(erosionof : Intenseerythema(darkpinkorredskin). (table No.1) 1 . 1 and using the latest diagnostic classifications 31 - Adhesives for - Adhesives - Type ofdressings. - Exudationfrom - Superinfectionby - Occlusionbyfolds. - Pressureand - Sweat. - Hygieneand - Absorbent - Urineand/or This consists of sub-scale 4 itemsthat assess the dressings. injuries. flora. friction byfolds. cleaning products. products. faeces. (annex 7) > FACTORS 50%ofthesizeerythema). IMPLIED : The BradenScale . 2, 3 © FedericoPalomar © FedericoPalomar © TeresaSegovia 30 is avalidatedscalethat IMAGES 2-5 , MASD
29 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 30
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES their therapeuticapproach. for actions specific and preventive take and them favour that relationships causal the with deal by incontinence associated tothehumiditycaused lesions Currently, separatepressureulcersoftheskin severalstudiesshowtheneedtoaetiologically CHARACTERISTICS OFDIFFERENTIATION BETWEENMASD AND PU 7.3. Dermatitis by dermatitis Peristomal exudation associated with dermatitis Cutaneous mucus salivation or stoma. of fluidsfromthe to prolongedcontact Skin affection related the skin. some extremitywith with exudationof to prolongedcontact Skin affection related or nostrils. oropharyngeal cavity or mucusfromthe contact withsaliva with theprolonged Skin affection related 1-3, 8,10,19,20,32-34 - Related - Pressure. - Rubbingorfriction. - Mucosity. - Saliva. - Adhesive ofthe - Type ofcollecting - Fluidsproceeding - Basepathologies: - Exudationnot disorders, etc.) psychiatric (neurological, processes pathological device. device. from ostomy. lymphedema, etc. injuries. coming from (table No.2) © TeresaSegovia © PedroPita ©JM RumboPrieto , inordertoadequately Table No. 2 SHAPE LOCATION CAUSES APPEARANCES OTHER POSSIBLE COLOUR EDGES NECROSIS DEPTH CHARACTERISTICS OF THELESION . Clinical-morphologicaldifferencesbetweenMASDandPU Pressure +moisture=mixedorcombinedlesions(MASDPU) Figure 8. ©Teresa Segovia Presence ofmoisture. Pain oritching. (clinical signsofskininfection). Fever, candidiasis, leukocytosis, to moisture). Pink orwhite(macerationdue erythema). Non-uniform redness(diffuse Irregular anddiffuse. There isusuallynonecrosis. Superficial andveryextensive. Linear infurrowsorfolds. than oneplace. Diffuse anddispersedinmore form of“butterflywings”. Tend tobe“mirrored”orinthe Irregular. pressure /shearing. In boneprominences,without area. In perinealandperigenenital parts oftheskin. In skinfolds,softandextensive MOISTURE ASSOCIATED SKIN DAMAGES(MASD) PU Pressure +moisture(MASD +PU) MASD – Itmaybepresent(escharornecrotic – Superficialordeep(accordingto – Limitedtoasingleplace. – Well confined. – Circularandregular. – Onsoftpartssubjectedtopressure – Onbonyprominences. – Presenceofpressureand/or – Fetidsmell. – Itching,burning. – Chronic/acutepain. – Indurationorfluctuation. – Fromredtopurple,according – Sometimes,raisedandthickened – Clearlydistinguishable. plaque). stages). and /orshearing. shearing. category. edges. PRESSURE ULCERS (PU) (figure 8) .
31 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 32
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES exposed tomoisture Toof theskinareas / hygiene cleaning adequate on based care plan skin haveastructured 8.3. SKINCARE profuse sweating,drains,woundexudate,fever Assess allof the processesthat can causeanexcess of moisture intheskin:incontinence, Braden scalearerecommended is advisable.Preferably,monitored evolution theEVE,PATof the scaleandmoisturesub-scale The useof a validatedinstrumentthat allows the condition of the skinto be checkedandits RISK ASSESSMENT 8.2. out adifferential diagnosisofthelesions to carry to beable and rise tothelesion gave which the cause to determine in order examination, of the skinandaphysical An anamnesisisrecommended,togetherwithavisualexamination 8.1. DETERMINETHECAUSEOFLESION into accountthefollowingproposedactivities: The integralapproachof the MASDincludethat their preventionandtreatmentis madetaking 08 GENERAL GUIDELINESON PREVENTION AND TREATMENTPREVENTION AND (Source ofthe image: GPCValencia. 2008) Figure 8. (figure No.8) Bodyareasat riskofexcessivemoisture [R =High] . [GP] . 16, 17 . 14 [R =Low] 15 . 16 as wellthenetworkof informalcarers. and that integratesboththeprofessionals for alllevelstowhich itisaddressed understandable the skincare themselves, on the different hygiene products available and their benefits, would help to maintain A number of studies have concluded that a better byprofessionalsandusers knowledge [GP] with soapandwater and thereforedonotaltertheprotectivefunction of the skinasbywashing deodorant effect), theydonotleavetheskinexcessivelydryormoist in addition greater and care of time less cost, (lower benefits more provide rinsing, for water using not by wipes) or disposable (aerosols these products rinsing); remove without and step action(apply (cracks, fissures or small excoriations), it is recommended to use cleaning products with a single are presented skin orthatlesions eczema (dermatitis),macerated In casesofcutaneous folds, perianalandperigenitalareas as thiscanleadto friction andgeneratediscomfort, payingspecialattentionto the areasof softly,must bedried verycarefully,that theskinberubbed small “littletouches”,avoiding using (dryness oftheskin). skin lesionsduetomoistureandpreventsexcessivebodycooling The skin the riskof that bestprevents of theprocedures it isone patients, since incontinent in especially The subsequent dryingafter washing with soapand water requiresanadequatetechnique, moisture orincontinence,thisprocesscantakeupto24h. exposure to 45 minutesto restore itsnormalpH(between 4.8-5.6),butincasesofprolonged or worseningtheexistingone.It is estimatedthattheskintakes,in normalconditions,about contact dermatitis, and encouraging micro-organisms by pathogenic in theriskofcolonisation skin mantle, as well as, disturbing the balance of saprophytic flora with the consequent increase the hydrolipidic or removing damaging even stratum and of thecorneal the thickness reducing with thefaecesandurine,thatskin’sits alkalinisation, causing pHcanbefurtherincreased duetofrequentandrepetitiveuse,orwhencomingintocontact sulphate, theycanproduce, As soapysolutionscontainfatty acids ortriglyceridesandionicsurfactantssuchassodiumlauryl excessive andunnecessarydryingoftheskin to heatlesions, also lead is toohot,thiscould If thewaterusedforwashing chemicals. soluble of the organic residuespresentintheskinandachemicalactionthatfacilitatesdissolution the water During washing produces a mechanical action(drag)whichhelpsto remove the skins exposedtomoistureandforfragile for that istooaggressive a technique soaps isconsidered use ofconventional and repeated function; however,its protective of theskinand hydration to maintain type ofdrying thefrequent be thebestfrequency,on whatwould evidence and themostappropriate washingtechnique Traditionallysoap andwaterhavebeenusedtocleantheskin.It to speak of is notpossible patients orthosewithfragilevulnerableskins incontinent of case the in especially integrity, skin keep to step first the constitute skin, the of The cleaning of thorough the areas exposedto moisture, as prolonged wellas a proper drying . 13, 35-39 [GP] 14 . Hence the need to develop a structured health education plan that is plan education health a structured to develop . Hencetheneed [R =Low] 1, 7,13,14,25 [E] . [E] 16, 17 [R =Low] .
14, 35-37 . 35-37 13 . 16 13, 37
33 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 34
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES of iatrogeniccomplications. The mostusualarethefollowing: faced with an excess of external moisture, incontinence and other body fluids, as well as causes and promotethe emollients, moisturisingandbarrierproducts),provide topical protection when substances, The useofmoisturebarrierproducts,alsocalledskinprotectors(moisturising effects ofmoistureandincontinence Toand protectedfromthe it hydrated by keeping forskinprotection carryoutaprogramme 8.4. SKINPROTECTION [GP] drying the skinfromexcessive protecting moisture, while external repelling forces and the resistanceoffriction protection, aretransparentsubstancesthatact byreducing cream inskincare. mixed asabarrier evaporated; rapidly film; flexible the formation ofa base) thatallows with silicone (plasticizer Polyphenyhnethylsiloxane contains those which products: barrier three typesof silicone basically There are productsthat • Barrier a bacterialcontaminationinsitu in theskinasitcancause of infection of signs if thereissuspicion barrier as product used skin). of friction(fragile irritated skin,duetothehighpossibility substances to useoil-based viscous and have a concentration >20 % zinc they are difficult to remove so it is advisable irritation;inaddition,thecaseofpasteorcream astheyaremore can generate of zinc oxide. of notlessthan10% with aconcentration skin and for useinintegral recommended being protection for excess moisturewithbarriercreamsbasedonzincoxide of urineandfaeces. exposure to thecontinuous skin of anadequate There isevidence used for treatment of erythema associated withuse of absorbent products(diaper)and known compoundsduetoitsactionasaskinprotectorandrepairer, and iscommonly (O Zinc is an essentialtrace element that is to be foundinvirtually allcells.Zinc oxide productsthat • Barrier to theexcessivetimeneeded tobeabsorbedintheirentiretybynormal skin. them, due productsbysaturating with theabsorbent of interfering have thedisadvantage excess moistureinadultpatients. and and resistanceagainstthefriction,pressure the skinhydration toimprove option of pruritus. the sensation easing dryness, increasingfrictionalresistanceandalsoreducingerythemaeczema, of theskinandpreventcutaneous the hydration to improve stand outduetotheirproperties emulsion, therearealsothosemixedwithsiliconeandaloe,amongothersubstances. They (vit. E)ina99%. and tocopherol stearic, ofphytosterols and palmitic and linoleic), fatty acids(linolenic areessential glycerides Hyper-oxygenated fattyacids(AHHO): • Hyper-oxygenated 2 Zn), formulated as acream,paste,ointment,creamoroil,isoneofthemostwidely Zn), formulated . 14, 35, 36 As be takennotto care should a warning, abuse siliconecreamsthat already 41 13 Hexamethyldisiloxane (silicone basedsolvent)whichisnonirritatingand Hexamethyldisiloxane On the other hand,its mixing withotherproducts(especiallyperfumes) 17, 41 and the siloxanes (group of silicone-based oils, likedimethicone), of silicone-based (group andthesiloxanes incorporate silicones: incorporate zincoxide: [R =Very Low] [R =Low] [R =Low] 39,40 [R =High] Therefore theyconstituteanimportantprevention 35, 36 . 16, 17 . skin they help They areoftenusedbecause 14 16, 17 . 15-17 and should not be used in casesofvery not beused andshould 15 is inoiland Their formulation 6 Normustzincoxidebe [R = Low] 41 ; 16-17
dressings: • Adhesive tissues, inadditiontogreaterpainandirritationof themaceratedoreczematousskin. with alcoholarenotrecommended rapid dryingof the excess moisturefrom the skin. These are films that are associated with alcoholic solutions or volatile products to barrierfilm: • Non-polymer encourage to excessivemoisture exposed to incontinence, folds and soft parts to prevent bodily fluids irritating the skin due polyurethane film should not be used on areas with moderate exudate or very exudative very or exudate moderate with areas on used be not should film polyurethane Under this group are included polyurethane films and extra-fine hydrocolloid dressings. The Karaya is a vegetable gum (polysaccharide) that withother is usedincombination Karaya isavegetablegum(polysaccharide) productswith • Barrier they canalsocauseabrasionsandirritativemacerationintheareaoflesion.41 (diaper,product by theabsorbent faeces liquid and of theurine absorption etc.), alginates, reactions, andmayinterferewiththe jelly)causeclogging jelly (orpure100%petroleum exposure of faeces andurine 42 for This isindicated the treatment and protectionof erythema associatedto continuous 98% and % 48 between be to tends use for concentration normal The oil). paraffin in or alternative to other barrierproducts.It is commonlyusedmixedasanexcipient(stringy an for theskin;being function hydrating and a protecting by having characterised Petroleum jellyisanemollientsubstancethatmixedwithothercompounds.It is productswith • Barrier and leadto macerating thehealthy skin bacterial proliferation for its ease toretaintheexudate and moisture,whichcan encourage [R = Very Low] of wound,stomaordrain used in the preventionand treatment of area of the dermatitisanytype in theperilesional products orbythefrictionincontactzone. contact withoilybased every 24hoursincasesof application severe incontinence. affected area,itsprotectiveeffectto repeatthe advisable for 72hours;being isstable the cream)has is necessaryto been applied, let it dry 30-60 secondsbeforecoveringthe (or film the Once gases. and vapour water of exchange the to permeable are but pass, to fluids or moisture allow not do that barrier waterproof a form they as skin the on effect terpolymer). (e.g., acrylate alcohol-free and by theirprotective They arecharacterised Generally,and plasticizer,of anacryliccopolymer theyarecomposed is non-irritating which barrierfilm: • Polymer with oil-basedoil(paraffin). treatment; inthecaseofointment,itmustberemoved macerates theskininlong-term / or and often irritates viewed, to be the lesion not allow is thatitdoes its disadvantages ostomies, due to its beneficial protection action of the skin against the maceration. Among incontinence) (faecal cases ofrecurrentdiarrhoea for severe and/or maceratedskinsurface. The useofkarayabasedproductsarerecommended absorb excess moisture andimprovetheadhesionof the barrierproductto the moist to the capacity by having It ischaracterised formulations. ointment paste and based be foundinwater- Itcanusually powder). (karaya in theformofanexcipient compounds . 16 The use of polyurethane film is also not advisable as barrier products barrier as advisable not also is film polyurethane of use The [R =Low] [R =Moderate] karaya: petroleumjelly: 41 [GP] . 16 . 16 [R = Moderate] The excessiveuseof products mixedwithpetroleum [BP] . 16, 42 Its use is also recommended in thoseareas Itsuseisalsorecommended . 17 14 In the basic skinhygiene,solutions , 16 as theymaycausetoxicityinthe 37 The film becomes inactive in [GP] 3 and incontinence of incontinence and 14, 16 Barrier films are
35 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 36
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 8.5. GENERAL CLEANING AND HYGIENEMEASURES control devices,foreachcaseinparticular: of using the possibility to assess products, thereisalsoaneed to theuseofbarrier In addition ECZEMA: SKIN WITHERYTHEMA OR SKIN EXPOSED TO MOISTURE: HYGIENE MEASURES CLEANING AND treat localinfection also can treat and to with silverderivatives if theyarecombined contamination microbacterial exogenous absorbent are highly alginates and hydrofibres hydrocolloid family, foam and hydropolymeric (those ofthehydrocellular dressing of scheduled frequency on the amount of Use absorbentdressingsdepending exudates from wounds andthe fromwounds: • Exudate Control detemperaturaycambioropacuandoseanecesario sweating: • Profuse Use ofappropriatedevicesandmonitordrainleaks • Drains: Collectors, bladderprobesandabsorbentdiapers • Incontinence: [R =Low] . 28 • • • • • • • • • • • • Protection withbarriercreamswith:silicone, Protection withbarriercreamszincoxide Hydration with AGHO (hyper-oxygenated fatty Cleaning productswithasinglestepaction(apply Non-irritating agents:(propyleneglycol, Irritants: Sodiumlaurethsulphate,methyl. Repetitive useofsoapswithfattyacidsand/or Daily moisturising. Proper dryingoftheskin,gentlywithoutrubbing. Use ofpotablewateratroomtemperature. Use non-irritantproducts(pH5.5,hypoallergenic). Observation ofareasexposedtomoisture. karaya, petroleumjelly, polymeric-acrylic,etc. (10 % -30%).Lassarpaste. acids) innon-oilyemulsion. and removewithoutrinsing). cocamidopropil betaine,polysorbate-20). triglycerides =riskofskinalkalinisation. [R =Low] [R =Low] CARE . 28 . 28 [R =Low] . 28 8.6. DECISION ALGORITHM FORTHEPREVENTIONOFMASD Visual scaleoferythema Absorbent dressings Control ofexudate: (EVE) Exuded SKIN STATUSSKIN THE ASSOCIATED AND RISK FACTORSRISK ASSESSMENT Related toexposureto: Comprehensive approach (Educational techniques, (urine andfaeces) Associated with use ofmanifolds and absorbents) to incontinence: Risk ofinjury Incontinence humidity YES (use offattyacidshyperoxygenation (Use ofmoisturizers+emollients) Braden’s moisturesubscale Topical moisturizingmeasures Cleaning measures-hygiene (use ofcleaningsolutions) Skin protectionmeasures and products barrier) causes ofhumidity mucus andothers Sweating, saliva, NON
37 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 38
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES according tothescientificevidencewouldbe: ED tofacilitatetheself-careofpatient.Somemosteffectivetechniques, educational the riskofmoisturelesions,aswellpromote strategies possibletoreduceand/oreliminate of preventive interventions thatmakethedesign educational have various professionals Health and themaincarer. for the carethat recommendations involve theviews,preferencesandexpectationsof the patient It their appearance. is thereforeapriority,that include clinicalpracticeguidelines to develop occurrence, impactthattheiremergenceentails,earlydetectionoflesionsandactionbefore on theaetiology,include: Basicknowledge physiopathology, risk factors, care topreventtheir education ahealth of programme topreventthe these lesions(workshops,brochures…),which appearance have should fields health All capacities). their of evaluation (prior patient characteristics ofeach to theindividual be structuredandadapted should ED programmes measure. who treatMASD. professionals This beingthemosteffective preventive,cheapandeffective of thehealth the decision-making to improve they actassupport treatment; since and prevention It is demonstratedthat the EDfavoursinvolvementofpatientandmaincarersin measures. and treatment prevention toidentifytheriskandproperlyimplement that, earlyon,theyareable C] of their own qualityof life. A correct EDfavoursthepreventionandtreatment of lesions of this type of in themaintenanceand/orimprovement lesion to achieve greaterindependence treatment and the prevention in carers, areactivesubjects and families as their as well allergies; (ED) isthatthepatientsaffected ofhealtheducation The objective withMASD,oratriskof 8.7. HEALTH EDUCATION . 17 It is also important that professionals learn todifferentiate It is alsoimportantthatprofessionals thistype of lesionsfromothersso rehabilitation ofthepelvicfloor, hygienic-dieteticmeasure, etc. their self-care. training, in bladder treatments thatconsist reinforcement positive They are that arereceptivefor in thosepatients/ individuals recommended These aretechniques andrehabilitativetechniques: • Behavioural-educational cleaning andhygiene,correctapplicationofthetopicaltherapies,etc. assistance ofacarer.require about adequate strategies are:teaching The recommended They who are constitutedby care strategiesorientedtowardthosedependentindividuals andinstructive techniques: • Educational 13-17 [GP ]. 14, 37,43 [GP] . . 14, 37,43 . [R = 8.8. MODEL FORTHEPREVENTION AND TREATMENT OFTHEMASD • Rehabilitationtechniques. • Educational techniques. • Behavioral techniques. EDUCATION Measures of
SANITARY minimize risks minimize
IIdentification suitable,
of patients Care at risk TREATMENT OFTHE • Use ofabsorbent dressings. • Use ofabsorbent devices. devices.• Use ofcollecting products.• Use ofbarrier fat acids. • Use ofhyperoxygenated CLEANING -HYGIENE • Dry carefully withoutrubbing.• Dry • Use products. non-irritating rubbing. • Proceed smoothly, without PREVENTION AND SKIN EXPOSED PROTECTION TO MOISTURE Measures of
Measures of
state surveillance state
Handling and care skin the of Assessment and Assessment of incontinence • Use ofemollients. • Use products. ofmoisturizing • Use ofhyperoxygenated fat acids. HYDRATION Measures of
39 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 40
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 09 [GP] [R] [GP] [E] [E] [R] [R] [R] and perigenitalareas. and with special attentionto the areas of folds andperianal The skinmust be driedsoftly, very carefully, without rubbing for paediatricuse. as theyarelessirritativeandrecommended recommended, are cocamidopropyl surfactants likebetaine amphoteric and/orsoaps with glycol, polysorbate-20 propylene surfactants like The useof soaps basedonnon-ionic excessive andunnecessarydryingoftheskin. to could originate,inaddition lesions dueto the heat, Too hotwatershouldnot be used(preferablytepid), this exposed tomoistureandforfragileskins. considered a technique that is too aggressive for skins The frequent and repeated use of conventional soaps is wound exudate,fever, etc. profuse sweating,drains, moisture intheskin:incontinence, Assess alloftheprocessesthatcancauseanexcess cleaned, aswellaproperdryingoftheskin. be carefully moisture should to prolonged The areasexposed scale arerecommended. the EVE,PATof theBraden scaleandmoisturesub-scale of theskinandmonitoritsevolution.Preferably,condition Use of instrument a that validated allows youto check the differential diagnosisofthelesions. which gaveriseto the lesionandto be ableto carry out a inordertodeterminethecause examination, and aphysical Carry out an anamnesis,a visual examinationof the skin
SUMMARY OFEVIDENCE RECOMMENDATIONS EVIDENCE [E]/RECOMMENDATION [R]/ GOOD PRACTICE[GP]
(GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Valencia, 2012), (GPC Valencia, 2012), (GPC Valencia, 2012). (GPC Valencia, 2012). (GNEAUPP, 2006). (GNEAUPP, 2006), (GNEAUPP, 2006). LEVEL /GRADE (Global IADExpert (Global IADExpert Panel, 2015). Panel, 2015). HIGH LOW LOW LOW LOW LOW LOW LOW 35 35 14 14 14 16 16 16 16 17 17 [R] [GP] [GP] [GP] [R] [R] [R] [R] [R] [GP] [GP] stoma ordrain. of anytypewound, area in theperilesional dermatitis treat and prevent to films barrier polymeric non-irritant Use in protectingtheskinagainstmaceration. action beneficial their to due ostomies, of incontinence and incontinence) (faecal diarrhoea severe casesofrecurrent It is recommendedtouseproductswithaKarayabasefor continuous exposureoffaecesandurine. to the treatmentandprotectionoferythemaassociated for Barrier products with petroleumjellyareindicated skin. moisture, whileprotectingit from excessive dryingof the external repelling of frictionforcesand the resistance help to Barrier productswithsilicon protect theskin,reducing contamination insitu. suspected intheskinsinceitcouldleadtoabacterial are of infection if signs not beused should Zinc oxide products beforeapplyingitagainontheaffected skin. Remove the zinc oxidebarrierproductwithoil-based creams basedonzincoxide. Protect the skin from the excess moisturewithbarrier and moisture. and skinresistance againstthefriction,pressure hydration skin) toimprove fatty acids (inhealthy Use hyperoxygenated moisture andincontinence. keeping ithydratedandprotectedfrom the effects of Toof theskin fortheprotection carryoutaprogramme their benefits,wouldhelptomaintaintheskincare. themselves, onthedifferentand hygieneproductsavailable Aand theusers by professionals betterknowledge small and removewithoutrinsing). step action(apply with asingle or fissures (cracks, products to usecleaning excoriations), itisrecommended lesions skin presents which or skin macerated (dermatitis), of skineczema In cases (PREVENCARE, 2008). (GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Valencia, 2012), (GPC Valencia, 2012), (GPC Valencia, 2012) (GPC Valencia, 2012), (GPC Valencia, 2012). (GPC Valencia, 2012), (Revisión sistemática, (GNEAUPP, 2006). (GNEAUPP, 2006) (GNEAUPP, 2006), (GNEAUPP, 2006), (Global IADExpert Panel, 2015). (JBI, 2007). MODERATE VERY LOW VERY LOW VERY LOW VERY LOW VERY LOW VERY LOW 2009). HIGH LOW LOW LOW 41 38 35 14 14 14 14 . 16 . 16 16 16 16 16 17 17 17 17 13 ,
41 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 42
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES [GP] [R] [R] [GP] [R] [R] [R] rehabilitation inself-caretoautonomouspatients. and /or education techniques, behavioural and techniques patients ineducational Instruct carersofdependent treatment oflesions. A and favourstheprevention correcthealtheducation particular, shouldalsobeassessed: of usingcontroldevices,foreachcasein The possibility macerating healthyskin. and lead which canencouragebacterialproliferationto the exudateandmoisture, product duetoitseaseinretaining barrier a as advisable not is film polyurethane of use The moderate exudateorthatareveryexudative. with injuries on film polyurethane touse advisable not is It hygiene. in basicskin Solutions withalcoholarenotrecommended moisture. to prevent bodily fluids that irritate the skin due to excessive folds andsoftparts to incontinence, in thoseareasexposed The use of non-irritant polymeric barrier films is recommended – – – – Incontinence Profuse sweating Drains and thefrequencyofscheduleddressing. on the amountofexudatefromwounds depending clothes whennecessary and monitorleakagefromdrains. diapers. Exudate fromwounds : Use of suitable devices (bags, redon drains…) (bags, redon devices : Useofsuitable : Collectors, bladder probes andabsorbent probes bladder : Collectors, : Temperature controlandchangeof : Use absorbentdressings (GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Zaragoza,2013). (GPC Valencia, 2012). (GPC Valencia, 2012). (GPC Valencia, 2012). (GPC Valencia, 2012). (GNEAUPP, 2006). MODERATE MODERATE MODERATE VERY LOW VERY LOW LOW LOW C C 16 16 16 16 16 17 17 17 17 2. 1. 10 9. 8. 7. 6. 5. 4. 3. 12. 11. 10. 14. 13. integral delasheridascrónicas En: Soldevilla Agreda J. J., García Fernández F. P., Torra iBouJ. E., editores. Clasificación y diferenciación diagnóstica de las lesiones relacionadas con la dependencia R lesiones cutáneasasociadasalahumedad(LESCAH) las de cuidado el mejorar para metodológica y conceptual propuesta Una humedad. por S . L J., G fecal y su relación con el hábito defecatorio en pacientes atendidos en medicina primaria medicina en atendidos pacientes en defecatorio hábito el con relación su y fecal M de laincontinenciaurinariaenEspaña S Coruña: FacultaddeCienciaslaSalud.Universidad A Coruña;2014. B conocimientos Z presión Z conocerlas mejorparapoderprevenirlas revisión definición, S sin problema un adultos: sistemática en incontinencia a asociada Dermatitis G la de Influencia humedad, fricción,cizallaypresión crónicas. enfermedades con y encamados pacientes en úlceras las de P Lesions. JNursScholarsh Theoretical Model for the Development of Pressure Ulcers and Other Dependence-Related G Crónicas; 2014. para elEstudioy Logroño: GrupoNacional en ÚlcerasporPresiónyHeridas Asesoramiento con ladependencia relacionadas GNEAUPP; 2006. presión por úlceras y G 2008. exceso de exudado y exceso de sudoración et al. T Med clínic.2010;135(2):59-62.
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abala lea pr uea: ieecain prevención y diferenciación humedad: por Úlceras D., ópez P., ornes B
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45 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 46
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 12 ANNEX 1 2 1 0 4 3
VISUAL ERYTHEMA SCALE(EVE) ANNEXES Broken skin. Severe erythema(redorpurpleskin). Moderate erythema(pinkskin). Little erythema(almostimperceptible). No erythema. ANNEX 2 Type 2 Type 1 TYPE Type 6 Type 5 Type 4 Type 3 ICONOGRAPHIC SCALINGOFMOISTUREDIAPERDERMATITIS (DPH) Deep dermisaffection. ULCER: Affectation oftheepidermis. CANDIDIASIS: Superficial epidermis. HUMIDITY: IRRITATIVE ERITEMA + Dry epidermis. ECZEMA DESCAMPING: Epidermal inflammation. ERYTHEMA +EDEMA: Thickened epidermis. LICHENIFICATION: SEVERITY CLASSIFICATIONBY AFFECTION MODERATE MILD + MILD AFFECTATION VERY HIGH HIGH MODERATE +
47 PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES 48
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ANNEX 3 PERINE SKIN CONDITION OFTHE IRRITANT DURATION OFTHE IRRITANT INTENSITY OFTHE (Contributing factors:antibiotics,lowalbumin,totalparentalnutrition,colonization,other.) FACTORS CONTRIBUTING None or1factor. Clean andintact. diaper every8hours. Needs changesof or urine. Feces formed And / PERIANAL ASSESSMENT TOOL (PAT) 1 2 factors. without candidiasis. dermatitis withor Erythema and/or diaper every4h. Needs changesof without urine. Soft feceswithor 2 3 ormorefactors. without dermatitis. Eroded skinwithor diaper every2hours. Needs changesof without urine. Liquid feceswithor 3 ANNEX 4
Perianal Dermatitis Grading Scale 1 2 3 4 5 6 COLOR OF No Mild Moderate Severe THE SKIN erythema. erythema. erythema. erythema.
INTEGRITY Intact. Light Erythema / Ampoules or Broken or Crust or OF THE SKIN eczema. skin disease. vesicles. macerated skin. peeling. SYMPTOMS None. Tingle. Pruritus. Burning. Pain. AREA OF (The length and width measured in centimeters, first for the right side and EXTENSION then for the left side). PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
49 50
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ANNEX 5 CUTANEOUS ERYTHEMA CUTANEOUS AREA EXPOSED CUTANEOUS EROSION None. None. None. 0 Incontinence Associated Dermatitis,IAD erosion. epidermal Slight superficial Mild redness. cm Small area(<20 2 ). 1 exudate. with orwithout dermial erosion Moderate redness. Moderate erythema. Moderate 2 without exudate. erosion withor moderate dermial erosion and Severe epidermal redness. Severe erythema. Severe 3 exudation. moderate erosion with Extreme tissue 4 ANNEX 6
SEVERITY SCALE OF SKIN LESIONS BY INCONTINENCE
A) TOTAL REDNESS AREA
Punctuation ❐ 0 No area. ❐ 1 Small area (≤ 20 cm2). ❐ 2 Moderate area (> 20 cm2 ≤ 50 cm2). ❐ 3 Large area (> 50 cm2).
B) SEVERITY OF REDNESS AT THE WORST POINT
Punctuation ❐ 0 No redness. ❐ 1 Soft redness (spots and uneven appearance). ❐ 2 Moderate redness (severe in spots, but not uniform appearance). ❐ 3 Severe redness (severe in uniform appearance).
C) TOTAL DENUDATION AREA OF THE SKIN
Punctuation ❐ 0 No area. ❐ 1 Small area (≤ 2 cm2). ❐ 2 Moderate area (> 2 cm2 ≤ 5 cm2). ❐ 3 Large area (> 5 cm2).
D) SEVERITY OF DENUDATION OF THE SKIN AT THE WORST POINT
Punctuation ❐ 0 No denudation of the skin. ❐ 1 Soft denudation in the epidermis (some glassy appearance). ❐ 2 Partial gross denudations that extend to the glassy layer of the epidermis, but do not include it (glassy appearance of the skin). ❐ 3 Partial or complete denudations that extend to the glassy layer of the epidermis and by itr (very glassy appearance of the skin, humid or wet surface).
Total score (A + B + C+ D) PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ASSOCIATED GUIDE FOR MOISTURE PRACTICAL
51 52
PRACTICAL GUIDE FOR MOISTURE ASSOCIATED SKIN DAMAGES ANNEX 7 ERYTHEMA CUTANEOUS AREA EXPOSED CUTANEOUS EROSION CUTANEOUS Exposure tohumidity None. None. None. HUMIDITY SUB-SCALEOFTHEBRADENSCALE erosion. Slight epidermal Mild redness. (< 20cm Small area 2 ). Scale exudation. with orwithout dermal erosion Moderate redness. Moderate erythema. Moderate without exudate. erosion withor moderate dermal erosion and Severe epidermal redness. Severe erythema. Severe Exposure leveloftheskin to moisture exudation. moderate erosion with Extreme tissue
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