Skin & Wound Care Considerations in Special

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Skin & Wound Care Considerations
in Special Populations:
Bariatric
Tucson Affiliate of the WOCN Society Conference
March 8, 2014
Karen Lou Kennedy-Evens RN, FNP, APRN-BC
Learning Objectives
• Describe the top three most common skin
challenges in the bariatric population.
• Discuss the pathogenic factors contributing to
these common alterations in skin integrity.
• Review the skin and wound care considerations
of the most commonly seen skin challenges in the
obese population.
Incidence of Obesity
• 35% of the
world’s adults
over 20 are
overweight
• World wide
obesity has
doubled since
1980
Future Generation
Obesity increases risk of:
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Hypertension
Type 2 diabetes
Coronary heart disease
Abnormal lipid concentrations
Delayed wound healing
Admissions to acute care, home care and out
patient clinics
• Prolonged acute care to prevent complications
One-third of critical care patients
are obese or morbidly obese.
Comorbities Associated with Obesity
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Hypertension
Ischemic heart disease
Type 2 diabetes
Stroke
Osteoarthritis
Chronic renal failure
Obstructive sleep apnea
Restrictive lung disease
Immobility
Depression
Metabolic syndrome
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Ovarian cancer
Breast cancer
Irritable bowel syndrome
Nonalcoholic fatty liver
disease
GERD
Colon cancer
Disorders of the gall
bladder
esophageal cancer
Surgical/Post-op Complications
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Risks of sepsis
• Systemic inflammatory
response syndrome (SIRS)
Wound infections
• Multi-organ dysfunction
Dehiscence
syndrome (MODS)
Venous thromboembolic
• Increase risk for skin
disorders
breakdown and wound
deterioration.
Loss is Skin Integrity due to:
• Adipose has less blood supply  inadequate
oxygenation
• Excessive sweating increases skin moisture and
risk of bacterial/fungal invasion especially in
deep folds
• Immobility friction and shear due to weight
stress
• Malnutrition
• Iatrogenic injury due to tubes, catheters and
other interventions
Skin Changes with Obesity
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Stretch marks (striae)
Hirsutism in women
Aerochordons (skin tags)
Acanthosis nigricans
Specific Skin/Wound Issues
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Atypical pressure ulcers
Perigenital irritant dermatitis
Intertrigo
Fungal infections
Cellulitis
Fournier’s gangrene
Erythrasma
Diabetic foot ulcers
Venous insufficiency with possible ulceration
Lymphedema
Abdominal elephantiasis
Surgical site infections
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increased chance of dehiscence and evisceration.
Atypical Pressure Ulcers
• Skin folds that create pressure on each
other
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Neck
Upper back
Upper medial thigh
Flanks
Posterior legs
Pannus
• No risk assessment scales validated for
the obese
Interventions
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Relief of pressure
Skin fold management
Moisture management
Appropriate sized beds for repositioning
Adequate staff for repositioning
Fabrics
Perigenital Irritant Dermatitis
• Due to urinary and/or fecal incontinence
• Inability for self-care after toileting
• Environment not set up for bariatric
clientele resulting in unable to cleanse
and dry the urethral and rectal
orifices/without the danger of falling
Intervention
• Easy cleaning with appropriate equipment &
supplies
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Toilet risers
Extra wide toilet seats
Bariatric commodes
Hand rails for support
Prepackaged cleansing & protection
Perineal care with each incident
Appropriate sized briefs and/or pads
Drying fabrics
Intertrigo
• Maceration due to excess moisture
• Infectious or noninfectious
• Friction from two opposed skin
surfaces
• painful and/or pruritic
• Presents as:
– Erythematous, macerated plaques
– Erosions with possible scaling
– Candida intertrigo: satellite papulopustules
– Found in perineal area, deep skin folds
Interventions
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Topical or oral antifungal
Drying agents
Fans or cool hair dryer
Special textiles with drying and
antimicrobial properties
Barriers to Skin Care
• Body habitus
• Lack of bariatric
equipment
• Inappropriate
environmental
design
• Caregivers fatigue
Bariatric Equipment
Staff/Patient/Family Education
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Bathing & hygiene
Skin fold management
Perigental care
Toileting
Odor management
Caregiver injury prevention
Educational Props
Other issues
• Psychosocial issues
• Bariatric-specific surgery
References
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Beitz, J., Providing quality skin and wound care for the bariatric patient:
An overview of clinical challenges . Ostomy Wound Management. Jan 2014
Blackett A., Gallagher S., Dugan S., Gates J., Henn T., Kennedy-Evens K.,
Lutz J., Caring for persons with bariatric health care issues. Journal
Wound Ostomy Continence Nursing. 2011
Gallagher, S., The intersection of ostomy and wound management, obesity
and associated science. Ostomy Wound Management Jan 2014
Rush A, Muir M. Maintaining skin integrity in bariatric patients. Journal
of Community Nursing. 2012
World Health Organization. Obesity and Overweight. 2013.
www.who.int/mediacentre/factssheet/
Wound Ostomy Continence Nurses Society. Safety and Comfort issues for
Nursing Care of the Obese Patient. Mt. Laurel, NJ. WOCN 2013
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