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INTACT SKIN –
AN INTEGRITY NOT
TO BE LOST
– R. Gary Sibbald, MD, FRCPC(Med)(Derm); Karen Campbell, RN, MScN, NP/CNS; Patricia
Coutts, RN; and Douglas Queen, BSc, PhD, MBA
Maintaining skin integrity can be challenging but it is vital
to overall health, particularly in elderly patients. In this population, skin integrity is frequently compromised as a result
of under- or over-hydration, which may cause serious complications. Plans of care must include preventive efforts such
as the use of barriers and protectants including zinc oxide
preparations, petrolatum- and silicone-based ointments and
creams, liquid-forming products, adhesive dressings, fluid
managers, skin cleansers, and moisturizers. A team
approach that includes the patient, caregivers, and healthcare professionals is needed to address patient concerns
regarding independence/dependence, utilization of support
systems and services, pain, and control of body fluids. The
healthcare provider’s role in this team should emphasize
continuity of care, patient satisfaction, and product selection
— all vital to protecting skin integrity.
Ostomy/Wound Management 2003;49(6):27–41
he skin is the body’s largest organ and performs
many important functions, including protection
against infectious pathogens, ultraviolet light,
noxious substances, and fluid/electrolyte loss; thermoregulation; sensation; metabolism (eg, vitamin D);
and communication.1,2
A breach of skin integrity can result from a variety
of occurrences and cause a range of consequences,
some of which can be life-threatening.3 These breaches,
which can be very debilitating,4 frequently occur in the
elderly because aged skin is more prone to compromise. Aging affects the skin by thinning the epidermis,
dermis, and subcutaneous layers, as well as by reducing
epidermal turnover, time to healing, injury response,
barrier function, chemical clearance rate, sensory perception, immune function, vascular responsiveness,
thermoregulation, and the production of sweat, sebum,
and vitamin D.1,5,6
Excreted bodily fluids are responsible for the most
common breaches of skin integrity in institutionalized
elderly7— specifically, the consequences of fecal or urinary incontinence or presence of wound exudates on
the skin.8 The body’s waste effluents can be particularly
caustic to the skin. For example, fecal material contains
more than 500 different organisms,9 which produce
several contact irritant substances.
The patient/caregiver team is primarily responsible
for the maintenance of healthy skin. Many skin care
T
Dr. Sibbald is Associate Professor of Medicine and Director of Continuing Education, Department of Medicine, University of
Toronto; and Director, Dermatology Day Care and Wound Healing Clinic, Sunnybrook and Women’s College Health Sciences,
Toronto, Canada. Ms. Campbell is a Clinical Nurse Specialist, Parkwood Hospital, University of Western Ontario, London,
Ontario. Ms. Coutts is the Wound Care and Study Coordinator, Debary Dermatologicals, Mississauga, Ontario. Dr. Queen has
a medical consultancy business, CanCARE Services Consultancy, Toronto, Ontario, Canada. Please address correspondence to:
Douglas Queen, BSc, PhD, MBA, CanCare Services Consultancy, 35 Rosedale Road, Unit 2, Toronto, Ontario, Canada M4W
2P5; email: cancare@rogers.com.
June 2003 Vol. 49 Issue 6
27
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persistent skin/effluent contact occurs, whether in
young or older patients, skin damage can result in diaper rash, or as it is called in the elderly, incontinent
dermatitis. The prevalence of urinary incontinence in
nursing homes is estimated at 50% or greater.
Additional statistics from chronic care facilities show
Threats to Skin Integrity
urinary incontinence prevalence to be between 50%
Common clinical situations that can result in damand 70%.16,17 Therefore, knowledge of the skin’s funcage to the skin include the presence of a draining
wound, urinary or fecal incontinence, and the use of
tion and the role incontinence plays in contact irritant
10,11
skin adhesives.
dermatitis is crucial for every caregiver.
Incontinent dermatitis occurs when urine comes
Periwound maceration. Wounds are often excellent
into contact with aged skin, which is often dry and
providers of local moisture, but when present in excess
cracked. This provides an excellent environment for the
and allowed to contact skin, moisture can be damaging
12
growth of bacteria,18-20 resulting in the production of
to the periwound area. Wound exudate often contains
not only water, which in itself can be detrimental, but
ammonia.21 Ammonia increases the pH of the skin,19
also cellular debris and enzymes.13 This cocktail can be
reducing the acid mantle’s protective capacity as a baccorrosive to the intact skin surrounding the wound.
terial barrier,19,20 subsequently providing the opportuniIn addition, dressings may leak and are often
ty for chemical irritation by urine, feces, and excess
changed only after leakage has occurred. As a result, the
moisture to cause skin breakdown.
surrounding skin is exposed to potentially damaging
Fecal incontinence offers reason for greater clinician
wound exudate on a continual basis.12,14 Moisture and
concern.22 As feces passes through the gastrointestinal
maceration will increase the skin’s permeability to irritract, digestive enzymes are deactivated. When feces
tating substances, increasing the likelihood for critical
mixes with urine on the skin, the urine converts to
3
microbial colonization. This can lead to delayed healammonia, and the resultant alkaline pH reactivates the
digestive enzymes, further increasing the risk of skin
ing, increased risk of infection, and wound enlargebreakdown and local bacterial infection.18,19
ment. Furthermore, less friction is required to damage
14
skin when it is overhydrated.
When petrolatum or zinc-based products are used
on patients with incontinent dermatitis, they must be
Traditionally, both zinc oxide and petrolatum ointremoved and reapplied following each incontinent
ments have been used to protect the periwound area.15
episode. This, in turn, can cause more skin damage due
Although effective in preventing contact of wound
to the friction required to remove these products.
exudate with the periwound skin, this approach can
Skin adhesives. Adhesive products that strip the skin
interfere with dressing absorption and adhesion.
also may compromise the skin’s barrier properties.
These preparations are also messy to use and often
These products include tapes and adhesive bandages
difficult to remove.15
such as hydrocolloids, films, and some foams. Skin tack
Incontinence-related dermatitis. The body is convaries among adhesive products. High-tack products
stantly emitting fluid, particularly as waste excretion. If
have a bonding pressure that will cause skin tears
if inappropriately removed. Acrylic adhesives, priOstomy/Wound Management 2003;49(6):27–41
marily found in film dressings, are best removed
KEY POINTS
by pulling laterally to decrease the skin bond
• Environmental and physical factors pose a continuous
before lifting off the skin.23 Careful technique
challenge to skin integrity, particularly in individuals with
requires more caregiver time to minimize skin
frail, dry, or overhydrated skin.
damage.
• As evidenced by this overview of products, procedures,
Problems of prolonged skin contact with fluand patient, caregiver, and provider concerns related to
the process of preventing skin breakdown, successful preids and their assessment and treatment are outvention efforts are broad and multifaceted.
lined in Table 1.
• This review serves as a reminder to practice holistically
and may help institutions develop such plans of care.
practices and products may help maintain integrity.
The following review of the role of skin health on general health and strategies to provide effective skin care
may help providers maintain skin integrity.
28
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TABLE 1
ASSESSING AND MANAGING CORRECTABLE CAUSES AND
AGGRAVATING FACTORS OF COMPROMISED SKIN
Problems to Correct Issues
Challenges
Solutions
Assess:
Mobility
Cognitive impairment
Medication adverse effects
Prevent overflow and
enzymatic action; assess and
determine causative factors
Behavior modification
Surgical intervention
Pharmacological treatment
modifications
Establish regular bowel routine
Increase bulk and fiber into stool
Correct or improve causative factor
Obtain wound moisture and
bacterial balance
Urinary incontinence
Urinary containment
Control odor
Maintain skin integrity
Fecal incontinence
Fecal containment
Control odor
Maintain skin integrity
Wound drainage
Wound discharge containment
Control odor
Maintain skin integrity
Stoma discharge containment
Control odor
Maintain skin integrity
Fistula discharge containment
Control odor
Maintain skin integrity
Prevent hyperhydration and
increased bacterial burden of
surrounding skin
Keep peristomal skin intact
Maintain securement of
appliance to prevent leakage
Divert effluent/drainage from
the surrounding skin
Border skin moisture control
Infection control
Maintain skin integrity
Prevent skin breakdown
Prevent bacterial proliferation
Maintain access site
Stoma drainage
Fistula drainage
Access sites leakage
Physical Skin Barriers and Protectants
Physical barriers. For the purpose of this review, a
physical barrier is defined as a permanent interface
between two surfaces to protect skin integrity. Skin barrier products have been developed for this protective
need.24-26 A summary of the pros and cons of a number
of these products is presented in Table 2.
Zinc oxide preparations. Zinc oxide barriers —
probably the most widely used barrier preparations —
have been readily available for a number of years, and
zinc oxide and petrolatum ointments have been routinely used to protect the periwound skin.27 For example, the most commonly used diaper rash treatments
for babies are zinc oxide and petrolatum-based skin
barrier products. In people with sensitive skin, such as
babies and the elderly, zinc preparations are helpful.
Such preparations are often robust, easily accessible,
and inexpensive, making them conducive for general
use. Although generally effective, significant product
variability exists between preparations with regard to
potential allergens (especially perfumes) and consisten-
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Determine correct appliance with
specialized expertise
Determine appropriate
management regimen with
specialized expertise
Regular assessment to ensure
appropriate portal protection
Ensure aseptic technique
cy. This, in turn, affects their potential to damage skin.27
Zinc products are also labor-intensive, and bacterial
contamination in situ is possible. Due to their robustness and permanency, they can clog containment
devices, and interfere with absorbency, adhesion, and
antimicrobial properties of topical treatments. Most
importantly, caregivers are unable to visualize the
underlying skin.
Ointments/creams. Ointment preparations tend to
be petrolatum-based, although recently, silicone-based
creams have been introduced. The petrolatum-based
products are similar to the zinc-based products discussed above — they are readily accessible, not too
expensive, and widely used as skin barriers for other,
less medically intense, situations (eg, as lip balms).
Petrolatum-based products are also variable (35 grades
of petrolatum are available) with potential added allergens and varying consistency. They tend to melt and
wash off easily and, like zinc-based products, have the
tendency to clog containment devices or interfere with
the absorbency of dressings.28
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TABLE 2
COMPARISON OF SKIN BARRIER PRODUCTS
Barrier
Pros
Cons
Comments
Liquid-forming
barrier films
Ease of application
Uniform application
Flexible and conformable
Visualize underlying skin
Resist wash off
Do not trap contaminants
Low sensitization rate
Form a solid interface
between two surfaces
May have a long wear time
Visualization of underlying
skin may be possible
Robust (stiff)
Familiar and readily accepted
Inexpensive and readily
available
Some contain alcohol and/or
acetone (burn/sting on application)
Require education regarding
frequency and thickness of
application
Some products may allow
adhesive dressings to be
applied over the surface
Edges may lift
Trapping of moisture allows bacterial
proliferation
Adhesive allergies
Smell/odor may occur
Potential allergens and variable
consistency
Messy and difficult to remove
May become contaminated, requiring
removal
May inhibit absorbency and adhesion
of overlying dressings/devices
Potential allergens
Product variability
Tend to melt and wash off
Often inhibit absorbency and
adhesion of other devices
Require frequent reapplication
May need to be used with
central window, requiring
training and expertise
Adhesive dressings
(transparent films,
thin hydrocolloids)
Zinc oxide
ointment/paste
Petrolatum and related Inexpensive (petrolatum) and
accessible
ointments/creams
Silicone-based products are more expensive but they
are far less variable, easier to apply, have lower frictional
resistance, and are more resistant to wash off. They are
transparent, allowing visualization of the skin underneath.
An important disadvantage of ointments and creambased products is user variance in application amounts
and techniques and the need to reapply the product.
Also, many preparations contain potential allergens
such as perfumes.
Liquid-forming barriers. Liquid-forming barriers are
relatively new and provide important user benefits.
They are flexible and conformable, easy to use, allow
uniform application/distribution, resist wash off, do
not trap contaminants, and provide visualization of the
underlying skin. Reports indicate a lower allergic sensitization rate with some of these products when compared with traditional therapies.29 Unlike their zinc and
petrolatum counterparts, some of these products work
well with adhesive dressings and do not interfere with
containment devices.
32
OstomyWound Management
Unable to visualize
underlying skin
If not contaminated, no
need to remove; just fill in
the gaps
Quantity applied varies by
users
Although reported to be cost-effective, the unit purchase price of liquid-forming barriers is relatively high.30
Most, but not all, contain carrier agents, such as acetone
or alcohol, which can cause burning and stinging on
application. A learning curve to correctly apply these
preparations must be considered. Some of the newer
products provide a flexible, durable, moisture-repellent
film on the skin, and an alcohol-free liquid form with a
variety of application options is available.30 This product
can be used on sensitive infant and aged skin.23,31
Adhesive dressings. Adhesive dressings, such as films
or thin hydrocolloids, are also used as skin barriers.
They are applied using a picture window framing technique, where a hole is cut in the dressings to allow for
the movement of effluent into a management device
(eg, absorbent dressing) while protecting the wound
margin. Framing the surrounding skin prevents effluent from attacking healthy skin by forming a solid
interface between the two components. This approach
has the benefit of providing a constant barrier that does
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TABLE 3
COMPARISON OF SKIN PROTECTANTS
Protectant
Pros
Skin cleansers
Can be effective debris
Change skin pH and dry skin
removers – surfactant action Known sensitizers
Maintain skin surface integrity May contain allergens (perfumes,
by lubricating/hydrating skin
lanolins, preservatives, stabilizers)
surface
Moisturizers
Provide inexpensive
Fluid managers
absorptive surface
(dressings, briefs)
Briefs, calcium alginates, and
hydrofibers bind fluid within
their structure
Separates fluid/effluent from
Fluid managers
skin surface
(containment
devices)
Cons
Variability of product performance
characteristics
Absorptive foams do not lock fluid
within dressing structure
Need expertise for attachment and
maintenance on the skin surface
Cumbersome for patients to have
external pouch
not require frequent changing while allowing visualization of the underlying skin through the dressing.
Although this approach has some advantages, some
less beneficial considerations must be addressed.
Dressing edge roll, lifting, and trapping of exudate or
bacterial proliferation may occur. Adhesive dressing
allergies are also a possibility. The typical meltdown
and odor associated with some hydrocolloid dressings
may be problematic.32 The learning curve and skills
required for sizing and creating the drainage port must
be considered.
Protectants. To distinguish protectants from barriers,
and for the purpose of this review, a protectant is
defined as an indirect temporary technique or application
to maintain the integrity of skin at high risk. A number
of skin protectants have been developed and marketed,
each with its own advantages and disadvantages (see
Table 3).
Fluid managers. Fluid managers are absorbent
devices that remove fluid/effluent from the skin surface
(eg, dressings, diapers, and fluid containment devices).
Dressings may serve as barriers on intact skin, as well as
protectants when applied over an open wound. These
products are designed to remove or collect fluid and
34
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Comments
Overuse can cause more harm
than good
Important to apply after bathing
while skin is damp to trap surface moisture
Urea + lactic acid preps
(humectants/hydrating agents
should not be applied to
denuded skin — burning and
stinging)
Should match product performance with patient needs
Pouch changes should be
regularly scheduled to prevent
over-accumulation of fluid and
odor
nothing else. Although absorbent, some dressings or
diapers do not wick fluid away from the skin; rather,
they form a dynamic equilibrium. As a result, the fluid
can be more damaging to the skin interface, causing
dressing strike-through and leakage.
It may be difficult to chose from among multiple
devices with differences in absorptive capacity and wear
time, even within the same product category.
Skin cleansing. Skin cleansers or cleansing regimens
are for the skin and should not be used for open
wounds where they can have a detrimental effect on
healing. These products are essentially designed to
remove debris from the skin surface. In general, they
are surfactant-based and are superior to water or saline
for debris removal because they have been specifically
developed for this purpose.
However, using these products presents some potential disadvantages. Many contain known sensitizers (eg,
perfumes). As part of their cleansing action, they
change skin pH or remove its acid mantle, which can
result in drying and stripping. Healthcare providers are
often confused by products in this category — sterile
and nonsterile, ionic and nonionic — and some are
more toxic than others. Too much detail leads to confu-
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sion and misuse of products, and overuse of this class of protectant can
cause more harm than good.33
Moisturizers. Moisturizers are defined as hydrators or lubricants and primarily are used to preserve suppleness and barrier function. Hydrating
agents, consisting of urea or lactic acid preparations, bind moisture in the
stratum corneum. Such products are comfortable and soothing and, therefore, generally preferred by patients. They need to be applied to intact skin
or they may cause a burning or stinging sensation.
Moisturizers are routinely used by the majority of the general population
either on a regular or sporadic (eg, after sun) basis. With fragile aged skin,
regular moisturizing is imperative to healthy skin maintenance. The stratum
corneum requires a 10% moisture content to maintain integrity. This is
often a problem for aged skin in hot, dry winter environments. Lubricants
(eg, emollient creams and petrolatum) trap insensible losses of moisture,
maintaining stratum corneum moisture. Vanishing creams contain little oil
and will dry the skin surface with evaporation. Preparations with higher oil
content are often greasy. Lanolin has high moisture retention properties, but
it is an allergen. When used as a moisturizer, the product should be applied
after bathing while the skin is damp, not wet (after partially drying). This
helps trap any moisture in the skin as a result of bathing, providing a good
reservoir for skin hydration.
For the majority of users, allergic reaction is not an issue, but patients
with leg ulcers have a high allergy sensitization rate.34 Many moisturizers
contain allergens (lanolins, perfumes, preservatives, emulsifiers, and stabilizers are common components). However, patient-related and healthcare
provider issues also affect product choice.
Patient-Centered Concerns
Caregivers are responsible for the maintenance of healthy skin, but this is
a team responsibility,35 and the patient is the center of the team. The
patient’s desires and preferences should be central to any plan of care or
adherence to treatment will be low. Resolving common patient issues, such
as independence over dependence, requires collaborative support from the
patient’s social network and healthcare providers. Managing pain and body
fluid (urine, feces, and wound drainage) and minimizing odor are important
to preserving dignity. Quality of life is often a more important consideration
than achieving a cure that may be unrealistic or impossible. A summary of
patient-centered concerns is presented in Table 4.
Independence/dependence and support systems. The loss of control of
body functions is a slippery slope that can lead to the patient losing his/her
independence, resulting in institutionalization. A key factor is loss of mobility.36 This loss may be enhanced by cognitive impairment or the side effects of
polypharmacy.37 Urinary incontinence is cited as one of the major causes of
institutionalization.38 Assessment must include the cause of the impediment,
and treatment to maintain independence must be instituted when possible.
Support systems must be available, preferably through family and a social
network, and complemented by social service agencies. The patient must be
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TABLE 4
PATIENT-CENTERED SKIN CARE CONCERNS
Concern
Issues
Challenges
Solutions
Independence/
dependence
Loss of control
Loss of mobility
Cognitive impairment
Assess independent living versus
dependence (assisted living or
institutions)
Healthcare
support systems
Treat cause of impediment to maximum function in appropriate
setting
Promote independence where possible
Make patient and caregivers
significant contributors to the
care plan
Coordination of care across
Center care around patient
the continuum
Lack of access to
services/care
Foster involvement of immedi- Assess and evaluate the available
Involve potential partners
ate family, significant others,
options
and social network
Maintain activities of daily life Identify important personal gaps for Implement non-pharmacological
maximal function
and pharmacological management of important issues
Containment of body fluids
Provide security and confidence for Address and control the cause to
and odor to maintain dignity
optimal daily functioning
minimize exudate control
Social support
systems
Comfort and pain
Control of body
fluids/odors
comfortable with the decision tree, and healthcare
providers must discuss options for filling current gaps
in the care plan. Not all situations are amenable to
independent living; the healthcare providers’ communication skills and empathy will help bridge difficult life
decisions when independence is lost.
Patient care must be coordinated between healthcare
professionals and support services. The social work and
service administrators must examine the need for
homemaking, volunteers, meals-on-wheels, and accessibility to care, as well as the support system for medical
emergencies. When the patient’s well being cannot be
ensured in the community, institutional options must
be presented and difficult choices made.
Comfort/pain: The patient’s point of view. Healthcare
providers are reluctant to provide adequate pain relief
due to the fear of addiction. As an example of pain
assessment and management, clinicians can consider
Diane Krasner’s pain model39 for chronic wounds, which
divides the cause of pain into three categories:
• Incident pain — ie, due to debridement
• Repetitive pain — ie, due to dressing changes
• Continuous pain — ie, due to uncorrected
cause such as infection and ischemia.
Pain treatment, therefore, needs to be tailored to the
periodicity of pain (eg, long-acting preparations should
be ordered for continuous discomfort).
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Control of body fluids. Excess body fluids need to be
controlled so the patient has the confidence to allow
social interaction. The treatment of the cause may
include controlling bacterial burden or frank infection,
using adequate pouching or drainage devices, and providing compression therapy for venous ulcers.
Healthcare Provider’s Role
According to Wells, “Elder care requires an understanding of complex interactions with multiple potential intervention points: normal aging involves a gradual mix of physiological, social, and psychological
changes within a nonspecific time frame and with individual variance. The sum of this defines the old.”40
Patient satisfaction is dependent on the acknowledgment of patient-centered concerns. Specialist caregivers
and their teams are available to focus on eldercare. By
helping the elderly maximize functioning and minimize the effects of chronic illness, the caregiver-patient
collaboration promotes improved quality of life.
In achieving this goal, the healthcare provider is
faced with a multitude of issues. Care design must
incorporate ease of use, cost-effectiveness, and be based
on best clinical practices. A summary of healthcare
provider concerns is presented in Table 5.
Continuity of care. One of the greatest healthcare
provider concerns is the need for continuity of care
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TABLE 5
HEALTHCARE PROVIDER CONCERNS FOR PATIENT SKIN CARE
Concern
Issues
Continuum of care Need for continuity and uniformity of care across types
of institution and regarding
varying levels of expertise
Lack of evidenced based care
Best available
practice
Patient satisfaction Identify and understand
patient issues
Product selection Product selection often random
and not scientifically based
Ease of use/
versatility
Cost containment
Challenges
Solutions
Communication between all stakeholders by linking education,
implementation, and patient care
outcomes
Translating evidence into practice
Centralized health record across
the continuum available to all
healthcare professionals
Allow patient to become a partner
in the care plan
Critically appraise evidence or lack
thereof (identify gaps)
Products often require
Obtain experience and critical
specialized expertise for
evaluation of practical usage
optimal use
Increased public demands with Appraise and select the most cost
limited human and financial
effective treatment to maximize
resources
benefit
across all types of institutions and varying levels of
expertise within those institutions. The challenge is to
respect individual expertise among team members,
allowing each member to share his/her knowledge in a
particular area. This leads to an educational process
that can be linked to implementation in practice and
patient outcomes.
This challenge can be evaluated using Dixon’s Four
Levels of Evaluation41 — perception/opinion data, competency, clinical process, and impact on patient care and
health status. Through this evaluation process, a “best
available practice” can translate evidence into patient
care. Barriers to translating research evidence into clinical practice exist; those involved in healthcare need to
decrease the traditional delay between the availability of
the evidence and its application into practice.42 This can
only be accomplished by optimizing communication
between all stakeholders. The improved outcomes may
be easier to achieve when centralized health records are
available across care continuums, including home care,
acute care, and long-term care.
Patient satisfaction. Patient care outcomes and satisfaction are important elements for the healthcare
provider to evaluate. Often, healthcare providers do not
take the time to allow patients to verbalize their current
problems. Through listening without interrupting,43 the
healthcare provider can identify and understand the
38
OstomyWound Management
Education with implementation
into practice
Negotiate collaborative approach
to care
Standardized protocols translating
evidence base and expert
knowledge to local practice
Choose products that are healthcare provider friendly
Utilize best possible treatment in a
cost-effective manner
patient perspective.44 This would certainly clarify issues
regarding skin care and the effects this has on everyday
living. Patient perspective also might include satisfaction with treatment and provision of services as well as
the level of understanding patients have about their
conditions. By making the patient a partner in the care
decision, a collaborative process evolves that enhances
the treatment outcome. Often, healthcare providers
refer to patients as noncompliant when the patient does
not do what the healthcare provider instructs or if the
patient is asked to adhere to a specific protocol and fails
to do so. If, however, the patient is included in the decision from the beginning of the treatment process and a
negotiated collaborative approach is taken, noncompliance will be less of an issue and treatment outcomes
will be enhanced.
Product selection. Although a major component of
the plan of care, the product used is often selected at
random with no scientific basis. When selecting a product, Ovington and Peirce45 ask three questions about
the product feasibility: 1) What are the realistic goals of
care for this patient? 2) What products are available? 3)
How capable is the caregiver?
Ease of use/versatility. Two important areas of product selection focus around ease of use or versatility and
cost containment. The healthcare provider must
remember the importance of evidence ratings in this
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decision making process. Ovington et al45 present an
example of this tactic using the AHCPR guidelines for
pressure ulcers.46 Their approach focuses on the use of
clinical judgment to select a type of moist wound
dressing suitable for the ulcer. The authors also demonstrated that studies of different types of moist wound
dressings showed little difference in pressure ulcer healing outcomes.45 The same principles can be applied to
skin barriers and protectants.
Caregiver familiarity with ease of use and versatility
of a product requires a knowledge base. Some products
require more expertise for optimal use than others.
Ability to obtain experience and critically evaluate the
practical usage of the product will enhance appropriate
product choice.
Cost containment. Limited human and financial
resources and an increase in public demand have made
cost containment a high-priority issue. Low unit price
is not necessarily the best value. The healthcare
provider needs to be able to appraise and select the
most cost-effective choice, which is defined as the cost
of achieving a desired treatment outcome to maximize
the benefit to the patient.47 Through this process, the
healthcare provider can select and utilize the best treatment in the most cost-effective and efficient manner.
Conclusion
The skin barrier is constantly challenged with a
range of irritant and allergic substances, even in healthy
individuals. When health is compromised, the skin is
more vulnerable to injury. The clinical challenges and
consequences of assessment, treatment, and healthy
skin maintenance are factors, not only in skin care, but
also in overall well being. A number of barriers and
protectants have been developed and marketed for the
protection and maintenance of skin integrity and
should be implemented as part of a comprehensive care
plan that makes skin integrity a priority. Economically,
prevention is better than the treatment of lost skin
integrity. The basic premise here is to remember to,
“treat the whole patient rather than what comes out of
the hole.”48 Clinicians should not jeopardize their
integrity by failing to protect the integrity of their
patients’ skin. - OWM
References
1. Bryant R, Wysocki A. Skin. In: Bryant R, ed. Acute and
Chronic Wounds: Nursing Management. St. Louis, Mo.:
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Mosby Year Book Inc.; 1992:1–25.
2. Sams WM. Structure and function of the skin. In: Sams
WM, Lynch PJ, eds. Principles and Practice of
Dermatology. New York, NY: Churchill Livingstone;
1990.
3. Kemp MG. Protecting the skin from moisture and associated irritants. J Gerontol Nurs. 1994;20(9):8.
4. Jirovec M, Brink C, Wells T. Nursing assessments in the
inpatient geriatric population. Nurs Clin North Am.
1998;23:219–230.
5. Silverberg N, Silverberg L. Aging and the skin. Postgrad
Med. 1989;86:131.
6. Gilchrest BA. Skin aging and photoaging. J Am Acad
Dermatol. 1989;(21):610.
7. Fiers SA. Breaking the cycle: the etiology of incontinence
dermatitis and evaluating and using skin care products.
Ostomy/Wound Management. 1996;42(3):32–34.
8. Williams C. 3M Cavilon No Sting Barrier Film in the
protection of vulnerable skin. Br J Nurs.
1998;7(10):613–615.
9. Whitman DH. Intra-Abdominal Infections:
Pathophysiology and Treatment. Frankfurt, Germany:
Hoescht;1991:20–21.
10. Bryant RA. Saving the skin from tape injuries. AJN.
1988;88(2):189.
11. Dealey C. Using protective skin wipes under adhesive
tapes. Journal of Wound Care. 1992;1(2):19–22.
12. Weir D. Pressure ulcers: assessment, classification and
management. In: Krasner D, Rodeheaver G, Sibbald RG,
eds. Chronic Wound Care: A Clinical Source Book for
Healthcare Professionals, 3rd ed. Wayne, Pa: HMP
Communications;2001:621.
13. Chen WYJ, Rogers AA. Characterisation of biological
properties of wound fluid collected during the early
stages of wound healing. J Invest Dermatol.
1992;99(5):559–564.
14. Braden B. Risk Assessment in pressure ulcer prevention.
In: Krasner D, Rodeheaver G, Sibbald RG, eds. Chronic
Wound Care: A Clinical Source Book for Healthcare
Professionals, 3rd ed. Wayne, Pa: HMP
Communications;2001:647.
15. Phillips TJ. OW/M commentary: a clinician’s guide to
common dermatological problems. Ostomy/Wound
Management. 1994;40(9):70–79.
16. Ouslander J, Kane R, Abrass I. Urinary incontinence in
elderly nursing home patients. JAMA.
1982;248:1194–1198.
17. Palmer MH, German PS, Ouslander JG. Risk factors for
urinary incontinence one year after nursing home
admission. Res Nurs Health. 1991;14:405–412.
18. Berg RW. Etiological factors in diaper dermatitis: the role
of urine. Pediatric Dermatology. 1986;3:102–106.
19. Berg RW. Etiology and pathophysiology of diaper dermatitis. Adv Dermatol. 1986;3:75–98.
20. Urinary Incontinence Guideline Panel. Clinical Practice
27-41, Queen layout
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
5/22/03
4:22 PM
Page 41
Guideline Number 2: Urinary Incontinence in Adults.
Rockville, Md: US Department of Health and Human
Services. Public Health Service. Agency for Health Care
Policy and Research; 1992. AHCPR Publication, No. 920038.
Nobel W, Somerville D. The Microbiology of Human
Skin. Philadelphia, Pa: WB Saunders; 1974.
Allman RM, Laprade CA, Noel LB, et al. Pressure sores
among hospitalised patients. Annals of Internal Medicine.
1986;105:337–342.
Irving V. Reducing the risk of epidermal stripping in the
neonatal population: an evaluation of an alcohol-free
barrier film. Journal of Neonatal Nursing. 2001;(7):5–8.
Rolstad BS, Harris A. Management of deterioration in
cutaneous wounds. In: Krasner D, Kane D, eds. Chronic
Wound Care: A Clinical Source Book for Healthcare
Professionals, 2nd ed. Wayne, Pa: Health Management
Publications, Inc.; 1997:209.
Coutts P, Sibbald RG, Queen D. Peri-Wound Skin
Protection: A Comparison of a New Skin Barrier vs.
Traditional Therapies in Wound Management. Poster at
CAWC Meeting, London, Ontario. November 2001.
Campbell KE, Keast DH, Woodbury GM, Houghton PE,
Lemesurier A. The Use of a Liquid Barrier Film to Treat
Severe Incontinent Dermatitis-Case Reports. Poster at
CAWC Meeting, London, Ontario. November 2001.
Sibbald G, Cameron J. Dermatological aspects of wound
care. In: Krasner D, Rodeheaver G, Sibbald RG, eds.
Chronic Wound Care: A Clinical Source Book for
Healthcare Professionals, 3rd ed. Wayne, Pa: HMP
Communications;2001:275.
Grove GT, Lutz JB, Burton SA and Tucker JA.
Assessment of diaper clogging potential of petrolatum
based skin barriers. Poster at the 2nd National MultiSpecialty Nursing Conference on Urinary Continence,
January: 21-23, 1994.
Campbell K, Woodbury MG, Whittle H, Labate T,
Hoskin A. A clinical evaluation of 3M No Sting barrier
film. Ostomy/Wound Management. 2000;46(1):24–30.
Kennedy KL, Leighton B. Cost-Effectiveness Evaluation
of a New Alcohol Free Film-Forming Incontinence Skin
Protectant. White Paper - 3M Healthcare, USA. 1999.
Neonatal Skin Care: Guidelines for Practice. National
Association of Neonatal Nurses, California;1997.
Thomas S, Loveless P. A comparative study of the properties of twelve hydrocolloid dressings. World Wide
Wounds. 1997;July. Available at: www.worldwidewounds.com. Accessed March 15, 2002.
Bettley FR. Some effects of soap on the skin. Br Med J.
1960;1:1675.
Pasche-Koo F, Piletta PA, Hunziker N, Hauser C. High
sensitization rate to emulsifiers in patients with chronic
leg ulcers. Contact Dermatitis. 1994;31(4):226–228.
Fowler EM, Ouslander J, Paper J. Managing incontinence
in the nursing home population. J Enterostomal Ther.
1990;(17):77–86.
36. Perez ED. Pressure ulcers: updated guidelines for treatment and prevention. Geriatrics. 1993;48(1):39–44.
37. Larsen PD, Martin JL. Polypharmacy and elderly
patients. AORN J. 1999;69(3):619–622.
38. Fantl JA, Newman DK, Colling J, et al. Clinical Practice
Guideline Number 2: Urinary Incontinence in Adults:
Update. Rockville, Md: US Department of Health and
Human Services. Public Health Service. Agency for
Health Care Policy and Research; 1996. AHCPR
Publication No. 96-0682.
39. Krasner D. The chronic wound pain experience: a conceptual model. Ostomy/Wound Management.
1995;41(3):20–25.
40. Wells TJ. Managing falls, incontinence and cognitive
impairment: nursing research. In: Funk SG, Tornquist
EM, Champagne MT and Weisse RA, eds. Key Aspects to
Elder Care: Managing Falls, Incontinence and Cognitive
Impairment. New York, NY: Springer Publishing
Company;1992.
41. Davis D, Taylor A. Two decades of Dixon: the
question(s) of evaluating continuing education in the
health professions. The Journal of Continuing Education
in the Health Professionals. 1997;17:207–213.
42. Haynes B, Haines A. Getting research findings into practice. Barriers and bridges to evidence-based clinical practice. BMJ. 1998;317:273–276.
43. Beckman HB, Frankel RM. The effect of physician
behaviour on the collection of data. Ann Intern Med.
1984;1010:692–696.
44. Price P. Health-related quality of life and the patient’s
perspective. Journal of Wound Care. 1998;7(7):365–366.
45. Ovington L, Peirce B. Wound dressings: form, function,
feasibility, and facts. In: Krasner D, Rodeheaver GT,
Sibbald RG, eds. Chronic Wound Care: A Clinical Source
Book for Healthcare Professionals, 3rd ed. Wayne, Pa.:
HMP Communications;2001:311–319.
46. Panel for the Prediction and Prevention of Pressure
Ulcers. Clinical Practice Guideline Number 3: Pressure
Ulcers in Adults: Prediction and Prevention. Rockville,
Md: US Department of Health and Human Services.
Public Health Service. Agency for Health Care Policy and
Research; 1992. AHCPR Publication 92-0050.
47. Khachemourne A, Phillips TJ. Cost effectiveness in
wound care. In: Krasner D, Rodeheaver GT, Sibbald RG,
eds. Chronic Wound Care: A Clinical Source Book for
Healthcare Professionals, 3rd ed. Wayne, Pa: HMP
Communications; 2001:191–198.
48. Coutts P (2002) – personal communication
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