Instrument Designed and validated by WOC nurses and their faculty - - PowerPoint PPT Presentation

IAD and its Severity Instrument

 Designed and validated by WOC nurses and

their faculty

 2 WOC nurses established initial face validity  Content and criterion validity via 9 WOC nurses

in North Central Region of WOCN

 Interrater reliability via 247 WOC nurses

attending 2007 National Conference

 Descriptive, ranks severity allowing longitudinal

assessment; responsiveness has not yet been tested

Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

IAD and its Severity Instrument

Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

IAD and its Severity Instrument

Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527.

Validity and Reliability of IADS

 Original article describing instrument development

evaluated face validity (2 WOC nurse)

 Original article evaluated criterion validity

(establish association between IADS and external criteria)

 Original article evaluated inter-rater reliability (are

scores similar when administered by different clinicians)1

 IADS used in several in press publications in

JWOCN

Borchert K et al. Journal of Wound, Ostomy and Continence Nursing 2010; 37(5): 527-35.

IAD: Institute Defined Skin Care Regimen Routinely Followed

Doughty D et al. Journal of Wound, Ostomy and Continence Nursing 2012; 39(3): 303-15.

IAD: Principles of Prevention & Treatment

IAD: Cleanse

 When frequent bathing necessary,

current evidence suggests….

– Gentle cleansing: NO scrubbing 1,2 – Consider type of washcloth – Select cleanser with pH close to acid mantle of skin – Select product that minimizes potential irritants, scents, etc.

• 1. Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2007; 34(2):134.
• 2. Voegeli D. Journal of Wound, Ostomy & Continence Nursing 2008; 35(1).

IAD: Cleanse

 Some clinicians have raised

concerns about effectiveness of no-rinse cleansers and residue

 Study comparing bacterial

counts in skin of volunteers using controlled bacterial exposure technique (E. coli and Staph aur.); both CFU dramatically; no differences based on technique1

• 1. Ronner AC et al. Journal of Wound, Ostomy & Continence Nursing 2010; 37(3): 260.

Moisturize

 Three categories

– Humectants attract water to the skin – Emollients replace lipids to stratum corneum; designed to smooth skin surface – Occlusives shield skin from exposure to moisture and potential irritants; we will call these by their FDA category name: skin protectants – Sparse evidence concerning their role in preventing or treating IAD1

• 1. Beeckman D et al. Journal of Advanced Nursing 2009; 65(6): 1141-54.

Protect

 Skin Protectants should

– Act as a “moisture barrier”, protecting skin from deleterious effects of exposure to irritants and excess moisture – Maintain hydration and favorable skin’s normal transepidermal water loss (TEWL) – Avoid maceration when left on for prolonged period of time – Options

 Ointment based skin protectants  Liquid acrylates (marketed as a skin barrier) Gray M. Skin Protectants in the Treatment of Irritant Dermatitis In: Sek CK. Advances in Wound Care, Volume 1. New Rochelle, NY: Mary Ann Liebert, Inc.

Protect

 Ointment based skin

protectants

– Petrolatum: blend of castor seed oil & hydrogenated castor

• il

– Dimethicone: silicone based oil – Zinc Oxide: white powder, mixed with cream or ointment base

Clinical Evidence

 Petrolatum

– Good protection against irritant – Avoided maceration – Modest skin hydration

 Dimethicone

– Variable protection against irritant – Modest protection against maceration – Good skin hydration

 Zinc Oxide

– Good protection against irritant – Did not avoid maceration – Poor skin hydration

Hoggarth A et al. OWM 2005; 51(12): 30.

Protect

 Skin barriers (polymer acrylate)

– Non-alcohol preferred

Less pain Less drying

 No different when compared to ointment based

skin protectants in one robust RCT (powered for economic rather than efficacy outcomes)

Bliss DZ et al. Journal of Wound, Ostomy & Continence Nursing 2009; 35 (2).

RCT of 1-Step Pre-Moistened Cloth vs. Soap & Water for Prevention and Treatment of IAD

 Block randomization of 11 nursing home; 6 units

allocated to intervention (pre-moistened cloth with no rinse cleanser, emollient & humectant moisturizers and 3% dimethicone skin protectant) and 5 to standard treatment (pH neutral soap and water)

 141 subjects; prevalence of IAD at enrollment 22.3% in

intervention group, 22.8% in control group

 Pre-moistened wash cloth reduced IAD prevalence 8.1%

vs 27.1% (p=0.003) and non0significant effect on IAD severity 3.8 vs 6.9 (p=0.06)

Beeckman D et al. Journal of Wound, Ostomy and Continence Nursing 2011; 37(6): in press.

IAD Product Selection: SORT Statements

Doughty D et al. Journal of Wound, Ostomy and Continence Nursing 2012; 39(3): 303-15.

IAD: Treatment

 Establish or continue defined skin

care program based on “cleanse, moisturize & protect”, consider changing skin protectant

 Minimize exposure to irritants

(aggressively manage UI or FI)

 Treat secondary cutaneous

infections

 Allow skin to heal or apply

protectant with active ingredients designed to promote healing

IAD Product Selection: SORT Statements

Doughty D et al. Journal of Wound, Ostomy and Continence Nursing 2012; 39(3): 303-15.

IAD Product Selection: SORT Statements

Doughty D et al. Journal of Wound, Ostomy and Continence Nursing 2012; 39(3): 303-15.

IAD Treatment: Severe Cases

 Create Skin Paste with aluminum

sulphate or acetate and karaya powder

– Applied as compress; causes protein precipitation & has antimicrobial properties – Exerts drying & soothing effect; followed by application of moisture barrier – Often used when dermatitis complicated by extensive erosion and serous exudate

IAD: What about Dressings

 Topical Dressings

– Hydrocolloids – Thin film dressings

 Act as barrier to urine & stool  Promote moist environment

for wound healing

 Can be combined with topical

treatments

Dressings: Practical Concerns

 Role of topical Dressings

– Maintaining adherence significant challenge – Skin surfaces complex – Borders often roll when

• intments or moisturizing

products have been applied – Undermining of urine or stool may occur

IAD: Contain/ Prevent Exposure to Urine Stool

 Establish or continue defined skin

care program based on “cleanse, moisturize & protect”, consider changing skin protectant

 Minimize exposure to irritants

(aggressively manage UI or FI)

 Treat secondary cutaneous

infections

 Allow skin to heal or apply

protectant with active ingredients designed to promote healing

Conclusions

 IAD is a prevalent and clinically relevant

condition

 Defined skin regimen key to prevention

and treatment of IAD

 Principles of skin regimen: cleanse,

moisturize & protect