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 technique 1 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 IAD 1 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 oil – 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 ointments 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