The role of barrier protection in pressure ulcer … role of barrier protection in pressure ulcer...
Transcript of The role of barrier protection in pressure ulcer … role of barrier protection in pressure ulcer...
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The role of barrier protection in pressure ulcer prevention
AbstractThis article considers the anatomy and physiology of the skin, the natural protection the skin provides in relation to barrier protection and the importance of barrier protection in pressure ulcer prevention. The current national pressure ulcer agenda including high impact actions and the SSKIN care bundle, along with their implementation within one NHS Health Care Trust are discussed.
Key words: Barrier protection ■ Pressure ulcer prevention ■ SSKIN bundle
The�most�significant�role�of�the�skin�is�to�be�a�protective�barrier�against�the�external�environment.�The�skin�is�covered�with�a�naturally�produced�lipid�layer,�which�helps� to�maintain�moisture�balance,�prevents�drying�
and� provides� an� effective� waterproof� barrier.� Normal� skin�pH� is� around� 5.5,� which� significantly� reduces� the� ability�of� bacteria� to� proliferate� (Butcher� and�White,� 2005).� Skin�dryness�may�occur�from�excessive�washing�or�use�of�alkaline�soaps,�which� alters� the� pH�of� the� skin� reducing� its� barrier�function�(Wysocki,�2000).�Bodily�fluids�including�urine�and�faeces� can� waterlog,� macerate� and� corrode� the� outer� layer�of� the� epidermis� (stratum� corneum)� leading� to� weakening�and�breakdown�of�the�skin,�often�painful�in�nature�(Wounds�International,�2010).�As�the�skin�ages,�the�epidermis�gradually�thins� and� the� papillae� that� lie� between� the� epidermis� and�the� dermis� become� flattened,� reducing� the� skin’s� resistance�to�shearing�forces�(Voegeli,�2010)�and�its�ability�to�perform�many�of�its�essential�functions�(Wysocki,�2000).
Skin assessmentIdentifying� early� signs� of� pressure� damage� is� vital� in� the�prevention� of� category� II� and� II� pressure� ulcers.� The�European� Pressure� Ulcer�Advisory� Panel� (EPUAP)� (2009)�and� the�National� Institute� for�Health� and�Care�Excellence�(NICE)�(2005)�advocate�that�essential�skin�assessment�should�be� undertaken� and� should� be� part� of� training� for� health�professionals.� Importantly,� the� need� to� protect� vulnerable�
Jackie Stephen-Haynes
areas�of� the�skin�and�prevent�skin�breakdown�is�considered�to�be�a�cornerstone�of�professional�care�across�all�spheres�of�practice� (Voegeli,� 2008).� Consideration� should� be� given� in�skin�assessment�to�skin�changes�in�the�older�person�(Wounds�UK,�2012)�and�skin�changes�at�life’s�end�(Sibbald�et�al,�2009).�
Newton� and� Cameron� (2003)� advocate� four� essential�aspects� of� skin� assessment:� colour,� texture,� temperature�and� integrity.� The� skin� should� be� observed� for� signs� of�colour� change,� reddening� or� blanching� (white� areas)�in� Caucasian� skin� types� and� for� a� bluish� purple� hue� in�darker� skin� types.� Skin� assessment� should� also� include�observation� for� increased� heat,� swelling,� pain� or� guarding�of� an� area� and� evidence� of� shiny� areas� or� superficial�breaks� owing� to� shearing� forces� against� the� skin.� The�implementation� of� care� rounds� including� assessing� and�monitoring� of� skin� (Bartley,� 2011)� as� part� of� harm-free�care� (Institute� for� Healthcare� Improvement,� 2011)� has� led�to� the� implementation� of� a� visual� skin� assessment� during�each� care� round� (1–2� hourly)� in� community� hospital�and� at� each� district� nursing� visit.� Thomas-Hess� (2000)�proposes�the�following�key�areas�for�skin�management:�
�■ Take� caution� with� the� force� applied� when� washing� the�skin� and� avoid� massaging� areas� that� could� be� easily�damaged
�■ Offer�prompt�attention�when�incontinent�episodes�occur�and�protection�of�skin�with�barrier�protection�
�■ Aim� to� avoid� drying� of� the� skin� through� extremes� of�temperature
�■ Ensure�that�patients�are�positioned,�transferred�and�turned�properly�to�avoid�friction�and�shear�forces
�■ Cleanse�the�skin�at�frequent�intervals,�using�a�pH-balanced�cleansing�agent�followed�by�moisturisers�and�barrier�cream.
Pressure ulcer agenda There� is� a� significant� challenge� in� delivering� high-quality�care�while� improving�its�efficiency�amid�an�era�of�growing�demand�for�healthcare�resources.�In�England,�a�recent�White�Paper,�which�is�centered�on�efficiency�improvements,�outlined�government�strategy�to�address� these� issues�(Department�of�Health� (DH),� 2010a).The� Operating� Framework� for� the�NHS� in�England� for� 2012–13� requires� that� service� quality�and� the�patient�experience�must� improve,� and�productivity�increase� (DH,� 2012).�The� DH� (2010a)� identifies� pressure�ulcers�as�a�future�outcome�indicator,�reporting�that�in�2007/8�there�were�42 995�episodes�of�pressure�ulcers.�Pressure�ulcer�prevention�is�an�area�that�is�recognised�as�having�significant�impact� on� quality� of� care� and� this� has� been� increasingly�elevated�on�political� agendas� in� recent�years.�This� is�owing�
Jackie�Stephen�Haynes�is�Professor�in�Tissue�Viability,�Professional�Development�Unit,�Birmingham�City�University�and�Consultant�Nurse,�Worcestershire�Health�and�Care�NHS�Trust
Accepted for publication: October 2013
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to� the� increasing� emphasis� on�preventative�health� care� and�a� belief� that� pressure� ulcers� are� preventable� (NHS,� 2012).�The� National� Patient� Safety� Agency� (NPSA)� has� been�urging�NHS�organisations�across�England�and�Wales�to�work�towards�preventing�all�pressure�ulcers�(NPSA,�2010a;�2010b).
Pressure ulcer care deliveryCurrent� care� delivery� in� relation� to� pressure� ulcers� is�informed� by� NICE� guidelines� (2005),� EPUAP� guidelines�(2009)� and,� more� latterly,� through� the� introduction� of�High�Impact�Actions�‘Your�Skin�Matters’� (DH,�2010b)�and�the� quality� agenda� Quality,� Innovation,� Productivity� and�Prevention� (QIPP)� (DH,�2010a).�An� initial� target� ambition�was� set�out�aiming�to�prevent�category�III�and�IV�pressure�ulcers;� this� has� been� expanded� by� the� introduction� of� the�elimination�of�avoidable�pressure�ulcers�across�the�Midlands�and�East�in�the�UK�(NHS�Midlands�and�East,�2012).
Several�intrinsic�and�extrinsic�factors�contribute�to�pressure�ulceration� development.� Intrinsic� factors� include� sensory�impairment,� immobility,� age,� poor� nutrition,� incontinence,�and� chronic� illness� (NICE,�2005).�Extrinsic� factors� include�pressure,� shear,� friction,� and� the� impact� of� incontinence�(NICE,�2005;�EPUAP,�2009).�The�significance�of�each�is�not�fully� understood� (EPUAP,� 2009)� and� the� cause� of� pressure�ulcers�has�been�the�subject�of�much�research�and�discussion.�
Pressure�has�been�considered� to�be� the�most� significant�physical� force�responsible� for� the�development�of�pressure�ulceration�(NICE,�2005).�Pressure�over�a�bony�prominence�will� compress� the� capillaries� and� prevent� nutrients� and�oxygen� accessing� the� skin.� Unrelieved� pressure� leads� to�tissue� ischaemia,� with� metabolic� wastes� accumulating� in�the� interstitial� tissue,� ultimately� resulting� in� hypoxia� and�cell�death.�Sample�biopsies� from� tissues� reddened� through�pressure� have� been� demonstrated� to� show� an� increase�in� bacterial� loading� within� the� tissues� as� a� result� of� the�hypoxia� (Sugama� et� al,� 2005).� As� the� amount� of� shear/friction� increases,� the� amount� of� pressure� required� to�cause� ulceration� is� reduced� (Conner� and� Clack,� 1993).�Shear,� friction,� and� microclimate� have� also� recently� been�identified� by� an� expert� panel� as� a� major� cause� of� tissue�damage�(Wounds�International,�2010).�Specifically,�there�is�an�inverse�relationship�between�shear,�friction�and�pressure.�The� cause� of� pressure� damage� and� the� rate� at�which� this�occurs�is�clinically�important�and�clinicians�need�to�be�alert�to� the� reduced� time� for� pressure� damage� to� occur� when�shear/friction� is� a� consideration� (Wounds� International,�2010).�
Importantly,� pressure� ulcers� are� a� considerable� burden�for� the� NHS,� being� a� significant� cause� of� morbidity�and� mortality� (Posnett� et� al,� 2009).� Gorecki� et� al� (2009)�conducted�a�review�of�31 studies,�reporting�the�impact�of�pressure�ulcers�and�pressure�ulcer�interventions�on�health-related� quality� of� life� (HRQoL).� Pressure� ulcers� were�found� to� significantly� affect� physical,� social,� psychological,�and� financial� aspects� of�HRQoL.�Pain�was� identified� as� a�significant� concern� and,� importantly,� patients� attributed�their�pressure�ulcers�to�inadequate�health�care�and�a�lack�of�knowledge�on�the�part�of�health�professionals�regarding�the�prevention�of�pressure�ulceration.
The�financial�cost�of�pressure�ulcers�has�been�estimated�at�£2.3–£3.1�billion�per�year�in�the�UK,�which�would�account�for� 3%� of� the� annual� NHS� expenditure� at� 2005/6� levels�(Posnett� and�Franks,�2007).�The�DH�(2010a)�estimates� that�a� category� III� pressure� ulcer� costs� between� £363�000� and�£543�000�to�treat�and�that�a�category�IV�ulcer�costs�between�£447�000�and�£668�000.�The�majority�of�these�wounds�are�chronic�in�nature�and�are�cared�for�in�the�community�setting�by�GPs�and�community�nurses�(Drew�et�al,�2007).
Once� the� level� of� risk� has� been� ascertained,� the� key�to� reducing� it� relies� on� appropriate� preventative� care�and� treatment� plans� being� developed� and� implemented�(NICE,� 2005).� The� education� of� staff� at� all� levels� and�disciplines� on� risk� assessment� using� validated� tools,� care�planning,� documentation� and� the� implementation� of�appropriate�pressure�reducing�equipment�is�paramount�in�the�identification� and� subsequent� prevention� of� pressure� ulcers�(Institute�for�Healthcare�Improvement,�2008).��
High Impact Actions and SSKIN bundlesThe�high�impact�actions�(DH,�2010b)�indicate�the�majority�of� pressure� ulcers� that� develop� in� NHS-provided� care� are�avoidable,�stating�that�it�is�the�processes�regarding�prevention�that� fail.� It� identifies� that� to� eliminate� pressure� ulcers�requires�input�from�the�multidisciplinary�team.�This�requires�development�of� simple�processes� that�will� reduce�avoidable�pressure�ulcers�(DH,�2010b).
The� latest� guidance� relates� to� the� actual� delivery� of�prescribed�care�in�the�prevention�of�pressure�ulcers�through�the�use�of�SSKIN�bundle�documentation�packages�(Institute�for�Healthcare�Improvement,�2011).�Following�the�successful�implementation� of� the� SSKIN� care� bundle� in� Wales,� it�was� implemented� in�Scotland� in�2011�and� is� supported�by�Healthcare�Improvement�Scotland�(2013).�A�bundle�of�care�is�defined�as�a�structured�way�of�improving�processes�of�care�and� significantly� improving� patient� outcomes� (Institute� for�Healthcare�Improvement,�2011).�
McCarron�(2011)�clarifies�the�crucial�aspect�of�a�successful�care�bundle�as�ensuring�that�every�identified�intervention�is�performed� in� a� sequence� of� steps� and� that� no� component�is� eliminated.� Omitting� any� one� of� the� interventions� in� a�SSKIN� bundle� is� likely� to� result� in� the� development� of� a�pressure� ulcer.� The� critical� difference� between� a� SSKIN�bundle� and� a� traditional� care� plan� is� that� a� bundle� is� an�essential�set�of�steps�in�a�process�where�a�complication�may�arise�if�one�is�missed�(Institute�for�Healthcare�Improvement,�2011).� Bundles� were� initially� used� to� reduce� ventilator-associated� pneumonia� (Resar� et� al,� 2005)� and� are� now�advocated� as� a� structured� method� for� preventing� pressure�ulceration�(Lloyd�Jones,�2012).
The�objective�of�a�bundle�is�to�make�a�process�more�reliable�by� improving� motivation,� compliance� and� implementation�of� a� strategy� for� care� (Stephen-Haynes,� 2011).�Therefore,�SSKIN� care� bundles� are� essential� in� the� prevention� of�pressure�ulcers�and�should�be�implemented�for�every�patient�at�risk�to�achieve�the�elimination�of�avoidable�pressure�ulcers.�
The�SSKIN�bundle� acronym� represents� the� five� essential�elements�of�pressure�ulcer�prevention�(Institute�for�Healthcare�Improvement,�2011):�
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Surface�SkinKeep�moving�Incontinence�Nutrition.All� elements� in� the� bundle� are� based� on� robust� evidence�
and�delivery�of� the�bundle� is�measured� through�compliance�with� every� element.�The� aim� of� the� bundle� is� to� tie� best�practices�together�in�a�reliable�way�to�reduce�the�occurrence�of�a�pressure�ulcer.�Successfully�completing�the�bundle�is�based�on�all�elements�being�carried�out� together�at� the� same�time�(i.e.�at�the�patient’s�bedside�at�2-hourly�intervals)�or�at�every�district�nursing�visit.�The�bundle�encourages�attention�to�detail�through�its�individual�elements�and�helps�establish�good�habits�that� ultimately� impact� on� outcomes� (i.e.� reducing� pressure�ulcers).�The�bundle� therefore�makes� it�easy� for�people� to�do�the�right�thing�at�the�right�time.�Most�importantly,�the�bundle�makes�the�process�for�preventing�pressure�ulcers�visible�to�all.
SurfaceEnsuring� the� appropriate� surface� is� available� within� a�24-hour� period,� that� it� is� being� used� correctly� and� is�clinically� effective� and� fit� for� purpose� with� an� Electro-Biomedical�Engineering�Department�(EBME)�and�Portable�Appliance�Testing�(PAT)�undertaken.�
SkinEarly� visual� inspection� of� skin� with� a� focus� on� early�detection�and�prevention�of�breakdown�or�deterioration�by�early� intervention� of� pressure� relieving� regimes,� cleansing,�moisturising�and�skin�barrier�protection.�
Keep movingEnsuring� patients� are� repositioned� or� encouraged� to�mobilise�independently�at�every�care�round�in�community�hospitals�and�at�every�district�nursing�visit�and�recorded�in�the�SSKIN�care�bundle.�
IncontinenceAt�each�care�round,�staff�ensure�that�the�patient�is�clean,�dry�and� comfortable.� Incontinence� assessments� are� undertaken�and�barrier�protection�is�implemented�both�preventively�and�as�a�treatment�strategy.�
NutritionEnsuring� patients� have� an� appropriate� dietary� and� fluid�intake� to� maintain� their� nutritional� status� and� hydration�levels.�This� should� be� conducted� 2-hourly� as� part� of� care�rounds� within� community� hospitals� and� at� every� district�nursing� visit.� Intake� and� supplement� therapy� is� monitored�and�documented�accordingly.
Following�the� implementation�of� the�SSKIN�bundle,� the�Midland� and� East� have� reduced� the� incidence� of� pressure�ulcers�by�36%�in�6 months�(Ford,�2012).�
Barrier film protection: prevention, treatment and management The�aim�of�a�barrier�film�or�cream�is�to�mimic�the�skin’s�natural�barrier� function� with� the� purpose� of� protecting,� repairing,�
restoring� or� preventing� skin� damage.� The� moisturising�capability� lays� down� a� durable� protective� barrier� affording�the� optimum� protection.�The� use� of� no-sting� barrier� films�began� in� the� UK� in� the� late� 1990s� and� this� has� increased�steadily.�Guest� et� al� (2011)� found� that� despite� barrier� films�being� more� expensive� to� purchase� than� zinc� oxide� and�petroleum-based� products,� the� reductions� in� labour� more�than�offset�the�additional�cost.�According�to�Guest�el�al,�the�potential�savings�in�the�right�care�settings�could�reach�several�millions�of�pounds.
Sorbaderm barrier protection Sorbaderm�No-Sting�Barrier�Film�is�a�non-cytotoxic�acrylate�co-polymer� liquid� film� that� forms� a� flexible� long-lasting�waterproof�barrier�for�the�protection�of�intact�or�the�treatment�of�damaged�skin.�With�its�high-moisture�vapour�transmission�rate,� it� acts� as� a� protective� interface� between� the� skin� and�bodily� fluids,� adhesive� products,� and� mechanical� stress� and�aims� to� mimic� the� body’s� natural� protection� function.�The�barrier� film� can� be� used� clinically� for� incontinence,� peri-stomal� skin� protection,� peri-wound� skin� protection� and�adhesive�trauma�protection.�It�provides�up�to�72 hours�of�skin�protection�depending�upon�the�severity�of�the�corrosive�fluid�or� exposure� and� as� it� does� not� contain� alcohol,� it� does� not�sting.� It� is� transparent,� allowing� for� continuous� visualisation�and�monitoring�of�skin�at�risk�of�breakdown.�
Sorbaderm� No-Sting� Barrier� Cream� is� a� highly�concentrated,�long-lasting�latex�and�fragrance-free�protective�barrier�that�does�not�clog�incontinence�or�dressing�devices,�providing�effective� skin�moisturising�and� long-term�barrier�protection�from�bodily�fluids.
Stephen-Haynes�and�Stephens�(2012)�report�a�study�with�two� arms� involving�95 subjects�within� a�UK�primary� care�organisation.�The� objective� was� to� determine� the� clinical�outcomes� and� acceptability� of� a� no-sting� barrier� film� and�cream�product.�
Study outcomesThe� indications� included� in� the� study� were� peri-wound�protection,�incontinence�and�pressure�ulcers.
The�clinical�indications�explored�were:��■ �Prevention�of�skin�breakdown�■ �Maintenance�of�skin�condition�■ �Peri-wound�maceration�■ �Excoriation�and�incontinence-related�skin�protection�■ �Adhesive�skin�strippingOf�the�95 patients�recruited,�the�barrier�cream�was�evaluated�
in�39 patients�and�the�no-sting�barrier�film�in�53 patients.�
Inclusion criteria�■ Patient�>18�years�of�age�■ Patient�is�willing�to�participate�and�has�capacity�to�consent�■ Patient� has� an� indication� suitable� for� treatment� with� a�barrier�product
�■ Patient�will�be�seen�regularly�by�the�evaluator.
Exclusion criteria�■ Patient�is�<18�years�of�age�■ Patient� does� not� wish� to� participate� or� have� capacity� to�
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also� be� considered� (Clark,� 2010;� Deakin� et� al,� 2010).Economic�models�including�nursing�time�and�material�costs,�favour� the� use� of� barrier� films� and� creams� (Clark,� 2010;�Deakin�et�al,�2010).�
There� is� increasing� evidence� relating� to� the� clinical� and�financial� benefits� of� skin� protection� and,� in� particular,� to�that� of� no-sting� barrier� films� and� barrier� creams� when�compared�with�more�traditionally�used�skin�protection�such�as� petroleum-based� creams� (Stephen-Haynes� and� Stephens,�2012).�The� author� acknowledges� that� the� current� emphasis�on�pressure�ulcer�prevention�led�to�a�low�number�of�patients�with�pressure�damage�taking�part�in�this�95-patient�study.�In�addition,� subjectivity� was� a� limitation� of� the� original� study�due� to� reflective� comparison� to� previous� treatment� regime�rather�than�any�form�of�direct�comparator.
Clinical care studiesFigure 1� shows� a� 67-year-old� female with� a� sacral� pressure�ulcer�with�a�high�exudate�levels�due�to�damage�to�the�peri-wound�skin�caused�by�wound�exudate.�Sorbaderm�No-Sting�Barrier�Film�was�used�for�48�hours.�Figure 2�demonstrates�the�impact�of�the�barrier�film�on�the�peri-wound�area;�the�peri-wound�skin�is�now�intact.�
Figure 3�shows�the�pressure�ulcer�and�damage�to�the�peri-wound�area�of� a�50-year�old�gentleman.�The�pressure�ulcer�occurred�following�a�trauma�injury.�Figure 4�demonstrates�the�improvement�in�his�peri-wound�skin�following�the�application�of�Sorbaderm�No-Sting�Barrier�Film�for�72 hours.�
Figure 5� is�a�photo�of�a�back�ulcer�on�a�74-year-old� lady�who�has� arthritis� renal� failure� and�a� curvature� to� the� spine.�She�has�been�a�very�heavy� smoker� for�most�of�her� life�and�has�a�cough.�On�investigation,�a� tumour�was�noted�but�not�treated�at�her�request.�
This�patient�developed�a�pressure�ulcer� to�her� spine.�This�started�as�a�small�area�with�a�large�area�of�excoriation�to�the�peri-wound� area.�When� the� author� first� saw� this� lady,� the�peri-wound�area�was�excoriated�from�both�exudate�and�the�dressings�being�removed.�The�patient�found�dressing�changes�very�painful�and�sat�upright�in�bed,�uncomfortable�for�many�hours�at�a�time.�This�left�the�skin�on�the�curvature�of�her�spin�vulnerable� and� more� easily� damaged� by� shear� and� friction�from� movement� in� the� bed.� Sorbaderm� No-Sting� Barrier�Cream�was�applied�to�the�peri-wound�and�this�has�improved�the�peri-wound�skin�and�decreased�her�discomfort.
A� 67-year-old� gentlemen� with� Parkinson’s� disease�developed�the�ulcer�shown�in�Figure 6.�His�Parkinson’s�disease�causes�frequent�movement,�resulting�in�shear�and�friction.�He�developed� this� ulcer� following� a� problem� with� his� seating�(he�has�a�moulded�wheelchair).�The�peri�wound�needed� to�be�maintained�during� debridement.�The� excessive�moisture�during� this� period� of� debridement� and� the� involuntary�movements� could� have� resulted� in� extensive� peri-wound�excoriation� and� enlargement� of� the� ulcer.�The� exudate� did�cause� excoriation� as� Figure 6� shows,� but� the� Sorbaderm�No-Sting�Barrier�Film helped�to�reduce�this�(Figure 7).�When�barrier� film� is� applied� to� the�whole�of� the� area,� it� supports�the�dressing�in�place�and�prevents�irritation�and�skin�stripping�from�the�secondary�dressing.
A�72-year-old� lady�acquired�a�category IV�pressure�ulcer�
Figure 1. Excoriation caused by wound exudate
Figure 3. Excoriation caused by wound exudate
Figure 5. Peri-wound excoriation
consent�■ Patient�not�suitable�for�barrier�product�treatment�■ Instructions�for�the�product�use�cannot�be�followed�■ Any�other�reason�the�evaluator�feels�the�patient�should�be�excluded.
Results In�arm�one,�36 patients�were�evaluated.�There�were�18 males�and�18 females�and�of�these,�6�specifically�related�to�pressure�ulceration,� with� exudate� levels� reported� to� be� moderate�or� high.� None� of� the� six� developed� signs� of� maceration�throughout�the�study�process.�All�(n�=�6)�reported�a�dramatic�visible�improvement�to�skin�condition�within�24–48 hours.�
In� the� second� arm,� the� total� number� of� patients� was� 59;�3 patients�with�shear�and�friction�damage�showed�significant�improvement�following�the�use�of�barrier�protection.�
These� results� are� supported� by� Deakin� et� al� (2010)� and�Clark� (2010)� who� reported� positive� results� in� support� of�Sorbaderm� No-Sting� Barrier� Film� and� No-Sting� Barrier�Cream.� Importantly,� clinical� and� service-user� acceptance,�adoption� strategy� costs� and� educational� requirements� must�
Figure 2. Skin improved after 48 hours application of barrier protection
Figure 4. Skin improved after 48 hours application of barrier protection
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to� her� sacrum� (Figure 8)� following� an� acute� admission� for�breathing�problems�and�dizzy�spells�(she�was�diagnosed�with�Guillain-Barré� syndrome� so� carers� and� relatives� had� been�unable�to�move�her).�This�patient�was�previously�mobile,�very�independent� and� healthy� for� her� age.� She� looked� after� her�husband�who�was�found�to�have�early�dementia.
When�this�patient�was�transferred�to�a�community�hospital,�this� ulcer� had� very� heavy� exudate� and� the� cavity� was� very�large� (12 cm� x� 9 cm� x� 4 cm� deep)� (Figure 9).�The� ulcer,�and� resulting� loss� of� immobility,� caused� this� patient� to� be�depressed� (she� had� loss� of� feeling� in� her� legs� although� this�was�returning�slowly).�
The� author� and� colleagues� had� to� consider� how� to�effectively� manage� the� exudate� while� protecting� the� peri�wound.�Sorbaderm�No-Sting�Barrier�Film�was�commenced�upon�her�admittance�to�the�community�hospital�owing�to�the�high�volume�of�exudate.�
The�wound�was� very� painful� to� dress,� requiring� entonox�(gas� and� air).� Negative� pressure� wound� therapy� was� used�to� dress� the� wound� at� the� beginning;� maintenance� of� the�peri-wound� area� was� very� important� in� order� to� achieve�a� good� seal� and� prevent� the� ulcer� from� getting� bigger.�Following�a�multidisciplinary�team�meeting,�the�team�started�physiotherapy�with�the�patient�and�she�began�to�walk�within�5 weeks.�Her�ulcer�has�now�almost�healed�(Figure 10)�and�she�has�returned�home�with�her�husband.�
ConclusionThe�prevention�of�pressure�ulcers�and�maintenance�of�healthy�skin� integrity� is� a�key�government� agenda�and�a� significant�clinical�challenge�for�health�professionals�and�carers.�Pressure�ulcer�prevention�and�management�are�of�particular�significance�in�an�increasingly�elderly�population�owing�to�mobility�issues,�continence� status� and� skin� changes� that� can� occur� with�ageing,�chronic�illness,�and�at�the�end�of�life.�It�is�essential�for�all�nurses�and�allied�health�professionals�to�consider�pressure�ulcer�prevention�and�be�knowledgeable�regarding�prevention�and� treatment� processes.� Ensuring� fundamental� nursing� is�delivered�and�the�SSKIN�care�bundle�is�implemented�every�time�for�every�patient�is�essential�in�the�prevention�of�pressure�ulcers.�The�evidence�suggests�the�use�of�SSKIN�bundles�and�the�appropriate�use�of�barrier�film�protection�can�contribute�to� the� prevention,� treatment� and� maintenance� of� the� skin’s�barrier�function,�helping�to�protect�and�restore.�� BJN
Conflict of interest: Sorbaderm Barrier Cream and Sorbaderm Barrier
Figure 6. Pressure ulcer with surrounding skin affected by shear, friction and moisture
Figure 10. The improved wound
Film used in the author’s study were supplied by Aspen Medical.
Bartley�A��(2011)�The�Hospital�Pathways�Project.�Making�it�happen:�Intentional�rounding.�The�King’s�Fund�Point�of�Care�and�the�Health�Foundation.�http://tinyurl.com/c7zyohv�(accessed�30�October�2013)
Butcher�M,�White�R�(2005)�The�structure�and�function�of�the�skin.�In:�White�R� (Ed)� Skin care in wound management: Assessment, prevention and treatment.�Wounds�UK,�Aberdeen:�1-16
Clark� M� (2010)� Preventing� skin� breakdown� with� barrier� films� and� creams.�Wounds UK�6(4):�132-8
Conner�L,�Clack�J� (1993)�In�vivo�(CT�scan)�comparison�of�vertical� shear� in�human�tissue�caused�by�various�support�surfaces.�Decubitus�6(2):�20-3,�26-28�
Deakin�A,�Stapleton�M,�Chadwick�K�(2010)�Evaluating�a�skin�barrier�film�in�faecal�and�urinary�incontinence.�Wounds UK�6(2):�107–11
Department� of� Health� (2010a)� The NHS Quality, Innovation, Productivity and
Figure 7. Improvement seen following application of barrier protection
Figure 9. Undermining has improved after 1 week and peri wound is intact
Figure 8. The peri wound is intact following use of the barrier film. Note the undermining at the wound edge
S58� British�Journal�of�Nursing,�2013�(Tissue�Viability�Supplement),�Vol�22,�No�20
©�2
013�
MA
�Hea
lthca
re�L
td
Prevention challenge: An introduction for clinicians.�DH,�London.�http://tinyurl.com/os7xoqn�(accessed�30�October�2013)
Department�of�Health� (2010b)�High Impact Actions for Nursing and Midwifery.NHS Institute of Innovation and improvement.� http://tinyurl.com/peojl3q�(accessed�30�October�2013)
Department�of�Health�(2012).The Operating Framework for the NHS in England 2012/13.�http://tinyurl.com/ax66ola�(accessed�30�October�2013)
Drew� P,� Posnett� J,� Rusling� L� (2007).�The� cost� of� wound� care� for� a� local�population�in�England.�Int Wound Journal�4(2): 149-55
European�Pressure�Ulcer�Advisory�Panel� (2009)�Pressure�ulcer�prevention:�A�quick� reference� guide.� http://tinyurl.com/378oexd� (accessed� 30� October�2013)
Ford�S�(2012)�Pressure�ulcers�cut�by�a�third�in�midlands�and�east.�Nursing Times.net.�http://tinyurl.com/p9clbqs�(accessed�30�October�2013)
Gorecki�C,�Brown�J,�Nelaon�A�et�al�(2009)�Impact�of�pressure�ulcers�on�quality�of�life�in�older�patients:�a�systematic�review.�J Am Geriatr Soc 57(7): 1175-83
Guest� J,� Greener� M,�Vowden� K,�Vowden� P� (2011)� Clinical� and� economic�evidence� supporting� a� transparent� barrier� film� dressing� in� incontinence-associated�dermatitis�and�peri�wound�protection.�J Wound Care�20(2): 76-84
Health�Care�Improvement�Scotland�(2013)�SSKIN care bundle.�http://tinyurl.com/lqke8ql�(accessed�30�October�2013)
Institute� for� Healthcare� Improvement� (2008)� 5� Million� Lives� Campaign.��Getting�Started�Kit:�Prevent�Pressure�Ulcers�How-to�guide.�http://tinyurl.com/cfaohln�(accessed�30�October�2013)�
Institute�for�Healthcare�Improvement�(2011)�What is a bundle?�http://tinyurl.com/onf69xn�(accessed�30�October�2013)
Lloyd-Jones�M�(2012)�Prevention�and�treatment�of�superficial�pressure�damage.�Nursing and Residential Care�14(1):�14-20
McCarron�K�(2011)�Understanding�care�bundles.�Nursing Made Incredibly Easy�
KEY POINTS
n The prevention of pressure ulcers is a key national agenda
n SSKIN bundle implementation is an essential part of the elimination of
avoidable pressure ulcers
n Timely skin assessment, skin care and the use of barrier protection are an
important component of the strategy for pressure ulcer prevention
n An evaluation of barrier films and creams indicates the importance of barrier
protection as an essential component of pressure ulcer prevention
9(2):�30–3.�National� Institute� for�Health� and�Clinical�Excellence� (2005)�The�prevention�
and�treatment�of�pressure�ulcers.�NICE,�LondonNational�Institute�for�Health�and�Clinical�Excellence�(2006)�The�management�
of�urinary�incontinence�in�women.�NICE,�London�National�Patient�Safety�Agency�(2010a)�NHS to adopt zero tolerance approach to
pressure ulcers.�http://tinyurl.com/pn89tw6�(accessed�30�October�2013)National�Patient�Safety�Agency�(2010b)�Serious Incident Reporting and Learning
Framework (SIRL). National framework for reporting and learning from serious incidents requiring investigation.� http://tinyurl.com/2vqkojm� (accessed� 30�October�2013)
Newton�H,�Cameron�J�(2003)�Skin Care in Wound Management. A clinical education in wound management.�Medical�Communications�UK�Ltd,�Holsworthy
NHS�Midlands�&�East�(2012)�Pressure�ulcers.www.stopthepressure.comNHS� (2012)� Harm� Free� Care.� NHS,� London.� http://tinyurl.com/d9r89vw�
(accessed�30�October�2013)Posnett� J,�Franks�P� (2007)�The cost of skin breakdown and ulceration in the UK.
Skin breakdown: the silent epidemic.�Smith&�Nephew�Foundation.�Hull:�6-12Posnett� J,� Gottrup� F,� Lundgren� H,� Saal,� G.� (2009)�The� resource� impact� of�
wounds�on�health�care�providers�in�Europe.�J Wound Care�18(4):�154–61Resar� R,� Pronovost� P,� Haraden� C,� Simmonds�T,� Rainey�T,� Nolan�T� (2005)�
Using� a� bundle� approach� to� improve�ventilator� care�processes� and� reduce�ventilator-associated�pneumonia.�Jt Comm J Qual Patient Saf�31(5): 243-8
Sibbald�R,�Krasner�D,�Lutz�J�et�al�(2009)�SCALE:�skin�changes�at�life’s�end:�final�consensus�statement.�Adv Skin Wound Care�23(5):�225–36
Stephen-Haynes� J� (2011)� Pressure� ulceration� and� the� current� government�agenda�in�the�UK.�Br J Community Nurs�16(Sup5):�S18-S26
Stephen-Haynes� J,� Stephens� C� (2012)� Evaluation� of� clinical� and� financial�outcomes� of� a� new� no-sting� barrier� film� and� barrier� cream� in� a� large�UK� primary� care� organisation.� Int Wound J� doi:� 10.1111/j.1742-481X.2012.01045.x.�[Epub�ahead�of�print]
Sugama� J,� Sanada� H,� Nakatani�T,� Nagakawa�T,� Inagaki� M� (2005)� Pressure-induced� ischemic� wound� healing� with� bacterial� inoculation� in� the� rat.�Wounds�17(7):�157–68
Thomas-Hess�C�(2000)�‘Skin�care�and�wound�prevention�strategies’.� In:�Skin and Wound Care.�Lippincott,�Williams�and�Wilkins,�USA
Voegeli�D�(2008)�The�effect�of�washing�and�drying�practices�on�skin�barrier�function.�J Wound Ostomy Continence Nurs 35(1):�84–90
Voegeli�D�(2010)�Basic�essentials.�Why�elderly�skin�requires�special�treatment.�Nursing and Residential Care�12(9):�422–9
Wounds� International� (2010) Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document.�Wounds� International,�London.�http://tinyurl.com/oj7f6uv�(accessed�30�October�2013)
Wounds� UK� (2012)� Best Practice Statement. Care of the Older Person’s Skin. :�Wounds� UK,� London.� http://tinyurl.com/q9rrt2c� (accessed� 30� October�2013)
Wysocki�A�(2000)�‘Anatomy�and�physiology�of�skin�and�soft�tissue’.�In:�Acute and chronic wounds: nursing management.�Mosby,�St�Louis�
Dermatology Differential Diagnosis is an essential dermatology guide for nurses Key Features• Based on the popular monthly Dermatology Differential Diagnosis series published in the highly respected
journal of Practice Nursing. • A practical guide to the differential diagnosis and management of common skin disorders and questions
to test your knowledge. • Provides concise content on the aetiology, diagnosis, management and prevention, enabling practitioners
to treat patients effectively. • Highly illustrated with colour images throughout. ISBN-13: 978-1-85642-401-1; ISBN-10: 1-85642-401-4; 297 x 210 mm, paperback; 200 pages; publication 2010; £29.99
‘This book is an invaluable resource for both nurses and general practitioners working in a primary care setting who wish to improve both the quality of care and the quality of life for those patients with skin problems.” Practice Nurse
Treat common skins conditions in general practice
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by Jean Watkins
DermatologyDifferentialDiagnosis