SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT.

Name of the Author.

Name of Department.

Name of Institution of Study.

Author contact information.

Wd Count: 3900
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QUESTION: 12.1

First is by assessing the medical history of the patient.1This is by enquiring about the patient's

medical history. Some patients have more than one doctor.2This can lead to uncoordinated care

risking complications. Enquire on current medication being taken. This is due increased risks of

adverse drug to drug interations.Such risks are very high with patients with renal failure. Enquire

from patient on drugs they are allergic to. Drug dosage is also considered depending on the age

or the progression of the ulcer. This is because hepatic blood flow decreases with age leading to

reduction in hepatic drug removal with a reduction in age.1

Doing an assessment of risk factors of the venous. This factors are; the family medical

background on venous complications and varicose veins and whether they were treated .Also

history of deep vein thrombosis because it is a usual causative agent of venous ulcerate. Previous

information about treatment and management of vein inflammation is also assessed and its

occurrence.1, 2This normally can either be single incidence or re occurring case. In addition the

medical history on number of surgery procedures performed, cases of fractures that have

occurred or trauma affecting the lower limb is also assessed and determined. Patient’s occupation

is assessed due to fact that certain daily occupation involves tasks that requires one to stand or sit

for a prolonged time which could increase the risks.

Assessment of leg ulcer background treatment progress includes information; when it started, to

evaluate rate of prognosis because ulcers affecting veins have a slower growth rate when

compared to those ulcers that infect arteries. Evaluating previous medical information about leg

ulcerations and its size. Determining the previous size of the ulcer helps in evaluating the impact

of treatment plan.
 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 3

Physical examination.2This is done with a patient that has leg ulcer or dermatitis. This can be

characterized by a discoloration or skin that has hardened around there ulcer with wound

discharging a foul smelling substance. Examination checks for oedema and itching over the

affected area .Evaluates thickening of tissues beneath the skin. Presence of prominent dilated

veins. 1Assessing the state of wound bed for inflammations or any signs of infection. And how

the wound edges looks like, its state, if it appears rolled or flat.

Assessing of circulation by determining the color and temperature.1 Patients with venous

diseases have warm, well perfused feet with palpable foot pulses. A hand held Doppler

assessment should be undertaken where possible. This may help in determining the safe level of

compression bandaging.

Lastly, nutritional status. In a study, wipke-tevis and stotts discovered moderate to high

nutritional risking lead to about 84% of patients who had at least one venous leg ulcer. This

study also discovered that calorific and protein intake in 15 out of 20 patients was inadequate to

enable the ulcers to heal.

Diagnosis of venous leg ulcer that cause dermatitis include methods such as Doppler study. This

particular method processes such as those of measuring the pressure of blood at the ankle and

comparing with the arm. It should be less than that of the arm. It is useful to do the test for it is

the major treatment of venous ulcers where bandages or stockings are compressed in order to

improve circulation of the vein.

Treatment involve ulcer cleaning and dressing. Dressing is done once a week. Compression

bandages purposes in the squeezing of legs and allowing blood to flow to the heart. Also,

associated symptom treatments such as legs and ankles swellings. This can be treated by

advising the patient to keep their leg elevated whenever possible or by using compression
 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 4

bandage. Itchy skin is also a symptom and is treated with emollient or mild corticosteroid cream

or ointment. Infected ulcers are treated by use of antibiotics. Taking medications such as

corticosteroids or topical calcineurin inhibitors to reduce pain and swelling.

QUESTION: 12.1 (I)

MASD is a skin erosion and inflammation which is caused by an extended exposure to the

several moisture sources which include the stool or urine, perspiration, saliva, wound exudate

and mucus. Pressure ulcer is localized injury to the skin over a bony prominence, due to the

pressure, or pressure in combination with shear.3

MASD and pressure ulcer differ in many ways. First is the location. MASD occur over a bony

prominence while pressure ulcer is usually limited to one .4

MASD wound shape is likely to have diffuse, different superficial spots while pressure ulcers

present in wounds of a regular shape.3, 4

MASD has no necrosis while pressure ulcer has on a bony prominence with a black necrotic

scab.

MASD edges are usually irregular and superficial while pressure ulcer edges are more distinct.

Lastly, MASD presents with uniformly redness distributed on the skin or pink and white

surrounding the skin due to moisture, while pressure ulcer presents with non-blanch able redness

and black necrosis.4

QUESTION: 12.2 (II)

In skin assessment care plan for IAD, include checking skin cause if skin change, 4 color of the

skin and condition of the skin. This helps with coming up with an effective treatment. First is the

cause of skin change: is it caused by stool, urine or both; what is the duration of time which the
 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 5

skin is exposed to content moisture. Inquire from patient or caregiver about toileting and bathing

routines, for instance children and elderly people could be exposed due to diapers.3

Color of skin is inspected whether it’s darker than the normal skin tone, signs of in

inflammation. Color of the skin may be different depending on color pf the person’s category.

Fitzpatrick’s scale is often applied in dermatology numerically grouped non YIAD-damaged

skin. On a scale of 1-6 from white to deeply pigment based on patients skin color. Patients

having a skin of dark color, redness may not be clear because it can appear as a discoloration if

compared to that of surrounding skin. Burning sensation has been reported by many patients who

are having pain and pruritus in areas which have been discolorized.4

Condition of the skin is also assessed: whether the skin is open or intact, closed, has a rash or

infection, presence of lesions. Open skin is described as erosion. Erosion is intra epidermal. Also

the breakdown of the skin in IAD may be classified as an erosion. Presence of yeast or fungal

infection is checked. Fungal infections are identified by the margins which are red active and

yeast is involved with satellite pustules & papules.

Treatment plan after assessment involves cleaning the skin with surfactants to loosen irritants.

Cleaning should be gentle to avoid rubbing. After cleaning moisturizer is applied to maintain the

skin’s moisture barrier function. vulnerable skin is treated with silicone-based barrier ointments

or creams, petrolatum or zinc oxide ointments or creams and a film-forming liquid acrylates

(cyanoacrylate formulations) sprays or wipes.3 Damaged skin is treated with wick super

absorbents. Traumatic injury is dressed with fluid lock dressing and tapes are avoided which can

damage the skin.4

Skin with fungal infection are treated with antimicrobials. Severed fungal incontinence

dermatitis is treated with combination product such as nystatin-triamcinolone.

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Question: 12.3

Poor wound healing can be seen in either aged or pediatric patients due to different causes. First,

in neonates and infant, there is a reduced barrier function that is more susceptible to infection,

chemical absorption, and bacterial colonization.5They are more susceptible to blisters and skin

tear due to their loose bound in the epidermis to the dermis. They are more sensitive to adhesives

too. Infants still in diapers have a high risk of increased infection and dermatitis. This may affect

the healing of nearby wounds.

Maceration. This can both on aged or pediatric patient. Fecal and incontinence can alter the

skin's integrity. Especially due to prolonged use of diaper and limited mobility.5

In aged people there is reduced skin elasticity. This is due to degradation of collagen fibers and

elastic tissue. This tissues help in wound healing.5Less elasticity in this tissue makes it hard for

wounded skin to return to its original state infants this tissues may not be fully developed.5

Age-related illness grand medication also affect wound healing .conditions such as obesity,

diabetes and cardiovascular diseases affect blood flow. Healing requires nutrients which are

supplied by the blood. Lack of sufficient blood flow may stale the wound healing process.5 Also

diabetes mellitus and cardiovascular disease can impair the development of granulation tissue

Medications such impair corticosteroids inhibit lymphocyte function and collagen synthesis.

Aged patients may have inadequate nutritional intake. This is very crucial for hastening wound

healing. Poor nutrition may result in delayed inflammatory response and delayed formation of

matrix proteins. Also it may alter hormonal responses that aid in healing. Insufficient hydration,

blood circulation, compromised immune and respiratory systems any of which can increase the

risk delayed wound healing.

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Impaired hemostasis, inflammation, proliferation, and resolution results in slow wound healing

and 1decreased wound strength .This is because the levels of macrophage-produced growth

factors have decreased. Decreased macrophages function and delayed infiltration of

macrophages and lymphocytes increases secretion of inflammatory mediators.5 Angiogenic

factors are essential in wound repair and reduced levels result in poor wound healing.

In neonates and infants, protein calorie malnutrition, infection, edema, hypertension needing

inotropic therapies and physiology instability which prevent pressure redistribution safely slows

down wound healing. Neonates have minimal to no antigen exposure hence at higher risk of life

threatening secondary bacterial growth on wound bed.

A decrease in their dermal to epidermal cohesion, stratum corneum deficiency, thermoregulation

which is impaired, body surface to weight ratio close to five times more than those of the adult,

and an immune system which is immature – including the functions of the liver and kidneys –

put neonates at a high risk of developing epidermal stripping, an increased epidermal loss of

water with and heat loss, infection and percutaneous absorption toxicity.

Skin healthy program for slow wound patient include moisturizing the skin well. 5Skin require

adequate moisture to be viable. Aged people are prone to dry skin which increases risk for

thickening, infection and impairs wound healing. Very wet skin is a risk factor of developing

maceration which affects wound healing.5

Medications, such as anti-inflammatory drugs and steroids, interfere with the wound healing

process. Reviewing the medication is need to before administration.5

Proper nutrition is essential for healthy skin as well as optimal healing. Nutritional supplement

may help in preventing malnutrition. A wound is unable to heal properly if you lack the

necessary nutrients for cell repair and growth.5

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Proper cleaning of wound is required to prevent further infection. Infections slow healing

process. After cleaning proper drying is necessary.5For infants, there skin is delicate and requires

gentle cleaning and handling.

To manage extravasation injury it involves using dressings that are sterile and transparent when

protecting intravenous lines, this ensures that site inspections are done hourly as it is

recommended. Also there is additional recommendations from medical experts when managing

this type of injuries, it requires using hydrogels with silicone dressings incorporated in them to

be applied: simply using boots or gloves that have hydrogels filled in them at the affected site or

using hydro-fibers that have covered with a thin hydrocolloid fiber.5

It is also recommended when handling neonates using diapers that are obtained commercially for

normal use should be avoided and also applying ointments made from petrolatum or using

barrier products made from Zinc oxide when protecting theirs skins. In the presence of C.

albicans, ointments with antifungal characteristics should be used. Additionally, it’s stressed

that using products or powders with dyes or fragrances must be avoided.

To minimize pressure against this patients who have been diagnosed with this type of ulcers:

excess pressure is reduced by using support surfaces on cribs, isolettes, incubators, and beds that

recommended based on the age of the patient. Turning and repositioning of patients is done after

every 120 minutes as it required clinically. Additionally neonates can be relieved pressure by

parents or a medical personnel holding them. Any clothing should be made loose in presence of

an edema and opposing forces such as friction should be maintained at a very minimal level.

Also the required standards in managing wounds in case a ulcer develops, dictates that the

wound should be cleaned thoroughly and efforts made to ensure no bacterial infections that

occurs.5
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QUESTION: 12.4 (I)

Bariatric patients are predisposed to delay wound healing due to the following risk factors. First

is bariatric patients have deeper skin folds, more skin surfaces and little skin perfusion.6 The skin

folds are often warm and moist risking them to getting fungal and bacterial infections.in relation

to skin fold patients hygiene may be hard.6 Patient or caregiver might not be able to clean the

folds well. Bariatric patients also have excessive sweating which may keep the skin moist .this

areas are prone to infection. Fat folds with rolls of adipose tissues also create pressure and

friction and can lead to skin breakdown.

Wound dehiscence is more likely to occur in the bariatric patients .this is due to the increased

stress on the suture line. Wound may open up partially or completely taking long for the wound

to heal. This may also create a new wound. Movements or any motion may cause this as adipose

tissue folds create pressure or friction which may cause dehiscence.6

While bariatric patients are overweight, they can be malnourished. Their diet may be lacking

essential nutrients.6 There lab nutritional levels may not be within normal limits the blood supply

to fatty tissues may be insufficient to provide enough amounts of nutrients and oxygen.as

adipose tissue grows there is increased demand for circulatory vesicles.6 Poor vascularity results

in inadequate oxygenation which leads to delayed wound healing, evisceration, infection and

dehiscence.

Cardiovascular diseases and diabetes also pauses a risk factor in wound healing of bariatric

patients .overweight patients are at a risk of hyperglycemia which negatively affects immunity

and circulation. High glucose level can be related to preexisting type 1 and 2 diabetes.6 Diabetes

patients have slow wound healing .patients with hypertension are at risk of decrease in blood

circulation because the walls are less permeable, inadequate oxygen supply and supply of
 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 10

nutrients important to for healing. This slows the rate of healing. Also medications administer to

manage this diseases ma affect the healing process.

To optimize wound healing the following treatment options should be considered. First nutrients

necessary for healing should be present. 6These nutrients can be given though supplements with

vitamins, proteins and other nutrients. Patient’s hygiene should be good. Skin should be cleaned

gently and dried to prevent infection, maceration and skin breakdown .infections treated with

antibiotics

QUESTION: 12.4 (II)

Assessment of skin fold to develop a care routine is important. Bariatric patient have more skin

surface and deeper skin folds. Skin fold assessment is done while the patient is lying flat in

hospital gown. Patient and care giver are guided on what will be done because the inspection is

carried throughout the body surface. This should be in a private room.6When the patient is

comfortable skin folds are gently opened for closer visualization .this may reveal an

erythematous, moist denude area in the fold. This area can be painful and communication with

the patient may be useful.6 Common area with skin fold is checked such as behind the neck, the

flank area, under the breasts, arms and abdomen. Also the rectal and perinea region, calf and

ankle and the upper and lower thighs are common areas. Skin folds are one of difficult areas to

maintain integrity .wounds present or any abnormal sign are noted. Lifting and separating skin

folds can be difficult .request for extra help if need be.6 Where patients are very sick, the skin

folds become taut and hard to separate due to resuscitation of fluids. It’s important to know the

history of the patient’s skin condition prior the assessment. Pressure ulcers are checked as obese

patients are prone to pressure ulcers between the folds themselves. Positioning the patient on one

side may help with offloading.

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It is also important to assess and document, both during the admitting assessment and on a

regular basis, bariatric patients' ability to participate during repositioning, transferring, and

ambulation. Their ability may be impaired by pain, medication, level of consciousness, or

mobility limitations secondary to their other medical condition(s). These abilities can change

daily in acute care settings, or even hourly in critical care settings. Important areas to assess

include: required level of assistance for patient; weight bearing capability; height and weight;

and conditions likely to affect transfer/repositioning techniques, such as hip/knee replacements,

paralysis, amputations, contractures, osteoporosis, skin/wound conditions, and spine stability.

Additionally a consultation from a professional trained to assess bariatric patients' physical

function and strength as it relates to mobility is required. Physical therapists have the tools and

skills to meet this need. Facilities that have patient handling programs in place will have

protocols and tools already available for assessing the patient needs related to safe patient

handling.6

Treatment of skin fold involves skin fold cleansing. Cleaning skin folds especially if denuded is

very painful. Using synthetic washcloths or no rinse cleaning cloth is preferred .patting method is

used rather than scrubbing .after cleansing drying the skin well is important using a soft towel or

by patting. Also hair drier can be used in cool setting. Cleaning helps prevent risk of skin

infection. Deep folds are kept as open to air as possible .special drying products such as inter dry

are used too. Powders that inhibit infection can be effective.6Using absorbent materials for

example textile from coloplast has ionic silver which provides antifungal and antibacterial action

up to 5days.movement of the patient should is done using special bariatric patient’s equipment’s.
 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 12

This is to prevent abrasions, skin tears and pressure ulcers. This can be done by careful handling,

shifting and repositioning.6

The skin of the patient should be frequently cleaned using a cleanser whose pH has been

balanced, this involve the use of gentle strokes which help in avoiding the harm which may be

caused to fragile tissues. The action of scrubbing should be avoided. In the simplification of this

process, the use of handheld showers is encouraged with no use of rinse cleansers. Patient should

also wear loose fitting clothes which are made material having absorbent fibers.

Bariatric patients are supposed to undergo through a regular assessment for skin areas which are

potential to breakdown; a further caution should be carried out in cases where the skin has

already undergone breakage where an appropriate plan for managing the wound is implemented.6

Management of microclimate with support surface which at the same time cools and dries the

skin of the patient at places which are of interface of the bed and the patient’s body.

Traditionally, in order to carry out the same purpose, the use of low air-loss mattresses was

implemented. This is effective only for microclimate management when the particular patient is

regularly turned, because the body of the patient occludes the mattress’s holes which leads to the

negation of the benefit. It is also important to use proper bed linens. Microclimate is also

managed through the use of support surfaces which are designed to dry the skin and cool it at

interface, ambulation and turning.6

Bariatric patients have a high risk of skin tears due to the added efforts which necessitate the

process of repositioning and transfers. This particular kind of injury is reduced by the use of an

education program which applies the use of safe positioning and safe transfer caregiver

techniques. Additional factors which may put the patients at an increased risk should be assessed

including those of using the corticosteroids. The use of dressings which are absorptive and non-
 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 13

adherent appropriately encourages the useful actions taken to care for skin tears. This works

hand in hand in the prevention of friction in the body folds therefore, helping in the reduction of

moisture and heat of the skin folds while maintaining hygiene. Reducing friction involves the use

of patting motion while washing and carrying out drying while using soft washcloths of a baby

or cleansing cloths which are disposable. Visualization of skin folds should be done at base. This

process can greatly help in the process of lifting bariatric patient’s folds.

Question: 12.5

A table showing differences between peristomal pyoderma gangrenosum and peristomal

moisture associated skin damage.

Perstomal pyoderma gangrenosum Peristomal moisture associated skin damage

Definition It is an ulcerative skin condition It is inflammation and

erosion of the skin that begins at the

stoma or skin junction and can extend

outward due to.8

prolonged exposure to urine or stool

Causes Half of cases are associated with systemic Moisture must be present caused by urinary

disease such as inflammatory bowel disease, incontinence or diarrhea.7

arthritis, and hematological cancer.7,8,9

Shape Have irregular borders that are rolled or Diffuse, different superficial spots are more

undermined. likely to be moisture lesions.

Necrosis Lesions are dusky red or purple and There is no necrosis in a moisture lesion

extremely painful.7,9

Characteristics Are characterized as nodules, plaques, or Skin damage is characterized by erythema

 SKIN AND PERISTOMAL-PERIWOUND ASSIGNMENT. 14

sterile pustules that rapidly enlarge and (with or without denudation), serious

erode to form open red ulcers with irregular exudate; might include edema, blisters,

borders.8,9 moist skin, or maceration.9

Color Usually purple or dusky red lesions on the Pink or white surrounding skin:

skin.8 Maceration due to moisture

Also uneven redness.9

Treatment  Treatment of the Underlying disease  Use a skin sealant/barrier film to

is key. protect the skin.8,9

 Goals are to reduce inflammation  Providing topical treatment for the

and pain, to optimize wound healing, damaged skin.

and minimize exacerbating factors.8  Proper skin cleaning and dry helps in

treatment.7
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1. Sibbald RG, Alavi A, Sussman G, Ayello E, Goodman L. Dermatological aspects of

wound care. In Krasner DL, Rodeheaver GT, Sibbald RG, Woo KY, editors. Chronic

Wound Care: A Clinical Source Book for Healthcare Professionals. 5th ed. Vol 1.

Malvern, PA: HMP Communications, 2012:207-222.

2. Woo KY, Sibbald RG. The ABCs of skin care for wound care clinicians: dermatitis and

eczema. Adv Skin Wound Care. 2009; 22(5):230-6.

3. McNichol, L, Ayello EA, Phearsman LA, Pezzella PA, Culver, EA. Incontinence

Associated Dermatitis: State of the Science and Knowledge Translation. Advances in

Skin and Wound Care. 2018, 31(11) in press.

4. Black, J, Gray M., Bliss, DZ, et al. MASD Part 2: Incontinence-associated dermatitis and

intertriginous dermatitis. A Consensus. JWOCN. 2011;38(4):359-370.

5. Reddy M, Holroyd-Leduc J, Cheung C, Woo K. Geriatric principles in the practice of

chronic wound care. In Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic

Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, Pa:

HMP Communications, 2007:663-678.

6. Kennedy-Evans KL, Henn T, Levine N. Skin and wound care for the bariatric patient. In

Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic Wound Care: A Clinical

Source Book for Healthcare Professionals. 4th ed. Malvern, Pa: HMP Communications,

2007:695-700.

7. Shavit E, Afsaneh A, Sibbald, RG. Pyoderma Gangrenosum: A Critical Appraisal.

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8. Poritz LS, Lebo MA, Bobb AD, Ardell CM, Koltun WA. Management of peristomal

pyoderma gangrenosum. J Am Coll Surg. 2008; 206(2):311-5.

9. Woo KY, Sibbald RG, Ayello EA, Coutts PM, Garde DE. Peristomal skin complications

and management. Adv Skin Wound Care. 2009; 22(11):522-532.