Skin Care Guidelines for the Management of Incontinence & Moisture Associated Dermatitis. State whether Clinical, Health & Safety,Non Clinical

Transcription

1 Skin Care Guidelines for the Management of Incontinence & Moisture Associated Dermatitis Guidelines apply to all health care professionals involved in managing Incontinence Associated Dermatitis & Moisture Associated Dermatitis State whether Clinical, Health & Safety,Non Clinical Clinical Services where Guideline applies Community Health Services (CHS) Adult Mental Health (AMH/LD) Learning Disabilities (AMH/LD) Families and Young Persons Children s Services (FYPC) Target Audience Clinical staff in CHS, AMH/LD and FYPC Description of Guideline These guidelines describe the processes to be followed in LPT for a structured approach to skin care in the management of Incontinence Associated Dermatitis and Moisture Associated Dermatitis. All registered staff have a duty to ensure all patients with incontinence/moisture related problems within their care are: - Assessed within recommended time frames - Provided with appropriate information for pressure ulcer risk to be minimised and appropriate prevention strategies planned for patients at high risk of developing pressure ulcers. - Have an individualised plan of care outlining the appropriate implemented management of the problem for those patients identified as having continence issues. Keywords Skin, Incontinence, Moisture, Urinary, Faecal Related legislation, Standards, Professional Guidelines Codes of Practice or Ethics: Version - Number NICE (2010) Prevention and Treatment of Incontinence Associated Month Dermatitis and Year - Best Practice Principles: Incontinence Associated Dermatitis - Moving Prevention Forward Page 1

2 TABLE OF CONTENTS Guideline Summary Page 3 Glossary Page 3 Implementation Guide Page 4-5 Guidelines - Importance of a correct assessment - Importance of aiding the management of the skins ph levels - Risk factors for Incontinence Associated Dermatitis and Moisture Associated Dermatitis - Recognising Incontinence Associated Dermatitis - Differentiating between Moisture and Pressure Damage - Candidiasis - Prevention and Treatment of Incontinence Associated Dermatitis and Moisture Associated Dermatitis - Implementing a Structured Skin Care Regime - The use of dressings in Incontinence Associated Dermatitis and Moisture Associated Dermatitis - Care Planning Page 6-10 Page 6 Page 6 Page 7 Page 7 Page 7 Page 7 Page 8 Page 8 Page 8 Page 9 Page 9-10 Evaluation Plan Page 11 References Page 11 Consultation With Key Stakeholders Page 12 Appendices Page Page 2

3 GUIDELINE SUMMARY This document establishes best practice for Community Health Services, Adult Mental Health, Learning Disabilities and Families, Young Persons and Children s Services. While not requiring mandatory compliance, staff must have good clinical rationales for not implementing standards or practices set out within the guideline, or for measuring consistent variance in practice. Introduction These guidelines are for use by all healthcare professionals who have contact with patients who have incontinence/moisture related issues. It should be used in conjunction with the Pressure Ulcer Prevention and Management Policy. - Incontinence is one of the major risk factors for the development of skin breakdown. The effects of age on the physiology of the skin, combined with incontinence in the older population, can result in the skin becoming increasingly vulnerable to damage, resulting in incontinence dermatitis (Ree s & Pagnamenta, 2009). - Incontinence dermatitis (ID) is a skin condition that affects people who are incontinent. This can result in inflamed, excoriated, infected and damaged skin that causes pain & discomfort. Friction and shearing forces combined can result in patients being at higher risk of developing pressure ulcers. Incontinence-associated dermatitis (IAD) represents a significant health challenge worldwide (Beeckman. D, 2015). - Prolonged exposure of the skin to moisture results in damage, although commonly linked to continence issues, can in fact occur in any situation where there is continuous risk (Holroyd, 2015). Taking this into consideration, moisture related dermatitis should be considered as a diagnosis if the patient is not incontinent. - Moisture-associated dermatitis is an erosion of the skin caused by prolonged exposure to various sources of moisture, including excessive perspiration, wound exudate, mucus, saliva, and their contents. Acronym or Term Patient Moisture Lesion Incontinence Associated Dermatitis Moisture Associated Dermatitis Contact Dermatitis Candidiasis Definition For the purpose of these guidelines a patient is considered to be any person in receipt of healthcare from Leicestershire Partnership NHS Trust regardless of age or care setting. A moisture lesion is an area of skin damage that has occurred due to incontinence or moisture. Pressure ulcers should not be mistaken for moisture lesions; refer to appendix A for key differences between pressure ulceration and moisture lesions. Ulceration that has occurred due to a combination of pressure / shear and moisture should be recorded as a pressure ulcer and categorised accordingly (Tissue Viability Society 2012). Incontinence-associated dermatitis (IAD) describes the skin damage associated with exposure to urine or faeces. Moisture-associated skin damage (MASD) is caused by prolonged exposure to various sources of moisture, including perspiration, wound exudate, mucus, saliva, and their contents. Contact dermatitis is inflammation of the skin that occurs when you come into contact with a particular substance. It can be caused by: an irritant a substance that directly damages the outer layer of skin an allergen a substance that causes the immune system to respond in a way that affects the skin Candidiasis is a fungal infection due to any type of Candida (a type of yeast). Page 3

4 Lichen Sclerosus Psoriasis Lichen sclerosus is a long-term skin condition that mainly affects the skin of the genitals. It usually causes itching and white patches to appear on the affected skin. Condition can become cancerous. Psoriasis is a skin condition that causes red, flaky, crusty patches of skin covered with silvery scales. Bacterial Vaginitis Bacterial vaginosis (BV) is a common yet poorly understood condition, in which the balance of bacteria inside the vagina becomes disrupted. IMPLEMENTATION GUIDE GUIDELINE AIM - Leicestershire Partnership NHS Trust (LPT) aims to design and implement guideline documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. - It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. - This document has been assessed to ensure that no one receives less favorable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. - In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. - This applies to all the activities for which LPT is responsible, including guideline development and review. GUIDELINE WHO These guidelines are applicable to all staff employed by LPT Community Health Services, Adult Mental Health, Learning Disabilities, Families, Young Persons and Children s services. It is aimed at supporting clinical staff caring for patients potentially at risk of skin breakdown from Incontinence and Moisture Associated Dermatitis. WHAT: - The Trust Board has a legal responsibility for Trust guidelines and for ensuring that they are carried out effectively. - Trust Board sub-committees have the responsibility for ratifying guidelines. - Divisional Directors and Heads of Service are responsible for the operational management of these guidelines: Ensuring that staff develop and maintain professional competence in skin care in the management of urinary and faecal incontinence and adhere to the processes set out within these guidelines. - Managers and senior health care professionals with line manager responsibility are responsible for ensuring that these guidelines are adhered to by all staff within their clinical areas. - All Healthcare Staff have a responsibility to adhere to these guidelines. - All registered staff have a duty to ensure all patients within their care are risk assessed within recommended time frames and that those patients at risk of pressure ulcers are provided with appropriate information for pressure ulcer risk to be minimised; those who are identified as high risk have an individualised prevention plan of care. - Registered healthcare staff must ensure that the delegation of care to non-registered healthcare workers is appropriate. Page 4

5 HOW: These guidelines should be applied in conjunction with the following: - The LPT Wound Care Formulary - European Pressure Ulcer Advisory Panel Guidelines (EPUAP 2009) - The Code of Practice for the Provision of Alternating Pressure Air Mattresses and Cushions in the Community - Continence Assessment tools - Nutritional screening tools - Waterlow/Bradon Q risk assessment tools - Pressure Ulcer Prevention and Management Policy - Infection Prevention and Control Guidelines for the Management of Suspected or Confirmed Infectious Diarrhoea and/or Vomiting - Infection Prevention and control Personal Protective Equipment Policy CHPC112 WHY: To uphold the standards of care for skin care in the management of Incontinence and Moisture Associated Dermatitis Page 5

6 SKIN CARE GUIDELINES IN THE MANAGAEMENT INCONTINENCE ASSOCIATED DERMATITIS AND MOISTURE ASSCOIATED DERMATITIS 1.0 The Importance of a Correct Assessment 1.1 In order to correctly diagnose IAD/MAD a holistic assessment needs to be performed to ensure the patient receives the correct treatment, the documentation is accurate and to ensure that the damage is not incorrectly reported. 1.2 Differentiating between IAD, MAD and pressure damage and other skin conditions can be challenging but correct diagnosis should always begin with a detailed patient medical history. 1.3 A wound assessment chart should also be completed, along with photographic evidence with the patients consent. These tools will act as a baseline for treatment and improve communication between services. 1.4 It is also important during your assessment to highlight, as necessary, the presence of any fungal infection. 1.5 Skin should be checked regularly as part of SSKIN for signs of IAD/MAD. 1.6 Please refer to Pressure Ulcer Prevention and Management Policy for further clarification. 2.0 Importance of aiding the management of the skins ph level 2.1 The skin is the first line of defense against potential environmental hazards and the external layer of the skin needs to be intact to act as its barrier (Baadjies, Karrouze and Rajpaul, 2014). 2.2 It is important to aid the management of the skins ph ideally, the skins ph should be 5.5 and it should be maintained at this level of acidity. As we age the skin naturally gets more alkaline in response to our lifestyle and environment, which causes dryness irritation and sensitivity which can lead to dermatitis or eczema. 2.3 The ph level of the skin can be disrupted by several factors including air, water, sun, cosmetic products and chemicals. 2.4 IAD is caused by several factors, such as changes in skin ph, waterlogged skin, skin damage caused by mixing urine and faeces and damage caused by faecal enzymes such as proteolytic and lipolytic (Nazarko, 2007). When faeces and urine are mixed together, bacteria in the faeces convert urea in the urine to ammonia, which makes the skin more alkaline. 2.5 Commercially available soaps and cleansers are alkaline with ph of 9, and when used to cleanse the skin following episodes of incontinence the ph of the skin can become alkaline stripping it of its acid mantle (Kirsner and Froelich, 1998). This acid mantle inhibits the growth of bacteria. Page 6

7 3.0 Risk factors for Incontinence Associated Dermatitis and Moisture Associated Dermatitis 3.1 Some of the key risk factors for IAD outlined by Wounds International (2015) include: Incontinence: The mixing of urine and faeces creates an alkaline skin ph. - Faecal incontinence (diarrhoea/formed stool) - Urinary incontinence - Double incontinence (faecal and urinary) - Frequent episodes of incontinence (especially faecal) Poor skin condition (e.g due to aging/steroid use/diabetes). Compromised mobility Diminished cognitive awareness Inability to perform personal hygiene Pain Raised body temperature (pyrexia) Medications (antibiotics, immunosuppressant s) Poor nutritional status Critical Illness Nazarko (2007) also identified the following as main risk factors for IAD: Ageing Friction and shear when moving and handling Poor quality of care 4.0 Recognising Incontinence and Moisture Associated Dermatitis 4.1 IAD/MAD can appear in individuals with light skin initially as erythema. In patients with darker skin tones skin may be paler, darker, purple, dark red, yellow. It can be difficult to detect the difference between moisture and pressure damage, therefore it is vital to perform a full holistic assessment to ensure correct diagnosis and treatment. Remember: - If the patient is not incontinent then it s not Incontinence Associated Dermatitis - If the patient is not exposed to moisture from perspiration then it is not Moisture Associated Dermatitis - Please refer to appendix 1 for further clarification. - The epidermis may be damaged exposing moist, weeping superficial wounds. If necrosis or deep slough is present pressure is involved and requires reporting appropriately through e-irf and an appropriate management plan developing - Patients can experience pain, burning, itching or tingling. - Areas normally affected by Moisture and Incontinence Associated Dermatitis are: skin folds including groins, buttocks, sacral cleft, breasts, armpits and ears 5.0 Differentiating between moisture, pressure damage and other skin conditions 5.1 Performing a full holistic assessment is imperative to ensure your diagnosis is accurate. 5.2 Differentiating IAD/MAD from pressure ulcers and other skin conditions such as contact dermatitis (e.g. from textiles or skin products), or lesions due to infections (e.g. herpes simplex), or fungal infection, lichen sclerosis, psoriasis or bacterial vaginitis. If you have any concerns regarding diagnosis and/or treatment you should liaise with the patients GP in the first instance, who then may refer onto a Tissue Viability Specialist. Page 7

8 Lichen sclerosis is a condition that can become cancerous and patients are reviewed every few months in clinic. 5.3 Correct assessment and diagnosis of Incontinence Associated Dermatitis is important and necessary to ensure that: - The patient receives appropriate treatment - Documentation is accurate - Quality reporting and correct reimbursement can be facilitated 5.4 Please refer to appendix 2 for further clarification and guidance. 6.0 Candidiasis 6.1 Patients with IAD are susceptible to secondary skin infections, candidiasis being one of the most common secondary infections associated with IAD. It typically appears as a bright red, pimple-like rash spreading from a central area. Products are available to treat yeast infections. A swab should be performed before treatment is commenced to diagnose the infection and ensure effective treatment is prescribed. 6.2 Seek advice from the patients General Practitioner on the choice of treatment. 7.0 Prevention and Treatment of Incontinence Associated Dermatitis and Moisture Associated Dermatitis 7.1 In light of this evidence, the following is recommended for the prevention and treatment of IAD/MAD: - Complete a continence assessment to highlight the cause of the problem and to ensure it is appropriately treated and/or managed. - Ensuring that continence assessments are reassessed annually and/or if there is a change in the patient condition, skin integrity and/or presentation of incontinence. - Ensure that all continence aids are used/applied appropriately. - Implement a structured skin care regime that aims to maintain the skins natural ph and reduce the risk of moisture and incontinence associated dermatitis. - Implement prevention strategies to reduce the risk of pressure ulcer development by following the relevant LPT policy. 8.0 Implementing a Structured Skin Care Regime Do not use baby wipes or perfumed soap on the patient s skin as it may change the skins natural ph level. Talcum powder can also cause the skin to become too dry/flaky and will affect its integrity. 8.1 A structured skin care regime consists of two key interventions cleanse & protect: Cleansing the skin - To remove urine and/or faeces, i.e. the source of irritants that cause IAD. This should be done after each episode of incontinence and prior to the application of a skin protectant as part of a routine process to remove urine and faeces. - Healthy intact skin can be washed in plain warm water and/or a ph balanced soap and ensuring that the skin is gently dried following cleansing. Page 8

9 - Broken/excoriated skin should be washed in plain warm water and soft gauze wipes. Protecting the skin - After cleansing the skin it should be protected to prevent IAD by avoiding or minimising exposure to urine and/or faeces and friction. - Healthy skin A barrier cream can be applied to protect the skin from bodily fluids Barrier Cream Application: Apply a pea sized amount to the affected area, gently smoothing it into the skin. Reapply twice daily, cream will remain on the skin after cleansing. Apply sparingly; if the after-feel is oily you have applied too much. - Broken/Excoriated Skin A barrier film can be applied to protect the skin from bodily fluids No Sting Barrier Film Application: - Available in 1ml foam applicators or 28ml pump spray. Apply a uniform coating of film over the entire treatment area when using the foam applicator. - When using the spray bottle hold the spray nozzle 10 to 15cm from the skin and apply in a smooth, even coating over the entire treatment area, whilst moving the spray in a sweeping motion. - Reapplication is recommended every hours as a minimum. The film remains on the skin after cleansing however if the skin is significantly soiled and requires more through cleansing then the film may require reapplying. - Ensure the skin is thoroughly dry following application before releasing the buttocks. - Patients may benefit from an additional intervention (RESTORE). If the skin is dry/flaky and requires rehydration to support and maintain skin barrier function this can be achieved with the use of a soap substitute. - This should be used by washing the skin once a day with a mixture of warm plain water and a soap substitute, following which the skin should be gently dried and a protectant should be applied. - Bowl washed and dried following use - single patient use only 8.2 There should be visible improvement in the skin condition and reduction in pain in 1 2 days. 8.3 For patients who continue to have unresolved IAD, seek advice from the Continence Specialists and/or the Tissue Viability Team. 8.4 Please also refer to appendix 1 for further clarification. 9.0 The use of dressings in Incontinence Associated Dermatitis and Moisture Associated Dermatitis 9.1 In some cases of severe IAD where skin loss is present dressings can be used. Successful application, however, may be significantly challenged by skin contours such as folds and creases and the presence of frequent or continuous moisture and soiling. (Wounds International 2015) 10.0 Care Planning 10.1 Please refer to the core care plan in appendix 3 which can be individualised to meet the needs of the patient. Page 9

10 10.2 The care plan should include: - Any changes in bowel habit - Assessment of reversible causes and contributory factors to incontinence - Type of continence aids, sizes - Whether skin is intact/broken/excoriated - Structured skin care regime Page

11 EVALUATION PLAN Collect data and review data on a regular basis. TVN to monitor referrals for Incontinence and Moisture Associated Dermatitis Review and feedback - Feedback gained from appropriate specialties. - To be reviewed by Clinical Network Groups for each division REFERENCES Baadjies. R Karrouze. I and Rajpaul. R (2014) Using no-rinse skin wipes to treat incontinence-associated dermatitis, British Journal of Nursing, Tissue Viability Supplement, Vol 23, No 20 Beeckman. D (2015) Incontinence-associated dermatitis (IAD): an update, Dermatological Nursing 14(4): p32-36 Holroyd. S (2015) Incontinence-associated dermatitis: identification, prevention and care, British Journal of Nursing, 2015 Supplement, Vol. 24, ps37 Kirsner. R and Froelich. C (1998) Soaps and detergents: understanding their composition and effect, Ostomy Wound Management, Mar;44 (3A Supplement), 62S-69S Nazarko, L. (2007). Skin care: Incontinence dermatitis. Nursing & Residential Care, 9(7), NICE (2010) Prevention and Treatment of Incontinence Associated Dermatitis (online) Available at: (Accessed on July 4 th 2016) Rees. J & Pagnamenta. F (2009) Best practice guidelines for the prevention and management of incontinence dermatitis, Nursing Times; 105: 36 Tissue Viability Society (2012) Achieving Consensus in Pressure Ulcer Reporting, p1-26 Wounds International (2015) Best Practice Principles: Incontinence Associated - Moving Prevention Forward, Enterprise House, London Page

12 CONSULTATION WITH KEY STAKEHOLDERS Key individuals involved in developing the document Name Laura Browne Chris Rippin Designation Tissue Viability Nurse Continence Specialist Nurse Circulated to the following individuals for comments Name Anita Kilroy-Findley Joanne Earle- Marshall Yvonne Aldous Hannah Konig Clare Tacey Alicia Kelly Ann Silver Robert Metcalfe Susan Baker Roz Gretton Katie Willets Corrinne Hutton Lynne Moore Elizabeth Crompton Designation Tissue Viability Clinical Lead Tissue Viability Operational Lead Tissue Viability Nurse Tissue Viability Nurse Tissue Viability Nurse Tissue Viability Nurse Tissue Viability Nurse Tissue Viability Nurse Continence Specialist Nurse Continence Specialist Nurse Modern Matron Children s Services Clinical Team Lead Children s Services Practice Development Nurse Learning Disabilities Senior Matron Mental Health Page

13 Appendix 1

14 Appendix 2 Differentiating Between Moisture and Pressure Damage Moisture Lesion (moisture from urine, sweat or faeces must be present) Location Can occur over a bony prominence but pressure and shear must be excluded and moisture must be present. A linear spilt in the natal cleft is a moisture lesion. A teardrop shape wound to the natal cleft is a pressure ulcer. Shape Diffuse and superficial in appearance, can mirror where 1 buttock ulcer matches another. Often more than one in a group. Depth Very superficial; size and depth may change if it becomes infected. Necrosis Moisture lesions have no necrosis. Edge Irregular edges, may be jagged Treatment where friction is also present. Identify the cause, implement good hygiene, educate carers and prescribe suitable preventative measures i.e. barrier cream or film. Pressure Ulcer (pressure and/or shear must be present) Usually over a bony prominence but can occur anywhere on the body where there is sustained pressure. circular = direct pressure teardrop = pressure and shear Variable according to categorisation (1-4) Necrotic tissue on a pressure point is a pressure ulcer. Usually well-defined edges that may mirror the cause. Use the wound management dressings Formulary to identify a dressing suitable for the stage of healing. Page

15 Appendix 3

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17 Appendix 4 Page

18 Page

19 Appendix 5 Guideline Training Requirements The purpose of this template is to provide assurance that any training implications have been considered Training topic: Type of training: Skin Care in the Management of Incontinence and Moisture Associated Dermatitis. Incorporated in Pressure Ulcer Prevention Training. Mandatory (must be on mandatory training register) X Role specific Personal development Division(s) to which the training is applicable: Adult Learning Disability Services Adult Mental Health Services X Community Health Services Families Young People Children Staff groups who require the training: Please specify All healthcare staff involved in the management of Incontinence and Moisture Associated Dermatitis Update requirement: Who is responsible for delivery of this training? Have resources been identified? Has a training plan been agreed? Where will completion of this training be recorded? No update required. E-learning available if refresh required. Tissue Viability Team Training incorporated in Pressure Ulcer Prevention Training No In place X Trust learning management system Other (please specify) How is this training going to be monitored? Evaluation forms post training sessions Page

20 Appendix 6 The NHS Constitution NHS Core Principles Checklist Please tick below those principles that apply to this policy The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services Shape its services around the needs and preferences of individual patients, their families and their carers Respond to different needs of different sectors of the population Work continuously to improve quality services and to minimise errors Support and value its staff Work together with others to ensure a seamless service for patients x x x x x Help keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance x x Page

21 Appendix 7 Due Regard Screening Template Section 1 Name of activity/proposal Guidelines for Skin Care in the Management of Incontinence and Moisture Associated Dermatitis Date Screening commenced August 2016 Directorate / Service carrying out the Tissue Viability and Continence Team Assessment Specialist Name and role of person undertaking Laura Browne TVN this Due Regard (Equality Analysis) Give an overview of the aims, objectives and purpose of the proposal: AIMS: To ensure the Guidelines for Skin Care in the Management of Incontinence and Moisture Associated Dermatitis considers all necessary aspects for due regard OBJECTIVES: To ensure guidelines are fit for purpose Section 2 Protected Characteristic Age Disability Gender reassignment Marriage & Civil Partnership Pregnancy & Maternity Race Religion and Belief If the proposal/s have a positive or negative impact please give brief details The guideline is targeted towards all patients regardless of their age to assess their individual needs People with a disability that affects their mobility may be at a greater risk of developing incontinence and moisture associated dermatitis. The guideline is targeted towards all patients to assess their individual needs No impact No impact No impact No impact No impact Page

22 Sex Sexual Orientation Other equality groups? No impact No impact No impact Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B No x Low risk: Go to Section 4. Section 4 If this proposal is low risk please give evidence or justification for how you reached this decision: The guideline for the skin care in the management of incontinence and moisture associated dermatitis is for use across all divisions by healthcare staff involved in the care of IAD/MAD: risk assessment, interventions and management of patients requirements is expected to be performed on an individual patient by patient basis Signed by reviewer/assessor Date Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date X Page

23 Signature of Committee Chair Date Page