Moisture Associated Skin Damage (MASD)
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
Okay, in this lesson, we're going to continue our discussion of wounds caused by external mechanical factors.
Speaker A:In the last class, we talked about friction, skin tears and tape damage.
Speaker A:In this class we're going to discuss moisture associated skin damage, which is a very common problem that you will encounter in clinical practice.
Speaker A:Now, talking about moisture associated skin damage, also known as MASD from the big picture perspective, is skin damage that starts with over hydration of the skin and then the actual breakdown is caused by friction, by exposure to pathogens, or by enzymes or irritants.
Speaker A:So the way you want to look at this is that moisture acts as the setup guide, so it renders the skin very vulnerable.
Speaker A:And remember, we already talked about why that is.
Speaker A:When you have over hydrated skin, the skin cells are oedematous, the cell membrane is stretched, minor trauma causes breakdown.
Speaker A:Also, when the cells are edematous and the cell membrane is stretched, it's easy for pathogens and irritants to get in because you no longer have the same level of barrier function.
Speaker A:So we're going to talk about four different types of moisture associated skin damage, but in each one of them you'll see that some type of moisture is the setup guide.
Speaker A:And then the actual skin damage is caused either by trauma to the skin, pathogens or irritants.
Speaker A:So the four types are incontinence associated dermatitis, also known as iad, intertriditis, also known as itd, periwound MASD, and peristomal masd.
Speaker A:And we're going to talk about each of those in a little more detail.
Speaker A:Every one of you will see incontinence associated dermatitis every week, if not every day in clinical practice.
Speaker A:So what causes this?
Speaker A:Well, it tells you most of what you need to know in the title Incontinence associated dermatitis.
Speaker A:So it tells you that the problem is the skin is exposed on a repeated or prolonged basis to stool, to urine, or to a combination.
Speaker A:So you see the source of moisture is an external but very irritating source.
Speaker A:Then the actual breakdown in the skin is either due to mechanical trauma like friction.
Speaker A:That's what you see on the bottom.
Speaker A:It can also be due to pathogens like a yeast infection which you see on the top and on the bottom, sometimes it's seen by is caused by irritants like enzymes in liquid stool.
Speaker A:So it can be a combination of issues.
Speaker A:But again, what makes the skin vulnerable is overhydration and then mechanical trauma.
Speaker A:Irritants or pathogens cause the actual breakdown.
Speaker A:Well, risk factors are pretty obvious.
Speaker A:It's exposure to stool and or urine.
Speaker A:Now, we don't have great data on this, but the data that we do have suggests that exposure to urine alone is less likely to cause incontinence associated dermatitis.
Speaker A:And if it does occur, it's not as severe.
Speaker A:If you have a combination of fecal and urinary incontinence, you typically get faster breakdown and more severe breakdown.
Speaker A:Many times the enzymes in the stool are activated by the alkalinity of the urine and then that results in fairly rapid breakdown.
Speaker A:And finally, if you have patients with liquid stool, patients who are having diarrhea and they're incontinent like our patients with C.
Speaker A:Diff, then you're going to get pretty rapid breakdown of the skin because of the very high enzymatic content.
Speaker A:So multiple things working together here.
Speaker A:What do we see clinically?
Speaker A:Well, you see this many times a week in clinical practice, so you recognize it.
Speaker A:You see widespread erythema.
Speaker A:So all of the exposed skin is typically red erythematous.
Speaker A:It will look macerated many times.
Speaker A:It will be very tender to the touch.
Speaker A:You may have a secondary fungal rash.
Speaker A:You may have patchy areas of skin loss, or sometimes if it's severe, you may have extensive areas of skin loss.
Speaker A:But one of the definitive characteristics is that the damage is limited to areas that are exposed to urine and or stool.
Speaker A:So that helps tremendously with accuracy and classification.
Speaker A:Now, as always, we want to start with prevention.
Speaker A:And there are many things we can do to prevent iad.
Speaker A:First of all, if our patient can get out of bed or if they can notify us, we can either toilet them or assist them with a bedpan.
Speaker A:If they are unable to recognize, you know, that they need to get up and go to the bathroom or they need the bedpan, then you can think, well, can I use containment devices?
Speaker A:Because if I can use containment devices that will keep the stool in the urine off of the skin, we have a lot of containment devices that we can use.
Speaker A:We can use external catheters in men, we can use internal bowel management systems in patients with diarrhea.
Speaker A:We now have suction devices connected to wall suction for urinary incontinence in women.
Speaker A:So toilet them if you can.
Speaker A:If not, see if there is a containment device that you could use that would keep urine and stool off of the skin.
Speaker A:Think about strengthening the barrier function of the skin by using cleansers and moisturizers that are gentle or ph balanced or no rinse and that replace lost lipids so that you're constantly filling the gaps between the skin cells and maintaining that barrier function.
Speaker A:Many times we do have to use absorptive products.
Speaker A:And if we have to use absorptive products, we want to use them correctly.
Speaker A:And that's the point of this slide.
Speaker A:So you know a lot of this already from what you have learned in clinical practice.
Speaker A:For a long time, we closed absorptive products up around the patient because we felt like that was more secure.
Speaker A:But we know that when we close absorptive products around the patient, we almost always create an occlusive environment.
Speaker A:When you create an occlusive environment, skin temperature rises, skin humidity rises.
Speaker A:It's like putting on a plastic rain suit and walking outside in July.
Speaker A:You immediately start to sweat.
Speaker A:Well, that's what happens to the skin.
Speaker A:The skin starts to sweat, temperature rises, the skin is overhydrated, and now you have skin that is extremely vulnerable.
Speaker A:But if you use absorptive products correctly, you can avoid that.
Speaker A:So the current guidelines are to use absorptive products that wick urine and stool away to keep the skin dry, to leave the products open under the patient when they're in bed, close the product only when the patient's out of bed, walking in the hall, going off the unit.
Speaker A:And you also want to use your moisturizers and moisture barrier products to create a barrier, an additional barrier between the skin and the urine, between the skin and the stool.
Speaker A:Now, most of us use creams and ointments, so we do a couple of different things.
Speaker A:I'm imagining that a lot of you have the disposable cleansing wipes that are impregnated with dimethicone.
Speaker A:So if you have those, you're essentially cleansing, moisturizing, and protecting all in one step.
Speaker A:There are others of you that might use the foam cleansers and soft washcloths, and then you might apply a moisture barrier ointment after each incontinent episode.
Speaker A:Both of those protocols are very appropriate.
Speaker A:There's a third thing you could do.
Speaker A:You could use a liquid barrier film that is alcohol free.
Speaker A:So many of you use Kavalon type products.
Speaker A:Kavalon is probably the most widely used for IAD prevention and the one that has been studied in the literature.
Speaker A:So you know that what it does is it forms a plastic film over the skin that essentially waterproofs the skin against urine and at least solid stool.
Speaker A:We don't know how much protection we get from liquid stuff.
Speaker A:So let's talk a little bit more about the specific options we have when we're selecting moisture barrier ointments or if we're thinking about using a liquid moisture barrier product, many of them contain dimethicone.
Speaker A:So if you're using the cleansing moisturizing moisture barrier wipes, most of them contain dimethicone.
Speaker A:Now dimethicone acts to replace lost lipids, so it helps to seal the gaps between cells and it also creates a film that helps to protect against urine and solid stool.
Speaker A:An advantage of dimethicone is it's not greasy and it's not occlusive.
Speaker A:So it's an appropriate option.
Speaker A:If you have a patient who has a combination of incontinence and diaphoresis, it will not trap moisture, so it allows the skin to breathe.
Speaker A:It's very easy to apply and does not have to be removed.
Speaker A:So it's a very skin friendly, user friendly option for protecting skin and it does give good protection against urine and good protection against solid stool.
Speaker A:But again, when it comes to liquid stool, it's protected, probably not going to give you enough protection.
Speaker A:So you think of dimethicone as kind of a level one moisture barrier, great for routine use.
Speaker A:But if you have a patient who's developing dermatitis, if you have a patient with diarrhea, you need to ramp it up, move to another level.
Speaker A:Another widely used product is petrolatum.
Speaker A:And of course there's many products that are petrolatum based or kind of vaseline type products.
Speaker A:Products.
Speaker A:Good things about these products, again, easy to apply, easy to remove, you won't cause damage when you're removing them.
Speaker A:They also provide good protection, good protection against urine, good protection against form stool, but inadequate protection against liquid stool.
Speaker A:Here's the other thing you have to know about petrolatum products.
Speaker A:You have to teach your staff or the caregiver to apply these products in a thin layer.
Speaker A:All you need is a thin layer to waterproof the skin to create that moisture barrier.
Speaker A:If you apply it in a thick layer, what's likely to happen is it will transfer to the brief or the underpad.
Speaker A:You'll waterproof the brief or the underpad, not what you want to do at all.
Speaker A:And trap the moisture against the skin.
Speaker A:So you think about with ZnO products, we frequently tell people to put on a thick layer, but that is not true with petrolatum.
Speaker A:So you have to help your staff differentiate if you use both types of products.
Speaker A:If you use only petrolatum, then you just teach them one rule.
Speaker A:A thin layer, never a thick layer.
Speaker A:Now let's talk about zinc oxide.
Speaker A:Zinc oxide has some major advantages and some major disadvantages.
Speaker A:The major advantage is that it is very waterproof, very moisture proof.
Speaker A:So zinc oxide is going to give you the highest level protection when you have a combination of urine and stool, or when you have liquid stool.
Speaker A:Nothing protects quite like zinc oxide.
Speaker A:But the downside to that is that it can be very difficult to remove.
Speaker A:Sometimes it's difficult to apply and it's almost always difficult to remove.
Speaker A:So then you run the risk that staph will cause additional skin damage.
Speaker A:Trying to take it off.
Speaker A:I actually saw somebody trying to take it off with a tongue depressor.
Speaker A:So you have to teach people, here's how we use this product.
Speaker A:You have to teach them, use your perineal cleansing foam or perineal cleansing wipes to remove the zinc oxide.
Speaker A:Can also use mineral oil.
Speaker A:Water is never enough, so you have to teach people how to apply it.
Speaker A:A nice even layer.
Speaker A:It doesn't have to be super thick, but you do want the area coated nicely.
Speaker A:You want to remove soiled layers of zinc oxide using your perineal cleansing wipes or your perineal cleansing foam or mineral oil.
Speaker A:And then you can replace the layer you removed with another layer of zinc oxide.
Speaker A:Now, what are some things you can do that might make zinc oxide easier to use?
Speaker A:So if you're using it for prevention, you can get combination products where you have a combination of zinc oxide and petrolatum.
Speaker A:And that can be very helpful because the petrolatum makes it easier to apply and remove because you still get the resistance of the zinc oxide.
Speaker A:So you think first level protection that works really well against urine and against solid stool.
Speaker A:Dimethicone or petrolatum.
Speaker A:Petrolatum should be applied in a thin layer.
Speaker A:You think high level protection, this is what you need.
Speaker A:When you have a combination of urine and stool, especially if the stool is liquid, you've got to use zinc oxide.
Speaker A:You want to make sure your staff knows how to apply it, how to remove it.
Speaker A:You might want to think about a zinc oxide petrolatum combination.
Speaker A:Now, what about liquid barrier film?
Speaker A:So there have been a couple of studies, one I remember really well, where they looked at patients in a long term care facility and they used four products for protection against incontinence associated dermatitis.
Speaker A:So they used the petrolatum base, the dimethicone based, zinc oxide based and a liquid spray out.
Speaker A:And the specific type that they used was the Kavalan, because Kavalan has a no rinse formulation.
Speaker A:Not all of the liquid skin barriers have that.
Speaker A:And so they looked at cost, they looked at time that staff used in applying the product and they Looked at outcomes.
Speaker A:All four provided good outcomes.
Speaker A:The ointments took more staff time because they had to be reapplied after every incontinent episode.
Speaker A:With the liquid spray on barrier, they were able to apply it, I believe it was three times a week.
Speaker A:So it was less costly and it took less staff time.
Speaker A:Now, they were working with patients who had urinary incontinence and sometimes solid stool.
Speaker A:They were not working with patients with diarrhea.
Speaker A:Those of you who use Kavalon products know that there's a product on the market now, the Kavalon Advanced skin protectant System that is designed to provide at least partial protection against liquid stool.
Speaker A:So you may choose to use that.
Speaker A:Now, one thing that you should know, and that's the third bullet point, is if you're using the cyanoacrylate products like the Kavalon Advanced or Marathon, or if you're using the spray on liquid skin barriers, some of those products break down if you are using them in conjunction with a moisture barrier or a moisturizer like Dimethicum.
Speaker A:So, for example, if you were going to use either your Kavalon or your Kavalon advance, you would have to make sure your staff would not using the perineal cleansing wipes impregnated with dimethicone.
Speaker A:So a good rule of thumb throughout the whole wound care curriculum is you need to know how your products work together.
Speaker A:And if you have any questions, you need to go to your vendor reps and say, is there any contraindication to using this product in combination with this product?
Speaker A:So a rule of thumb in using the liquid skin barriers is that many of them wash off with perineal cleansers that contain dimethicone and other moisturizers.
Speaker A:You should always check.
Speaker A:So we've talked about prevention, now let's talk about management.
Speaker A:So mild incontinence associated dermatitis is characterized by redness.
Speaker A:So you definitely have erythema.
Speaker A:The patient's typically complaining of tenderness because they definitely have an inflammatory process going on.
Speaker A:But at this point, with mild ied, you have no skin loss.
Speaker A:If you don't already have a prevention program in place, you want to put a prevention program in place.
Speaker A:If you do have one in place, you want to ramp it up and make sure that everything's being done correctly.
Speaker A:You, you want to relook at your containment or absorptive products.
Speaker A:So let's say I had a patient and the patient has started out and they had urinary incontinence and occasional episodes of fecal incontinence.
Speaker A:But now they've developed C.
Speaker A:Diff.
Speaker A:So they have frequent episodes of diarrhea with very, very irritating liquid stool.
Speaker A:So what I've been using is absorptive products under the patient.
Speaker A:And maybe I've been using my dimethicone based moisture barrier because I'm just using the cleansing wipes.
Speaker A:Okay, well that's not enough anymore.
Speaker A:Now I've got to ramp it up.
Speaker A:I've got to add a zinc oxide product for better protection.
Speaker A:I might also think about, should I be using a bowel management system for this patient?
Speaker A:Could I use a rectal pouch for this patient?
Speaker A:How can I give this patient better, better protection?
Speaker A:What about severe iad?
Speaker A:Now you look at this and it makes you hurt and you know that patient is in terrible pain.
Speaker A:So these are the patients, you turn them over to do perineal care and they're crying because it hurts so bad, their skin is so raw.
Speaker A:So you relook at what's going on.
Speaker A:Many of these patients will need an internal bowel management system.
Speaker A:You probably could not keep a pouch on here, so you would really be looking at the bowel management system.
Speaker A:You're going to need zinc oxide.
Speaker A:Almost always, you're going to need zinc oxide to manage this level of iad.
Speaker A:Now here's the problem.
Speaker A:Zinc oxide products do not typically adhere well to a wet surface.
Speaker A:So I bet a lot of you have encountered this.
Speaker A:You go to apply it and it just slides off.
Speaker A:So what can you do?
Speaker A:Well, one thing you can do is you can do what we call crusting before you apply the zinc oxide.
Speaker A:So what is crusting?
Speaker A:Crusting means that you take either ostomy powder or antifungal powder, depends on whether or not there's any fungal rash.
Speaker A:And you sprinkle the powder all over the raw surfaces and dust off the excess.
Speaker A:And the powder is going to cling to all of the denuded surfaces and form a gummy protective layer.
Speaker A:Then what you can do is you can take your liquid skin barrier like Skin prep, no sting.
Speaker A:It has to be alcohol free.
Speaker A:So you could do Skin prep, no sting.
Speaker A:You could do Kavalan and you could spray over the powder.
Speaker A:So now you've created a dry, crusty surface and now you can apply the zinc oxide.
Speaker A:So I talked to people across the country, that's a very common approach when they have severe IAD crusting plus the zinc oxide.
Speaker A:What else could you do?
Speaker A:If you happen to have in your formulary a hydrophilic paste that is designed to adhere to a moist surface that would be perfect because the hydrophilic paste products do contain zinc oxide.
Speaker A:They also contain carboxymethyl cellulose, sorry, carboxymethylcellulose, so they stick to those denuded surfaces.
Speaker A:The one that I'm aware of that's very widely used is Triad by Coloplast.
Speaker A:There might be another on the market.
Speaker A:I just haven't seen that.
Speaker A:So if you happen to have that available to you, that would also be very appropriate.
Speaker A:So you could either crust and use the zinc oxide.
Speaker A:You could use Triad or a comparable hydrophilic paste.
Speaker A:Or if you have access to the gauze that's impregnated with zinc oxide and gelatin, like Visco paste or a comparable product, you could cut long strips and then fan fold them and create dressings that you could put over these very determined, muted surfaces.
Speaker A:You're going to use whatever combination works for these patients.
Speaker A:So sometimes I've done crusting plus zinc oxide plus the fan folded strips.
Speaker A:Sometimes I've done the hydrophilic paste plus the fan folded strips.
Speaker A:You're going to do absolutely everything you can to turn this skin around.
Speaker A:You might also have IAD with candidiasis.
Speaker A:Remember that this is a perfect environment for fungal growth.
Speaker A:It's warm and wet and dark.
Speaker A:So many times you'll have a coexisting yeast trash.
Speaker A:If so you're going to go right back through.
Speaker A:Okay, what are we doing?
Speaker A:Am I managing appropriately?
Speaker A:Am I using my absorptive products correctly?
Speaker A:I maintain a non occlusive environment by leaving things open underneath the patient.
Speaker A:But in treating the candidiasis, you're going to use either a miconazole type product, some kind of azole product, or you're going to use nystatin.
Speaker A:Now, the benefits of an azole type product like miconazole is that it has a broader spectrum antifungal activity.
Speaker A:It's less expensive, very readily available, typically through distribution.
Speaker A:So most of the time you'll end up using a moisture barrier product with an antifungal like you see on the screen here.
Speaker A:But you could also take an antifungal powder, dust it over the involved area, spray it with a liquid barrier spray.
Speaker A:So of course, crust with an antifungal and then apply a barrier ointment.
Speaker A:It's just a lot of steps instead of one.
Speaker A:Okay, so we've talked about iad, now we're going to talk about itd.
Speaker A:So ITD is intertridinous dermatitis.
Speaker A:And this is dermatitis, can break down rashes that form in body folds.
Speaker A:So it's caused by trapped moisture and then mechanical trauma.
Speaker A:The moisture source here is internal.
Speaker A:It's literally coming out of the skin.
Speaker A:Because this is perspiration.
Speaker A:The skin loss is caused either by frictional forces between opposing body folds, or when you think about fissures that form in the gluteal cleft or underneath the pannis or underneath the breast.
Speaker A:Sometimes literally when you just spread the buttocks to assess, you can almost see the skin splitting.
Speaker A:Sometimes when you lift the pannas to assess, you create little linear breaks in the skin.
Speaker A:So very minor stretch can cause a break in the skin.
Speaker A:So you have over hydrated skin from trapped perspiration.
Speaker A:Then you have skin skin loss, either because two surfaces are rubbing against each other and you're getting friction, or because you lifted the breast, lifted the pan, separated the buttocks, and that little bit of stretch caused the skin to break.
Speaker A:That's how fragile it is.
Speaker A:When you have itd, you have high risk of coexisting fungal or bacterial infection.
Speaker A:We probably obviously fungal more often, but bacterial can occur as well.
Speaker A:So here's what you see.
Speaker A:Clinically, you see these linear breaks in the skin.
Speaker A:So on the far left you see it's in the axilla, and then in the middle bottom is in the gluteal cleft.
Speaker A:And then on the bottom right gluteal cleft and top axilla.
Speaker A:So anywhere you have body folds, you can get itd.
Speaker A:Now what do you see?
Speaker A:You're going to see linear lesions or you're going to see matching lesions, what's sometimes called kissing lesions, on opposite sides of a skin fold.
Speaker A:The surrounding skin is going to look macerated and over hydrated, and you may very well see a coexisting fungal rash or bacterial lesion like you see on the top right.
Speaker A:You want to prevent enterpriginous dermatitis.
Speaker A:Now, it's very common in our morbidly obese patients because they are frequently diaphoretic and it's very hard to keep the skin underneath the folds completely dry.
Speaker A:But here are the things that you can use.
Speaker A:We now have very effective wicking products.
Speaker A:So a lot of you have access to the wicking textile Inter Dry Ag.
Speaker A:If you have that, that's the perfect product to use.
Speaker A:But you have to teach staff how to use it correctly.
Speaker A:So they have to understand that you take a single layer of this fabric, you tuck one end of the fabric at the base of the fold, at least 2 to 4 inches of the fabric has to extend beyond the body fold, because the way it works is it moves moisture from the base of the fold to the atmosphere.
Speaker A:From the base to the atmosphere.
Speaker A:So if it's moving from the base to the environment, then one end has to be at the base of the body fold and the other end has to be open to the environment.
Speaker A:So you really have to teach people how to use it correctly.
Speaker A:Otherwise you'll come back and you'll find that they've made little twisty rolls of it and tucked it in all kinds of places.
Speaker A:If you do not have that, what else can you do?
Speaker A:Well, you could take something as simple as a knee sock and tuck it between body folds.
Speaker A:Any kind of absorptive fabric.
Speaker A:If you don't have a wicking fabric, you an absorptive fabric.
Speaker A:If you're in an inpatient setting, it's very helpful to put them on a support surface that has airflow.
Speaker A:So a support surface with a low air loss feature can be very helpful and causing evaporation of that diaphoretic moisture.
Speaker A:And if you're going to use a barrier product like, let's say that this patient is morbidly obese, diaphoretic, but also incontinent.
Speaker A:If you're going to use a moisture barrier product, you want to use something like dimethicone because it's non occlusive and it's breathable.
Speaker A:It allows moisture to pass through.
Speaker A:You would not want to use petrolatum because it would trap moisture.
Speaker A:If they had very severe diarrhea, you would use zinc oxide because it would protect against the liquid stool, but it will create a drier surface because of its astringent effects.
Speaker A:Let's say you already have breakdown.
Speaker A:You have a linear break in the skin.
Speaker A:You have kissing lesions on either side of a body fold.
Speaker A:What can you use Again?
Speaker A:We'll talk about dressings in much greater detail in a later class.
Speaker A:But right now you think, well, what do I need?
Speaker A:Well, I would need something that is soft because it's got to fit into a body fold.
Speaker A:And I don't want it to be uncomfortable.
Speaker A:It has to manage the moisture.
Speaker A:So I don't want to trap any more moisture.
Speaker A:So I wouldn't use anything like tegaderm or oxide.
Speaker A:Probably wouldn't use a hydrocolloid.
Speaker A:But what if I had a porous soft foam?
Speaker A:Could I use a Porosol foam?
Speaker A:And put.
Speaker A:Put it at the base of the fold and allow moisture to pass through, Allow the dressing to absorb the exudate, stop the frictional forces that would be appropriate.
Speaker A:If you had minimal moisture at this point and you just needed separation and a moist wound surface, then you could think about a hydrocolloid.
Speaker A:But in general, you're probably going to think about soft absorptive foam dresses.
Speaker A:What if it's in the gluteal cleft and there is no way a dressing is going to stay?
Speaker A:Well, then you're right back to what we talked about under incontinence associated dermatitis.
Speaker A:What's going to work there?
Speaker A:What am I trying to do?
Speaker A:So I'm trying to create a drier surface.
Speaker A:I'm trying to stop friction.
Speaker A:So could I put a thin layer of zinc oxide and then a very soft gauze?
Speaker A:Tuck that soft gauze between the buttocks so that the buttocks aren't rubbing against each other so I stop the friction.
Speaker A:So you always go back to what you're trying to do and what options you have available.
Speaker A:If you have candidiasis, you're going to need an antifungal.
Speaker A:If you thought it was candidiasis and you started out with an antifungal and it's not improving, then you have to think, could this be a fun, could this be a bacterial infection?
Speaker A:And if you think it could be a bacterial infection, you want to do a culture so that you can treat with the appropriate antibiotic.
Speaker A:Fungal is much more common.
Speaker A:However, the last two types of MASD are periwound moisture associated skin damage and peristomal moisture associated skin damage.
Speaker A:Now, in this course we're talking a lot about wounds and wound management.
Speaker A:And you think about when you're managing a wound, most of the time there's wound exudate.
Speaker A:And if we don't do a good job of managing the wound exudate, that exudate is going to extend onto the periwound skin and cause skin damage.
Speaker A:Damage in part because of maceration, exposure to moisture, but also you have to be aware that the wound fluid from a chronic wound, like a pressure injury or any type of chronic wound, has very high levels of inflammatory substances.
Speaker A:And those inflammatory substances can cause an acute inflammatory reaction in the periwound skin.
Speaker A:So our goal is to always manage the exudate, keep it off the periwound skin, protect the periwound skin.
Speaker A:The other thing that happens when the periwound skin gets wet with drainage, and you've probably all seen this, is then there's increased risk for medical adhesive related skin injury, tape damage.
Speaker A:So we take off a dressing and we cause additional skin damage because the skin was already over hydrated and very vulnerable.
Speaker A:So what do we see with periwound moisture associated skin damage?
Speaker A:First of all, you're going to see maceration and erythema of the periwound skin.
Speaker A:So it's over hydrated from the moisture.
Speaker A:It's erythematous because of the inflammatory reaction.
Speaker A:You may very well have patchy areas of skin loss.
Speaker A:You might have a yeast rash, because again, what better place for a fungal organism than in a nice warm, wet, dark spot underneath a wound dressing?
Speaker A:So how can you prevent periwound masd?
Speaker A:You want to incorporate this into to your wound care routinely.
Speaker A:You should always be caring for the periwound scan.
Speaker A:You should always be preventing periwound masd.
Speaker A:So the first thing you think of is, you know, the problem with periwound masd is over hydration of the periwound skin.
Speaker A:So I should start by thinking about what dressings I'm using to manage the exudate.
Speaker A:I should make sure that I'm changing the dressing frequently enough to prevent overflow onto the periwound skin.
Speaker A:The other thing is you should routinely protect the periwound skin either with a moisture barrier ointment or with a liquid skin barrier, because that periwound could become part of the wound.
Speaker A:So routinely, we'll come back to this routine.
Speaker A:Routinely, you will protect the periwound skin either with a moisture barrier or a liquid skin barrier.
Speaker A:What if they come in and they already have periwound masd?
Speaker A:You're going to look at what kind of dressing is being used.
Speaker A:Do we need to use a more absorptive dressing?
Speaker A:Do we need to change the dressing more frequently?
Speaker A:What's been used to treat the periwound skin, if anything, and what should we be using from this point on?
Speaker A:Many times we'll end up doing the crusting procedure to the periwound scan.
Speaker A:So again that sprinkling ostomy powder or antifungal powder to any damaged skin around the wound, dusting off the excess, and then spraying with a liquid skin barrier.
Speaker A:And then the last one is peristomal moisture associated skin damage.
Speaker A:So, so if you're taking the ostomy course, you'll hear a lot more about this in that course.
Speaker A:But let's say you're going to take the wound course and you're not taking the ostomy course right now and you're thinking, oh, well, I won't have to deal with this.
Speaker A:But you probably will because the Staff will call you and they'll say, we need your help.
Speaker A:Look at this skin.
Speaker A:We don't know what's causing this.
Speaker A:Exactly.
Speaker A:We don't know what to do about it.
Speaker A:Should we be putting, like an oil on it?
Speaker A:Well, of course you can't do that because then nothing will stick.
Speaker A:So let's just go through peristomal masd because you may very well be dealing with it.
Speaker A:So what's causing the damage?
Speaker A:You've got over hydration from the urine or stool.
Speaker A:So it's essentially iad, but it's around the stoma and it's managed totally differently.
Speaker A:So the primary moisture source is external.
Speaker A:In some cases, you also have an internal source.
Speaker A:So some patients are perspiring very heavily, like if they're working out or something.
Speaker A:So they might be sweating a lot underneath the ostomy appliance.
Speaker A:And then if they get a leak, they have over hydrated skin now exposed to stool or urine.
Speaker A:What you see, you're going to have maceration erythema of the peristomal skin.
Speaker A:Look at the slide on top.
Speaker A:In that case, there's significant skin loss.
Speaker A:The patient might report itching, they might report burning.
Speaker A:Burning is more common.
Speaker A:Sometimes you'll see skin overgrowth.
Speaker A:If it's a chronic condition, which is what you see on the bottom, where it almost looks like wart, like lesions, where the skin has compensated for constant exposure to moisture.
Speaker A:Well, how do you prevent peristomal masd?
Speaker A:And of course, it's very obvious you want a secure pouching system that stays on and is changed at appropriate intervals.
Speaker A:So you want to look at what's going on with the pouching system.
Speaker A:Do you need to modify the pouching system?
Speaker A:Do you need to call in an ostomy nurse if you're not an ostomy nurse?
Speaker A:So you get a good fit between the pouch and the abdominal surface, you want to make sure that the patient is cutting the right size hole and the barrier wafer so that they're not exposing excess amounts of skin to the urine or the stool.
Speaker A:Any exposed skin should be protected.
Speaker A:So we protect the exposed skin with ostomy paste if it is a fecal diversion.
Speaker A:If it's a urinary diversion, you can just use a liquid skin barrier.
Speaker A:Or for either one, you could use a solid barrier ring.
Speaker A:So if you're doing ostomy care and in your formulary, you have solid barrier rings that can work for any kind of ostomy.
Speaker A:You want to make sure your patient's changing the pouch at appropriate intervals.
Speaker A:Sometimes patients Stretch out their pouch wear time because of insurance issues and they're trying to reduce out of pocket costs.
Speaker A:So we need to talk to them about appropriate time frame for pouch change.
Speaker A:And then again, this crusting technique gets you out of a of difficult situations.
Speaker A:So if you have patchy areas of skin loss around a stoma, crusting is a perfect approach because you can sprinkle on the powder, either ostomy powder or antifungal powder.
Speaker A:If you need antifungal, dust off the excess spray with your liquid spray and now you have a dry surface and you can put the pouch back on.
Speaker A:So a lot of times people want to put zinc oxide or petrolatum or something around the stoma because they see this area of irritation.
Speaker A:That's about the worst thing they could do because then the pouch will not stick.
Speaker A:So you want to have other options.
Speaker A:Okay, so in summary, I want you to be very aware of the term masd.
Speaker A:You're going to see it a lot in the literature, you see it a lot more in clinical practice now.
Speaker A:So an umbrella term for moisture associated skin damage where you have a combination problem.
Speaker A:You start with over hydration.
Speaker A:Over hydration, maceration of the skin that makes the skin vulnerable.
Speaker A:Then you get friction damage that causes skin loss.
Speaker A:You get enzymatic absorption that breaks the skin down.
Speaker A:You might get pathogen absorption that makes the skin causes skin breakdown.
Speaker A:So moisture is the setup guide.
Speaker A:Friction irritants, pathogens as the actual causes of skin breakdown.
Speaker A:Incontinence associated dermatitis.
Speaker A:What's the issue?
Speaker A:Exposure to stool and or urine.
Speaker A:So you're always trying to create a barrier between the stool skin and the stool or urine and you're trying to find a better way to contain the stool or urine.
Speaker A:In otrigynous dermatitis, that's where you have trapped perspiration and body folds.
Speaker A:So you want to wick the perspiration away to protect that skin and prevent breakdown.
Speaker A:Peristomal masd.
Speaker A:You want to obtain and maintain a secure pouching system that protects the peristomal skin.
Speaker A:Periwound domesd.
Speaker A:You want to routinely protect the skin around the wound either with moisture barriers or a liquid barrier spray.
Speaker A:Always.
Speaker A:What are you trying to do?
Speaker A:Keep the skin dry and as cool as possible once the wound occurs.
Speaker A:You're going to use moist wound healing to get it to heal.
Speaker A:Okay, that's it for masd.
Speaker A:Next up will be pressure and shear.
