Skin Matters: No Ifs, Ands, or Butts: Save the SKIN and STOP the Sore
All butt(ock)s are not created equal and all altered buttock skin integrity is not created equally. Although altered skin integrity on the buttocks is frequently identified as pressure ulcers, other sources must be considered. Unless clinicians identify the etiology accurately, they will not 1) be able to interpret the applicable risk factors or 2) intervene appropriately and institute prevention care plans. By following this simple mnemonic, nurses can save the SKIN and STOP the sore. Select the Source (Etiology)
Know the Threats (Risks)
Institute Obstruction (Prevention)
Name the Plan (Interventions)
The following chart, based on the author’s clinical experience, details eight threats to skin integrity and how to identify, prevent, and intervene. Each of the patients’ wounds pictured was referred to ET nursing for the treatment of a pressure ulcer.
Source: Foreign objects
Threats: Bedpans, tubes
Obstruction:
• Remove from bedpan after 30 minutes
• Take care when repositioning
Plan:
• Treat altered skin per institution protocol
Source: Friction
Threats: Low-density foam mattress; incontinence; traction; fidgety bed/chairbound patients
Obstruction:
• Use “lift” sheets
• Gatch knees
• Use a trapeze
• Use a plastic bag under bottom sheet
• Use silk panties
• Investigate incontinence
• Consider decreasing traction or Trendelenbergs positioning
• Use low-friction chair cushion
Plan:
• Consider soap-free linen (coarse woven sheets stiffen with age; finely woven sheets soften with age)
• Consider using lubricated pads
Source: Infection: herpes zoster
Threats: Immunosuppression and/or prior exposure
Plan:
• Institute antiviral treatment and use foam, hydrocolloid, hydrogel, or transparent adhesive dressing
Source: Infection: monilia
Threats: Antibiotic therapy; draining wound in groin; incontinence
Obstruction:
• Start yogurt
• Wash and dry perineum
• Consider cleanser
Plan:
• Use antifungal powder (versus cream)
Source: Infection: Pseudomonas cellulitis. (Painful, dusky red, with blue-green purulent drainage; grape juice odor)
Threats: Secondary infection of existing lesion; suppression of normal bacterial flora by broad-spectrum antibiotics
Plan:
• Use acetic acid 2.5% soaks
• Use oral antibiotics
Source: Intertrigo/maceration: perspiration
Threats: Obesity
Obstruction:
• Wash and dry folds
• Use antiperspirant or aluminum hydrochloride
• Remove plastic underpads and use cotton draw pad
Plan:
• Use light hydrocolloid powder
Source: Maceration: urine
Threats: Urinary incontinence
Obstruction:
• Investigate incontinence
• Contain urine with absorbent products (or external collectors) and maintain skin integrity
• Change absorbent products based on output
• Wash with mild soap, rinse, and pat dry; lubricate with water-soluble moisturizing cream; protect with water-repellent ointment
Plan:
• Seal with water-insoluble (copolymer) barrier film
Source: Stool burn
Threat: Diarrhea (antibiotics, pseudomembraneous enterocolitis; short bowel syndrome; tube feedings)
Obstruction:
• Start yogurt
• Contain stool with absorbent products and maintain skin integrity (as with urinary incontinence)
• Collect stool with fecal incontinence pouch, commercial fecal collection device, or nasal airway (not indwelling catheter)
• Ask dietitian to review dietary requirements (and check for medications with sorbitol)
Plan:
• Use hydrocolloid powder or moisture barrier ointment or water insoluble (copolymer) barrier film
Source: Tape stripping
Threat: Frequent dressing changes
Obstruction:
• Avoid use of tape on fragile/impaired skin
Plan:
• Treat altered skin integrity per institutional protocol
• Protect skin with barrier film
• Use stretch net or mesh
• Select the Cause
• Know the Risks
• Institute Avoidance
• Name the Plan
The Skin Matters series is made possible through the support of the Skin Health Division of Coloplast Corp., Marietta, Ga. This article was not subject to the Ostomy Wound Management peer-review process.
