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.