DOI: 10.1097/01.WON.0000264818.65366.db

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Issn Print: 1071-5754

Publication Date: 2007/03/01


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Context for WOC Practice: The Inextricable Connections Between Wound and Continence Care

Mikel Gray

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Excerpt

This issue of the journal has a dual focus, moisture-associated skin damage (MASD) and pressure ulcers. At first glance, these topics may lead the reader to believe we are exclusively focusing on wound care, but in fact, both focus areas bridge wound, ostomy, and continence care. The focus on MASD reminds us all that urinary and fecal incontinence is an essential concern for any clinician who manages patients with perineal skin wounds and that perineal skin care is a critical aspect of managing urinary or fecal incontinence. Similarly, the CE article in the pressure ulcer focus area evaluates the effect of a bowel management system on pressure ulcer incidence in the critical care units of a university-based health system.
During the next 2 years, you are likely to hear much more about the concept of MASD and its relationship to pressure ulcer risk, its significance to bariatric care, and its role in managing highly exudative wounds and fistulae. Do not be surprised that you heard it first in the Journal of Wound, Ostomy, and Continence Nursing.
The clinical manifestations of MASD are familiar to every WOC nurse, although the effort to combine disorders as varied as incontinence-associated dermatitis, intertrigo, and periwound skin maceration is relatively novel. Nevertheless, during a recent meeting with Dr Gary Sibbald, the concept of moisture-associated skin damage was discussed in some detail. Although all participants agreed that MASD is a common phenomenon, it was immediately recognized that we have only the most rudimentary understanding of how exposure to urine, stool, perspiration, or wound exudate leads to skin damage or the relationship between incontinence-associated dermatitis and pressure ulcer risk.
Donna Bliss, Cindy Zehrer, Kay Savik, and Graham Smith report their economic evaluation of 4 skin damage-prevention regimens in nursing home residents with incontinence of urine or stool. All of the regimens were based on accepted principles: cleanse, moisturize, and protect. Three programs used an ointment or cream-based skin protectant to accomplish this final principle of prevention, and the fourth used a polymer-based barrier film as a skin protectant. The program that used the polymer-based barrier film was less costly than those using ointment or cream-based barrier products, probably owing to the film barrier being applied 3 times weekly, and after known incontinence episodes, as compared to the ointments and creams that were applied more frequently. Read this article and Mandy Fader's commentary on it to gain insight from this robust and well- designed economic comparison of perineal skin prevention programs, including a better understanding of our incomplete knowledge concerning why these programs work.
In this issue's Evidence-Based Report Card, Dorothy Weir and Mikel Gray systematically review literature on maceration of the periwound skin, a common clinical manifestation of MASD. Read this review to discover the sparse evidence for preventive interventions and the absence of any evidence concerning its treatment.
The Challenges in Practice section provides a forum for promoting critical thinking about current clinical problems when evidence is lacking. In this issue's challenge, Catherine Ratliff and Marilu Dixon present the decision-making process that led to selection of a single skin protectant for their facility's neonatal care unit. This decision was based on an in-house product evaluation, demonstrating improvement in skin condition in 5 neonates with incontinence- associated (diaper) dermatitis, possibly the most common clinical manifestation of MASD encountered by WOC nurses. Linda Bohacek's subsequent commentary focuses on existing knowledge about prevention vs intervention when managing incontinence-associated dermatitis and offers alternatives to this intervention.
Included in this issue is a round-table discussion of moisture vs pressure in MASD, attended by Linda Bohacek, Dorothy Weir, Jan Zdanuk, and Mikel Gray.
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