Moisture Lesions Research Articles

Is the varying management of incontinence-associated dermatitis due to a lack of understanding of etiology?

Incontinence-associated dermatitis, previously and sometimes still referred to as moisture lesions or moisture damage, is a commonly seen contact dermatitis that is a reactive response of the skin to chronic contact to urine and faecal matter. Understanding the etiology is fundamental to creating a skin care plan and successfully prevention. Systemic reviews and studies have shown that the continued variability in management results from a combination of knowledge base, observation, diagnosis, and product selection. This article aims to improve clinicians' understanding of incontinence-associated dermatitis and its management.

Series 5, chronic wounds; part 4h. Pressure ulcer care of the obese patient

British Journal of Healthcare AssistantsVol. 15, No. 1 ClinicalSeries 5, chronic wounds; part 4h. Pressure ulcer care of the obese patientMenna Lloyd JonesMenna Lloyd JonesConsultant Editor, BJHCASearch for more papers by this authorMenna Lloyd JonesPublished Online:10 Feb 2021https://doi.org/10.12968/bjha.2021.15.1.22AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Black J, Hotaling T. Ten top tips: bariatric skin care. Wounds International. 2015;6(3):17–21 Google ScholarBarankin B. Skin presentations common in obese patients. 2015. https://www.dermatologytimes.com/view/skin-presentations-common-obese-patients (accessed 11 November 2020) Google ScholarNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: quick reference guide. 2019. https://www.epuap.org/wp-content/uploads/2016/10/quick-reference-guide-digital-npuap-epuap-pppia-jan2016.pdf (accessed 23 October 2020) Google ScholarParsons L. Skin presentations common in obese patients. January 12 2015. https://www.dermatologytimes.com/view/skin-presentations-common-obese-patients (accessed 11 November 2020) Google ScholarRush A. Bariatric care: pressure ulcer prevention. Wound Essentials. 2009;4:68–74 Google ScholarTickle J. Prevention and management of pressure ulcers and moisture lesions in the bariatric patient. Wound Essentials. 2015;10(2):69–74 Google ScholarWorld Health Organization. Obesity and overweight. 2020. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (accessed 11 November 2020) Google Scholar FiguresReferencesRelatedDetails 2 February 2021Volume 15Issue 1ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 10 February 2021 Published in print 2 February 2021 Information© MA Healthcare LimitedPDF download

Skin integrity-the perpetual challenge.

In an Essity-sponsored symposium, entitled 'Skin integrity-the perpetual challenge', three key opinion leaders discussed the importance of recognising and managing skin vulnerability in a patient-centred way. Peter Bradley summarises the main points they presented at the EWMA 2020 Virtual Conference This article offers an introduction to the symposium, Skin integrity-the perpetual challenge, held on 18 November 2020, as part of the EWMA 2020 Virtual Conference. There were three speakers. Dimitri Beeckman, Professor of Skin Integrity and Clinical Nursing, Ghent University, Belgium, focused on moisture lesions or MASD (moisture-associated skin damage). Karen Campbell, Consultant, Primacare Living Solutions and Adjunct Professor, MClScWH, Western University, London, Ontario, Canada, focused on the concepts related to skin vulnerability. She aimed to identify shared risk factors for skin conditions and ways to promote skin integrity, formulating a synergistic prevention approach to break down barriers in practice. The third speaker was Alessandro Corsi, Wound Care Consultant and Surgeon, Director of Wound Care Unit, IRCCS San Raffaele Hospital, Milan. He looked in detail at the dressings available in this area, detailing how he and his team had successfully used the Essity line of Skin Sensitive silicone dressings in their hospital.

Series 5, chronic wounds, part 4e. Pressure ulcers: moisture lesions

Series 5, chronic wounds, part 4e. Pressure ulcers: moisture lesions

Prevalencia hospitalaria de lesiones relacionadas con la dependencia en la provincia de Burgos. Estudio multicéntrico

espanolRESUMEN Objetivo: Determinar la prevalencia hospitalaria de lesiones relacionadas con la dependencia (LRD) en la provincia de Burgos. Determinar las caracteristicas de las LRD. Identificar las valoraciones del riesgo de padecer lesion por presion (LPP) y el uso de dispositivos de prevencion de LPP. Cuantificar los registros de enfermeria de LRD. Metodologia: Estudio observacional, descriptivo, transversal y multicentrico, realizado mediante observacion directa y revision de la historia clinica de adultos ingresados en unidades de hospitalizacion. Realizado en tres hospitales de Burgos en 2018. Resultados: La poblacion sumo 511 pacientes; presentaron LRD: 188. Se detectaron 328 LRD: 176 (53,65%) LPP, 48 (14,63%) lesiones por humedad, 81 (24,69%) lesiones por friccion, 11 (3,35%) lesiones combinadas y 12 (3,65%) lesiones multicausales. Las LPP de categoria 1 fueron las mas numerosas, sumando un 35,36%. El 78,96% de las LRD se consideraron adquiridas en el hospital. La prevalencia de LRD es del 36,79%. Las prevalencias por tipos de LRD son: LPP 20,93%, lesiones por humedad 9%, friccion 12,72%, combinadas 1,76% y multicausales 1,56%. El 35,61% de los pacientes presentaba algun tipo de dispositivo preventivo; el 60,07% presentaba valoracion del riesgo de padecer LPP; el 30,31% presentaba registro de la lesion, y el 18,37% contaba con plan de cuidados especifico. Conclusiones: La prevalencia de LRD, obtenida por inspeccion directa, cuadruplica los resultados nacionales, pero parece reflejar con mayor exactitud la realidad que los datos obtenidos mediante los registros de enfermeria. Es aconsejable universalizar la valoracion del riesgo de padecer LPP a todos los pacientes, la mejora de los registros de enfermeria y reforzar los esfuerzos preventivos. EnglishABSTRACT Aim: To determine the hospital prevalence of dependencerelated lesions (DRL) in the province of Burgos. Determine the characteristics of the DRL. Identify the risk assessments of pressure ulcer (PU) and the use of PU prevention devices. Quantify the DRL nursing records. Methodology: Observational, descriptive, cross-sectional and multicenter study, performed through direct observation and review of the health record of adults admitted to hospitalization units. Results: The population totaled 511 patients, of wich 188 presented DRL. 328 DRL were detected: 176 (53.65%) PU, 48 (14.63%) moisture lesions, 81 (24,69%) friction lesions, 11 (3.35%) combined lesions, and 12 (3.65%) multifactorial lesions. The most numerous was PU category 1 totaling 35.36%. 78.96% of the DRL were determined to be hospital acquired. The prevalence of DRL is 36.79%. The prevalences for DRL types are: PU 20.93%, moisture lesions 9%, friction 12.72%, combined 1.76% and multifactorial 1.56%. 35.61% of patients had some type of preventive device, 60.07% had a risk assessment for PU, 30.31% had a record of the lesion and 18.37% had a specific care plan. Conclusions: The prevalence of DRL, obtained by direct inspection, quadruples national results, but it seems to be more accurate than the data obtained through nursing records. It is advisable to universalize the assessment of the risk of suffering PU to all patients, to improve nursing records and to reinforce preventive efforts.

A trust-wide skin guideline to reduce incidence of moisture lesions

A trust-wide skin guideline to reduce incidence of moisture lesions

Incontinence-associated dermatitis in older people: prevention and management

British Journal of Community NursingVol. 23, No. 5 Care of the Older PersonIncontinence-associated dermatitis in older people: prevention and managementAnn YatesAnn YatesSearch for more papers by this authorAnn YatesPublished Online:30 Apr 2018https://doi.org/10.12968/bjcn.2018.23.5.218AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References All Wales Tissue Viability Nurse Forum and All Wales Continence Forum. All Wales best practice statement on the prevention and management of moisture lesions. 2014. https://tinyurl.com/h5z7equ (accessed 18 April 2018) Google ScholarBale S, Tebble N, Jones V, Price P. The benefits of implementing a new skin care protocol in nursing homes. J Tissue Viability. 2004; 14(2):44–50 https://doi.org/https://doi.org/10.1016/S0965-206X(04)42001-4 Crossref, Medline, Google ScholarBardsley A. Prevention and management of incontinence – associated dermatitis. Nurs Standard. 2013; 27, (44): 41 – 4. https://doi.org/https://10.7748/ns2013.07.27.44.41.e7618 Crossref, Medline, Google ScholarBeeckman D, Schoonhoven L, Fletcher J et al.. Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification education tool on classification by nurses. BMJ Quality and Safety. 2010; 19(5):e3–e3. https://doi.org/https://doi.org/10.1136/qshc.2008.028415 Crossref, Google ScholarBeeckman D, Van Damme N, Schoonhoven L et al.. Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Incontinence Group, ed. Cochrane Database of Systematic Reviews. 2016; https://doi.org/https://doi.org/10.1002/14651858.cd011627.pub2 Google ScholarBeeckman D, Van der Bussche K, Kottner J et al.. The Ghent Global IAD Categorisation Tool (GLOBIAD). 2017. https://tinyurl.com/y9h4mvza (accessed 18 April 2018) Google ScholarFonda A, DuBeau CE, Harari D, Ouslander JG, Palmer M, Roe B. Incontinence in the Frail Elderly. 2004. https://tinyurl.com/ydbp6tzt (accessed 18 April) Google ScholarLichterfeld A, Hauss A, Surber C et al.. Evidence-Based Skin Care: A Systematic Literature Review and the development of a basic skin care algorithm. J of Wound, Ostomy and Cont Nurs. 2015; 42(5):501–24. https://doi.org/https://doi.org/10.1097/won.0000000000000162 Crossref, Medline, Google ScholarHaroun MT. Dermatology. 2003. https://tinyurl.com/ydytlaeb (accessed 19 April 2018) Google ScholarLichterfeld A, Hauss A, Surber C et al.. Evidence-Based Skin Care: A Systematic Literature Review and the Development of a Basic Skin Care Algorithm. Journal of Wound, Ostomy and Continence Nursing. 2015; 42(5):501–24. https://doi.org/https://doi.org/10.1097/won.0000000000000162 Crossref, Medline, Google ScholarNHS England. Excellence in continence care: practical guidance for commissioners, providers, health and social care staff and information for the public. 2015. https://tinyurl.com/p5oldkp (accessed 18 April 2018) Google ScholarVoegeli D. Factors that exacerbate skin breakdown and ulceration In Marks R. Skin breakdown: The silent epidemic. Smith and Nephew Foundation: Hull; 2007. Google ScholarVoegeli D. New insights on incontinence – associated dermatitis. 2017. https://tinyurl.com/y7gasszs (accessed 18 April 2018) Google ScholarWagg A, Harari D, Husk J, Lowe D, Lourtie J. Royal. College of Physicians and Healthcare Quality Improvement Partnership. National audit of continence care: combined organisational and clinical report. 2010. https://tinyurl.com/ovtdcox (accessed 18 April 2018) Google ScholarWatkins J. Early identification of skin problems in older patients. Br J Health Care Assistants 2011. 5(9):424–28. https://doi.org/https://doi.org/10.12968/bjha.2011.5.9.424 Link, Google ScholarWounds UK. Care of the older person's skin. 2018. https://tinyurl.com/lfpmkmt (accessed 19 April 2018) Google ScholarYarde D. Age should not be a barrier to high-quality continence care. 2012. https://tinyurl.com/y9k5rsgq (accessed 19 April 2018) Google ScholarYates A. The importance of good continence care for older people. Nursing and Residential Care. 2016; 18(10):535–9. https://doi.org/https://doi.org/10.12968/nrec.2016.18.10.535 Link, Google ScholarYates A. Urinary continence care for older people in the acute setting. Br J Nurs. 2017; 26(9): 539. https://doi.org/https://doi.org/10.12968/bjon.2017.26.9.s28 Link, Google ScholarYates A. Preventing skin damage and incontinence – associated dermatitis in the older person. 2018. Br J Nurs 27 (3) 2-3 https://doi.org/https://doi.org/10.12968/bjon.2018.27.2.76 Google Scholar FiguresReferencesRelatedDetailsCited byAssessment and documentation of incontinence-associated dermatitis after implementation of a standardised instrument: a comparative studyMary Montague, Matthew Karafa, Nancy M. Albert11 September 2019 | Journal of Wound Care, Vol. 28, No. Sup9 2 May 2018Volume 23Issue 5ISSN (print): 1462-4753ISSN (online): 2052-2215 Metrics History Published online 30 April 2018 Published in print 2 May 2018 Information© MA Healthcare LimitedPDF download

The Design and Implementation of a Local Strategy to Increase the Accuracy of Pressure Ulcer Classification: The Pressure Ulcer Guidance (PUG) Tool

Skin inspection should be seen as an essential part of patient assessment and therefore should be compulsory for all hospital admissions. Recognising this as a key factor of risk assessment can ensure healthcare professionals are providing the best possible care and protection for their patients. Identifying skin damage on initial assessment ensures appropriate and early intervention, thus minimising or even preventing the risk of damage to the skin and avoiding pressure ulcer development. Once a pressure has developed the patient is generally dependent on others to manage, treat and care for their ulcer. Healthcare providers need to recognise that a pressure ulcer is a crucial element in preventing a full recovery, it can lead to increased hospital stay, resulting in ongoing treatment which may take weeks, even months of nursing care. Patients may also experience pain and discomfort, which has serious consequences on a patient’s quality of life, as well as a very costly exercise for the National Health Service (NHS). Understanding the mechanism of how the skin can be damaged and identifying the different stages of pressure damage can help in reducing, or even avoiding hospital acquired pressure ulcers. However, failure to identify pressure ulcers correctly can lead to inaccurate reporting and consequently inappropriate management. This article aims to explain the development and introduction of a new strategy to aid healthcare professionals overcome the difficulties in classifying pressure ulcers and differentiating superficial pressure ulcers from moisture lesions. Using the European Pressure Ulcer classification guide (EPUAP 2014) a pressure ulcer guide wheel, or ‘PUG wheel/ tool’, was designed to help healthcare professionals understand pressure ulcer categories and differentiate between pressure ulcers and moisture lesions [1]. To test the accuracy regarding classification, a group of 20 Tissue Viability Link Nurses were tested using this new tool against various verified pressure ulcer and moisture lesion images. A supporting poster was also designed to help healthcare professionals understand the staging system.

Fundamentals of tissue viability, 1.4. Skin care: barrier products

British Journal of Healthcare AssistantsVol. 11, No. 4 ClinicalFundamentals of tissue viability, 1.4. Skin care: barrier productsMenna Lloyd JonesMenna Lloyd JonesSearch for more papers by this authorMenna Lloyd JonesPublished Online:14 Apr 2017https://doi.org/10.12968/bjha.2017.11.4.166AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References All Wales Tissue Viability Nurse Forum, All Wales Continence Forum (2014) All Wales Best Practice Statement on the Prevention and Management of Moisture Lesions. http://tinyurl.com/h5z7equ (accessed 7 March 2017) Google ScholarBeldon P (2008) Moisture lesions: the effect of urine and faeces on the skin. Wound Essentials 3: 82–7. www.wounds-uk.com/pdf/content_9427.pdf (accessed 7 March 2017) Google ScholarBianchi J, Hardy D (2012) Cavilon skin care products made easy. www.wounds-uk.com/made-easy/cavilon-skin-care-products-made-easy (accessed 7 March 2017) Google ScholarCutting KF (2006) Silicone and skin adhesives. Journal of Community Nursing 20(11): 36–8 Google ScholarJones ML (2013) Barrier products and their purpose. www.wounds-uk.com/pdf/content_10827.pdf (accessed 7 March 2017) Google ScholarJones ML (2017) The fundamentals of tissue viability. Skin care – series 1.3. Emollients. British Journal of Healthcare Assistants 11(3): 148–9 Link, Google ScholarVoegeli D (2007) Factors that exacerbate skin breakdown and ulceration. In: Marks R, Skin Breakdown, The Silent Epidemic. Smith & Nephew Foundation, Hull Google ScholarVoegeli D (2010) Care or harm: exploring essential components in skin care regimens. Br J Nurs 19(13): 810–4 Link, Google ScholarVoegeli D (2013) Moisture-associated skin damage: an overview for community nurses. Br J Community Nurs 18(1): 6–12 Link, Google Scholar FiguresReferencesRelatedDetails 2 April 2017Volume 11Issue 4ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 14 April 2017 Published in print 2 April 2017 Information© MA Healthcare LimitedPDF download

The Problems Encountered in a CTEV Clinic: Can Better Casting and Bracing Be Accomplished?

The aim of the study is to create awareness in the practicing health care workers toward the problems encountered during casting and bracing of clubfoot following Ponseti method, and in turn avoid them. Retrospective audit of 6 years' clubfoot clinic records to analyze problems associated with Ponseti method. Problems were encountered in 26 cast and in 6 braced patients. Just 4 patients out of 71 syndromic (5.6%) experienced problems during casting compared with 3% overall incidence. The common problems encountered in casted patients were moisture lesions, hematoma, dermatitis due to occlusion, pressure sores, and fractures. There was excessive bleeding in 1 patient at time of tenotomy. In braced patients, pressure sores and tenderness at tenotomy site were major problems. None of the syndromic patients experienced difficulties during bracing. Problems were encountered with Ponseti method during casting, tenotomy, or bracing. Syndromic children had lesser complication rate than idiopathic clubfeet. It is important to be aware of these problems so that appropriate intervention can be done early. Level IV: Retrospective.

Differentiation between moisture lesions and pressure ulcers using photographs in a critical area

To identify difficulties for nurses in differentiating between moisture lesions and pressure ulcers, proper classification of pressure ulcers to assess the adequate classification of the Grupo Nacional para el Estudio y Asesoramiento de Úlceras por Presión y Heridas Crónicas (GNEAUPP) and the degree of agreement in the correct assessment by type and category of injury. Cross-sectional study in a critical area during 2014. All nurses who agreed to participate were included. They performed a questionnaire with 14 photographs validated by experts of moisture lesions or pressure ulcers in the sacral area and buttocks, with 6 possible answers: Pressure ulcer category I, II, III, IV, moisture lesions and unknown. Demographics and knowledge of the classification system of the pressure ulcers were collected according to GNEAUPP. It involved 98% of the population (n=56); 98.2% knew the classification system of the GNEAUPP; 35.2% of moisture lesions were considered as pressure ulcers, most of them as a category II (18.9%). The 14.8% of the pressure ulcers photographs were identified as moisture lesions and 16.1% were classified in another category. The agreement between nurses earned a global Kappa index of .38 (95% CI: .29-.57). There are difficulties differentiating between pressure ulcers and moisture lesions, especially within initial categories. Nurses have the perception they know the pressure ulcers classification, but they do not classify them correctly. The degree of concordance in the diagnosis of skin lesions was low.

Non-rinse skin cleansers: the way forward in preventing incontinence related moisture lesions?

The use of non-rinse skin cleansers in the care of patients who are at risk of tissue breakdown is not new within the National Health Service (NHS). Back to the Floor Continence Care Rounds (introduced in 2012 to facilitate bedside continence care education) at University Hospitals Birmingham had identified that in the current climate of austerity and efficiency savings, the use of non-rinse cleanser was being randomly rationed. Our objective was to determine whether the introduction of a smaller tube of non-rinse cleanser with targeted education would improve usage and ultimately improve the skin of incontinent patients. There were five clinical areas randomised into two groups. In group 1 three clinical areas were provided with targeted education and new sizes of tubes of non-rinse skin cleanser. In group 2, the two remaining clinical areas acted as control groups, one receiving targeted education only and the remaining had no education or new sized tubes. The incidence of incontinence associated moisture lesions from each clinical area was monitored for 13 weeks pre and post study period. The in-depth study undertaken at University Hospitals Birmingham, over a 6-month period, confirmed a trend in staff committing to the ethos of prudency, and in turn compromising the use of the most effective treatment and prevention of incontinence associated moisture lesions. The ability of the Trust staff to recognise and respond to a change in practice and the responsiveness of a commercial provider to the proposed new methodology has resulted in a significant reduction in incontinence associated moisture lesions across the trust. The clinical areas included in the study demonstrated a 70-76.9% reduction in moisture lesion incidence compared to an 8.3-13.6% reduction in the control groups. The results strongly suggest that a reduction in incontinence associated moisture lesions can be achieved by a simple change in nursing regime. The combination of solid education provision, alongside a more appropriate size of product, has demonstrated significant patient benefit, greater adherence in practice and a reduction in waste. The integrity of the patients' tissue was preserved and staff were satisfied with their input and the patients' progress. The outcomes of this study will have an impact on patient benefit and on the efficiency for trusts resulting in greater patient satisfaction and a more appropriate use of limited resources. SCA provided 20ml tubes of TENA Wash Cream free of charge and the TENA Nurse Advisor for support during the education provision element of the study.

Managing pressure ulcers and moisture lesions with new hydrocolloid technology.

In efforts to reduce the number of avoidable pressure ulcers in a large trust, a number of initiatives have taken place to increase staff awareness about the importance of preventing and treating pressure ulcers and moisture lesions. New documentation, the use of the 'Think Pink' folders and a social media campaign have all proved successful in seeing the number of avoidable pressure ulcers reported within the trust reduce. As part of this initiative an evaluation took place of a new hydrocolloid dressing. This proved effective at reducing healing times, reducing dressing spend and facilitating regular inspection of the affected areas.

Pressure ulcers or moisture lesions: the theatre perspective.

Pressure ulcers continue to be a cause for concern in the healthcare industry (IHI 2015). Unfortunately older patients are at a greater risk of developing pressure ulcers (Kottner et al 2013); moisture lesions and the presence of other comorbidities could have long term effects on the patient's health and recovery.

Pressure ulcers in four Indonesian hospitals: prevalence, patient characteristics, ulcer characteristics, prevention and treatment.

The objective of this article was to study characteristics of pressure ulcer patients and their ulcers, pressure ulcer preventive and treatment measures in four Indonesian general hospitals. A multicentre cross-sectional design was applied to assess pressure ulcers and pressure ulcer care in adult patients in medical, surgical, specialised and intensive care units. Ninety-one of the 1132 patients had a total of 142 ulcers. Half (44·0%) already had pressure ulcers before admission. The overall prevalence of category I-IV pressure ulcers was 8·0% (95% CI 6·4-9·6), and the overall nosocomial pressure ulcer prevalence was 4·5% (95% CI 3·3-5·7). Most pressure ulcer patients had friction and shear problems, were bedfast, had diabetes and had more bedridden days. Most ulcers (42·3%) were category III and IV. One third of the patients had both pressure ulcers and moisture lesions (36·3%) and suffered from pain (45·1%). The most frequently used prevention measures were repositioning (61·5%), skin moisturising (47·3%), patient education (36·3%) and massage (35·2%). Most pressure ulcer dressings involved saline-impregnated or antimicrobial gauzes. This study shows the complexities of pressure ulcers in Indonesian general hospitals and reveals that the quality of pressure ulcer care (prevention and treatment) could be improved by implementing the recent evidence-based international guideline.

Lesiones por humedad. Revisión de conocimientos

Incontinence-associated dermatitis, a clinical manifestation of moisture-associated skin damage, is a condition characterized by irritation and inflammation, and is a common consideration in patients with fecal and/or urinary incontinence. Due to the location and appearance of “moisture lesions”, they are often mistaken for pressure ulcers. Objective: To perform a literature review about the term “moisture lesions”. Methods: We conducted a search of data through the metasearch Gerion Andalusian Public Health System. The term used for search centered on the concept: "moisture lesions". Data extraction was performed by a single person. We identified and analyzed 18 articles in which the term “moisture lesions” is treated. Results and conclusions: Differential diagnosis, usually based on visual examination, can help determine whether incontinence-associated dermatitis or a pressure ulcer is present.Treatment goals include protection of the skin from further exposure to irritants and establishment of a healing environment. This review of literature underscores the scant amount of evidence-based information available and highlights the need for further studies. This should encourage nurses to pay closer attention to moisture lesions and its assessment and treatment.

A critical care network pressure ulcer prevention quality improvement project.

Pressure ulcer prevention is an important safety issue, often underrated and an extremely painful event harming patients. Critically ill patients are one of the highest risk groups in hospital. The impact of pressure ulcers are wide ranging, and they can result in increased critical care and the hospital length of stay, significant interference with functional recovery and rehabilitation and increase cost. This quality improvement project had four aims: (1) to establish a critical care network pressure ulcer prevention group; (2) to establish baseline pressure ulcer prevention practices; (3) to measure, compare and monitor pressure ulcers prevalence; (4) to develop network pressure ulcer prevention standards. The approach used to improve quality included strong critical care nursing leadership to develop a cross-organisational pressure ulcer prevention group and a benchmarking exercise of current practices across a well-established critical care Network in the North of England. The National Safety Thermometer tool was used to measure pressure ulcer prevalence in 23 critical care units, and best available evidence, local consensus and another Critical Care Networks' bundle of interventions were used to develop a local pressure ulcer prevention standards document. The aims of the quality improvement project were achieved. This project was driven by successful leadership and had an agreed common goal. The National Safety Thermometer tool was an innovative approach to measure and compare pressure ulcer prevalence rates at a regional level. A limitation was the exclusion of moisture lesions. The project showed excellent engagement and collaborate working in the quest to prevent pressure ulcers from many critical care nurses with the North of England Critical Care Network. A concise set of Network standards was developed for use in conjunction with local guidelines to enhance pressure ulcer prevention.

Developing a critical care bowel management assessment tool to manage faecal incontinence.

Critical care patients with faecal incontinence are at high risk of developing moisture lesions, pressure ulcers and secondary infection. The aims of this quality improvement programme were to identify the level of harm caused by faecal incontinence in critical care, and to review current critical care nursing practice on the use of bowel management systems, with the intent to implement changes to prevent delayed insertion. A four-step approach was used to guide the improvement programme. A total of seven case studies across three critical care units were reviewed and information was collected on stool type and frequency, duration of diarrhoea and skin integrity prior to bowel management system insertion. Critical care nurses may not always use a consistent approach to the assessment of patients at risk of moisture or pressure damage due to faecal incontinence. Lack of knowledge about the maintenance of bowel management systems was viewed as a likely reason for the inconsistent approach. A Critical Care Bowel Management Assessment Tool was created, to contribute towards a more standardised approach to bowel assessment and management. Inadequate assessment and management of faecal incontinence may have implications for critically ill patients. Further evaluation is required in order to demonstrate over time whether the changes made, as a result of this quality improvement programme, have led to sustainable improvement.

Reduced skin integrity: is what we have enough?

Skin integrity, its assessment, management and prevention of deteriation truly is the responsibility of all healthcare workers from ward to board, from office to treatment room, and from Parliament to pharmacy. Maintenance of good skin integrity is everyone's business, and we all need to re-group and re-focus if harm to patients skin integrity is to be avoided ( Bateman, 2013 ). This article discusses reduced skin integrity pertaining to pressure ulcers and moisture lesions and the healthcare conundrum that we are currently experiencing with rising prevalence and incidence of skin damage alongside national and local drivers guiding change. There has never been a greater emphasis on patient safety and quality of care as there is currently, with healthcare clinicians, managers, procurement, industry and private service providers having to come together collaboratively to improve patient outcomes and provide safe, effective, financially sound pressure ulcer prevention and management strategies that are acceptable to patients and their carers. This article will explore the financial, clinical and management arena we currently practice within and asks the question: is this enough?

Response to Moore Z & Cowman S (2012) Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland, Journal of Clinical Nursing 21, 362–371

We note the recent paper by Moore and Cowman (2012) with considerable interest. The authors are to be congratulated on this valuable research. Whilst much of the data presented are unremarkable, we were intrigued to note the risk status, particularly in respect of incontinence, a parameter in the European Pressure Ulcer Advisory Panel (EPUAP) minimum data set (MDS), but not in the Braden scale. The EPUAP MDS does not differentiate between faecal and urinary incontinence. Moreover, the measures of moisture in the Braden scale are subjective, and it is not known what type of moisture was considered: wound exudate, urine or perspiration. This then begs the question how did the authors establish a mathematical link between pressure ulceration and moisture? In our experience, this does not translate into clinical observations. If moisture alone was a major determinant in pressure ulcer (PU) development, we would see a much greater incidence of damage than is currently recorded and in a wider patient population (including neonates). Moisture undoubtedly influences the mechanisms of skin damage from friction and shear transmission in epithelial and underlying tissues; this is evident in healthy individuals as well as compromised patients. Moisture serves to macerate the skin, and the alkalinity of urine and the digestive enzymes of faeces all serve to precipitate skin damage from any insult. The key issue is whether moisture predisposes to pressure damage or whether it is a factor in PU formation. Our view is that pressure damage is caused by a combination of pressure, shear and friction. Moisture simply acts as a mechanism which alters the body’s natural defence mechanism; it provides an environment in which shear forces and friction coefficients are, in effect, increased. It also changes the ability of the stratum corneum to withstand these forces. As such, is incontinence any more of a risk for PU development than washing the skin regularly with soaps? The differences are as follows: • Incontinence is a common phenomenon in the whole population. • Many incontinent individuals have other co-morbidities which increase PU risk. • Incontinence will precipitate the use of other interventions (such as cleansing with soap), which may also have negative effects on skin health. • The effects of urine and faeces on the skin may have prolonged and exponential effects on factors such as skin pH. PU is predominantly the result of an ischaemic event – even in more commonly occurring pressure damage (such as sacral or heel damage), the ulcer is caused by degradation of ischaemic tissue. The precise distinction between moisture lesions and superficial PU is still unresolved. Until