Skin & Wound Care Considerations in Special Populations: Bariatric

1. Skin & Wound Care Considerations in Special Populations:Bariatric Tucson Affiliate of the WOCN Society Conference March 8, 2014 Karen Lou Kennedy-Evens RN, FNP, APRN-BC

2. Learning Objectives • Describe the top three most common skin challenges in the bariatric population. • Discuss the pathogenic factors contributing to these common alterations in skin integrity. • Review the skin and wound care considerations of the most commonly seen skin challenges in the obese population.

3. Incidence of Obesity • 35% of the world’s adults over 20 are overweight • World wide obesity has doubled since 1980

5. Future Generation

6. Obesity increases risk of: • Hypertension • Type 2 diabetes • Coronary heart disease • Abnormal lipid concentrations • Delayed wound healing • Admissions to acute care, home care and out patient clinics • Prolonged acute care to prevent complications

7. One-third of critical care patients are obese or morbidly obese.

8. Comorbities Associated with Obesity • Hypertension • Ischemic heart disease • Type 2 diabetes • Stroke • Osteoarthritis • Chronic renal failure • Obstructive sleep apnea • Restrictive lung disease • Immobility • Depression • Metabolic syndrome • Ovarian cancer • Breast cancer • Irritable bowel syndrome • Nonalcoholic fatty liver disease • GERD • Colon cancer • Disorders of the gall bladder • esophageal cancer

9. Surgical/Post-op Complications • Risks of sepsis • Wound infections • Dehiscence • Venous thromboembolic disorders • Systemic inflammatory response syndrome (SIRS) • Multi-organ dysfunction syndrome (MODS) • Increase risk for skin breakdown and wound deterioration.

10. Loss is Skin Integrity due to: • Adipose has less blood supply  inadequate oxygenation • Excessive sweating increases skin moisture and risk of bacterial/fungal invasion especially in deep folds • Immobility friction and shear due to weight stress • Malnutrition • Iatrogenic injury due to tubes, catheters and other interventions

11. Skin Changes with Obesity • Stretch marks (striae) • Hirsutism in women • Aerochordons (skin tags) • Acanthosisnigricans

12. Specific Skin/Wound Issues • Atypical pressure ulcers • Perigenital irritant dermatitis • Intertrigo • Fungal infections • Cellulitis • Fournier’s gangrene • Erythrasma • Diabetic foot ulcers • Venous insufficiency with possible ulceration • Lymphedema • Abdominal elephantiasis • Surgical site infections • increased chance of dehiscence and evisceration.

13. Atypical Pressure Ulcers • Skin folds that create pressure on each other • Neck • Upper back • Upper medial thigh • Flanks • Posterior legs • Pannus • No risk assessment scales validated for the obese

14. Interventions • Relief of pressure • Skin fold management • Moisture management • Appropriate sized beds for repositioning • Adequate staff for repositioning • Fabrics

15. Perigenital Irritant Dermatitis • Due to urinary and/or fecal incontinence • Inability for self-care after toileting • Environment not set up for bariatric clientele resulting in unable to cleanse and dry the urethral and rectal orifices/without the danger of falling

16. Intervention • Easy cleaning with appropriate equipment & supplies • Toilet risers • Extra wide toilet seats • Bariatric commodes • Hand rails for support • Prepackaged cleansing & protection • Perineal care with each incident • Appropriate sized briefs and/or pads • Drying fabrics

17. Intertrigo • Maceration due to excess moisture • Infectious or noninfectious • Friction from two opposed skin surfaces • painful and/or pruritic • Presents as: • Erythematous, macerated plaques • Erosions with possible scaling • Candida intertrigo: satellite papulo-pustules • Found in perineal area, deep skin folds

18. Interventions • Topical or oral antifungal • Drying agents • Fans or cool hair dryer • Special textiles with drying and antimicrobial properties

19. Barriers to Skin Care • Body habitus • Lack of bariatric equipment • Inappropriate environmental design • Caregivers fatigue

20. Bariatric Equipment

21. Staff/Patient/Family Education • Bathing & hygiene • Skin fold management • Perigental care • Toileting • Odor management • Caregiver injury prevention

22. Educational Props

23. Other issues • Psychosocial issues • Bariatric-specific surgery

24. References • Beitz, J., Providing quality skin and wound care for the bariatric patient: An overview of clinical challenges . Ostomy Wound Management. Jan 2014 • Blackett A., Gallagher S., Dugan S., Gates J., Henn T., Kennedy-Evens K., Lutz J., Caring for persons with bariatric health care issues. Journal Wound Ostomy Continence Nursing. 2011 • Gallagher, S., The intersection of ostomy and wound management, obesity and associated science. Ostomy Wound Management Jan 2014 • Rush A, Muir M. Maintaining skin integrity in bariatric patients. Journal of Community Nursing. 2012 • World Health Organization. Obesity and Overweight. 2013. www.who.int/mediacentre/factssheet/ • Wound Ostomy Continence Nurses Society. Safety and Comfort issues for Nursing Care of the Obese Patient. Mt. Laurel, NJ. WOCN 2013