Obesity, diarrhea and skin care

Nurses General Nursing

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I'm a senior student and my patient this week was a very obese, trached woman with C-diff. Her skin was in very bad shape due to moisture, feces and yeast in her skin folds and peri area. She couldn't tolerate the wiping deep in the folds by the end of my day (pain & rolling would cause her to de-sat) and I left clinical feeling that in trying to keep her clean, we caused her a lot of pain.

We used the ordered nystatin powder, barrier cream and butt paste but with the diarrhea, we were still cleaning her and changing the bed every hour. We repositioned Q2, and used some linen laid between her legs and under her panniculus to help keep her dry. She was red all over and starting to get pressure sores.

Has anyone found any tricks or methods to protect the skin in this situation? Thanks

Specializes in CWON - Certified Wound and Ostomy Nurse.

Swanson hit the nail on the head. People often don't know the difference between the two and thus IAD often gets mislabeled as a pressure ulcer. With IAD the skin is red, raw, and painful. Visualize bad diaper rash. If you are having to clean up a person that frequently a rectal tube would be of great benefit. Some facilities only allow them to be used in ICU's. There are other containment systems that can be applied on the skin surface instead. Otherwise a thick barrier cream should be applied, only removing the outer layer that is soiled. No washcloths. Use the premoistened wipes to remove and then reapply a very thick layer once again. You'd be amazed at how quickly a zinc oxide paste can help that tissue. Use the moistened wipes for the intertriginous dermatitis (within the skin folds) and use dry nystatin powder, not a cream. InterDry Ag works well too to wick moisture out of those areas - your primary problem which is causing candida growth. It needs to lay flat, not rolled, layered or bunched, allowing visibility of the outer fabric (2") to appropriately wick.

I agree with the fecal management system. There are also cloths called "InterDry" which are designed for placing in skin folds and preventing breakdown from skin to skin contact. Depending on how bad it is, you may have to ask for a pain medication (IV push if possible for quick action) for when skin care is performed. When patients develop cracks and fissures in their skin folds it is extremely painful to have the area wiped clean. Consider temporarily turning up her O2 (or applying a trach collar if she's room air) if she's desatting when she's supine and being turned.

Specializes in Critical Care/Vascular Access.

Looks like most of this has been mentioned already, but just to reiterate.......

On my floor, with a patient having that much diarrhea and with compromised skin integrity, they would have had a BMS already (bowel management system, similar to but more long term than a rectal tube), and maybe a foley too. At least until the c. dif. was under control and the diarrhea had calmed down.

For the folds, besides powder and the usual maintenance, we use a lot of InterDry for our obese and less mobile patients (a previous poster talked about it too). Be careful with the powdering and lotion. I often go to clean obese patients who just have powder and/or lotion caked into their folds. More is not always better.

Specializes in Oncology.

Yep, when I read this I instantly thought that this patient needs a bowel management system. Does your facility have specialized skin care nurses that can be called to consult? Ours are always coming up with interesting products and ideas. We have a special, thicker barrier cream than our standard one with added zinc oxide that can be ordered and protects the skin better. It's called z guard and it's pretty effective. Further, look into doing everything you can to prevent desatting with movement. Encourage coughing/deep breathing and suctioning before clean up. Also, as mentioned, she may need a systemic antifungal if her skin is that bad. Hopefully her c diff is benign treated aggressively?

Specializes in Anesthesia, ICU, PCU.
A seemingly contradictory name, but dignicare and flexiseal are two of the main trade names for rectal tubes.

My thought exactly when my hospital switched to this new brand of rectal tube called "Dignicare." There is 0 dignity involved with either incontinence or having a tube inserted in your... ahem. Maybe this is why I'm not in marketing.

Agree with this intervention though. MD should check for rectal tone before you place it. Usually a bowel regimen (senna ATC) is ordered to keep the BMs of a consistency compatible with the bowel management system. This is important because C. diff. is located, and transmitted, via stool once the colonization is confirmed by PCR - so it stands to reason that containing the contagion is preferred to constant incontinence care by RNs who have to go into another patient's room. Also the antibiotic that caused it should be discontinued, but this is an MD/Infectious Disease decision. Nursing-wise: make sure you flush it q.shift or more frequently given the consistency. In my experience these things are notorious for eventually leaking, so I treat the skin assessment/care and Braden scoring the same as if they didn't have the tube. Technically skin breakdown with IAD isn't pressure-related, but moisture-related skin loss.

Specializes in ICU.

Just wondering where was your instructor during all this? That is something that just floors me; you pay a ton of money to attend nursing school. This would have been a prime teaching moment for your nursing instructor.

Specializes in Emergency and Critical Care.

I would like to commend you for being respectful to this patient about the obesity and other issues this poor patient was going through, and trying to find the right way to treat her. Thank you

On top of all the great input on this thread, I find that adhesive fecal bags are totally underused.

They are basically like an ostomy bag that sticks around the orifice. They are good for when a rectal tube is not a feasible option ex. stool is not quite liquid, patient's rectal anatomy, possible bleeding risk etc. It does take a little skill and patience to apply them without having them leak but when they do work, they save your patients' skin.

Make sure your patient's skin is dry, dry, dry before applying them, and you may have to hold them in place for a minute to make sure they mold and stick to the contours of the perineum and buttocks.

My instructor was with me, helping to clean up. We are very careful as "guests" of the facility, not to step on toes. I may have this patient again this week, if she is still in this ICU bed. If so, I will do my innocent student questioning to the primary nurse regarding a rectal tube/bag and if the wound care nurse has assessed her skin.

I should have clarified that she is not only trached, but vented. This is the ICU, so it seems this is the setting for a bowel management system.

Also, it's cheap, it's easy, it protects skin from moisture and painful air, it cleans up easily, it doesn't stink, and it helps skin heal. It's the classic A&D ointment. Once you get things clean and dry, slather it on. Amazing stuff.

Specializes in ICU.

Definitely a flexiseal. Coloplast also makes a skin fold management product with silver in it. Supposedly it works great or what you described.

Specializes in Hospice, Geriatrics, Wounds.

Interdry is an excellent product for skin folds. Go to their website and u can sign up for a free sample.

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