Obesity, diarrhea and skin care

[DawnJ]

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

For actually cleaning the patient, double-gloved hands are better than any sort of wipe or towel, IMO.

Have a garbage can right next to you, several pads (chux), a box of gloves, and a bunch of peri-foam (whatever it's called).

Switch between wiping with palm and fingers to using the edge of the hand like a squeegee. You'll go through a ton of gloves but it's very gentle on the skin (that is, low friction). It's kind of gross, though.

[BrandonLPN, LPN]

For actually cleaning the patient, double-gloved hands are better than any sort of wipe or towel, IMO.

Have a garbage can right next to you, several pads (chux), a box of gloves, and a bunch of peri-foam (whatever it's called).

Switch between wiping with palm and fingers to using the edge of the hand like a squeegee. You'll go through a ton of gloves but it's very gentle on the skin (that is, low friction). It's kind of gross, though.

Are you saying to just wipe the BM off directly with your gloved hand?

[Clovery]

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.

If the patient is on a vent, there should be a 100% O2 button you can push to temporarily give an oxygen boost (on our vents, it automatically goes back to the original setting after 3 minutes). Of course always ask before touching the vent, but this is a useful button for patients who desat when they're supine and being turned. Also keep in mind that resistance against the vent (setting off the high pressure alarms) is a sign of pain. Many of my patients who are obese and on vents require pre-medication for pain before we turn and clean them. If a patient is experiencing pain during routine nursing care, it's the nurse's job to advocate for the patient by bringing this to the physician's attention and getting a PRN order for pain meds. The doctors may not realize the patient's pain because they aren't turning and repositioning the patients when they make their rounds.

Are you saying to just wipe the BM off directly with your gloved hand?

For people with severely macerated or inflamed backsides... yeah, I've had it work really well... as long as the stool isn't real pasty or sticky.

Double- or triple-gloved hand and lots of peri-foam and sometimes warm water.

Very low friction... but it does take longer, for sure.