Obesity, diarrhea and skin care

  1. 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
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    About DawnJ

    Joined: Jun '11; Posts: 322; Likes: 405
    Many nursing hats; from US
    Specialty: 2 year(s) of experience


  3. by   tokebi
    Sounds like she could use a rectal tube... as long as it's watery and nothing solid. If there's no contraindication, such as thrombocytopenia, see if her MD will consider ordering one?

    In the meantime, I would try putting a silicone dressing (Mepilex or Aquacel) over the most irritated area. Those dressings are supposed to be waterproof and you can just wipe over it and they will stay on. If the irritation is all over, it wouldn't work though.
  4. by   RNperdiem
    This patient sounds like a candidate for a fecal management system/rectal tube. Keep up with the barrier cream, and call a wound/ostomy nurse for a consult if the patient's skin is still getting worse.
  5. by   mhy12784
    Should advocate for your patient to get a dignicare or whatever brand your hospital uses.
  6. by   not.done.yet
  7. by   sapphire18
    Quote from mhy12784
    Should advocate for your patient to get a dignicare or whatever brand your hospital uses.
  8. by   MunoRN
    Quote from sapphire18
    A seemingly contradictory name, but dignicare and flexiseal are two of the main trade names for rectal tubes.
  9. by   SwansonRN
    Definitely someone who sounds like they need a rectal tube! On the side: Remember pressure sores and incontinent associated dermatitis are two different things. IAD can get very bad, but it is not a pressure ulcer. A lot of people make the mistake that once the skin opens it's a stage II.
  10. by   DawnJ
    Thanks, I hadn't heard of IAD as it's own thing
  11. by   Esme12
    Rectal tube...flexiseal
  12. by   annie.rn
    Concur w/ recital tube. For the yeast, I have found using a thick moisture barrier ointment mixed together w/ an antifungal cream works well. The key is to get the skin folds very clean and thoroughly dry (this takes time, especially if rubbing is painful...air drying is best but hard, if not impossible to do depending on pt. situation). Once dry, apply a layer of the above mentioned cream. I find that Nystatin powder usually becomes a nasty, pasty mess b/c it is applied too liberally and then not cleaned up thoroughly between applications.
  13. by   NC29mom
    DIFLUCAN STAT! will also help with yeast. Never been huge fan if nystatin powder....
  14. by   CWONgal
    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.