Incontinence sores- at work now and need some ideas!

[NICU_Nurse, BSN, RN]

Hi, guys! I'm at work now and though I work with babies, the general principal is the same and I was wondering if anyone on has some suggestions?

We're taking care of a baby that has partial-thickness decubiti on both buttocks due to diarrhea (vanco therapy). It started out as maceration, and then opened up, and is actually just below the sub-Q level. The docs ordered 02 to the area, and here's where the issue lies.

The 02 is cold, and serves to dry the diaper area. Is this a good thing or a bad thing? Different nurses have different methods. Some alternate 3 hours of barrier cream vs. 3 hours of plain 02, some nurses put a barrier cream over the buttocks to protect from stool and urine while also aiming 02 to the bottom, etc.

Basically, in this instance, what's the best method of healing the sores? Drying out the bed of granulation, or a moist-healing environment?

Either way, how do you both protect the area from stool/urine AND dry it out with 02?

Tips, please! We have access to numerous creams (zinc, aquaphor, etc.) as well as Mepilex non-stick dressings, ostomy-type skin preps (that form a film), Tegaderm, you name it. Almost.

Help!

Thanks a lot!

[morte, LPN, LVN]

? check with resp therapy on warmed humidified O2?

[adrienurse, LPN]

Oh my. I don't think doctors here have ordered O2 to skin for 20 years. Usually the principles we follow are to keep the wound site moist but not overly so -- the thought of exposing the skin to concentrated O2 seems to contraindicate that principle.

I do acknowledge the difficulty of keeping a wound bed clean when it's exposed to urine and stool.

Mind you my experience is with geriatric bums. These are the steps we generally take, going down according to severity.

Step 1 -- we keep the skin clean. I've heard of avoiding cleansers entirely in the NICU and only using guaze and mineral oil to wash babies bums during changes.

Step 2 -- Barrier Creams. The 3M Triple Care cream is popular here, but when that fails, Calmoseptine Ung works well.

Step 3 -- Gauze dressing. Use an impregnated guaze like Jelonet or Bactigras next to the skin and cover with guaze. Mepitel also works and doesn't need to be changed as often.

Step 4 -- Use a small amount of hydrogel in the wound area and cover with dressing of choice. Tegaderm, which was so popular 8+ years ago seems to be used rarely here cause it doesn't really work (especially when there's stool involved).

Hopefully you won't have to go beyond step 4. My advice, consult a Clinical Nurse Specialist or Enterostomal nurse from another area of your hospital.

[prmenrs, RN]

I agree w/consulting a stoma therapy/wound nurse, but w/back up from a pharmacist familiar w/neonates to make sure there's nothing toxic to babies in any products. (e.g. never use Xeroform gauze on a baby, it has Bismuth in it--ok for adults, not so good for babies cuz they can absorb more thru their skin.) If no ET, maybe a burn consult?

Just leaving it exposed to air might help: make a small roll for the baby to lie over (roll @ hip level) diaper area open w/ diaper underneath him/her. Put a baby shirt on upside down w/the arms over his legs and the hole where the head usually goes is now in the diaper area. Diaper goes in front between baby and shirt. (This keeps his legs warm.) A blanket folded across the back and another across his legs w/diaper sticking up to protect it. You can put the (warmed) O2 on it, or just leave it hanging out there. If he poops, you'll see it right away.

Is the baby on oral Nystatin? It can help w/the diaper rash because one factor that gets it started is the yeast thing. Also, I've seen baby girls get yeast just like us big girls do. Ouch.

I don't think I'd use tegaderm any where near the problem area.

Make sure the baby gets the same nurses-a 'primary team'; you can work out a written plan based on recommendations from the Enterostomal Therapist, review it w/any new nurse that cares for child. Everyone should stick to the plan. Review it every few days as, hopefully, the kid gets better.

Keep in touch, we want to know what happens!

[gitterbug]

Just wanted to say you nurses covered this problem so well, I expect this little tyke will be on the mend soon. You are all awsome.

[Poochee]

This is a strictly at home remedy, that I get bashed for all the time, but it keeps rashes away. BTW, I loathe any and all barrier creams, My rationale, is that, you wont need a barrier, if a patient is cleansed promptly and appropriately. I love neosporin, thin layer. I wash each of my children, under the faucet, warm flowing water, I dont use soaps, wipes, just good old warm water, let them air dry, then diaper. When i have a child develop a rash, I go to a no diaper routine, air dry at all time, a thin layer of neosporin, and that cozy warm water for up to 3 minutes. Always works. But, with a wound to that extent,,and because I'm sure you can't move those babies that much, I dont know what to think, but my heart goes out to the little one, and for you nurses, I know it hurts the heart to see suffering. I know i had a bedridden man, buttocks would never heal, well I went at him with the warm h20, I would, put a 40 gallon garbage bag under him, some towels on top of that, and just let that water flow over him, air dry completely, neosporin thinly, took 30 minutes, but I hate to see anyone with a bedsore, it worked. I hate barrier creams, they are always going to get soiled, and are HARD to wash off, cant they come up with some cream with neosporin in it, easy to wash off, that is moist on contact, but air dries, to a consistency that doesnt stick to the skin??????????

[CoffeeRTC, BSN, RN]

If the wound is into the sub q tissues it might be a stage 2 or 3. I would have a wound specialist look at it. I'm not sure what type of products you can use on infants due to the toxicity.

In LTC there are tons of things to do. Moiste wound healing is recomended now days.

[Antikigirl, ASN, RN]

I am a believer in keeping wounds open to air if able...the skin does have its natural way of healing..and I like to promote that!

Also, I tend to shy from soaps or lotions during this time for the same reason. What I have done is to use a little (and I mean little) aloe vista barrier cream to the wound and edges after cleaning gently with only water. Then I use alevin dressings (the type with the absorbant pad in the center) for the cushion on the wound, and the dressing adhesive for keeping out urine/bm. Any time the bandage is soiled or crimped, you do have to remove and replace however, but I find alevins aren't as sticky as other products, so it doesn't do as much damage to surounding skin if you have to remove and replace often.

We use to use tegraderms, but they kept in moisture too well and really hindered healing...also after time many of my patients (I too worked with geris) would get horrible blisters from them (and imagine that nice find when you take off a soiled tegraderm to discover a quarter sized blister you just opened by taking the bandage off...ouch!). I started using alevins after that and had sucess.

Also, you can use a non adhesive pad dressing with a small amount of tape to keep it in place if your patient moves too much and keeps having to have the alevin changed. It is less expensive this way, and if you have to change the dressing this much...might as well make it simple. The goals are basically clean/dry and free of pressure.