Published Mar 31, 2005
I work in an assisted living facility where caregivers do all direct care and meds...there is only one nurse per shift on the floor of 160 residents. So normally when I find a skin issue beyond what the caregivers or that one nurse can do, we call in home health to eval and get a wound care specilist!
Our facility does WONDERS with skin issues! No decubes or long term wounds in our place for sure...we really push and educate our caregivers well! I am so proud of our staff for keeping skin issues to almost 0!~
Alas...we had this one lady who started to get a blotchy red irregular rash on her groinal folds and breasts. Large breasted and has larger abdomen (so lots of deep folds). She was very active and kept these areas dry, but lately she has taken a decline and won't get out of bed.
Well, she declined so rapidly that I sent her to the ED this weekend. They had NO dx for her sudden weakness, but did culture the rash that had grown tremendously, and yeast was found to be the culprit!
Okay so they order 5 days of oral antifungal (now over), and nystatin powder QID for a week. The week is about over and it is now not only shiney, draining severly, uncomfortable, splitting skin, obvious open blister patches, and very very angry...but spread even further over her breasts (the groinal folds are doing well).
We can't seem to get the doctors interest at all! Calls, faxes the works and nothing! I found her today just looking horrid, and she had washcloths under her breasts to keep things dry, but I felt that detergents or just the coarseness of the material was irritating the area (I don't subscribe to terry cloth for this!). We got her hankerchief thin cotton pads to put there instead, and were able to do a make shift taping to raise her breasts so that they may be exposed to some air bra totally out of the question, folds about 3 inches deep!) Still trying to get a hold of her MD and illicit some sort of action!!!!
Any other words of advise? I mean this is the WORST I have ever seen in my 5 years of being a nurse...and it just is so miserable for her!
Thanks in advance! Really greatly appreciated!
(and yes, the caregivers are overseen by a nurse in this case and the nystatin is cleaned gently (very gently but well) so that their is no balling of the powder...and pat dry with a pad very gently...I mean it really hurts!).
this is so bad..the only thing i can advise is to have the don call the md and really raise some cain about this. if neglect continues return her to er until something is done...i have had er md at the charity hospital call me and threaten me saying they were going to insist on my being fired when i sent a patient back three times in one day...finally they admitted him...you are responsibility for this woman and sometimes you have to get on a soap box and scream until someone notices you
Antikigirl, ASN, RN
She had just gotten back from the hospital where her rash condition worsened (it wasn't that intense when we were treating it QID).
Yeah, My DON is about to send her out again, but she is very weak and doesn't want to go back to the hospital. Uhgggg! She has an MD appt on Monday...but ouch, to have to be in that much discomfort till then just gives me the ebbies!
Thanks so much for your reply :)
We had a similar situation and used nystaform powder with the same results unfortunately. How about using nystatin, but the cream kind, much kinder when washing off, and more soothing. Poor thing it can't be nice for her. Makes me glad I'm extremely small up top.
VivaLasViejas, ASN, RN
For years I preached about keeping skin folds clean in LTC, to no avail.......nobody would take the time to do this one simple thing, and that's washing under heavy breasts and abdominal folds, patting the skin dry, and finishing with a dusting of Gold Bond powder (plain cornstarch for those w/ sensitive skin). I learned to do this years ago, when I started really putting on the weight.......if I don't do it, yeast breaks out within a couple of days, and then it's really hard to clear up. The powder not only keeps the areas dry and cool, it prevents odor.......definitely a plus!
But, it's hard to get people to change habits, especially when they have to rush through care tasks like they do in nursing homes........even when doing so would prevent some skin issues from ever arising in the first place. I argued that one until I was blue in the face, and it rarely got done. Maybe someone else will have better luck.........
CoffeeRTC, BSN, RN
For years I preached about keeping skin folds clean in LTC, to no avail.......nobody would take the time to do this one simple thing, and that's washing under heavy breasts and abdominal folds, patting the skin dry, and finishing with a dusting of Gold Bond powder (plain cornstarch for those w/ sensitive skin). I learned to do this years ago, when I started really putting on the weight.......if I don't do it, yeast breaks out within a couple of days, and then it's really hard to clear up. The powder not only keeps the areas dry and cool, it prevents odor.......definitely a plus! But, it's hard to get people to change habits, especially when they have to rush through care tasks like they do in nursing homes........even when doing so would prevent some skin issues from ever arising in the first place. I argued that one until I was blue in the face, and it rarely got done. Maybe someone else will have better luck.........
Yep...its that time of the year again. We finally got rid of most of the nystantin and mycolog cream order for under the breast and fold areas and now they will be starting again...I love warmer weather, but it wouldn't be so bad if I can just get good skin care done!
you can treat topically with a powder with miconazole and smooth over entire area, pat with non-sting skin prep and apply hydrocolloid. Leave it on at least 72 hours and it should be gone. We use this frequently around stomas and it works well. debbie from louisville
which hydrocolloid are you using? do you use duoderm? so you use the powder, then the no-sting prep, then the duoderm?
hmmm. need some ideas for a really bad excoriation/rash/allergic reaction around a stoma. angry, red, shiny, weeping, pruitic, etc etc, everywhere except where the eakin seal has been. it's almost like an allergy to the whole wafer, except it does clear eventually-only to return with a vengeance.
hope you can help!
I had a patient in long-term care who had a rash that wouldn't go away. It turned out that she had undiagnosed diabetes, and when she was treated for that the rash cleared up. They should have checked for that in the hospital, but is there any chance that your patient has high blood sugar?
If you haven't heard of InterDry, find your Coloplast rep and ask to try. It is a fabric that is used for skin folds with yeast. We just starting trying it and its been great for pts with skin fold issues.
Interdry is great. It is impregnated with silver to help with bacteria. You leave part of it outside of the skin folds and it wicks the moisture away from the body. The rep says that it is washable and reuseable, but you will lose the silver properties in it. Then you can use your nystatin powder and the washed Interdry fabric to wick the moisture. It is expensive though.
The creams for yeast are horrible though. They simply keep the skin wet and still cause excoriation. Always go for powder form.
A cheaper alternative is to use washcloths or soft kleenex in the skin folds and change them regularly. It helps to absorb the moisture that is causing the problem. I've used this myself during the summer when my bra band got sweaty and rubbed me raw.
I also advocate the generic brands of Gold Bond powder for anyone that has wet skin fold issues. I've been told by a NP that using powder with talc increases the risk of cervical cancer slightly. I'll take my chances with the talk as I hate to get raw from bra or panties rubbing on me when I am hot and sweaty.
I have had good results with the antifungal creams, but you must scrupuously clean the area to be treated first, then dry before applying. Also, the treatments need to be done at least twice daily.
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