The Skin Safety Model: Reconceptualizing Skin Vulnerability in Older Patients

Enhancing skin health and safety in aged care (SKINCARE trial): A cluster-randomised pragmatic trial

BACKGROUND

Older nursing home residents are prone to develop different skin conditions at the same time, including xerosis cutis, skin tears, pressure ulcers, incontinence-associated dermatitis or intertrigo. Guidelines and recommendations mainly address these skin conditions separately. The overall aim of this study was to measure the effects of the implementation of a skincare and prevention package.

TRIAL DESIGN

A two-arm cluster-randomised controlled trial was conducted.

METHODS

In nursing homes being assigned to the intervention group, an evidence-based and structured skincare and prevention programme was implemented for six months. Nursing home residents in the control group received standard care as usual. Blinded dermatologists conducted head-to-toe skin assessments, and the researchers assessed skin barrier parameters including stratum corneum hydration and transepidermal water loss at the upper and lower extremities after three and six months. Outcomes included the cumulative incidence of incontinence-associated dermatitis, skin tears, pressure ulcers and intertrigo, and were presented as intention-to-treat and per protocol analysis. Skin dryness and resident-reported outcomes (pain, itch, quality of life) were assessed.

RESULTS

A random sample of 17 nursing homes in the federal state of Berlin, Germany, was drawn and randomised in intervention (n = 9) and control groups (n = 8). In total, 165 participants were allocated to the intervention, and 149 participants were allocated to the control group. The cumulative incidence of skin tears (19.2 %, 95 % CI 12.8-27.8), pressure ulcers (13.6 %, 95 % CI 8.1-21.9) and intertrigo (27.0 %, 95 % CI 18.4-37.7) was lower in the intervention compared to the control group, with cumulative incidences of 27.2 % (95 % CI 19.3-36.9) for skin tears, 16.9 % (95 % CI 10.6-25.9) for pressure ulcer, and 37.8 % (95 % CI 27.5-49.4) for intertrigo. The incidence of incontinence-associated dermatitis was higher in the intervention group (26.3 %, 95 % CI 17.9-36.8) compared to the control group (23.1 %; 95 % CI 14.6-34.5). Mean skin dryness was lower in the intervention group but showed variation. The impact on pain, itch, and quality of life was trivial.

CONCLUSIONS

The present study results indicate that the implementation of tailored and evidence-based nursing routines improves skin health and safety in residential long-term care. Evidence suggests that multiple adverse skin conditions can be prevented by regular skin assessments and individually tailored skincare routines. Positive effects on skin dryness were observed, but skin physiology parameters did not indicate changes of the skin barrier function.

TRIAL REGISTRATION

This study is registered at the German Clinical Trials Register (registration number: DRKS00015680; date of registration: January 29th, 2019) and ClinicalTrials.gov (NCT03824886; date of registration: January 31st, 2019).

Incidence and Predictive Model of Medical Adhesive-Related Skin Injury in Cancer Patients Managed With Central Venous Access Devices: A Retrospective Study

PURPOSE

The purpose of this study was to determine the prevalence of medical adhesive-related skin injury (MARSI) at the site of central venous access device (CVAD) implantation in patients with cancer, identify risk factors associated with MARSI in patients with cancer, and create a nomogram for predicting risk of MARSI.

DESIGN

Retrospective, single-center study.

SUBJECTS AND SETTING

The sample comprised 1172 consecutive patients who underwent CVAD implantation between February 2018 and February 2019; their mean age was 55.7 years (SD: 13.9). Data were collected at the First Affiliated Hospital of Xi'an Jiaotong University, located in Xi'an, China.

METHODS

Demographic and pertinent clinical data were collected from patient records. Routine dressing changes were performed every 7 days for peripherally inserted central venous catheters (PICCs) or 28 days for ports except in patients with existing skin injuries. Skin injuries related to use of medical adhesives and persisting for more than for 30 minutes were classified MARSI. Data were used to develop a nomogram for predicting MARSI. The accuracy of the nomogram was verified by calculating the concordance index (C-index) and drawing a calibration curve.

RESULTS

Among the 1172 patients, 330 (28.2%) had undergone PICC implantation, and 282 (24.1%) experienced 1 or more MARSIs representing an incidence rate of 1.7 events per 1000 CVAD days. Statistical analysis identified previous MARSI history, the need for total parenteral nutrition support, other catheter-related complications, a history of allergy, and PICC implantation as associated with a higher likelihood of developing for MARSI. Based on these factors, we established a nomogram for predicting the risk of developing MARSI in patients with cancer who underwent CVAD implantation. The C-index of the nomogram was 0.96, and the calibration curve of the nomogram showed that the predictive ability of the nomogram was strong.

CONCLUSIONS

We evaluated patients with cancer who were undergoing CVAD and identified that previous MARSI history, patients needing total parenteral nutrition support, other catheter-related complications, allergic history, and PICC implantation (compared with ports) were associated with a higher likelihood for developing MARSI. The nomogram we developed showed a good ability for predicting the risk of developing MARSI and may assist nurses to predict MARSI in this population.

Impact of skin care on body image of aging people: A quasi-randomized pilot trial

Aim

Support for various activities of daily living is essential for maintaining the health of residents in nursing homes. Although aging people who move to nursing homes often change their skin care habits, how these changes impact aging adults' social and mental well-being remains unclear. This study aimed to evaluate the effects of facial skin care on aging residents' self-body image, self-esteem, well-being, depressive symptoms and social cognitive function by a quasi-randomized controlled pilot trial in Japanese nursing homes.

Method

Thirty-seven older adult women living in nursing homes took part in this quasi-randomized controlled pilot trial. Eighteen participants applied a skincare gel-cream to the face twice a day for three months, while 19 participants used no skincare products. Self-body image and psychological measures such as the Cutaneous Body Image Scale (CBIS), the Rosenberg Self-esteem Scale (RSES), Philadelphia Geriatric Center Morale Scale (PGCMS) and Geriatric Depression Scale (GDS) were used in each nursing home to evaluate the pre- and post-treatment scores. In addition, cognitive items of the Functional Independence Measure (FIM) were evaluated as social cognitive function at pre- and post-treatment.

Results

There was a significant different change of the Cutaneous Body Image Scale scores (p = 0.045, r = 0.34) after three months between skin care group and control group. Although there were no clear significant differences in other psychological assessments, there was a higher number of them with positive changes in the skin care group compared to the control group.

Conclusion

Skin care may help improve cutaneous self-body image and positive emotion in aging female residents of Japanese nursing homes.

Technical aspects and validation of custom digital algorithms for hand volumetry

BACKGROUND

Establishing baseline measurements on normative data is essential to evaluate standards of care and the impact of clinical or surgical treatments. Hand volume determination is relevant in pathological conditions where the anatomical structures might undergo modifications like post-treatment chronic edema. For example, one of the consequences of breast cancer treatment is the possibility of developing uni-lateral lymphedema on the upper limbs.

OBJECTIVE

Arm and forearm volumetrics are well-studied techniques, whereas hand volumetry computation poses several challenges both from the clinical and digital perspectives. The current work has explored routine clinical and customized digital methodologies for hand volume appraisal on healthy subjects.

METHODS

Clinical hand volumes computed by water displacement or circumferential measurements were compared to digital volumetry calculated from 3D laser scans. Digital volume quantification algorithms exploited the gift wrapping concept or cubic tessellation of acquired 3D shapes. This latter digital technique is parametric, and a calibration methodology to define the resolution of the tessellation has been validated.

RESULTS

Results on a group of normal subjects demonstrated that the volumes computed from digital hand representations extracted by tessellation return values similar to the clinical water displacement volume assessment at low tolerances.

CONCLUSIONS

The current investigation suggested that the tessellation algorithm could be considered a digital equivalent of water displacement for hand volumetrics. Future studies are needed to confirm these results in people with lymphedema.

Skin tears in older adult residents of long-term care facilities: prevalence and associated factors

OBJECTIVE

To determine the prevalence of skin tears, and demographic and clinical factors associated with their presence in older adult residents of long-term care facilities.

METHOD

This observational, quantitative, cross-sectional, epidemiological study was conducted with older adult residents of three long-term care facilities in São Paulo, Brazil. For data collection, four instruments were used: a questionnaire assessing sociodemographic and clinical characteristics of the residents; and the Brazilian-Portuguese versions of the Mini-Mental State Examination, Skin Tear Audit Research (STAR) Skin Tear Classification System, and the Katz Index of Independence in Activities of Daily Living.

RESULTS

A total of 69 residents took part in the study. The prevalence of skin tears was 11.6%. Skin tears were significantly associated with the presence of haematoma (odds ratio, OR=9.159; p=0.017) and actinic purpura (OR=6.265; p=0.033), which increased the odds of skin tear development nine-fold and six-fold, respectively.

CONCLUSION

The findings agree with the international literature. Considering that this was the first epidemiological study on skin tears carried out in long-term care facilities for older adults in Brazil, its contribution lies in the systematisation of data collection and making data available on a field that has not yet been studied in this country.

An Adaptation of the Skin Safety Model to Guide Diaper Dermatitis Research in the NICU

Diaper dermatitis is an ever-present condition among infants. Little is known about the prevalence among infants in the NICU. This article presents an adaptation of the skin safety model (SSM) for the infant in the NICU. The concepts of the model were extracted, defined, and integrated into an adapted SSM model to provide a focus on the infant with diaper dermatitis in the intensive care setting. It is essential to include all factors of the infant's clinical characteristics and hospital experience in the modeling to accurately predict risk of skin vulnerability in this infant population.

Association Between Charlson Comorbidity Index and Community-Acquired Pressure Injury in Older Acute Inpatients in a Chinese Tertiary Hospital

PURPOSE

To explore the correlation between community-acquired pressure injury (CAPI) and comorbidities in elderly patients with emergency admission.

PATIENTS AND METHODS

Patients aged 65 years or above were enrolled from multiple departments, such as Internal Medicine, Surgery, Geriatrics, and Intensive Care Unit of Wuhan Third Hospital, which is affiliated to Wuhan University, from January to December 2020. Comorbidity data were extracted using the 10th edition of the International Classification of Diseases (ICD-10) from the hospital electronic medical record system, and the Charlson Comorbidity Index (CCI) was calculated using these data. Participants were divided into two groups according to whether pressure injury was present at admission. The baseline characteristics of the two groups were compared using Student's t-tests, Mann-Whitney U-tests, and chi-square tests. Univariate and multivariate logistic regression models were constructed to explore the relationship between CAPI and the CCI. Smooth curve fitting was used to show the relationship between the CCI and CAPI. By drawing the receiver operating characteristic curve, the CCI was used to predict CAPI.

RESULTS

A total of 5759 participants with an average age of 75.1 ± 7.6 were included in this population-based study. The prevalence of CAPI was 4.3%. In logistic regression analysis, there was a positive relationship between the CCI and CAPI after adjustment for sex, age, hypoproteinemia, and anemia (OR = 1.37, 95% CI = 1.29-1.45, p < 0.001, trend test p < 0.001). The area under the receiver operating characteristic curve was 0.75, and the maximum value of the Youden index was 0.35, with a critical value of 5.5.

CONCLUSION

The development of CAPI was positively correlated with the CCI. The risk of developing pressure injury increases with the number and severity of comorbidities. This study shows that the CCI has certain reference value in predicting CAPI.

Linking hospital and residential aged care: a nurse-led vascular-geriatric model of care

The interplay of frailty, multimorbidity and polypharmacy in the older person results in complex care needs. Monitoring and proactive management of chronic diseases in this context can be challenging. Early identification of deterioration reduces the risk of hospitalisation in older people, particularly in residential care, where the person can be particularly vulnerable. Deterioration of a resident often results in an expectation of in-hospital care, which especially where there are life-limiting conditions, may not align to the wishes of the person and their family. However, links between tertiary hospital services with the expertise to upskill and mentor those providing the more complex care to residents of aged care facilities need to be developed. Current models of care need to be adapted to incorporate the provision of specialist nursing within residential facilities to support higher-level care delivered in the person's familiar environment, improve the person and family experience, and reduce the costs and potential for iatrogenic problems associated with hospitalisation. Vascular dysfunction is common in aged care and results in impaired healing and complex wounds. We developed a Vascular and Geriatric (VaG) model of care to support specialist care for aged care residents with vascular dysfunction. The VaG model enhances existing links between hospital and residential care settings and builds workforce capacity in residential care facilities by the use of clinical consultation, peer learning and networking to increase the vascular skill set initially of the hospital outreach nurse and then modelled to residential care clinicians. This paper reports the development and implementation of the VaG model as part of the Aged Care Outreach Service.

Fresh Perspectives on Hospital-Acquired Neonatal Skin Injury Period Prevalence From a Multicenter Study: Length of Stay, Acuity, and Incomplete Course of Antenatal Steroids

The objective of this study was to explore neonatal skin injury period prevalence, classification, and risk factors. Skin injury period prevalence over 9 months and χ2, Mann-Whitney U, and independent-samples t tests compared injured and noninjured neonates, with P values less than .05 considered statistically significant. Injury prediction models were developed using Classification and Regression Tree (CART) analysis for the entire cohort and separately for those classified as high or low acuity. The study took place in 3 Australian and New Zealand units. Neonates enrolled (N = 501) had a mean birth gestational age of 33.48 ± 4.61 weeks and weight of 2138.81 ± 998.92 g. Of the 501 enrolled neonates, 206 sustained skin injuries (41.1%), resulting in 391 injuries to the feet (16.4%; n = 64), cheek (12.5%; n = 49), and nose (11.3%; n = 44). Medical devices were directly associated with 61.4% (n = 240) of injuries; of these medical devices, 50.0% (n = 120) were unable to be repositioned and remained in a fixed position for treatment duration. The strongest predictor of skin injury was birth gestation of 30 weeks or less, followed by length of stay of more than 12 days, and birth weight of less than 1255 g. Prediction for injury based on illness acuity identified neonates less than 30 weeks' gestation and length of stay more than 39 days were at a greater risk (high acuity), as well as neonates less than 33 weeks' gestation and length of stay of more than 9 days (low acuity). More than 40% of hospitalized neonates acquired skin injury, of which the majority skin injuries were associated with medical devices required to sustain life. Increased neonatal clinician education and improved skin injury frameworks, informed by neonatal epidemiological data, are vital for the development of effective prevention strategies.

Analysis of Factors Causing Skin Damage in the Application of Peripherally Inserted Central Catheter in Cancer Patients

Objective

To investigate the related factors of skin damage caused by peripherally inserted central catheter (PICC) in cancer patients.

Methods

It was a retrospective analysis of 202 cancer patients admitted to our hospital from February 2014 to July 2019. 50 cases of PICC-related skin damage and 152 cases of non-skin damage were studied. In addition, multivariate logistic regression analysis was used to determine independent risk factors for PICC-related skin damage, including cancer patients with catheter-related skin damage and patients without skin damage.

Results

50 patients with PICC skin damage (19 males and 31 females) and 152 patients without skin damage (62 males and 90 females) were retrospectively analyzed. The skin damage rate was 24.8%. The analysis of variance results showed that many factors are related to PICC catheter-related skin damage, including hormones (χ²/Z = 4.468, P < 0.05), body mass index (BMI) (χ²/Z = −2.443, P < 0.05), days with tube (χ² = 26.230, P < 0.05), chemotherapy cycle (χ²/Z = 25.638, P < 0.05), and self-care ability (χ²/Z = −1.968, P < 0.05). Logistic regression analysis showed that hormones (odds ratio (OR) = 3.896, P=0.045), BMI (OR = 1.129, P=0.017), days with tube (OR = 0.419, P=0.013), and chemotherapy cycle (OR = 3.302, P=0.028) are independent factors affecting PICC-related skin damage.

Conclusion

The independent influencing factors of skin damage during PICC catheterization are hormones, BMI, number of days with tube, and chemotherapy cycle.

Chronic wound care delivery in wound clinics, community nursing and residential aged care settings: A qualitative analysis using Levine's Conservation Model

AIMS AND OBJECTIVES

To explore patient experience of chronic wound care across diverse models of outpatient wound care delivery.

BACKGROUND

Chronic wounds represent a significant personal, family and healthcare system burden. Evidence suggests specialist wound clinics are more effective and less expensive, however, most outpatient wound care is delivered by general community nurses. There is little understanding of how patients experience diverse models of wound care delivery and the subsequent impact on their capacity to adapt to imbalances in their internal/external environment.

DESIGN

Descriptive, qualitative study.

METHODS

Eighteen patients with chronic wounds from three wound services were engaged in semi-structured interviews. Initial inductive analysis was refined deductively using Levine's Conservation Model.

RESULTS

Chronic wounds lead to imbalances and subsequent adaptions in energy conservation and personal, social and structural integrity. Nursing process and wound care system responses suggest specialist wound clinics provide access to the right person and care at the right time, with less care variation. The community nursing model is most effective with a small team of nurses and a documented care plan, with specialist wound nurse oversight. Residential aged care facilities emerged as important sites for wound care delivery revealing higher variance in care and less specialist wound oversight.

CONCLUSIONS

The application of Levine's conservation model provides a theoretical understanding and important insights into the patient experience of nurse and system elements across diverse models of wound care delivery. Specialist oversight by expert wound nurses with the capacity for medical specialist referral is the cornerstone of good wound care. A frequently reviewed wound care plan and skill development for nurses in primary, aged care and community settings are vital.

RELEVANCE TO CLINICAL PRACTICE

Shared care between specialist and primary care should include evidence-based pain assessment, clear referral pathways, collaborative relationships, telehealth capacity, patient-held wound plans and upskilling of frontline clinicians.

Skin integrity-the perpetual challenge

In an Essity-sponsored symposium, entitled 'Skin integrity-the perpetual challenge', three key opinion leaders discussed the importance of recognising and managing skin vulnerability in a patient-centred way. Peter Bradley summarises the main points they presented at the EWMA 2020 Virtual Conference This article offers an introduction to the symposium, Skin integrity-the perpetual challenge, held on 18 November 2020, as part of the EWMA 2020 Virtual Conference. There were three speakers. Dimitri Beeckman, Professor of Skin Integrity and Clinical Nursing, Ghent University, Belgium, focused on moisture lesions or MASD (moisture-associated skin damage). Karen Campbell, Consultant, Primacare Living Solutions and Adjunct Professor, MClScWH, Western University, London, Ontario, Canada, focused on the concepts related to skin vulnerability. She aimed to identify shared risk factors for skin conditions and ways to promote skin integrity, formulating a synergistic prevention approach to break down barriers in practice. The third speaker was Alessandro Corsi, Wound Care Consultant and Surgeon, Director of Wound Care Unit, IRCCS San Raffaele Hospital, Milan. He looked in detail at the dressings available in this area, detailing how he and his team had successfully used the Essity line of Skin Sensitive silicone dressings in their hospital.

Skin injury prevention and treatment in the older person: reframing our approach in the community setting

In the past, maintaining skin integrity has been synonymous with preventing and treating a single skin injury, namely pressure injury. However, there is growing recognition that this single-injury approach overlooks the multitude of skin injuries that may be sustained by older people. This article proposes that reframing the approach to skin integrity care away from the single-injury focus and towards a comprehensive and holistic paradigm is imperative. Guided by the Skin Safety Model, this article presents a case study illustrating comprehensive skin integrity assessment and care planning for an older person in the community setting. It is hoped that the information presented will guide community nurses in addressing skin injuries experienced by older adults in holistic and comprehensive way.

An Integrative Review of Clinical Characteristics of Infants With Diaper Dermatitis

BACKGROUND

Diaper dermatitis (DD) severity is demonstrated by the degree of erythema and skin breakdown. Many studies describe diaper dermatitis, but lack a full description of clinical characteristic (CC) involvement.

PURPOSE

The purpose of this literature review is to explore the descriptions of CC of infants with DD provided within infant DD literature.

SEARCH STRATEGY

PubMed and Web of Science were searched using the keywords: diaper dermatitis, diaper rash, infant, and neonate. The inclusion criteria for this project are as follows: published after 1990, English language, include skin assessment or evaluation, and infant/children < two years of age. Review and opinion articles were excluded.

RESULTS

A total of 454 studies were retrieved, 27 remained after review for duplicates and relevance. The CC described most often were: type of feeds, stool frequency, history of DD, use of antibiotics, and delivery mode.

SYNTHESIS OF EVIDENCE

The studies reported inconsistent CC and a lack of correlation between these characteristics and the condition of diapered skin. Many studies focused solely on the efficacy of interventions lacking description of possible relationships between DD and CC.

IMPLICATIONS FOR PRACTICE

Skin condition outcome variables can be improved with the acknowledgment of the impact CC have on the development of DD. The combination of assessment measures and CC may ultimately demonstrate more merit or rigor for describing DD severity and skin condition.

IMPLICATIONS FOR RESEARCH

Future research should expand this exploration to include environmental or contributing factors to continue to identify additional risk factors for DD.

Neonatal skin assessments and injuries: Nomenclature, workplace culture and clinical opinions-Method triangulation a qualitative study

AIM AND OBJECTIVE

To explore and establish the language, clinical opinions and workplace culture around neonatal skin injury nomenclature. Specifically, what nomenclature is used to describe, define, identity and communicate neonatal skin injuries including (a) terms, (b) locations, (c) associated risks and (d) mechanical forces.

BACKGROUND

Skin injuries are affirmed or denied based on visual assessment with findings reported by language rather than measurements. However, if language or nomenclature is ambiguous, assessments could be misinterpreted effecting healthcare delivery.

DESIGN

Qualitative enquiry including applied discourse analysis and between-method triangulation, within a larger exploratory mixed-methods study.

METHODS

Data were collected over two years from four sources: literature, documents, interviews/focus groups and free text injury assessments. Data analysis included content analysis, selective coding and thematic analysis. The collective data were further explored using discourse analysis and triangulation to achieve collective conclusions about opinions, emotions, feelings, perceptions and workplace cultures. The COREQ checklist provided structure for the reporting of study methods, analysis and findings.

RESULTS

A total of 427 data points were collected from literature, documentation and two clinical data sources. Data convergence revealed that neonatal skin injuries are described by numerous terms with preferences for "injury," "trauma" or "redness." Injuries occur in over 20 anatomical locations and risks for injuries included hospitalisation, specific treatments and prematurity. Essential medical devices, clinical condition, lack of clinician experience and overactive neonates were uniquely associated risks. There was incongruency between sources. The literature and documents empathise pressure as the primary force related to skin injury, while varied forces were identified within interviews, focus groups and free text injury assessments.

CONCLUSIONS

The variety of unique terms, locations and risks for injury indicate the need for updated neonatal skin injury frameworks. If frameworks and policies continue to be created without the empirical knowledge of neonatal clinicians, misrepresentation of neonatal skin injury locations and risk will continue to dominate the literature.

RELEVANCE TO CLINICAL PRACTICE

The recognition and management of neonatal skin injuries are related to language used to describe assessments in the absence of diagnostic confirmation, which has implications for both the neonate and the healthcare team.

Medical Adhesive-Related Skin Injuries and Associated Risk Factors in a Pediatric Intensive Care Unit

OBJECTIVE

To investigate the prevalence of medical adhesive-related skin injuries (MARSIs) and associated risk factors in a pediatric ICU (PICU).

METHODS

A cross-sectional design was adopted in the PICU of a university-based children's hospital in eastern China. A total of 232 patients were enrolled, and 611 person-days were analyzed.

MAIN OUTCOME MEASURES

Researchers assessed all patients daily for 2 weeks. The use of adhesives and prevalence of MARSIs were recorded. The patients' clinical data were also collected. The prevalence of MARSIs was calculated daily, and the risk factors were examined statistically.

MAIN RESULTS

The MARSI prevalence ranged from 23.53% to 54.17% (mean, 37.15%). Multivariate analysis identified being female, age 2 years or younger, hospital stays longer than 5 days, infection, edema, and surgery as independent risk factors. Prevalence by product ranged from 19 to 53 per 1,000 product-days with a mean of 34 MARSIs per 1,000 product-days. The major MARSI types were epidermal stripping and skin tear. The face was the most common MARSI site, and tracheal intubation was the most common inciting condition. Implicated products were acrylate tapes with elastic cloth backings.

CONCLUSIONS

Researchers concluded that MARSI is common in the PICU. Skin stripping and skin tear were the most common types, and the face was the most vulnerable site for MARSI, typically attributable to the cloth tape used to affix tracheal intubation. Careful attention should be paid to children with identified risk factors (females, age 2 years or younger, longer hospital stays, edema, infection, or surgery).

Nursing diagnoses for institutionalized elderly people based on Henderson's theory

OBJECTIVE

To develop nursing diagnostic statements for institutionalized elderly people.

METHOD

Descriptive study conducted with elderly subjects of a Long Stay Institution through the application of forms for the support of anamnesis and physical examination and a search of medical records. The diagnostic statements were developed based on the International Classification for Nursing Practice and categorized according to the Henderson's theoretical model.

RESULTS

Participation of 203 elderly people. A total of 153 nursing diagnoses were developed and distributed as follows: 115 (75.1%) in the Biological/Physiological Component, 14 (9.1%) in the Psychological Component, 21 (13.7%) in the Social Component, and three (1.9%) in the Spiritual/Moral Component.

CONCLUSION

The diagnostic statements portray situations of vulnerability to the health of institutionalized elderly that are influenced by biological, psychological, social and cultural factors and require a systematized, individualized and resolutive care for this public.

Enhancing SKIN health and safety in aged CARE (SKINCARE Trial): a study protocol for an exploratory cluster-randomized pragmatic trial

BACKGROUND

Aged long-term care receivers are affected by various adverse skin conditions like pressure ulcers, incontinence-associated dermatitis, dryness, intertrigo, and many more. Prevention of these skin problems and the provision of general hygiene and skin care activities are key areas of nursing practice. Numerous condition-specific guidelines are available and are implemented separately. On the other hand, there is huge overlap in terms of etiology, pathogenesis, and prevention of the skin conditions mentioned above. This leads to fragmented practice neglecting shared etiologies and prevention and treatment principles.

METHODS

The overall aims of this trial are to test the feasibility and to estimate possible effects of the implementation of a comprehensive skin care and prevention strategy targeting main nursing-relevant skin problems at the same time. A two-arm cluster-randomized controlled trial will be performed in 20 nursing homes randomly selected from the population of nursing homes of the state of Berlin, comparing skin care according to the skin care and prevention strategy with standard skin care.

DISCUSSION

It is expected that the implementation of this evidence-based skin care and prevention strategy will reduce the incidence of pressure ulcers, incontinence dermatitis, and other skin problems frequently related to care dependency. This trial will benefit individual patients and aged nursing home residents in general given the high prevalence and incidence of the addressed skin conditions. Findings of this exploratory trial may lay the foundation for a change in the development and evaluation of clinical standards and practices in general as it moves the perspective from individual conditions to a more comprehensive view on overlapping or coexisting health problems, in this case common skin conditions, in old-age long-term care receivers.

TRIAL REGISTRATION

The study is registered at the German Clinical Trials Register https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015680 (Deutsches Register Klinischer Studien, or DRKS; registration number: DRKS00015680 , date of registration: January 29, 2019) and ClincialTrials.gov (registration number: NCT03824886 , date of registration: January 31, 2019).

The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation

AIMS AND OBJECTIVES

To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI).

BACKGROUND

CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning.

DESIGN

Longitudinal qualitative study using Heideggerian phenomenology.

METHODS

Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed.

RESULTS

Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity).

CONCLUSIONS

Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy.

RELEVANCE TO CLINICAL PRACTICE

A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.

Medical Adhesive-Related Skin Injury Prevalence at the Peripherally Inserted Central Catheter Insertion Site: A Cross-sectional, Multiple-Center Study

PURPOSE

We examined prevalence and associated risk factors of medical adhesive-related skin injury (MARSI) at the peripherally inserted central catheter (PICC) insertion site in hospitalized oncology patients in Guangxi, China.

DESIGN

A cross-sectional, multiple-center epidemiological study.

SUBJECTS AND SETTING

The sample comprised 697 adult inpatients at 4 tertiary hospitals (3 general hospitals and 1 oncology hospital). The facilities are located in the western China.

METHODS

Trained nurses examined and assessed all subjects' skin exposed to medical adhesive during PICC maintenance process followed by recording the morphological features of the skin lesions, complaints of the patients, and information of catheter maintenance. Data related to patient demographics, PICC insertion information, disease, and laboratory parameters were collected through the electronic medical record. The prevalence of MARSI was calculated statistically and risk factors were examined using a logistic regression model.

RESULTS

A total of 697 patients (mean age, 48.86 years; range, 18-89 years) were enrolled. The prevalence of MARSI was 19.7% (137/697), including mechanical skin injury 5.0% (35/697), contact dermatitis 14.8% (103/697), folliculitis 1.0% (7/697), and moisture-associated skin damage 1.3% (9/697). There were significant differences in presence of MARSI and age, diagnoses, body mass index, smoking history, indwelling time of PICC, types of dressing, types of antiseptic, a history of MARSI, and skin allergies (P < .05). Multivariate analysis identified 50 years or older (odds ratio [OR], 2.202; 95% confidence interval [CI], 1.222-3.968; P = .009), a history of MARSI (OR, 14.834; 95% CI, 6.534-33.680; P = .000) as independent risk factors for MARSI. Additionally, type of transparent film dressing used was a risk factor for MARSI (OR, 3.292; 95% CI, 1.092-9.923; P = .034).

CONCLUSION

The prevalence of MARSI is significant in hospitalized oncology patients in China. Our study provided new knowledge for the epidemiology of MARSI and identified high-risk population, which will guide clinical nursing practice and ensure patient safety.

Prevalence of medical adhesive-related skin injury at peripherally inserted central catheter insertion site in oncology patients

Introduction:

The aim of our study was to identify the prevalence and risk factors of medical adhesive-related skin injuries (MARSI) at peripherally inserted central catheters (PICC) insertion site in oncology patients.

Methods:

A cross-sectional observational study lasting two weeks was carried out in four inpatient departments. Skin assessment data and photographs of skin were collected during PICC maintenance. Other related information came from medical records. The skin injuries were classified by dermatologists and PICC specialized nurses. MARSI prevalence was calculated and the associated factors were analyzed statistically.

Results:

All 419 patients were included. The prevalence of total MARSI at PICC insertion site was 125, (29.83%), including mechanical skin injury (73, 17.42%), contact dermatitis (CD) (39, 9.31%), moisture-associated skin damage (11, 2.63%), folliculitis (2, 0.48%). Multivariate analysis identified two independent risk factors for MARSI including age ≥50 y (p = 0.031, odds ratio [OR] = 4.521, 95% confidence interval [CI] [1.389, 20.620]) and hematologic malignancies (p = 0.000, OR = 2.514, 95% CI [1.590,3.97]. Oxaliplatin and arsenic trioxide infusion through PICC, history of skin allergies was associated with CD, with p = 0.020, OR = 3.492, 95% CI (1.220, 9.990); p = 0.003, OR = 4.565, 95% CI (1.661,12.547); p = 0.000, OR = 12.333, 95% CI (3.669, 41.454), respectively.

Conclusions:

MARSI at PICC insertion site is a frequent event among oncology patients. Epidemiological data and independent risk factors are presented in our study, which provide a basis for future study in this area.

Beware of the toilet: The risk for a deep tissue injury during toilet sitting

A pressure injury (PrI) compromises quality of life and can be life-threatening. The fundamental cause of PrIs is sustained deformations in weight-bearing soft tissues, e.g., during prolonged sitting on inadequate surfaces such as a toilet seat. In nursing homes and geriatric facilities, patients need assistance using the restroom, and patients being left on the toilet for tens-of-minutes is a real-world scenario, unfortunately. Nevertheless, there are no published studies regarding sustained tissue loads during toilet sitting and their effects on tissue physiology. Here, the biomechanical and microcirculatory responses of the buttock tissues to toilet sitting were investigated using finite element modeling and cutaneous hemodynamic measurements, to explore the potential etiology of PrIs occurring on the toilet. We found that prolonged sitting on toilet seats involves a potential risk for PrI development, the extent of which is affected by the seat design. Additionally, we found that specialized toilet seat cushions are able to reduce this risk, by lowering instantaneous tissue exposures to internal stresses (by up to 88%) and maintaining reduced interface pressures. Furthermore, hemodynamic variables were altered during the toilet sitting; in particular, tcPO₂ was decreased by 49% ± 7% (44 ± 2[mmHg] to 22 ± 4[mmHg]) during sitting. The current study confirms that investing in expensive PrI prevention (PIP) products is likely to be ineffective for an immobilized patient who is left to sit on a bare toilet seat for long times. This argument highlights the need for a holistic-care approach, employing PIP devices that span across the entire environment where bodyweight forces apply to tissues.

Skin care in nursing: A critical discussion of nursing practice and research

Skin (self-)care is part of human life from birth until death. Today many different skin care practices, preferences, traditions and routines exist in parallel. In addition, preventive and therapeutic skin care is delivered in nursing and healthcare by formal and informal caregivers. The aim of this contribution is a critical discussion about skin care in the context of professional nursing practice. An explicit skin assessment using accurate diagnostic statements is needed for clinical decision making. Special attention should be paid on high risk skin areas, which may be either too dry or too moist. From a safety perspective the protection and maintenance of skin integrity should have the highest priority. Skin cleansing is the removal of unwanted substances from the skin surface. Despite cleansing efficacy soap, other surfactants and water will inevitably always result in the destruction of the skin barrier. Thousands of products are available to hydrate, moisturize, protect and restore skin properties dependent upon their formulation and the concentration of ingredients. These products intended to left in contact with skin exhibit several actions on and in the skin interfering with skin biology. Unwanted side effects include hyper-hydration and disorganization of lipid bilayers in the stratum corneum, a dysfunctional barrier, increased susceptibility to irritants and allergies, and increases of skin surface pH. Where the skin barrier is impaired appropriate interventions, e.g. apply lipophilic products in sufficient quantity to treat dry skin or protect the skin from exposure to irritants should be provided. A key statement of this contribution is: every skin care activity matters. Every time something is placed on the skin, a functional and structural response is provoked. This response can be either desired or undesired, beneficial or harmful. The choice of all skin care interventions in nursing and healthcare practice must be based on an accurate assessment of the skin and concomitant health conditions and on a clearly defined outcome. A standardized skin care and skin care product language is needed for researchers planning and conducting clinical trials, for reviewers doing systematic reviews and evidence-base summaries, for nurses and other healthcare workers to deliver evidence-based and safe skin care.