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©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

Considerations for Bariatric Patients in Pressure Injuries and Wound CareApril 27, 2017

Susan S Morello BSN RN CWOCN CBN

Clinical Consultant

s-morello@hotmail.com

npuap.org

NPUAP MissionThe National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research.

©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

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©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

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• Pressure Injury Definition and Stages

• Prevention of Pressure Injury

• Treatment of Pressure Injury

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©2016 National Pressure Ulcer Advisory Panel | www.npuap.org

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THANK YOU to the following companies that have provided support for this webinar!

• Acelity

• American Medical

Technologies

• ArjoHuntleigh

• Coloplast

• Dabir Surfaces

• Leaf Healthcare

• Medline

• Mölnlycke

The NPUAP webinar commercial supporters

did not have any input regarding the

content of this presentation.

THANK YOU to the following companies that have provided support for this webinar!

• Permobil

• Position Health

• Select Medical

• Sizewise

• Span America

• Stryker

• Tamarack Habilitation

Technologies

• Wellsense

The NPUAP webinar commercial supporters

did not have any input regarding the

content of this presentation.

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Faculty Disclosure

The faculty member has listed no financial

interest/arrangements that would be

considered a conflict of interest.

• Susan S Morello BSN RN CWOCN CBN

Planning Committee Disclosures

• Jeffrey Levine, MD

• Mary Litchford, PhD, RD, LDN

• Sally O’Neill, PhD

• Mary Sieggreen, MSN, CNS, NP, CVN

The planning committee members have listed

no financial interest/arrangements that would

be considered a conflict of interest.

©2017 National Pressure Ulcer Advisory Panel | www.npuap.org

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Objectives

• Examine the factors which have an

impact on skin issues of the bariatric

patient

• Discuss prevention and treatment of skin

injuries when caring for a bariatric

patient

• Describe factors to be considered when

selecting a support surface, seat cushion

and/or other specialty equipment for a

bariatric patient

International GuidelinesRecommendations for Organizations

1.“Provide safe, respectful care and avoid

injuries to both the individual and health

professional.” C

2.“Maximize workplace safety by

implementing organization-wide bariatric

management strategies that address

manual handling techniques.” C

3.“Provide pressure redistribution support

surfaces and equipment appropriate to the

size and weight of the individual.” C

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Basic Considerations for the Bariatric Population

• There is nothing that makes an obese

person ordinary when it comes to being a

patient or a resident.

• BMI is not a way to evaluate the size of a

person. It is an instrument for evaluating

the “at risk” status of the individual.

• Sensitivity and respect are paramount

when caring for persons of size.

Skin Changes in the Bariatric Person

• Reduced tissue perfusion

• Compromise of moisture barrier

– Trans-epidermal Water Loss (TEWL)

– Lipid release

– Friction

• Chronic inflammation

– Pro-inflammatory cytokines

• Thinning of skin

Aggressive prevention is mandatory!

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Prevention of Skin Injuries

• Assessment

• Proper support surface

• Skin care

• Skin injury prevention protocols

Assessments

• Skin Assessment

– Skin Risk Assessment Tool

– Skin folds

• Look inside the folds…all places there is skin on

skin

– Pressure areas

• Not just bony prominences

• Differentiate

– Moisture Associated Skin Damage (MASD)

• Identify area

– Lymphedema and Lipedema

• Nutritional Assessment

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Support Surface Selection

• Weight capability is only one factor

– Important that those who make purchase

and rental decisions understand this.

• Width measurement

– At widest point of body…standard surfaces

are 32-36 in. or 81-91 cm.

• Address pressure redistribution

– Active or passive

– Cells vertical or horizontal

Selection…cont.

• Addressing microclimate

– How does one remove excess moisture,

control the temperature…

• Address friction/shear

– What will reduce or increase friction?

– What will reduce or increase shear?

• Address egress and ingress

– Consider hi-low bed

• Is the bed self-propelled?

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Seating

• Wheelchairs should be properly sized for

patient/resident and single patient use.

Sides should not bind. Adjustable parts

should have proper padding to avoid any

sharp edges.

• Seat cushions should be specific for

patient and, properly fitted and

prescribed by a professional and

reevaluated at least yearly better every 6

months.

Skin Care

• Cleanse

– Daily cleansing in all problem areas…skin

folds, under breasts, perineal area and any

other areas of excessive moisture

– pH appropriate products

– Pat dry

• Moisturize

– Humectants or emollients or combo of both

• Protect

– Moisture barrier crème

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Skin Injury Prevention Protocols

• Assessment:

– Skin…daily in all settings, ICU and post-op

require at each shift or more often

– Nutritional…on admission, then monitor and

re-evaluate at any condition change

• Support surface:

– Use of bariatric bed and mattress

– Established algorithm for support surface

selection, unit specific and based on

individual needs

Prevention Protocols cont.

• Support surface cont.

– Should be available on admission

– Available in E.D., radiology, interventional

radiology, pre-op, OR, post-op

• Skin Care

– Areas of excessive moisture may need to be

cleansed several times daily

– Apply moisturizer frequently during the day

– Use of wicking products should be used in

skin folds

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Prevention Protocols cont.

• Pressure Injury

– Turning and repositioning schedule based on

individual need….bed and chair. Select

positioning devices with care.

– Monitor HOB

– Early and often mobilization

– Consider use of a prophylactic dressing

– Consider use of friction/shear reducing

linens, bed linens and gowns

– Monitor adequate hydration and nutrition

– Moisturize, moisturize, moisturize

Prevention cont.

• Medical devices

– Monitor sites frequently and address any

reddened or irritated area immediately

– Obtain bariatric trach ties, bed pans,

catheters

• Tubes and tubing

– Keep them where you can see them

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Treatment Protocols

All of the preventions listed above, and…

• Turning and Positioning

– Avoid positioning on pressure injury site(s)

– Avoid positioning devices that create heat

– May need to reposition and/or turn more

frequently

• Dressings…pressure and other skin

injury

– Often curl when used, monitor carefully and

replace as needed. Moisture may prevent

adherence.

– Skin is already fragile…avoid tape when

possible

Treatment cont.

• Skin Injuries

– MASD

– Intertriginous dermatitis

– Wound dehiscence

– Skin tears

• Medical devices

– Use bariatric appropriate size

– Monitor sites frequently during the day

– Reposition devices if irritation or injury

occurs

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Bariatric Equipment

• Safety for patient

– Always obtain proper bariatric equipment

both size and durability appropriate

– Beds, chairs, wheelchairs, stretchers, canes,

lifts, slings, transfer devices, OR tables,

seating cushions…bariatric only

– Slings must be in good condition and

compatible with lift

– Have any device brought from home checked

Bariatric Equipment

• Safety for patient and caregiver

– Caregiver should not lift, turn or transfer a

bariatric patient manually. Use of equipment

is needed.

– Equipment must be in proper working

condition, inspected frequently and removed

if damaged in any way.

– Proper instructions for use of equipment

should accompany equipment and in-service

provided for its use.

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Bariatric Equipment

– Proper equipment provides best measure of

safety and care for patient as well as

caregiver

– See Safe Patient Handling Guidelines for

information

• https://www.publichealth.va.gov/employeehealth/pa

tient-handling/

***Documentation***

Sensitivity

• Respect for every patient

• Reconsider the use of terms like big bed,

large chair….use “another” or “better” or

“more comfortable”

• Recognize that obesity is not just a

personal problem. It is a universal health

problem with major health

consequences.

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Thank you for listening!

s-morello@hotmail.com

References

1. Bergman, R., Stefanovski, D., Buchanan, T., et al. (2011). A Better Index of Body

Adiposity. Retrieved June 5, 2014 from http://www.ncbi.nlm.nih.gov/pubmed/21372804

2. Black, J., Gray, M., Bliss, D., et al. (2011). MASD Part 2: Incontinence-associated dermatitis

and intertriginous dermatitis. Journal of Wound, Ostomy and Continence Nursing, 38(4),359-

370.

3. Gray, M., Black, J., Baharestani, M., et al. (2011) MASD Part 1: Overview and

pathophysiology. Journal of Wound, Ostomy and Continence Nursing, 38, 233-241.

4. Guo, S. & de Pieto, L. (2010). Factors affecting wound healing. Journal of Dental Research,

89(3), 219-229.

5. Kennedy-Evans, K., Henn, T., & Levine, N. (2007) Skin and wound care for the bariatric

patient. In Chronic wound care: a clinical sourcebook for healthcare professionals (4th ed. pp.

659-699). Malvern, PA: HMP Communications

6. Lowe, J. (2008) Skin integrity in in critically ill obese patients. Critical Care Nursing Clinics

of North America, 21(3), 311.

7. Morello, S. (2016) Skin and wound care for the bariatric population. In Wound, Ostomy and

Continence Nurses Society Core Curriculum Wound Management. (pp. 242-252).

Philadelphia, PA: Walters Kluwer.

8. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan

Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical

Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osbourne Park, Western Australia;

2014.

9. O’Lenick, A. (2009). Comparatively Speaking: Humectants vs Emollients vs Occlusive

Agents. Retrieved July 11, 2014 from http://www.cosmeticsandtoiletries.com

.

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