Skin & Wound Care Considerations in Special Populations:

Bariatric

Tucson Affiliate of the WOCN Society Conference

March 8, 2014

Karen Lou Kennedy-Evens RN, FNP, APRN-BC

Learning Objectives

• Describe the top three most common skin challenges in the bariatric population.

• Discuss the pathogenic factors contributing to these common alterations in skin integrity.

• Review the skin and wound care considerations of the most commonly seen skin challenges in the obese population.

Incidence of Obesity

• 35% of the world’s adults over 20 are overweight

• World wide obesity has doubled since 1980

Future Generation

Obesity increases risk of:• Hypertension• Type 2 diabetes• Coronary heart disease• Abnormal lipid concentrations• Delayed wound healing• Admissions to acute care, home care and out

patient clinics• Prolonged acute care to prevent complications

One-third of critical care patients are obese or morbidly obese.

Comorbities Associated with Obesity

Surgical/Post-op Complications

Loss is Skin Integrity due to:• Adipose has less blood supply inadequate

oxygenation• Excessive sweating increases skin moisture and

risk of bacterial/fungal invasion especially in deep folds

• Immobility friction and shear due to weight stress

• Malnutrition• Iatrogenic injury due to tubes, catheters and

other interventions

Skin Changes with Obesity• Stretch marks (striae)

• Hirsutism in women

• Aerochordons (skin tags)

• Acanthosis nigricans

Specific Skin/Wound Issues• Atypical pressure ulcers

• Perigenital irritant dermatitis

• Intertrigo

• Fungal infections

• Cellulitis

• Fournier’s gangrene

• Erythrasma

• Diabetic foot ulcers

• Venous insufficiency with possible ulceration

• Lymphedema

• Abdominal elephantiasis

• Surgical site infections– increased chance of dehiscence and evisceration.

Atypical Pressure Ulcers• Skin folds that create pressure on each

other– Neck– Upper back– Upper medial thigh– Flanks– Posterior legs– Pannus

• No risk assessment scales validated for the obese

Interventions

• Relief of pressure

• Skin fold management

• Moisture management

• Appropriate sized beds for repositioning

• Adequate staff for repositioning

• Fabrics

Perigenital Irritant Dermatitis

• Due to urinary and/or fecal incontinence

• Inability for self-care after toileting

• Environment not set up for bariatric clientele resulting in unable to cleanse and dry the urethral and rectal orifices/without the danger of falling

Intervention• Easy cleaning with appropriate equipment &

supplies– Toilet risers

– Extra wide toilet seats

– Bariatric commodes

– Hand rails for support

– Prepackaged cleansing & protection

– Perineal care with each incident

– Appropriate sized briefs and/or pads

– Drying fabrics

Intertrigo• Maceration due to excess moisture

• Infectious or noninfectious

• Friction from two opposed skin surfaces

• painful and/or pruritic

• Presents as:– Erythematous, macerated plaques

– Erosions with possible scaling

– Candida intertrigo: satellite papulo-pustules

– Found in perineal area, deep skin folds

Interventions

• Topical or oral antifungal

• Drying agents

• Fans or cool hair dryer

• Special textiles with drying and antimicrobial properties

Barriers to Skin Care• Body habitus

• Lack of bariatric equipment

• Inappropriate environmental design

• Caregivers fatigue

Bariatric Equipment

Staff/Patient/Family Education

• Bathing & hygiene

• Skin fold management

• Perigental care

• Toileting

• Odor management

• Caregiver injury prevention

Educational Props

Other issues

• Psychosocial issues

• Bariatric-specific surgery

References• Beitz, J., Providing quality skin and wound care for the bariatric patient:

An overview of clinical challenges . Ostomy Wound Management. Jan 2014

• Blackett A., Gallagher S., Dugan S., Gates J., Henn T., Kennedy-Evens K., Lutz J., Caring for persons with bariatric health care issues. Journal Wound Ostomy Continence Nursing. 2011

• Gallagher, S., The intersection of ostomy and wound management, obesity and associated science. Ostomy Wound Management Jan 2014

• Rush A, Muir M. Maintaining skin integrity in bariatric patients. Journal of Community Nursing. 2012

• World Health Organization. Obesity and Overweight. 2013. www.who.int/mediacentre/factssheet/

• Wound Ostomy Continence Nurses Society. Safety and Comfort issues for Nursing Care of the Obese Patient. Mt. Laurel, NJ. WOCN 2013