19808303
Description
Mind Map by Anndee Moon, updated more than 1 year ago
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Created by Anndee Moon
almost 5 years ago
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Moisture Associated Skin Damage
- Intertriginous Dermatitis (ITD)
- Risk Factors:
- Hyperhidrosis
- Obesity
- Pendulous breasts
- Deep skin folds
- Immobility
- Diabetes
- Hyperhidrosis
- Excessive Moisture:
sweat and sebum
- Increased TEWL
and higher pH
- Secondary fungal or
bacterial infections
- Fungal
- Bacterial
- Hemolytic streptococcus
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Cornyeobacterium
- Proteus mirabilis
- Hemolytic streptococcus
- Fungal
- Increased TEWL
and higher pH
- Symptoms
- Burning
- Itching
- Redness
- Scaling
- Satellite rash if
fungal
- Burning
- Interventions
- Keep skin clean and dry
- Dust with absorbant skin
barrier powder
- Spearate skin surfaces with skin
barrier, sealant, or soft cotton
material
- Commercially available textiles
to wick away moisture
- Keep skin clean and dry
- Risk Factors:
- Peristomal
- Risk Factors:
- Urine
- Stool
- Chemical irritants
- mechanical injury:
pouching system
- Excessive exposure to
urine, stool or mucus from
ostomy
- Can also be caused by
irritation fro removal of
pouch
- Can also be caused by
irritation fro removal of
pouch
- Urine
- Symptoms
- Erythema
- weepy
- shallow ulcerations
- Erythema
- Interventions
- Determine cause of leakage
- routine skin cleanser
and moisturizer
- skin sealant, skin barrier
ointment, skin barrier
paste or solid wafer to
protect skin
- Adequately
absorbative dressing
- Change dressing
before saturated
- Determine cause of leakage
- Risk Factors:
- Periwound
- Risk Factors:
- Wound exudate
- chemical irritants
- mechanical injury
- Acute vs chronic
- infected vs not infected
- Wound exudate
- Inflammation and erosion of
the skin associated with
exudate or bacteria from the
wound
- Exudate Assessment
- Sanguinous
- Maceration potential
- Maceration potential
- Serosanguious
- Maceration potential
- Maceration potential
- Serous
- Maceration Potential
- Maceration Potential
- Seropurulent
- Increased MMPs, toxins
- Increased MMPs, toxins
- Purulent
- Increased MMPs, toxins, can't absorb
- Increased MMPs, toxins, can't absorb
- Sanguinous
- Interventions
- Cleanser and moisturizer to
keep skin clean and dry
- Skin sealant, skin barrier
ointment, skin barrier paste, or
solid wafer to protect skin
- Change dressings
before saturated
- Use low air loss support
surface for moisture control
of large surface areas
unable to be protected by
dressings
- Cleanser and moisturizer to
keep skin clean and dry
- Risk Factors:
- Incontinence Associated Dermatitis (IAD)
- Risk Factors:
- fecal incontinences
- Urinary incontinence
- fecal incontinences
- Inflammatory response to
the injury of
water-protein-lipid matrix
of the skin
- Signs
- Erythema
- Swelling
- Oozing
- Vesiculation
- Crusting, scaling
- Burning
- Itching
- Erythema
- Intervention
- Treat etiology
- Identify at risk patients
- Absorptive padding and
change when saturated
- Mild incontinence
skin cleanser
- Moisturizer to skin
- Skin barrier
- Condom cath or
external pouch
- Indwelling catheters
- Skin sealant
- Change
undergarment
often
- Treat etiology
- Risk Factors:
- Prevention and Treatment
- Liquid acrylates
- Skin prep
- Skin prep
- Ointments
- Petroleum, xinc oxide, dimethicone
- Petroleum, xinc oxide, dimethicone
- Windowed dressings
- Barrier products around wounds
- Barrier products around wounds
- External collection devices
- Ostomy pouches/wound managers
- Ostomy pouches/wound managers
- Reduce exudate and edema
- Compression, elevation
- Compression, elevation
- Super absorbent dressings
- Hydrofibers, calcium alginates, foams
- Hydrofibers, calcium alginates, foams
- Liquid acrylates
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