Challenges in classification of gluteal cleft and buttocks wounds: consensus session reports.

The damaging effects of moisture, pressure, friction, and shear on human tissue are well-known among wound care experts. Nevertheless, accurate classification of these lesions is frequently challenging, even for experienced wound clinicians. The authors gathered clinical illustrations of gluteal cleft wounds and conducted a literature search as a basis for presentation to conference attendees, with the goal of gaining consensus regarding guidelines for accurate classification of these wounds. The aim of this article was to summarize results of the consensus sessions that occurred at the Wound Ostomy Continence Nurses' Society National conferences in 2011 and 2012, and to highlight areas where consensus has been achieved as well as areas in which consensus has not yet been reached.

Peristomal moisture-associated skin damage in adults with fecal ostomies: a comprehensive review and consensus.

Approximately 1 million persons living in North America have an ostomy, and approximately 70% will experience stomal or peristomal complications. The most prevalent of these complications is peristomal skin damage, and the most common form of peristomal skin damage occurs when the skin is exposed to effluent from the ostomy, resulting in inflammation and erosion of the skin. Despite its prevalence, research-based evidence related to the assessment, prevention, and management of peristomal moisture-associated skin damage is sparse, and current practice is largely based on expert opinion. In order to address current gaps in clinical evidence and knowledge of this condition, a group of WOC and enterostomal therapy nurses with expertise in ostomy care was convened in 2012. This article summarizes results from the panel's literature review and summarizes consensus-based statements outlining best practices for the assessment, prevention, and management of peristomal moisture-associated dermatitis among patients with fecal ostomies.

Differential assessment of trunk wounds: pressure ulceration versus incontinence associated dermatitis versus intertriginous dermatitis.

Differential assessment of trunk wounds is a critical element of their effective management. In reviewing the pathology and typical presentation for pressure necrosis, IAD, and ITD, four factors provide guidance in differential assessment: location, depth, characteristics, and exposure. Pressure ulcers are full-thickness lesions located over bony prominences or under medical devices. IAD and ITD are superficial lesions that occur in areas exposed to urine and/or stool (IAD) or trapped perspiration (ITD). Undermining and tunneling are common features of pressure ulcers, but never occur with IAD or ITD. Similarly, pressure ulcers frequently present with tissue necrosis, whereas ITD and IAD are commonly associated with maceration of the surrounding skin.

Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges.

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.

Incontinence-associated dermatitis: a comprehensive review and update.

In 2009, a multinational group of clinicians was charged with reviewing and evaluating the research base pertaining to incontinence-associated dermatitis (IAD) and synthesizing this knowledge into best practice recommendations based on existing evidence. This is the first of 2 articles focusing on IAD; it updates current research and identifies persistent gaps in our knowledge. Our literature review revealed a small but growing body of evidence that provides additional insight into the epidemiology, etiology, and pathophysiology of IAD when compared to the review generated by the first IAD consensus group convened 5 years earlier. We identified research supporting the use of a defined skin care regimen based on principles of gentle perineal cleansing, moisturization, and application of a skin protectant. Clinical experience also supports application of an antifungal powder, ointment, or cream in patients with evidence of cutaneous candidiasis, aggressive containment of urinary or fecal incontinence, and highly selective use of a mild topical anti-inflammatory product in selected cases. The panel concluded that research remains limited and additional studies are urgently needed to enhance our understanding of IAD and to establish evidence-based protocols for its prevention and treatment.

Issues related to accurate classification of buttocks wounds.

PURPOSE: This study was designed to determine the level of agreement among wound care nurses when asked to classify the etiology of 9 wounds located on the buttocks and within the intergluteal cleft. SUBJECTS: Study subjects were 100 wound care nurses who responded to an invitation placed on the WOCN Society's wound care forum and to an e-mail sent to members of the WOCN Iowa Affiliate. METHODS: Respondents were asked to view 9 unique wound photos and to determine whether the primary etiologic factor was pressure, moisture, incontinence-associated dermatitis, or skin tear. Subjects were given no background information regarding the patients but were allowed to add comments. RESULTS: The overall κ analysis of the 9 photos combined was 0.1708 (99% confidence interval, 0.1630-0.1786). The testing of the overall κ for the 9 photos equaling "0" or mere chance produced a P < .0001. Analyses revealed that the agreement between the 100 respondents for the 9 photos was only 17% better than chance alone. In summary, our study revealed only "Slight Agreement" between wound care nurses' classifications of photo subgroups or for all 9 photos analyzed together. IMPLICATIONS: Accurate wound classification impacts not only treatment decisions but also reimbursement, risk of litigation, and accuracy of data regarding prevalence and incidence of pressure ulcers. It is, therefore, critical for professional societies such as the WOCN to begin development of consensus definitions and guidelines to ensure consistency and accuracy in wound classification.

Regulatory guidelines for bladder management in long-term care: are you in compliance with F-Tag 315?

In 2005, the US Centers for Medicare & Medicaid Services established new guidelines for bladder management in long-term care. The key elements of the new regulations include appropriate use and management of indwelling catheters, individualized assessment and management of individuals with lower urinary tract dysfunction or incontinence, and evidence-based management of urinary tract infections. A specific expectation is that incontinent residents who are ambulatory with assistance and who respond to cues to void should be placed on a toileting program and not simply placed in absorptive products. This article provides specific guidelines for the implementation of the new regulations for bladder management in long-term care.

Incontinence-associated dermatitis: a consensus.

Incontinence-associated dermatitis (IAD) is an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. Little research has focused on IAD, resulting in significant gaps in our understanding of its epidemiology, natural history, etiology, and pathophysiology. A growing number of studies have examined clinical and economic outcomes associated with prevention strategies, but less research exists concerning the efficacy of various treatments. In the clinical and research settings, IAD is often combined with skin damage caused by pressure and shear or related factors, sometimes leading to confusion among clinicians concerning its etiology and diagnosis. This article reviews existing literature related to IAD, outlines strategies for assessing, preventing, and treating IAD, and provides suggestions for additional research needed to enhance our understanding and management of this common but under-reported and understudied skin disorder.

Issues and challenges in staging of pressure ulcers.

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.

Dressings and more: guidelines for topical wound management.

Principle-based topical therapy is a key element of effective wound care. Most products on the market provide passive support for wound healing by creating an environment favorable to repair (ie, clean, moist, insulated, and protected). There are also emerging therapies designed to actively manipulate the repair process. The clinician must make product decisions based on wound characteristics and response to treatment.