the role of barrier protection in pressure ulcer … role of barrier protection in pressure ulcer...

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S52 BritishJournalofNursing,2013(T issueViabilitySupplement),Vol22,No20 ©2013MAHealthcareLtd The role of barrier protection in pressure ulcer prevention Abstract This article considers the anatomy and physiology of the skin, the natural protection the skin provides in relation to barrier protection and the importance of barrier protection in pressure ulcer prevention. The current national pressure ulcer agenda including high impact actions and the SSKIN care bundle, along with their implementation within one NHS Health Care Trust are discussed. Key words: Barrier protection Pressure ulcer prevention SSKIN bundle T hemostsignificantroleoftheskinistobeaprotective barrieragainsttheexternalenvironment.Theskinis coveredwithanaturallyproducedlipidlayer,which helps to maintain moisture balance, prevents drying and provides an effective waterproof barrier. Normal skin pH is around 5.5, which significantly reduces the ability of bacteria to proliferate (Butcher andWhite, 2005). Skin drynessmayoccurfromexcessivewashingoruseofalkaline soaps, which alters the pH of the skin reducing its barrier function(Wysocki,2000).Bodilyfluidsincludingurineand faeces can waterlog, macerate and corrode the outer layer of the epidermis (stratum corneum) leading to weakening andbreakdownoftheskin,oftenpainfulinnature(Wounds International,2010).Astheskinages,theepidermisgradually thins and the papillae that lie between the epidermis and the dermis become flattened, reducing the skin’s resistance toshearingforces(Voegeli,2010)anditsabilitytoperform manyofitsessentialfunctions(Wysocki,2000). Skin assessment Identifying early signs of pressure damage is vital in the prevention of category II and II pressure ulcers. The European Pressure UlcerAdvisory Panel (EPUAP) (2009) and the National Institute for Health and Care Excellence (NICE)(2005)advocatethatessentialskinassessmentshould be undertaken and should be part of training for health professionals. Importantly, the need to protect vulnerable Jackie Stephen-Haynes areasoftheskinandpreventskinbreakdownisconsidered tobeacornerstoneofprofessionalcareacrossallspheresof practice (Voegeli, 2008). Consideration should be given in skinassessmenttoskinchangesintheolderperson(Wounds UK,2012)andskinchangesatlife’send(Sibbaldetal,2009). Newton and Cameron (2003) advocate four essential aspects of skin assessment: colour, texture, temperature and integrity.The skin should be observed for signs of colour change, reddening or blanching (white areas) in Caucasian skin types and for a bluish purple hue in darker skin types. Skin assessment should also include observation for increased heat, swelling, pain or guarding of an area and evidence of shiny areas or superficial breaks owing to shearing forces against the skin. The implementation of care rounds including assessing and monitoring of skin (Bartley, 2011) as part of harm-free care (Institute for Healthcare Improvement, 2011) has led to the implementation of a visual skin assessment during each care round (1–2 hourly) in community hospital and at each district nursing visit. Thomas-Hess (2000) proposesthefollowingkeyareasforskinmanagement: Take caution with the force applied when washing the skin and avoid massaging areas that could be easily damaged Offerpromptattentionwhenincontinentepisodesoccur andprotectionofskinwithbarrierprotection Aim to avoid drying of the skin through extremes of temperature Ensurethatpatientsarepositioned,transferredandturned properlytoavoidfrictionandshearforces Cleansetheskinatfrequentintervals,usingapH-balanced cleansingagentfollowedbymoisturisersandbarriercream. Pressure ulcer agenda There is a significant challenge in delivering high-quality carewhileimprovingitsefficiencyamidaneraofgrowing demandforhealthcareresources.InEngland,arecentWhite Paper,whichiscenteredonefficiencyimprovements,outlined governmentstrategytoaddresstheseissues(Departmentof Health (DH), 2010a).The Operating Framework for the NHS in England for 2012–13 requires that service quality andthepatientexperiencemustimprove,andproductivity increase (DH, 2012).The DH (2010a) identifies pressure ulcersasafutureoutcomeindicator,reportingthatin2007/8 therewere42 995episodesofpressureulcers.Pressureulcer preventionisanareathatisrecognisedashavingsignificant impact on quality of care and this has been increasingly elevated on political agendas in recent years.This is owing JackieStephenHaynesisProfessorinTissueViability,Professional DevelopmentUnit,BirminghamCityUniversityandConsultant Nurse,WorcestershireHealthandCareNHSTrust Accepted for publication: October 2013

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Page 1: The role of barrier protection in pressure ulcer … role of barrier protection in pressure ulcer ... This article considers the anatomy and physiology of the skin, ... responsible

S52� British�Journal�of�Nursing,�2013�(Tissue�Viability�Supplement),�Vol�22,�No�20

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The role of barrier protection in pressure ulcer prevention

AbstractThis article considers the anatomy and physiology of the skin, the natural protection the skin provides in relation to barrier protection and the importance of barrier protection in pressure ulcer prevention. The current national pressure ulcer agenda including high impact actions and the SSKIN care bundle, along with their implementation within one NHS Health Care Trust are discussed.

Key words: Barrier protection ■ Pressure ulcer prevention ■ SSKIN bundle

The�most�significant�role�of�the�skin�is�to�be�a�protective�barrier�against�the�external�environment.�The�skin�is�covered�with�a�naturally�produced�lipid�layer,�which�helps� to�maintain�moisture�balance,�prevents�drying�

and� provides� an� effective� waterproof� barrier.� Normal� skin�pH� is� around� 5.5,� which� significantly� reduces� the� ability�of� bacteria� to� proliferate� (Butcher� and�White,� 2005).� Skin�dryness�may�occur�from�excessive�washing�or�use�of�alkaline�soaps,�which� alters� the� pH�of� the� skin� reducing� its� barrier�function�(Wysocki,�2000).�Bodily�fluids�including�urine�and�faeces� can� waterlog,� macerate� and� corrode� the� outer� layer�of� the� epidermis� (stratum� corneum)� leading� to� weakening�and�breakdown�of�the�skin,�often�painful�in�nature�(Wounds�International,�2010).�As�the�skin�ages,�the�epidermis�gradually�thins� and� the� papillae� that� lie� between� the� epidermis� and�the� dermis� become� flattened,� reducing� the� skin’s� resistance�to�shearing�forces�(Voegeli,�2010)�and�its�ability�to�perform�many�of�its�essential�functions�(Wysocki,�2000).

Skin assessmentIdentifying� early� signs� of� pressure� damage� is� vital� in� the�prevention� of� category� II� and� II� pressure� ulcers.� The�European� Pressure� Ulcer�Advisory� Panel� (EPUAP)� (2009)�and� the�National� Institute� for�Health� and�Care�Excellence�(NICE)�(2005)�advocate�that�essential�skin�assessment�should�be� undertaken� and� should� be� part� of� training� for� health�professionals.� Importantly,� the� need� to� protect� vulnerable�

Jackie Stephen-Haynes

areas�of� the�skin�and�prevent�skin�breakdown�is�considered�to�be�a�cornerstone�of�professional�care�across�all�spheres�of�practice� (Voegeli,� 2008).� Consideration� should� be� given� in�skin�assessment�to�skin�changes�in�the�older�person�(Wounds�UK,�2012)�and�skin�changes�at�life’s�end�(Sibbald�et�al,�2009).�

Newton� and� Cameron� (2003)� advocate� four� essential�aspects� of� skin� assessment:� colour,� texture,� temperature�and� integrity.� The� skin� should� be� observed� for� signs� of�colour� change,� reddening� or� blanching� (white� areas)�in� Caucasian� skin� types� and� for� a� bluish� purple� hue� in�darker� skin� types.� Skin� assessment� should� also� include�observation� for� increased� heat,� swelling,� pain� or� guarding�of� an� area� and� evidence� of� shiny� areas� or� superficial�breaks� owing� to� shearing� forces� against� the� skin.� The�implementation� of� care� rounds� including� assessing� and�monitoring� of� skin� (Bartley,� 2011)� as� part� of� harm-free�care� (Institute� for� Healthcare� Improvement,� 2011)� has� led�to� the� implementation� of� a� visual� skin� assessment� during�each� care� round� (1–2� hourly)� in� community� hospital�and� at� each� district� nursing� visit.� Thomas-Hess� (2000)�proposes�the�following�key�areas�for�skin�management:�

�■ Take� caution� with� the� force� applied� when� washing� the�skin� and� avoid� massaging� areas� that� could� be� easily�damaged

�■ Offer�prompt�attention�when�incontinent�episodes�occur�and�protection�of�skin�with�barrier�protection�

�■ Aim� to� avoid� drying� of� the� skin� through� extremes� of�temperature

�■ Ensure�that�patients�are�positioned,�transferred�and�turned�properly�to�avoid�friction�and�shear�forces

�■ Cleanse�the�skin�at�frequent�intervals,�using�a�pH-balanced�cleansing�agent�followed�by�moisturisers�and�barrier�cream.

Pressure ulcer agenda There� is� a� significant� challenge� in� delivering� high-quality�care�while� improving�its�efficiency�amid�an�era�of�growing�demand�for�healthcare�resources.�In�England,�a�recent�White�Paper,�which�is�centered�on�efficiency�improvements,�outlined�government�strategy�to�address� these� issues�(Department�of�Health� (DH),� 2010a).The� Operating� Framework� for� the�NHS� in�England� for� 2012–13� requires� that� service� quality�and� the�patient�experience�must� improve,� and�productivity�increase� (DH,� 2012).�The� DH� (2010a)� identifies� pressure�ulcers�as�a�future�outcome�indicator,�reporting�that�in�2007/8�there�were�42 995�episodes�of�pressure�ulcers.�Pressure�ulcer�prevention�is�an�area�that�is�recognised�as�having�significant�impact� on� quality� of� care� and� this� has� been� increasingly�elevated�on�political� agendas� in� recent�years.�This� is�owing�

Jackie�Stephen�Haynes�is�Professor�in�Tissue�Viability,�Professional�Development�Unit,�Birmingham�City�University�and�Consultant�Nurse,�Worcestershire�Health�and�Care�NHS�Trust

Accepted for publication: October 2013

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to� the� increasing� emphasis� on�preventative�health� care� and�a� belief� that� pressure� ulcers� are� preventable� (NHS,� 2012).�The� National� Patient� Safety� Agency� (NPSA)� has� been�urging�NHS�organisations�across�England�and�Wales�to�work�towards�preventing�all�pressure�ulcers�(NPSA,�2010a;�2010b).

Pressure ulcer care deliveryCurrent� care� delivery� in� relation� to� pressure� ulcers� is�informed� by� NICE� guidelines� (2005),� EPUAP� guidelines�(2009)� and,� more� latterly,� through� the� introduction� of�High�Impact�Actions�‘Your�Skin�Matters’� (DH,�2010b)�and�the� quality� agenda� Quality,� Innovation,� Productivity� and�Prevention� (QIPP)� (DH,�2010a).�An� initial� target� ambition�was� set�out�aiming�to�prevent�category�III�and�IV�pressure�ulcers;� this� has� been� expanded� by� the� introduction� of� the�elimination�of�avoidable�pressure�ulcers�across�the�Midlands�and�East�in�the�UK�(NHS�Midlands�and�East,�2012).

Several�intrinsic�and�extrinsic�factors�contribute�to�pressure�ulceration� development.� Intrinsic� factors� include� sensory�impairment,� immobility,� age,� poor� nutrition,� incontinence,�and� chronic� illness� (NICE,�2005).�Extrinsic� factors� include�pressure,� shear,� friction,� and� the� impact� of� incontinence�(NICE,�2005;�EPUAP,�2009).�The�significance�of�each�is�not�fully� understood� (EPUAP,� 2009)� and� the� cause� of� pressure�ulcers�has�been�the�subject�of�much�research�and�discussion.�

Pressure�has�been�considered� to�be� the�most� significant�physical� force�responsible� for� the�development�of�pressure�ulceration�(NICE,�2005).�Pressure�over�a�bony�prominence�will� compress� the� capillaries� and� prevent� nutrients� and�oxygen� accessing� the� skin.� Unrelieved� pressure� leads� to�tissue� ischaemia,� with� metabolic� wastes� accumulating� in�the� interstitial� tissue,� ultimately� resulting� in� hypoxia� and�cell�death.�Sample�biopsies� from� tissues� reddened� through�pressure� have� been� demonstrated� to� show� an� increase�in� bacterial� loading� within� the� tissues� as� a� result� of� the�hypoxia� (Sugama� et� al,� 2005).� As� the� amount� of� shear/friction� increases,� the� amount� of� pressure� required� to�cause� ulceration� is� reduced� (Conner� and� Clack,� 1993).�Shear,� friction,� and� microclimate� have� also� recently� been�identified� by� an� expert� panel� as� a� major� cause� of� tissue�damage�(Wounds�International,�2010).�Specifically,�there�is�an�inverse�relationship�between�shear,�friction�and�pressure.�The� cause� of� pressure� damage� and� the� rate� at�which� this�occurs�is�clinically�important�and�clinicians�need�to�be�alert�to� the� reduced� time� for� pressure� damage� to� occur� when�shear/friction� is� a� consideration� (Wounds� International,�2010).�

Importantly,� pressure� ulcers� are� a� considerable� burden�for� the� NHS,� being� a� significant� cause� of� morbidity�and� mortality� (Posnett� et� al,� 2009).� Gorecki� et� al� (2009)�conducted�a�review�of�31 studies,�reporting�the�impact�of�pressure�ulcers�and�pressure�ulcer�interventions�on�health-related� quality� of� life� (HRQoL).� Pressure� ulcers� were�found� to� significantly� affect� physical,� social,� psychological,�and� financial� aspects� of�HRQoL.�Pain�was� identified� as� a�significant� concern� and,� importantly,� patients� attributed�their�pressure�ulcers�to�inadequate�health�care�and�a�lack�of�knowledge�on�the�part�of�health�professionals�regarding�the�prevention�of�pressure�ulceration.

The�financial�cost�of�pressure�ulcers�has�been�estimated�at�£2.3–£3.1�billion�per�year�in�the�UK,�which�would�account�for� 3%� of� the� annual� NHS� expenditure� at� 2005/6� levels�(Posnett� and�Franks,�2007).�The�DH�(2010a)�estimates� that�a� category� III� pressure� ulcer� costs� between� £363�000� and�£543�000�to�treat�and�that�a�category�IV�ulcer�costs�between�£447�000�and�£668�000.�The�majority�of�these�wounds�are�chronic�in�nature�and�are�cared�for�in�the�community�setting�by�GPs�and�community�nurses�(Drew�et�al,�2007).

Once� the� level� of� risk� has� been� ascertained,� the� key�to� reducing� it� relies� on� appropriate� preventative� care�and� treatment� plans� being� developed� and� implemented�(NICE,� 2005).� The� education� of� staff� at� all� levels� and�disciplines� on� risk� assessment� using� validated� tools,� care�planning,� documentation� and� the� implementation� of�appropriate�pressure�reducing�equipment�is�paramount�in�the�identification� and� subsequent� prevention� of� pressure� ulcers�(Institute�for�Healthcare�Improvement,�2008).��

High Impact Actions and SSKIN bundlesThe�high�impact�actions�(DH,�2010b)�indicate�the�majority�of� pressure� ulcers� that� develop� in� NHS-provided� care� are�avoidable,�stating�that�it�is�the�processes�regarding�prevention�that� fail.� It� identifies� that� to� eliminate� pressure� ulcers�requires�input�from�the�multidisciplinary�team.�This�requires�development�of� simple�processes� that�will� reduce�avoidable�pressure�ulcers�(DH,�2010b).

The� latest� guidance� relates� to� the� actual� delivery� of�prescribed�care�in�the�prevention�of�pressure�ulcers�through�the�use�of�SSKIN�bundle�documentation�packages�(Institute�for�Healthcare�Improvement,�2011).�Following�the�successful�implementation� of� the� SSKIN� care� bundle� in� Wales,� it�was� implemented� in�Scotland� in�2011�and� is� supported�by�Healthcare�Improvement�Scotland�(2013).�A�bundle�of�care�is�defined�as�a�structured�way�of�improving�processes�of�care�and� significantly� improving� patient� outcomes� (Institute� for�Healthcare�Improvement,�2011).�

McCarron�(2011)�clarifies�the�crucial�aspect�of�a�successful�care�bundle�as�ensuring�that�every�identified�intervention�is�performed� in� a� sequence� of� steps� and� that� no� component�is� eliminated.� Omitting� any� one� of� the� interventions� in� a�SSKIN� bundle� is� likely� to� result� in� the� development� of� a�pressure� ulcer.� The� critical� difference� between� a� SSKIN�bundle� and� a� traditional� care� plan� is� that� a� bundle� is� an�essential�set�of�steps�in�a�process�where�a�complication�may�arise�if�one�is�missed�(Institute�for�Healthcare�Improvement,�2011).� Bundles� were� initially� used� to� reduce� ventilator-associated� pneumonia� (Resar� et� al,� 2005)� and� are� now�advocated� as� a� structured� method� for� preventing� pressure�ulceration�(Lloyd�Jones,�2012).

The�objective�of�a�bundle�is�to�make�a�process�more�reliable�by� improving� motivation,� compliance� and� implementation�of� a� strategy� for� care� (Stephen-Haynes,� 2011).�Therefore,�SSKIN� care� bundles� are� essential� in� the� prevention� of�pressure�ulcers�and�should�be�implemented�for�every�patient�at�risk�to�achieve�the�elimination�of�avoidable�pressure�ulcers.�

The�SSKIN�bundle� acronym� represents� the� five� essential�elements�of�pressure�ulcer�prevention�(Institute�for�Healthcare�Improvement,�2011):�

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Surface�SkinKeep�moving�Incontinence�Nutrition.All� elements� in� the� bundle� are� based� on� robust� evidence�

and�delivery�of� the�bundle� is�measured� through�compliance�with� every� element.�The� aim� of� the� bundle� is� to� tie� best�practices�together�in�a�reliable�way�to�reduce�the�occurrence�of�a�pressure�ulcer.�Successfully�completing�the�bundle�is�based�on�all�elements�being�carried�out� together�at� the� same�time�(i.e.�at�the�patient’s�bedside�at�2-hourly�intervals)�or�at�every�district�nursing�visit.�The�bundle�encourages�attention�to�detail�through�its�individual�elements�and�helps�establish�good�habits�that� ultimately� impact� on� outcomes� (i.e.� reducing� pressure�ulcers).�The�bundle� therefore�makes� it�easy� for�people� to�do�the�right�thing�at�the�right�time.�Most�importantly,�the�bundle�makes�the�process�for�preventing�pressure�ulcers�visible�to�all.

SurfaceEnsuring� the� appropriate� surface� is� available� within� a�24-hour� period,� that� it� is� being� used� correctly� and� is�clinically� effective� and� fit� for� purpose� with� an� Electro-Biomedical�Engineering�Department�(EBME)�and�Portable�Appliance�Testing�(PAT)�undertaken.�

SkinEarly� visual� inspection� of� skin� with� a� focus� on� early�detection�and�prevention�of�breakdown�or�deterioration�by�early� intervention� of� pressure� relieving� regimes,� cleansing,�moisturising�and�skin�barrier�protection.�

Keep movingEnsuring� patients� are� repositioned� or� encouraged� to�mobilise�independently�at�every�care�round�in�community�hospitals�and�at�every�district�nursing�visit�and�recorded�in�the�SSKIN�care�bundle.�

IncontinenceAt�each�care�round,�staff�ensure�that�the�patient�is�clean,�dry�and� comfortable.� Incontinence� assessments� are� undertaken�and�barrier�protection�is�implemented�both�preventively�and�as�a�treatment�strategy.�

NutritionEnsuring� patients� have� an� appropriate� dietary� and� fluid�intake� to� maintain� their� nutritional� status� and� hydration�levels.�This� should� be� conducted� 2-hourly� as� part� of� care�rounds� within� community� hospitals� and� at� every� district�nursing� visit.� Intake� and� supplement� therapy� is� monitored�and�documented�accordingly.

Following�the� implementation�of� the�SSKIN�bundle,� the�Midland� and� East� have� reduced� the� incidence� of� pressure�ulcers�by�36%�in�6 months�(Ford,�2012).�

Barrier film protection: prevention, treatment and management The�aim�of�a�barrier�film�or�cream�is�to�mimic�the�skin’s�natural�barrier� function� with� the� purpose� of� protecting,� repairing,�

restoring� or� preventing� skin� damage.� The� moisturising�capability� lays� down� a� durable� protective� barrier� affording�the� optimum� protection.�The� use� of� no-sting� barrier� films�began� in� the� UK� in� the� late� 1990s� and� this� has� increased�steadily.�Guest� et� al� (2011)� found� that� despite� barrier� films�being� more� expensive� to� purchase� than� zinc� oxide� and�petroleum-based� products,� the� reductions� in� labour� more�than�offset�the�additional�cost.�According�to�Guest�el�al,�the�potential�savings�in�the�right�care�settings�could�reach�several�millions�of�pounds.

Sorbaderm barrier protection Sorbaderm�No-Sting�Barrier�Film�is�a�non-cytotoxic�acrylate�co-polymer� liquid� film� that� forms� a� flexible� long-lasting�waterproof�barrier�for�the�protection�of�intact�or�the�treatment�of�damaged�skin.�With�its�high-moisture�vapour�transmission�rate,� it� acts� as� a� protective� interface� between� the� skin� and�bodily� fluids,� adhesive� products,� and� mechanical� stress� and�aims� to� mimic� the� body’s� natural� protection� function.�The�barrier� film� can� be� used� clinically� for� incontinence,� peri-stomal� skin� protection,� peri-wound� skin� protection� and�adhesive�trauma�protection.�It�provides�up�to�72 hours�of�skin�protection�depending�upon�the�severity�of�the�corrosive�fluid�or� exposure� and� as� it� does� not� contain� alcohol,� it� does� not�sting.� It� is� transparent,� allowing� for� continuous� visualisation�and�monitoring�of�skin�at�risk�of�breakdown.�

Sorbaderm� No-Sting� Barrier� Cream� is� a� highly�concentrated,�long-lasting�latex�and�fragrance-free�protective�barrier�that�does�not�clog�incontinence�or�dressing�devices,�providing�effective� skin�moisturising�and� long-term�barrier�protection�from�bodily�fluids.

Stephen-Haynes�and�Stephens�(2012)�report�a�study�with�two� arms� involving�95  subjects�within� a�UK�primary� care�organisation.�The� objective� was� to� determine� the� clinical�outcomes� and� acceptability� of� a� no-sting� barrier� film� and�cream�product.�

Study outcomesThe� indications� included� in� the� study� were� peri-wound�protection,�incontinence�and�pressure�ulcers.

The�clinical�indications�explored�were:��■ �Prevention�of�skin�breakdown�■ �Maintenance�of�skin�condition�■ �Peri-wound�maceration�■ �Excoriation�and�incontinence-related�skin�protection�■ �Adhesive�skin�strippingOf�the�95 patients�recruited,�the�barrier�cream�was�evaluated�

in�39 patients�and�the�no-sting�barrier�film�in�53 patients.�

Inclusion criteria�■ Patient�>18�years�of�age�■ Patient�is�willing�to�participate�and�has�capacity�to�consent�■ Patient� has� an� indication� suitable� for� treatment� with� a�barrier�product

�■ Patient�will�be�seen�regularly�by�the�evaluator.

Exclusion criteria�■ Patient�is�<18�years�of�age�■ Patient� does� not� wish� to� participate� or� have� capacity� to�

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also� be� considered� (Clark,� 2010;� Deakin� et� al,� 2010).Economic�models�including�nursing�time�and�material�costs,�favour� the� use� of� barrier� films� and� creams� (Clark,� 2010;�Deakin�et�al,�2010).�

There� is� increasing� evidence� relating� to� the� clinical� and�financial� benefits� of� skin� protection� and,� in� particular,� to�that� of� no-sting� barrier� films� and� barrier� creams� when�compared�with�more�traditionally�used�skin�protection�such�as� petroleum-based� creams� (Stephen-Haynes� and� Stephens,�2012).�The� author� acknowledges� that� the� current� emphasis�on�pressure�ulcer�prevention�led�to�a�low�number�of�patients�with�pressure�damage�taking�part�in�this�95-patient�study.�In�addition,� subjectivity� was� a� limitation� of� the� original� study�due� to� reflective� comparison� to� previous� treatment� regime�rather�than�any�form�of�direct�comparator.

Clinical care studiesFigure 1� shows� a� 67-year-old� female with� a� sacral� pressure�ulcer�with�a�high�exudate�levels�due�to�damage�to�the�peri-wound�skin�caused�by�wound�exudate.�Sorbaderm�No-Sting�Barrier�Film�was�used�for�48�hours.�Figure 2�demonstrates�the�impact�of�the�barrier�film�on�the�peri-wound�area;�the�peri-wound�skin�is�now�intact.�

Figure 3�shows�the�pressure�ulcer�and�damage�to�the�peri-wound�area�of� a�50-year�old�gentleman.�The�pressure�ulcer�occurred�following�a�trauma�injury.�Figure 4�demonstrates�the�improvement�in�his�peri-wound�skin�following�the�application�of�Sorbaderm�No-Sting�Barrier�Film�for�72 hours.�

Figure 5� is�a�photo�of�a�back�ulcer�on�a�74-year-old� lady�who�has� arthritis� renal� failure� and�a� curvature� to� the� spine.�She�has�been�a�very�heavy� smoker� for�most�of�her� life�and�has�a�cough.�On�investigation,�a� tumour�was�noted�but�not�treated�at�her�request.�

This�patient�developed�a�pressure�ulcer� to�her� spine.�This�started�as�a�small�area�with�a�large�area�of�excoriation�to�the�peri-wound� area.�When� the� author� first� saw� this� lady,� the�peri-wound�area�was�excoriated�from�both�exudate�and�the�dressings�being�removed.�The�patient�found�dressing�changes�very�painful�and�sat�upright�in�bed,�uncomfortable�for�many�hours�at�a�time.�This�left�the�skin�on�the�curvature�of�her�spin�vulnerable� and� more� easily� damaged� by� shear� and� friction�from� movement� in� the� bed.� Sorbaderm� No-Sting� Barrier�Cream�was�applied�to�the�peri-wound�and�this�has�improved�the�peri-wound�skin�and�decreased�her�discomfort.

A� 67-year-old� gentlemen� with� Parkinson’s� disease�developed�the�ulcer�shown�in�Figure 6.�His�Parkinson’s�disease�causes�frequent�movement,�resulting�in�shear�and�friction.�He�developed� this� ulcer� following� a� problem� with� his� seating�(he�has�a�moulded�wheelchair).�The�peri�wound�needed� to�be�maintained�during� debridement.�The� excessive�moisture�during� this� period� of� debridement� and� the� involuntary�movements� could� have� resulted� in� extensive� peri-wound�excoriation� and� enlargement� of� the� ulcer.�The� exudate� did�cause� excoriation� as� Figure 6� shows,� but� the� Sorbaderm�No-Sting�Barrier�Film helped�to�reduce�this�(Figure 7).�When�barrier� film� is� applied� to� the�whole�of� the� area,� it� supports�the�dressing�in�place�and�prevents�irritation�and�skin�stripping�from�the�secondary�dressing.

A�72-year-old� lady�acquired�a�category  IV�pressure�ulcer�

Figure 1. Excoriation caused by wound exudate

Figure 3. Excoriation caused by wound exudate

Figure 5. Peri-wound excoriation

consent�■ Patient�not�suitable�for�barrier�product�treatment�■ Instructions�for�the�product�use�cannot�be�followed�■ Any�other�reason�the�evaluator�feels�the�patient�should�be�excluded.

Results In�arm�one,�36 patients�were�evaluated.�There�were�18 males�and�18 females�and�of�these,�6�specifically�related�to�pressure�ulceration,� with� exudate� levels� reported� to� be� moderate�or� high.� None� of� the� six� developed� signs� of� maceration�throughout�the�study�process.�All�(n�=�6)�reported�a�dramatic�visible�improvement�to�skin�condition�within�24–48 hours.�

In� the� second� arm,� the� total� number� of� patients� was� 59;�3 patients�with�shear�and�friction�damage�showed�significant�improvement�following�the�use�of�barrier�protection.�

These� results� are� supported� by� Deakin� et� al� (2010)� and�Clark� (2010)� who� reported� positive� results� in� support� of�Sorbaderm� No-Sting� Barrier� Film� and� No-Sting� Barrier�Cream.� Importantly,� clinical� and� service-user� acceptance,�adoption� strategy� costs� and� educational� requirements� must�

Figure 2. Skin improved after 48 hours application of barrier protection

Figure 4. Skin improved after 48 hours application of barrier protection

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British�Journal�of�Nursing,�2013�(Tissue�Viability�Supplement),�Vol�22,�No�20�� S57

SKIN CARE©

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to� her� sacrum� (Figure 8)� following� an� acute� admission� for�breathing�problems�and�dizzy�spells�(she�was�diagnosed�with�Guillain-Barré� syndrome� so� carers� and� relatives� had� been�unable�to�move�her).�This�patient�was�previously�mobile,�very�independent� and� healthy� for� her� age.� She� looked� after� her�husband�who�was�found�to�have�early�dementia.

When�this�patient�was�transferred�to�a�community�hospital,�this� ulcer� had� very� heavy� exudate� and� the� cavity� was� very�large� (12 cm� x� 9 cm� x� 4 cm� deep)� (Figure 9).�The� ulcer,�and� resulting� loss� of� immobility,� caused� this� patient� to� be�depressed� (she� had� loss� of� feeling� in� her� legs� although� this�was�returning�slowly).�

The� author� and� colleagues� had� to� consider� how� to�effectively� manage� the� exudate� while� protecting� the� peri�wound.�Sorbaderm�No-Sting�Barrier�Film�was�commenced�upon�her�admittance�to�the�community�hospital�owing�to�the�high�volume�of�exudate.�

The�wound�was� very� painful� to� dress,� requiring� entonox�(gas� and� air).� Negative� pressure� wound� therapy� was� used�to� dress� the� wound� at� the� beginning;� maintenance� of� the�peri-wound� area� was� very� important� in� order� to� achieve�a� good� seal� and� prevent� the� ulcer� from� getting� bigger.�Following�a�multidisciplinary�team�meeting,�the�team�started�physiotherapy�with�the�patient�and�she�began�to�walk�within�5 weeks.�Her�ulcer�has�now�almost�healed�(Figure 10)�and�she�has�returned�home�with�her�husband.�

ConclusionThe�prevention�of�pressure�ulcers�and�maintenance�of�healthy�skin� integrity� is� a�key�government� agenda�and�a� significant�clinical�challenge�for�health�professionals�and�carers.�Pressure�ulcer�prevention�and�management�are�of�particular�significance�in�an�increasingly�elderly�population�owing�to�mobility�issues,�continence� status� and� skin� changes� that� can� occur� with�ageing,�chronic�illness,�and�at�the�end�of�life.�It�is�essential�for�all�nurses�and�allied�health�professionals�to�consider�pressure�ulcer�prevention�and�be�knowledgeable�regarding�prevention�and� treatment� processes.� Ensuring� fundamental� nursing� is�delivered�and�the�SSKIN�care�bundle�is�implemented�every�time�for�every�patient�is�essential�in�the�prevention�of�pressure�ulcers.�The�evidence�suggests�the�use�of�SSKIN�bundles�and�the�appropriate�use�of�barrier�film�protection�can�contribute�to� the� prevention,� treatment� and� maintenance� of� the� skin’s�barrier�function,�helping�to�protect�and�restore.�� BJN

Conflict of interest: Sorbaderm Barrier Cream and Sorbaderm Barrier

Figure 6. Pressure ulcer with surrounding skin affected by shear, friction and moisture

Figure 10. The improved wound

Film used in the author’s study were supplied by Aspen Medical.

Bartley�A��(2011)�The�Hospital�Pathways�Project.�Making�it�happen:�Intentional�rounding.�The�King’s�Fund�Point�of�Care�and�the�Health�Foundation.�http://tinyurl.com/c7zyohv�(accessed�30�October�2013)

Butcher�M,�White�R�(2005)�The�structure�and�function�of�the�skin.�In:�White�R� (Ed)� Skin care in wound management: Assessment, prevention and treatment.�Wounds�UK,�Aberdeen:�1-16

Clark� M� (2010)� Preventing� skin� breakdown� with� barrier� films� and� creams.�Wounds UK�6(4):�132-8

Conner�L,�Clack�J� (1993)�In�vivo�(CT�scan)�comparison�of�vertical� shear� in�human�tissue�caused�by�various�support�surfaces.�Decubitus�6(2):�20-3,�26-28�

Deakin�A,�Stapleton�M,�Chadwick�K�(2010)�Evaluating�a�skin�barrier�film�in�faecal�and�urinary�incontinence.�Wounds UK�6(2):�107–11

Department� of� Health� (2010a)� The NHS Quality, Innovation, Productivity and

Figure 7. Improvement seen following application of barrier protection

Figure 9. Undermining has improved after 1 week and peri wound is intact

Figure 8. The peri wound is intact following use of the barrier film. Note the undermining at the wound edge

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S58� British�Journal�of�Nursing,�2013�(Tissue�Viability�Supplement),�Vol�22,�No�20

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Prevention challenge: An introduction for clinicians.�DH,�London.�http://tinyurl.com/os7xoqn�(accessed�30�October�2013)

Department�of�Health� (2010b)�High Impact Actions for Nursing and Midwifery.NHS Institute of Innovation and improvement.� http://tinyurl.com/peojl3q�(accessed�30�October�2013)

Department�of�Health�(2012).The Operating Framework for the NHS in England 2012/13.�http://tinyurl.com/ax66ola�(accessed�30�October�2013)

Drew� P,� Posnett� J,� Rusling� L� (2007).�The� cost� of� wound� care� for� a� local�population�in�England.�Int Wound Journal�4(2): 149-55

European�Pressure�Ulcer�Advisory�Panel� (2009)�Pressure�ulcer�prevention:�A�quick� reference� guide.� http://tinyurl.com/378oexd� (accessed� 30� October�2013)

Ford�S�(2012)�Pressure�ulcers�cut�by�a�third�in�midlands�and�east.�Nursing Times.net.�http://tinyurl.com/p9clbqs�(accessed�30�October�2013)

Gorecki�C,�Brown�J,�Nelaon�A�et�al�(2009)�Impact�of�pressure�ulcers�on�quality�of�life�in�older�patients:�a�systematic�review.�J Am Geriatr Soc 57(7): 1175-83

Guest� J,� Greener� M,�Vowden� K,�Vowden� P� (2011)� Clinical� and� economic�evidence� supporting� a� transparent� barrier� film� dressing� in� incontinence-associated�dermatitis�and�peri�wound�protection.�J Wound Care�20(2): 76-84

Health�Care�Improvement�Scotland�(2013)�SSKIN care bundle.�http://tinyurl.com/lqke8ql�(accessed�30�October�2013)

Institute� for� Healthcare� Improvement� (2008)� 5� Million� Lives� Campaign.��Getting�Started�Kit:�Prevent�Pressure�Ulcers�How-to�guide.�http://tinyurl.com/cfaohln�(accessed�30�October�2013)�

Institute�for�Healthcare�Improvement�(2011)�What is a bundle?�http://tinyurl.com/onf69xn�(accessed�30�October�2013)

Lloyd-Jones�M�(2012)�Prevention�and�treatment�of�superficial�pressure�damage.�Nursing and Residential Care�14(1):�14-20

McCarron�K�(2011)�Understanding�care�bundles.�Nursing Made Incredibly Easy�

KEY POINTS

n The prevention of pressure ulcers is a key national agenda

n SSKIN bundle implementation is an essential part of the elimination of

avoidable pressure ulcers

n Timely skin assessment, skin care and the use of barrier protection are an

important component of the strategy for pressure ulcer prevention

n An evaluation of barrier films and creams indicates the importance of barrier

protection as an essential component of pressure ulcer prevention

9(2):�30–3.�National� Institute� for�Health� and�Clinical�Excellence� (2005)�The�prevention�

and�treatment�of�pressure�ulcers.�NICE,�LondonNational�Institute�for�Health�and�Clinical�Excellence�(2006)�The�management�

of�urinary�incontinence�in�women.�NICE,�London�National�Patient�Safety�Agency�(2010a)�NHS to adopt zero tolerance approach to

pressure ulcers.�http://tinyurl.com/pn89tw6�(accessed�30�October�2013)National�Patient�Safety�Agency�(2010b)�Serious Incident Reporting and Learning

Framework (SIRL). National framework for reporting and learning from serious incidents requiring investigation.� http://tinyurl.com/2vqkojm� (accessed� 30�October�2013)

Newton�H,�Cameron�J�(2003)�Skin Care in Wound Management. A clinical education in wound management.�Medical�Communications�UK�Ltd,�Holsworthy

NHS�Midlands�&�East�(2012)�Pressure�ulcers.www.stopthepressure.comNHS� (2012)� Harm� Free� Care.� NHS,� London.� http://tinyurl.com/d9r89vw�

(accessed�30�October�2013)Posnett� J,�Franks�P� (2007)�The cost of skin breakdown and ulceration in the UK.

Skin breakdown: the silent epidemic.�Smith&�Nephew�Foundation.�Hull:�6-12Posnett� J,� Gottrup� F,� Lundgren� H,� Saal,� G.� (2009)�The� resource� impact� of�

wounds�on�health�care�providers�in�Europe.�J Wound Care�18(4):�154–61Resar� R,� Pronovost� P,� Haraden� C,� Simmonds�T,� Rainey�T,� Nolan�T� (2005)�

Using� a� bundle� approach� to� improve�ventilator� care�processes� and� reduce�ventilator-associated�pneumonia.�Jt Comm J Qual Patient Saf�31(5): 243-8

Sibbald�R,�Krasner�D,�Lutz�J�et�al�(2009)�SCALE:�skin�changes�at�life’s�end:�final�consensus�statement.�Adv Skin Wound Care�23(5):�225–36

Stephen-Haynes� J� (2011)� Pressure� ulceration� and� the� current� government�agenda�in�the�UK.�Br J Community Nurs�16(Sup5):�S18-S26

Stephen-Haynes� J,� Stephens� C� (2012)� Evaluation� of� clinical� and� financial�outcomes� of� a� new� no-sting� barrier� film� and� barrier� cream� in� a� large�UK� primary� care� organisation.� Int Wound J� doi:� 10.1111/j.1742-481X.2012.01045.x.�[Epub�ahead�of�print]

Sugama� J,� Sanada� H,� Nakatani�T,� Nagakawa�T,� Inagaki� M� (2005)� Pressure-induced� ischemic� wound� healing� with� bacterial� inoculation� in� the� rat.�Wounds�17(7):�157–68

Thomas-Hess�C�(2000)�‘Skin�care�and�wound�prevention�strategies’.� In:�Skin and Wound Care.�Lippincott,�Williams�and�Wilkins,�USA

Voegeli�D�(2008)�The�effect�of�washing�and�drying�practices�on�skin�barrier�function.�J Wound Ostomy Continence Nurs 35(1):�84–90

Voegeli�D�(2010)�Basic�essentials.�Why�elderly�skin�requires�special�treatment.�Nursing and Residential Care�12(9):�422–9

Wounds� International� (2010) Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document.�Wounds� International,�London.�http://tinyurl.com/oj7f6uv�(accessed�30�October�2013)

Wounds� UK� (2012)� Best Practice Statement. Care of the Older Person’s Skin. :�Wounds� UK,� London.� http://tinyurl.com/q9rrt2c� (accessed� 30� October�2013)

Wysocki�A�(2000)�‘Anatomy�and�physiology�of�skin�and�soft�tissue’.�In:�Acute and chronic wounds: nursing management.�Mosby,�St�Louis�

Dermatology Differential Diagnosis is an essential dermatology guide for nurses Key Features• Based on the popular monthly Dermatology Differential Diagnosis series published in the highly respected

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DermatologyDifferentialDiagnosis