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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
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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NPUAP in collaboration with the
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npuap.org©2017 National Pressure Ulcer Advisory Panel | www.npuap.org
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Released in November 2012, the 254-page,
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npuap.org©2017 National Pressure Ulcer Advisory Panel | www.npuap.org
• Pressure Injury Definition and Stages
• Prevention of Pressure Injury
• Treatment of Pressure Injury
Each downloadable slide set includes
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Purchase the slide sets today at 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
4/26/2017
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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!
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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