Dressing Change Tips Every Clinician Should Know to Help Prevent MARSI

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dressing removal

By Margaret Heale RN, MSc, CWOCN

Wounds are dressed every day, and much goes into the choices that are made to properly apply wound dressings. The condition of the periwound skin should be a major factor in the decisions made, as injuring this area can extend the wound and cause considerable pain. Tape removal is one of the most painful areas of wound care.1

Dressing Down: Preventing MARSI is Every Clinician's Responsibility

Periwound skin is affected by the dressing choice in several ways. If the wound is wet or the dressing is unable to manage the exudate, then the periwound skin may macerate. Exudate lying on the skin may also cause irritation, itching, and inflammation. Thirdly, the dressing product used (or the adhesive incorporated into it) may cause a localized sensitivity reaction. Last but definitely not least there is iatrogenic damage caused by the dressing application or removal, also known as tape stripping and medical adhesive-related skin injury (MARSI). Not only are dressings responsible for MARSI, but also any adherent device—from catheter securement devices to electrodes.

Different adhesives have different properties, and some are more likely than others to damage skin. A company merely stating that a border dressing is safer on the skin does not necessarily make it so. There has been much press given to safer adhesive technology, and a little less to other aspects of reducing the possibility of MARSI.

Tips for Preventing Medical Adhesive-Related Skin Injury During Dressing Changes

Earlier this year, Yates et al set the standard for MARSI interventions.2 Interestingly, the mechanics of proper adhesive removal were found very difficult to describe, though maybe this is understandable in the setting of a consensus approach.

Common sense and pictures may better convey some dos and don'ts, at the risk of being less agreeable to some. You can decide how you learn best. The term tape is used below for border dressing, semi-permeable transparent films, and negative pressure wound drape.

  • If the periwound skin is not healthy, use a wrap net or support garment. If a wrap is used on the lower leg, it should generally go from the base of the toes to above the calf, at mild compression unless contraindicated (severe arterial disease).
  • Most dressings should be fully covered with tape, not picture framed, as this supports the dressing better. Fully taping lessens evaporative heat loss, encourages moist wound healing, and reduces contamination and cross infection risk.
  • Only sufficient tape to secure the dressing should be on the skin, and should be placed considering the Langer lines to reduce tension and promote comfort. Some tapes have more "give" one way, and this too should be in the direction of the Langer lines.
  • Removing backing paper as the tape is pulled can stretch the skin. Stretching the skin to apply tape delivers stress that not only can shear the skin layers, but can also cause significant skin pain. Skin pain can be a major reason for pain from negative pressure wound therapy.
  • Post-operative blisters may be caused by edema or by stretched tape.
  • tape-no-tension

    Folding back a tab can ease removal. Press down on the skin as the tape is gently pulled back on itself. When possible remove in the same direction as hair growth.


  • Applying tape with no tension is very important. Turning back a tab makes removal easier.
  • Skin prep, barrier wipes, and sprays are meant to form a layer over the skin that protects it. They should be allowed to dry fully to function optimally and protect the skin on removal of the tape. Not allowing skin prep to dry when applying a condom catheter should be a dismissible offense!
  • To improve adhesion of devices, such as ostomy appliances, warmth and pressure work well. Rubbing shreds the adhesive and should be discouraged. Skin barrier wipes (skin prep) smooth out the natural, tiny skin contours that improve the qualities of the adhesive in the hydrocolloid barrier, and are generally not necessary.
  • Peeling back a dressing to look at a wound (and replacing it) increases the possibility of dislodgement and risk of bacterial contamination, and should be avoided.

removing-dressing

Removing the backing of a dressing by pulling it to secure the contact layer, can cause skin pain and may be a major factor in pain from NPWT. Edema post operatively or dressing placed in this way causes skin blistering.



Finally, adhesive remover wipes are designed to remove adhesives. They work. Use them. Sadly, most are tiny pads - they need to come in a larger size! Tape removal is one of the most painful parts of a dressing change. The pain caused is held in memory, and increases pain and anxiety at subsequent procedures. Please use adhesive remover wipes and take time to remove tape. Your patients will thank you.

Image Credit: Margaret Heale. Used with Permission

References
1. Denyer, J., Reducing pain during the removal of adhesive and adherent products., in British Journal of Nursing. 2011. p. S28-S35.
2. Yates, S.M., L; Heineche, SB; Gray, M., Embracing the Concept, Defining the Practice and Changing the Outcome. Journal of Wound, Ostomy and Continence Nursing, 2017. 44(1): p. 13-17.

About the Author
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

This is such an important topic. I have found that most of the time when skin surrounding a dressing is reddened or blistered, the real problem is that the adhesive was applied under tension. This is often mistaken for an allergic reaction to the adhesive. I stretch the skin slightly as I smooth down the final edges of water-resistant adhesive dressings so that the skin is not under tension when the dressing is in place.

Some adhesives are designed to loosen their grip when they are pulled parallel to the skin, allowing for atraumatic removal. Others are best removed with the “push-pull” technique described in the article. Instructions for Use often tell which method is best.

I find that stretch cloth adhesive borders work best for active and diaphoretic patients. In contrast, infants and elderly patients often do best with no adhesives at all. With a bit of ingenuity, it is possible to secure dressings on almost every site on the body, including the head and neck, with stretch netting of the appropriate size. Stretch netting also allows the “intelligent” backing of polymeric membrane dressings to continue to function to balance wound moisture.

It is important to note that if adhesives other than those incorporated into the dressings are used, picture-framing is still recommended for polymeric membrane dressings. These unique dressings are designed to conform to the shape of the wound, to insulate the wound, and to protect against contamination without extra adhesives across the center of the dressings. The “intelligent” backing permits more fluid to evaporate when the wound is highly exudative while allowing less evaporation from dryer wounds. Completely covering the backing with additional adhesives also makes it difficult to see through the backing. This can result in the dressings being left in place too long (when the visible darker color reaches a wound border, this indicates that it is time to change the dressing).

Polymeric membrane dressings also come in configurations designed to fit special anatomical areas without adhesives. Tube site dressings are proven to reduce complications from tracheostomies and g-tubes, but are also useful for pin sites and for central line sites in patients who cannot tolerate adhesives. Finger/toe dressings with a side seam split cover ears, and they are elastic enough that with the tip cut off they protect knuckles well. The larger sizes make nice sleeves for infants’ arms. Radiologists and Tissue Viability Nurses in the UK created a “cookbook” style cutting guide for protecting skin with polymeric membrane dressings without the use of adhesives. The booklet, published by Aspen Medical, Ferris, and Hill-Rom, can be found here: https://www.aspenmedicaleurope.com/wp-content/uploads/2015/05/PolyMem-Ra...

Sincerely,
Linda Benskin, PhD, RN, SRN (Ghana), CWCN
Independent Nurse Researcher for rural areas of tropical developing countries and
Clinical Research and Education Liaison, & Charity Liaison, for Ferris Mfg. Corp.

References:
1. Scott A. Polymeric membrane dressings for radiotherapy-induced skin damage. Br J Nurs. 2014 Jun 22;23(10):S24, S26-31.
2. Hegarty F, Wong M. Polymeric membrane dressing for radiotherapy-induced skin reactions. Br J Nurs. 2014 Nov;23 Suppl 20:S38-46.
3. Bostock S. Improving management of radiotherapy-induced skin reactions: a radiographer’s perspective. Wounds UK [Internet]. 2016 Sep [cited 2017 Jun 26];12(3). Available from: http://www.wounds-uk.com/journal-articles/improving-management-of-radiot...
4. Benskin LLL. PolyMem Wic Silver Rope: A Multifunctional Dressing for Decreasing Pain, Swelling, and Inflammation. Advances in Wound Care. 2012 Feb;1(1):44–7.
5. Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Manage. 2016 Jun;62(6):42–50.
6. Rafter L, Oforka E. Trauma-free fingertip dressing changes. Wounds UK. 2013 Mar;9(1):96–100.
7. Davies SL, White RJ. Defining a holistic pain-relieving approach to wound care via a drug free polymeric membrane dressing. J Wound Care. 2011 May;20(5):250, 252, 254 passim.
8. Blackman JD, Senseng D, Quinn L, Mazzone T. Clinical evaluation of a semipermeable polymeric membrane dressing for the treatment of chronic diabetic foot ulcers. Diabetes Care. 1994 Apr;17(4):322–5.
9. Dawson, Lewis C, Boch R. Total Joint Replacement Surgical Site Infections Eliminated by Using Multifunctional Dressing. 900 Cases Report over 4 years. Poster presented at: Australian College of Operating Room Nurses (ACORN); 2010 May 19; Perth, Australia.
10. O’Toole TR, Jacobs N, Hondorp B, Crawford L, Boudreau LR, Jeffe J, et al. Prevention of Tracheostomy-Related Hospital-Acquired Pressure Ulcers. Otolaryngol Head Neck Surg. 2017 Apr;156(4):642–51.
11. Agathangelou C. Using Polymeric Membrane Dressings to Solve Problematic Skin Damage From Gastronomy Leakage on Elderly Patients. Poster presented at: European Wound Management Association (EWMA); 2013 May 15; Copenhagen, Denmark.

Thank you for this great article. It is well thought out and correlates with the paper by Laurie McNichol a few years ago. I also appreciate the dark humor of the the dismissible offense of not allowing the skin prep to dry when applying a condom catheter! WOW, ouch!

There are a couple of really nice adhesive releasers on the market. Every outpatient pediatric surgery department should be using this to remove the securement adhesives on IV sites. My Daughter had a nasal ablation a few years ago. The only thing she remembers is the pain when they ripped the tape off her arm. This was definitely poor practice when you injure a healthy 8 year old's skin when removing tape.

Until these injuries are mandatory to report to a regulatory body, we will not see the focus on this preventable injury. Until then, we need to educate the masses about patient satisfaction surveys and tape injuries they should report to the hospital after discharge.

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