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Defining Lesions: Differentiating Between Moisture and Pressure

July 25, 2013

Perspective of Nursing Care from Past to Future by Matron Marley

By Margaret Heale, RN, MSc, CWOCN

Here I am again, Matron Marley, working as a volunteer in the local nursing home on just my second visit. I had a little difficulty getting in and discovered it was because of the door lock alarm on a resident. Such a good idea but a bit irritating. I managed to sneak in while the resident moved away briefly and entered into a bright airy reception area, so welcoming. The first home I ran was really dingy with cold stone steps to the 1st floor where the ‘geri’ ward was. Today I am greeted by a woman about my age with a pocket book asking, “Is the bus here yet, I have to pick up Robbie.” I heard the door click as she neared it, locking out my granddaughter who works here. I coaxed her away from the door with a promise to help her find the bus down a long hallway. It is soon revealed that she is a wanderer and spends much of her time trying to exit the building. Her mention of the bus brought to mind a patient I'd once had named Mable.

Mable wandered all the time. We would often find her in other residents’ rooms (and beds). Then there was ‘Mable’s Great Adventure' when she boarded a bus outside the hospital, wearing only a hospital gown. Shortly after her outing she suffered a stroke and became chair-bound which leads me into the problem we had with her. Unable to tolerate a catheter (our way of dealing with functional incontinence at the time) she developed ‘recliner butt.’ The skin of her buttocks had a permanent shiny purple hue with sometimes multiple tiny superficial open areas. The first time I saw it I was convinced it was the beginnings of a huge pressure ulcer (a deep tissue injury).

We kept her in bed on a Q2 check, change and turn schedule. I saw it several times throughout the day and marveled at the difference by the time it came for me to leave. It was still colorful but less shiny and macerated. I don’t remember if it felt normal but now we know that if the skin feels hard or boggy deep tissue injury should be suspected under such coloration (important but difficult to assess). A few lesions were already covered in new pink skin. We had no access to ointments at the time so I ordered an egg from the kitchen and she had egg white and oxygen therapy morning and night until her daughter brought in some ointment for nappy rash at our request. I managed to avoid this therapy for years, till I was interim charge on an orthopedic ward. When I saw the prescription from the doctor I called infection control (many eggs were known to harbor Salmonella) and I think we used a hydrocolloid paste instead. This was my first encounter with this type of moisture-associated skin damage and it took years before I fully appreciated the benefits of differentiating between moisture and pressure.

The absorptive products we had available were very poor quality and try as I may, there was little I could do. The skin protectants improved over the years though, from a basic petrolatum to a dreadful thick lanolin and zinc paste. The only way to clean this off was with arachis oil (which I discovered was derived from peanuts, so we stopped using it, in case of allergy issues). Then came an iodine spray and balsam of Peru. Finally, a silicone spray followed by wonderful cleansers and more condition-specific products, be they for urinary incontinence, fecal soiling or yeast.

It has recently become more and more important to define lesions around the buttock area accurately as either pressure- or moisture-related and there is an effort to also differentiate between pressure, friction and shear. Initially, when I discovered this, I thought ‘what does it matter, the caregiver will have to consider all aspects because they are so closely linked.’ Then I realized that it provides not just data to ensure reimbursement and detailed care planning but also a focus for care, that otherwise lacks a rationale. It is after all important that those giving specific care understand the purpose, otherwise we are back in my day when the comment,”well we always have done it this way,” was acceptable.

Differentiating between pressure, moisture, friction and shear is not easy and there are some useful sites that will help. The European Pressure Ulcer Advisory Panel has a class and test which I recommend, although Incontinence-associated dermatitis (IAD) is used rather than the broader term of moisture associated skin damage. Oh, and their categories are a little different from our stages (actually just simpler). Differential assessment of trunk wounds: pressure ulceration versus incontinence-associated dermatitis versus intertriginous dermatitis. The Journal of Wound, Ostomy and Continence will no doubt follow up the consensus meeting on Challenges in classification of gluteal cleft and buttock wounds with an update from this year’s consensus meeting at conference. Personally I think pictures are a must so the NPUAP site is great.

To return to Mable, I should tell you she was the only fully mobile patient on the geri-ward that I was sent to run. Next month I will tell you about eight of the other thirty four and why I became obsessive about what I thought was going to be a deep pressure ulcer on Mable’s buttocks.

I should finish in the present though, I spent the day with the woman with the handbag and we forgot about waiting for the bus and talked instead about Robbie and her husband, the war and her work as a teacher. We laughed.

Doughty D. Differential assessment of trunk wounds: pressure ulceration versus incontinence associated dermatitis, versus intertriginous dermatitis 2012 OW-M;58(4):20-22.

About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."

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.

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