CASE STUDY: PROSHIELD

HOSPITHERA,
YOUR PARTNER IN DAYCARE
W
12/2012
OUNDCARE
CONTENT:
NEWSFLASH nr°13
1.CASE STUDY: PROSHIELD
2.IN THE PICTURE: PULMAN
4.PRODUCTNEWS: CUREA P2
5.AGENDA
CASE STUDY: PROSHIELD
Proshield® Plus is een gladde, dikvloeibare, vetvrije en geurloze vochtbarrièrecrème die speciaal
ontwikkeld is voor de genezing en bescherming van de geïrriteerde, beschadigde huid bij
chronische diarree, incontinentie en decubitus graad 2-wonden. Daarnaast kan Proshield Plus
dagelijks preventief gebruikt worden op de nog intacte, gezonde huid.
De afgelopen maanden is er intensief onderzoek verricht naar de effectiviteit van Proshield® Plus.
Hieronder vindt u enkele case studies die we u niet willen onthouden. Klik op de studies om ze te bekijken.
Proshield Skin Care Protective System:
A Sequence of Evaluations
Evaluation of Proshield Plus in Nursing Homes for
inclusion onto Formulary in a Healthcare Trust
Gloucestershire
Results:
Introduction
Managing the symptoms of incontinence associated dermatitis presents many challenges to clinicians.
Loss of skin integrity results in inflammation, pain and excoriation, with an increased risk of infection
and pressure ulcer formation. As well as deterioration in quality of life for the patient, managing
such symptoms may result in prolonged treatment resulting in increased costs for the health care
provider.
The Proshield System has recently been introduced; it is effective across both broken and intact skin.
The spray/foam acts as a robust cleanser and moisturiser, whilst the barrier cream establishes a moist
wound interface and protects from shear and friction forces.
Method
• 66% (six) of the participants demonstrated ‘full healing’ (see graph below).
• One of the participants experienced a ‘’marked improvement’’ of the sacral area and top of the
legs at 35 days (had experienced incontinence over ‘’years’’ whilst the skin had been additionally
adversely affected by the application of steroid cream).
• Of the 2 remaining patients one ‘passed away’ and one was admitted to the acute sector.
• Full healing was recorded in 6 participants; 19 days being the average point to ‘healing’.
Red / inflamed skin
7 patients
Broken skin / moisture lesion
6 patients
Incontinence associated dermatitis
1 patient
Odour at outset
• One participant was experiencing ‘’moderate pain’’ at outset which reduced to ‘’slight pain’’ after
2 weeks and to ‘’no pain’’ after a further 2 weeks, concomitant with healing.
‘Week 4: patient skin not looking so inflamed. Patient very pleased with response...’’
1 patient
6 patients
‘’Sacrum has superficially bled and broken easily however after using Proshield this
has healed and is now intact’’
Urinary incontinence only
2 patients
‘’Sacral area healed at 4 weeks ...quick response’’
Faecal incontinence
1 patient
‘’Patient admitted to hospital (and) increased fluid from fistula compromised skin
condition...’’
All patients had previously had a variety of creams and dressings to manage these symptoms; and
which were reported as being present previously from 10 weeks up to 8 months.
Days to ‘healed’
7 days
patient 6
12 days
21 days
patient 5
21 days
28 days
patient 4
28 days
patient 3
patient 2
patient 1
0
5
10
15
20
25
8
n=505
8
EīeĐƟveŶess
as a barrier
AdhereŶce to
wet sŬŝŶ
8
A list of Nursing Homes was obtained and an initial letter and product
information was sent before Christmas 2011 to participants. In January
and February each Nursing Home was contacted and training meetings
were set up.
• During each training meeting, the following were discussed:
• Development of IAD, intertrigo and category II pressure ulcers
• Use of Proshield in these areas including moist and wet lesions
• Use of Proshield in providing protection from friction and shearing
forces
• Application (including over topical fungal treatments) and removal
This is one of the very first UK case study series for the Proshield skin care protective system 2011. It
has demonstrated that the Proshield system is extremely effective in treating incontinence related
dermatitis as well as compromised pressure areas. The response to healing occurs within a notably
reduced timescale. In this sequence of case studies Proshield has demonstrated its ability to be an
effective replacement for the various dressings (e.g. hydrocolloids) and creams that were previously
used to manage, however did not effectively resolve these symptoms. It was noted that participants
benefited in terms of quality of life including eradication of pain; eradication of odour and enhanced
comfort. Patients themselves expressed the benefits of Proshield eg ‘’patient was very pleased with
response...’’. Increased comfort may lead to increased mobility and other benefits may accrue. In
summary the costs of fully resolving the symptoms, such as incontinence associated dermatitis, were
reduced following commencement of the Proshield system. Managing damaged skin and limiting
further damage are important aspects in patient care and improving quality of life. This case series
shows transformation in skin integrity and healing. In one case the specialist mattress on order was
no longer required following skin integrity recovery with the Proshield system.
• Ingredients
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asked for in each case and the majority of residents had Proshield applied
to broken areas which were mainly on the sacral/perineum area. Some
PCQGBCLRQUGRFGLRCPRPGEMUCPCGBCLRGjCB?LBQMKC?JQMUGRFAJGLGA?JJWBPW
skin.
Supported by an educational grant from H&R Healthcare
Initially, sample products were left along with clinical data and
application guides, and details for obtaining further product.
Nursing Homes were then followed up on a regular basis; initially seven
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either a phone call or a visit.
In all, 56 Nursing Homes took part in the evaluation and 90 evaluations
were obtained.
8
Ease of
applicaƟŽŶ
PaƟĞŶt
comfort
ImprovemeŶt
iŶ skiŶ
coŶdŝƟoŶ
PreveŶts
dryiŶg of sŬŝŶ
Ease of
removal
The results shown echo the feedback that was given during visits and some Nursing Homes changed their ordering completely after seeing the
results. Comments such as: ‘much better and healed quickly; past history of healing slowly with dressings’, ‘more effective than other
protectants’ and ‘very effective and easy to use. Results seen immediately’ were common.
Of all the Nursing Homes who replied to whether they wanted to see Proshield Plus on formulary, only one did not. On investigation, this home
was using Proshield Plus only as a moisturiser on dry skin and whilst this is a minor indication, for evaluation purposes, injured skin is a better
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During the trial, there was a necessity in one Nursing Home to carry out further training on the application and removal of Proshield to ensure
that product instructions were followed and to ensure the use of thicker layers on broken skin. They went on to have very successful results, and
subsequently ordered for more residents.
Discussion
It was evident from the evaluations that training on the appropriate usage and the pathologies involved in injured skin associated with
incontinence and moisture was vital to the evaluation’s success.
Interestingly some carers assumed that Proshield Plus would prevent pressure ulceration instead of it preventing friction, shear and moisture
associated skin damage, and this is something that further education will support.
Conclusion
In all, 56 Nursing Homes took part in the trial most of them submitted evaluation forms. Comments from both carers and residents were very
positive.
Proshield Plus has successfully been added to the Nursing Home Formulary and a designated Clinical Specialist has been employed by the distributor
to assist with training and to ensure on-going correct and appropriate use. This will ensure that both existing staff and new recruits are instructed
in usage on both intact and injured skin and that appropriate amounts of the product are being applied in both cases. There is a big distinction
here as a thin transparent layer, whilst appropriate for prophylaxis, is not enough for an injured skin area which requires a thicker, opaque layer.
Supported by an educational grant from H&R Healthcare
THE USE OF PROSHIELD FOAM & SPRAY TO CLEANSE AND
NOURISH SKIN IN WOUNDCARE, WITHIN GENERAL PRACTICE
USE OF THE PROSHIELD SYSTEM ON
DAMAGED SKIN ACROSS AN ACUTE SETTING
Gerry Munro BSc (Hons), Senior Practice Nurse, Concordia Health Ltd.
Results
Cleansing limbs of patients
with leg ulceration within both
General Practice and Community
environments has long been
debated (Lindsay, 2007) and
historically, immersing limbs
in a bucket of tap water with
appropriate emollients is routine
practice. This procedure is reputedly
therapeutic and non-invasive. Lindsay (2007) states that soaking
limbs helps to maintain the patient’s personal hygiene and has
huge psychological benejts, especially when wounds produce
copious amounts of exudate or are malodorous. Conversely,
immersing an ulcer in water can increase exudate, periwound
maceration and risk contamination.
Since introducing Proshield Foam & Spray, the Practice Nurses have
reported a signijcant reduction in musculoskeletal pain, analgesia and
tiredness.
Practice and Community Nurses frequently treat several patients
in succession, requiring legs to be washed without a break inbetween. This time consuming, exhausting task often results in
nurses complaining of increased back, neck and knee pain.
The National Back Exchange (2007) and
NHS Employees (2009) emphasise safe
working practices within a healthcare
setting, highlighting the importance
of appropriate ‘Risk Assessments’ to
reduce incidences of musculoskeletal
injury. Lindsay (2007) supports the
consideration of the risk of back injury,
when jlling and transferring buckets
containing water.
Back pain and associated musculoskeletal
disorders are responsible for signijcant
levels of absence in the nursing profession,
costing an estimated £4.8 million in 2003.
Furthermore around 3,600 nurses, annually,
are forced to retire early due to back injuries
(NHS Employees, 2009). With retirement age
increasing it is imperative that we aim to
reduce the physical strain on nurses’ backs,
without compromising patient care.
Proshield Foam & Spray cleanser
is an effective alternative to
washing legs in buckets of tap
water, acting as a robust cleanser
and moisturiser. Primarily licensed
for incontinence associated skin
conditions for injured or intact
skin, its non-rinse formula is also
licensed for the removal of dried
blood and other hard to remove
debris (H&R Healthcare Ltd, 2012).
Guy’s and St Thomas’
NHS Foundation Trust
Nurses Comments
Additionally they reported at least 25% time saving, releasing valuable
appointment time. An improvement in holistic wound assessments and
documentation has also been noted.
Proshield Foam & Spray effectively improved the skin integrity of
2 patients with recurrent skin infections and associated wounds. It
softened and aided the removal of chronic hyperkeratosis leading to
healing in a non-healing wound. It effectively cleans and conditions
periwound skin on other sites including the scalp and arms.
Discussion
“Since changing to Proshield, I have noticed a signijcant reduction
in back, neck and knee pain and no longer need analgesics to go to
work”
“I seldom need to kneel on the koor now, with the associated difjculty
getting back up, I have had no further absence from work due to
back pain since implementing Proshield Foam & Spray as an effective
cleanser”.
“For patients requiring both legs to be washed and redressed, I have
reduced appointments by 10 mins... and no back ache....everyone is
happy”
“I really like it, nice, easier to use, no strain on my back now! Really
good on dry skin, patients like it!!!”
“I would not still be in this role, if we had not changed practice to
Proshield Foam & Spray”
Conclusion
Maintaining peri-wound skin integrity prevents maceration and further
tissue loss. Proshield Foam & Spray helps to prepare the wound edges for
additional treatments by removing debris and other contaminants. In one
Health Centre the use of Proshield Foam & Spray is deemed effective in
cleansing patients’ lower limbs and skin, reducing nurses’ musculoskeletal
pain and associated absence. It has proved time efjcient and patient
friendly, however, further data is required to analyse the overall cost
effectiveness.
If prevention is the key, why are Nurses continuing with these historical
practices? Although inexpensive, water quality is variable, and research
into its effectiveness to cleanse legs remains inconclusive (Lindsay, 2007).
Arguably, ideal cleansing solutions should be gentle, pH balanced,
light, easy to utilise and be effective in removing debris. Protecting the
granulating and epithelialising tissue, whilst remaining cost effective is
a vital part of woundcare. (Lindsay, 2007; Van Der Kar, Roche, Shi, and
Carson, 2012).
ddition@l AeneÆts
Additional benejts noted include the reduction in Health and Safety and
Infection Control issues associated with the use of buckets lined with bags,
as water is often splashed on the koor andor dripped from the liner,
especially when the liners split or were emptied. Decontaminating the
buckets can also be problematic, with the handles often being missed.
What’s more with the ever increasing demand on nursing staff, any
opportunity to improve efjciency by reducing prescribing cost and the
time element of treatments should be sought.
Patients Comments
“It’s got to be more hygienic….”
“It is so much nicer now you don’t get down on your hands and
knees… I never liked that, it felt wrong….”
“I don’t think it does your knees any good”
Method
“I was dreading you taking that bandage off. The blood was dried
so hard on my toe…. That was brilliant thank you.”
Practice Nurses within the Health Centre see on average 32
patients a week that require skin care,16 of these have leg
ulcers. Following one Practice Nurse requiring signijcant sick
leave due to repetitive back strain, a trial of Proshield Foam &
Spray cleanser was implemented.
“My legs feel so much cleaner and fresher … and so soft….”
References
H&R Healthcare Ltd. (2012) Proshield: Proshield® Plus and Proshield® Foam & Spray. www.
hrhealthcare.co.uk
Lindsay, E. (2007) To wash or not to wash: What’s the solution for chronic leg ulcers? Wound
Essentials vol 2 74- 83
NHS Employees. (2009) Back in Work. Introduction and key messages. NHS Employees. Leeds.
www.nhsemployees.org [Accessed on 16/07/2012]
National Back Exchange (2007) Risk Management Strategy.
“Oh look at the lather it makes.. isn’t it lovely? That feels so nice’’
www.nationalbackexchange [Accessed on 16/7/12].
“My skin is so much better, we are not getting white dust
everywhere (from the skin), when I take my stockings off”
Van Der Kar, C., Roche, E., Shi, L., and Carson, D. (2012) Gentle Cleansers with Infection
Prevention. Healthpoint Biotherapeutics, Research and Development, Fort Worth, TX
Supported by an educational grant from H&R Healthcare
INTRODUCTION
CASE STUDY 1
DISCUSSION
As one of London’s busy Teaching
Hospital Trusts, we aim to provide high
quality, personalised care to all of our
patients. Over the last 900 years we have
been at the forefront of innovation and
we see our approach in wound care to
be no different.
A was a 2 year old boy who had been in hospital for over seven months, following multiple surgical
laparotomies, and an anterior bowel resection. The stoma had been reversed, however pancreatic juices were
secreting from the stoma site causing severe excoriation to the surrounding skin. For over a month several skin
barrier products and absorbent dressings were used without any improvement, prior to the introduction of the
Proshield system (photo 1).
Moisture lesions refer to skin damage
caused by excessive moisture, often
due to faecal and urinary incontinence,
(Ousey, et al, 2012). Both urine and
faeces can have a detrimental effect
on skin integrity as their pH is alkaline
(pH 11 & 7 respectively), whereas
normal skin’s pH is 5.5 (acidic). Likewise
additional body secretions that are
alkaline in nature can also cause
increased irritation if in contact with
the skin. (e.g. Pancreatic juices - pH is
between 8 & 8.8).
Proshield Plus skin protectant was applied
every 8hrs. On day 3 (photo 2), there was
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(redness) and the bullae that were initially
present. Due to the pancreatic juices still being
secreted from the stoma onto the surrounding
skin both Proshield products were used to
prevent any further skin breakdown.
It is important that nurses are able to choose a product
that is easy to use and is effective in managing
moisture related skin damage. Ousey et al (2012)
highlights the important role skin protectants play in
both the protection and treatment of moisture lesions.
Additionally the Best Practice Statement: Care of the
Older Person’s Skin states that, soap substitutes should
be used in individuals with dry, vulnerable skin, or
skin determined to be vulnerable when washing and
cleansing. During routine personal hygiene most soaps
increase the skin’s pH to an alkaline level.
Proshield Foam & Spray cleanser (pH
balanced) and Proshield Plus skin
protectant’s primary clinical indications
for use are: for intact and injured
skin, predominantly associated with
incontinence, for example incontinence
associated dermatitis and moisture
lesions. The products are safe to use on
babies, children and the elderly.
Result
The objective of the evaluation was to
assess how effective Proshield Plus skin
protectant and Proshield Foam & Spray
cleanser were in the treatment of 3
patients with excoriated skin, caused by
moisture damage.
Photo 2.
CASE STUDY 2
B was an 11 month old baby boy, who was admitted after suffering continuous loose stools and excoriation of
the buttocks which had been deteriorating
whilst at home over the previous two weeks
(photo 3).
Education is paramount to ensure Proshield Plus and
Proshield Foam & Spray cleanser are used appropriately.
Therefore the Tissue Viability team demonstrated to
Nursing staff how to use the system correctly, and
supplementary ‘top-up’ sessions were implemented
as required. Nursing staff and parents were asked to
cleanse the damaged skin with Proshield Foam & Spray,
gently pat dry the area and apply Proshield Plus skin
protectant. Instruction sheets were left in the patients’
notes for staff and parents that were unable to attend
a training session.
CONCLUSION
Result
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within 2 hours of the skin protectant being
applied. By day 2 there was a vast improvement
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reduced (photo 4) and B was discharged home
on the 3rd day.
METHOD
Consent for inclusion in the poster and
for photographs has been obtained
from the patient and in the case of the
children; consent has been obtained
from the parents.
Photo 1.
Photo 3.
Photo 4.
Proshield Plus and Proshield Foam & Spray cleanser
demonstrated excellent results for all 3 patients. It was
effective in providing both a healing environment for
damaged skin and protected the skin from further
harm.
Although our initial evaluation was only on 3 patients,
Proshield Plus skin protectant and Proshield Foam &
Spray cleanser has continued to be recommended for
patients receiving Tissue Viability support.
CASE STUDY 3
C is an elderly lady who was admitted following
a fall at home. On admission it was noted that
C was doubly incontinent. Her skin was red raw
and bleeding. She was catheterised to support
the improvement of her skin integrity around the
perineum (photo 5).
REFERENCES
Ousey,K., Bianchi, J., Beldon, P., & Young, T. (2012) The
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Wounds UK Supplement.
Result
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subsided and there was no further bleeding
(photo 6).
Best Practice Statement: Care of the Older Person’s
Photo 5.
N
urses have a major role to play in assessing and preventing skin breakdown. It is essential to risk assess
all patients to identify those most likely to
be vulnerable. Incontinence poses particular
risk factors as both urine and faeces have
detrimental effects on the skin. This can lead
to incontinence associated dermatitis (IAD)
and pressure ulceration. The differentiation
between IAD and pressure damage is often
very challenging for nurses but it is imperative for nurses to make the correct diagnosis
to ensure appropriate treatment and care.
Skin care is a basic nursing skill. However,
with the ever challenging focus on the profession being evidence-based, it can be very
difficult for nurses to determine the best skin
care regime for their patients. Good robust
evidence is lacking in this area of care. With
the plethora of skin care products available,
it is essential that nurses are well informed
of their benefits and risks to enable them to
discuss the options with their patients and
make the right choices.
This article informs readers about the components of the ideal skin care regime using
the best available evidence identified through
searching the British Nursing Index, CINAHL
and Medline. This article will also identify the
components, risk factors and benefits of skin
care routines. It will give a brief update on
the basic function of the skin, what can go
wrong and lead to breakdown, incontinence
associated dermatitis and other skin conditions. It will also describe nine case studies
using a new product to the UK.
debbie flynn and sally
Williams examine how
moisture and pressure can
cause skin to break down,
how barrier creams can
help the skin to heal and a
new barrier system.
Continence and ageing
Farage et al (2007) discussed the effects of
the ageing process on urinary continence
and suggested that the bladder becomes
irritable, reduces in its capacity and empties less efficiently. A combination of these
factors, along with long-term conditions,
polypharmacy, obstetrical injury, dementia,
changes in nutritional status, and postmenopausal changes, can lead to incontinence.
It could be postulated that many of the
elderly female population did not have the
post natal care that is available today. Therefore, it is possible that pelvic floor and or
anal sphincter damage may have gone undetected, leading to urinary and faecal incontinence in later life.
What causes skin breakdown?
Gray et al (2002) described the four main
risk factors contributing to skin breakdown
particularly when related to incontinence:
„ Moisture
„ Skin pH
„ Colonization with microorganisms
„ Friction.
Urinary incontinence leads to the skin becoming over-hydrated, while the urea and
ammonia in the urine lead to alkalinity.
Faecal incontinence causes more damage
to the skin than urinary incontinence due
to the bacterial content and enzyme activity.
The enzymes contained in faeces are more
active and destructive in the presence of an
alkaline environment, having a devastating
effect on the skin with the prolonged ex-
The barrier function of the skin
Vincent Siaw-Sakyi, Tissue Viability Nurse Specialist, and Luxmi Mohamud, Tissue Viability Nurse Specialist
Guy’s and St Thomas’ NHS Foundation Trust London UK
Introduction
Barrier creams for skin
breakdown
9
8
7
Proshield EvaluaƟon Results
Conclusion
30
10
9
8
7
6
5
4
3
2
1
0
Method
‘’She had a very red bottom and was odourous, after using the cleanser the redness
and odour disappeared..’’
3 patients
Nurse assessed: Grade 2 pressure ulcer
As the evaluations were returned, the data was fed into a spreadsheet, and at the end of the trial the results were put into graph form (below).
Successful use by Community Nurses in the Trust, led to a wider and
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NURSE COMMENTS:
‘’.....Prescribed steroid creams...have thinned her skin. Since using Proshield wash
and cream we have seen a marked improvement’’
Incontinence: (faecal and urinary)
Results
From January to March 2012, an evaluation across Nursing Homes
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Proshield Plus; a product for both intact and injured skin associated with
incontinence. Seven parameters were assessed over the three months and
the results are discussed below.
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application to injured skin (e.g. Excoriated and partial thickness
associated with incontinence). It can also be used on areas vulnerable
to intertrigo from moisture and sweat and for clinically dry skin as it is a
super moisturiser.
• 44% of participants who were experiencing ‘’slight pain’’ at first application subsequently
experienced ‘’no pain’’.
Patient
PH1624-11/11-P007-1
Documentation at Presentation
Surrey
Introduction
Background
• Resolution of odour (in three patients) was noted between 1 to 4 weeks depending on the
recovery time of the compromised skin.
• 44% of all participants experienced ‘’no pain’’ at outset of application.
A multi-centre evaluation was conducted during April – July 2011. 9 patients were included. 5
patients were being cared for on District Nurse case loads and 4 were residents in care homes. The
ages ranged from 55 – 101 years and the average age was 84 years. All participants were female.
Some participants were fully ambulant whilst others less so. All soaps and creams/moisturisers were
substituted with the Proshield skincare protective system which was used after each episode of
incontinence to cleanse and protect the affected skin. All other products were effectively displaced.
Product focus
First Community Health & Care
Lizette Howers, Primary Care Pharmacist, NHS Surrey and Fay Boyett, Medicines Management Facilitator, Surrey Community Health
Gloucestershire Care Services
Louise Ling, Tissue Viability Nurse Specialist, Gloucestershire NHS
Photo 6.
Supported by an educational grant from H&R Healthcare
The skin prevents fluid loss, regulates body
temperature, and protects against harmful
substances. The stratum cornuem has layers of keratin-filled corneocytes arranged in
a brick-like fashion, which enable the skin
to protect its host (Black, 2007). However,
certain factors can soon compromise the
integrity of the stratum corneum and lead
to skin breakdown. This will leave the host
vulnerable to a number of adverse effects
that can lead to IAD.
posure to urinary leakage and perspiration.
Unless successfully identified, managed and
treated, this prolonged exposure will lead to
IAD and has a high risk of then developing
into ulceration.
Residents who are doubly incontinent
(have both urinary and faecal incontinence)
are at major risk of skin breakdown, particularly if their mobility is limited. The excessive toxic moisture present leads to the need
for frequent washing. The permeability of
the stratum corneum then increases and reduces the skin’s protective barrier function.
Increased pH (alkalinity) raises the risk of
bacterial colonization and increases the risk
of infection (Beeckman et al, 2009), most
commonly by organisms such as Candida
albicans (a type of fungus, which is also a
yeast) from the gastrointestinal tract and Staphylococcus species from the perineal skin.
These organisms will cause dermal infections that may initially be fungal in origin,
but bacterial infection is more likely to occur as Staphylococcus easily colonizes skin
already compromised by IAD.
Other skin conditions
Intertrigo (a rash in a body fold) and vulvar
folliculitis (inflammation of follicles around
the vulva) will occur as a result of poor
hygiene and excessive moisture caused by
incontinence in areas with opposing skin
surfaces (Nathan, 1996).
Puritis Ani is an inflammation of the perianal area. This can be caused by overzealous cleansing of the anus, leading to sudden
bursts of itching, causing great discomfort
and distress. Scratching will damage skin integrity and lead to the invasion of bacteria,
poor hand hygiene will also lead to cross
contamination and other infections.
debbie flynn
Senior Nurse Specialist Bladder &
Bowel Care Service Devon PCT, Team
Leader North & Mid Devon
sally Williams
Community Registered Nurse, Plymouth
Community Healthcare
Nursing & Residential Care November 2011, Vol 13, No 11
553
TreaTmenT Of mOisTure
relaTed lesiOns in Children
Jan Maxwell RSCN, SCM, MPH and Debby Sinclair RGN, RSCN, MSc;
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
introduction
Case study 1
No-one likes to see children in pain. Caring for babies and children with painful nappy rash
is a common complaint but one that we struggle to treat. This is evident by the vast array of
products available, over the counter or by prescription, to manage it.
A was a 3 week old baby with a spinal lesion that had been resected, leaving him
paralysed from the waist down. Antibiotics gave him diarrhoea and he quickly
developed an excoriated, bleeding bottom through very frequent nappy changes.
Babies or children can have delicate or fragile skin which is particularly vulnerable when they
are ill or undergoing medical treatments.
The new skin protectant was started and used at each nappy change. Within 3 days his
bottom had healed, despite the continuing incontinence. Parents continue to use the
product at home and A has had no further skin problems.
As Paediatric Tissue Viability Nurses we aim to be proactive by evaluating new products that
could improve care and general well-being in this patient group. This poster reflects our
experience in using a new dimethicone based skin protectant* on a variety of common and
troublesome moisture and other skin lesions in a children’s hospital.
methods
Between September 2011 and end January 2012, neonates, babies and children aged
between 1 week and 16 years of age, with perianal dermatitis/excoriation (associated with
incontinence), clinically dry/cracked skin, perianal thrush, pressure injuries (grades 1 and 2), and
other moisture lesions had the damaged skin treated with this skin protectant.
Photo 1: Before
results
The product was used on more than 40 patients but due to rapid turnover some could not be
followed up.
• 38 cases were followed from referral to recovery/resolution,
• 30 (79%) showed good improvement or healed,
• Time scale to healing - 3 to 21 days.
• In many cases use of the product continued as routine protection.
A series of case studies relating to the use of
Proshield Foam & Spray and Proshield Plus in an elderly care setting
Paulina Drzewiecka, Deputy Manager, Barrington Lodge Nursing Home, Cheltenham
Clinical evidence to support the benefits of using a
combination treatment of sorbion sachet EXTRA* dressing
and Proshield Plus skin protectant to promote wound healing
South Tees Hospitals
NHS Foundation Trust
When a new product enters the market it provokes a debate about its particular
application. In 2011 a new skin protectant, Proshield, was launched into the
medical market for intact and injured skin associated with incontinence.
Case Study - Patient 1
Method:
An 86 year old gentleman, whose medical history is dementia,
immobility and faecal incontinence. The incontinence and sedentary lifestyle
resulted in skin problems around the buttock area. The area was painful, the skin
integrity was poor, the epidermis was dry, damaged and broken with skin peeling
jE.PMQFGCJB$M?K1NP?WCDDCARGTCJWAJC?LQCBRFC?DDCARCB?PC??LB.PMQFGCJB
Plus provided barrier protection. This was repeated twice a day alongside patient
repositioning.
The Proshield System comprises of Proshield Plus (protectant barrier cream) and
Proshield Foam & Spray cleanser. The Proshield System provides an ideal solution to
skin cleansing, moisturising and barrier protection. These case series evaluate the
effect Proshield has on skin integrity.
Results:
The effects of using the Proshield System was already visible and
NJC?Q?LRJWQSPNPGQGLE@WB?WjE2FCPCU?Q?BCjLGRCGKNPMTCKCLRGL
the condition of the skin. The broken areas were healing, the skin appeared
moisturised and hydrated and the patient experienced less discomfort and pain. By
B?WjEDSPRFCPGKNPMTCKCLRQUCPCQCCLRFCGLHSPCBQIGLU?QPCQMJTGLE
RFC
area was pink and healthy and had decreased in size.
Discussion
Results
• The wound and the surrounding area need to be
cleaned properly
It is important for nurses to understand how to manage high
levels of exudate, and prevent peri-wound maceration.
• Measures need to be taken to prevent the start or
recurrence of infection
sorbion sachet EXTRA is a dressing indicated for moderate to
highly exuding wounds. It utilises the concept of Hydration
Response Technology, a combination of cellulose jbres and
gelling agents, to create a dressing that absorbs and retains
high levels of wound exudate.
After 8 weeks of treatment (January 2012), the overall
wound had improved immensely resulting in the shin
area being virtually healed.
• Effective pain relief needs to be considered
• Complete healing of wounds should always be the
aim
• Further measures need to be ensured in order to
promote skin health including the deterioration of
any existing wounds. Such measures would include
e.g. hydration, nutrition, and correct positioning
• The patient’s quality of life is paramount
The combination of the Proshield Foam & Spray
cleanser and the Proshield Plus protectant proved to
be an effective regimen for improving skin integrity
for two very different case studies. The skin integrity
resolved quickly and patient quality of life improved.
Fig 1. 15/12/11
Fig 2. 18/12/11
Fig 3. 21/12/11
Case Study - Patient 2
Conclusion
Method:
A 79 year old lady, with dementia, hypertension, immobility and
nutritional issues as well as urinary and faecal incontinence. The patient also had
a grade 4 pressure ulcer on her right heel which was caused by lack of movement
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The pressure ulcer was being treated with a variety of dressings.
Results:
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skin and Proshield Foam & Spray was used to cleanse away dried debris on
(?LS?PWRFjE2FCQSPPMSLBGLEQIGLU?QNCCJGLEBPW?LBAMKNPMKGQCB2FC
wound presented as a grade 4 pressure ulcer, serous discharge was noted on the
surrounding skin, there were no signs of clinical infection however the wound was
very painful.
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ÚUCCIQjERFCPCU?Q?T?QRGKNPMTCKCLRGL
the condition of the foot. The skin was well hydrated and oxygenated. The
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feel. The necrotic tissue in the wound and surrounding skin had resolved and the
wound was healing well.
WRF+?W
UCCIQjERFCPCU?QAMKNJCRCPCECLCP?RGMLMDRFCQIGLACJJQ
NPCTGMSQJWB?K?ECB@WLCAPMRGARGQQSCRFC?PC?U?QNGLI?LBFC?JRFW?LBRFCQIGL
was very well moisturised and hydrated. The patient presented with less discomfort
and no pain.
Problem
Introduction
The following steps are necessary in the treatment of
any type of wound:
Elderly people’s skin is very sensitive, often prone to
irritation and requires extra care, especially for those
patients who suffer from long-term illnesses, are
palliative, suffer from reduced mobility or who are
susceptible to wounds and skin abrasions. Also the skin
of patients who are unable to change their position
very often can be prone to pressure ulcers and other
related problems.
Using the correct skin care products is of great
importance. I would particularly recommend the
Proshield System as it is pH balanced, cleanses the skin
very well, moisturises and protects the skin leaving it
supple and hydrated.
In conclusion the Proshield System is very effective and
although the indications for use are primarily on intact
and injured skin associated with incontinence, it has
advantages for use in wound care.
Proshield Plus is a dimethicone based barrier cream, which is
primarily indicated for intact and injured skin associated with
incontinence, however can also be used to protect dry and
damaged skin.
Fig 5. 17/02/12
Fig 6. 11/05/12
Supported by an educational grant from H&R Healthcare
Perianal dermatitis
Multiple islands of epithelialisation tissue were evident
to the medial and rear aspects of the leg and to the edge
of the lateral aspect.
Dressing changes were reduced to twice weekly with no
evidence of any strike through on the bandages.
December 2011
The exudate was not only absorbed into the dressing but
also contained. The level of malodour had also reduced
and the patient had no pain at dressing change. Mrs B
no longer needed to use protective bed linen, and felt
happier in herself.
The products chosen were in adherence to the Hambleton &
Richmondshire PCT Wound Care Formulary Handbook.
Perianal dermatitis + thrush
Anal fissures
Other: e.g. stomas, dry skin,
pressure ulcers, facial lesions
Range
Days of
in years
treatment
(median) n = 38 (median)
0.02 - 5
12
3-8 (4)
(1.2 years)
0.36 - 2.5
9
3-10 (5)
(1.5 years)
0.1 -10
4
4-21 (9)
(0.9 years)
0.01 - 16.4
13
7-15 (9)
(5.7 years)
Results
-
~
+
Same or better
than alternatives
2
2
8
83%
1
4
4
88%
1
3
100%
3
5
61%
5
“-”= worse, “~”= no change, “+”= good improvement,
routine nappy Care
Throughout the hospital the nurses (and parents) use a range of products on their patients.
These include baby wipes, barrier creams and sprays, hydrocolloid paste, titanium-based cream,
honey barrier cream, petroleum jelly, and assorted mixtures recommended by ‘somebody’
who said they were effective. Often this doesn’t matter a lot, but when there is a problem or
children are undergoing chemotherapy for example, we have recommended the following:
Table 2: Examples encountered in nappy care that may lead to or exacerbate skin problems
Discussion
Method
A single patient case study was carried out, using a
combination of treatments; sorbion sachet EXTRA
dressing to promote wound healing and Proshield Plus to
protect the peri-wound skin, for a patient with a venous
leg ulcer. Consent for the poster and photographs has
been obtained.
Mrs B, is a 76 year old female, who has had a long
standing leg ulceration on her left leg for approximately
6 years and a history of recurrent infection. For the last 3
years Mrs B has been cared for within a complex wound
clinic setting.
On assessment Doppler results indicated the leg ulcer to
be venous in origin as the ABPI was 1.1.
Mrs B’s wound was producing large amounts of exudate
causing maceration of the peri-wound skin, she also
complained of malodour and pain. The wound required
re-dressing up to four times a week.
Previous treatments included a calcium alginate dressing
impregnated with silver and a secondary absorbent
dressing under compression bandaging with little
success. Despite the use of absorbent dressings, the level
of exudate meant the patient had to use additional bed
linen at night due to strikethrough onto her sheets.
In November 2011, the primary dressing was changed to
Fig 4. 10/01/12
The product was not always effective in situations such as:
• Extensively broken skin in the nappy area
• Profuse discharge around stomas
• Where parents had preconceived notions of what will/won’t work, with subsequent poor
compliance
Table 1: Use of new dimethicone skin protectant on different skin complaints in children
Penny Hutchinson, Complex Wound Clinic Nurse, South Tees Hospitals NHS Foundation Trust
Introduction
The product was well received and effective particularly in the following areas [see Table 1]:
• Simple perianal excoriation, i.e. with broken skin [case study 1]
• Anal fissures [case study 2]
• Perianal thrush, where antifungal creams were applied and then covered with the product
• Skin fold protection [case study 3]
After 8 weeks treatment
sorbion sachet EXTRA with a no-sting barrier jlm spray
to protect the surrounding skin and low dose/long term
antibiotics. In December 2011, following a product
update education session, the care pathway was reevaluated and the no-sting jlm spray was replaced with
Proshield Plus skin protectant. Having used Proshield
on incontinent patients to maintain skin integrity, with
the patient’s agreement, it was decided that a silicone
(dimethicone) based cream would provide a better
barrier to protect the surrounding intact healthy skin
from the heavy amount of wound exudate.
Although Proshield Plus is indicated for injured skin
associated with incontinence and not specijed for leg
ulcers, a clinical decision was made with the patient to
incorporate its use over the partial thickness wound as
well as the surrounding areas to great effect.
This dressing combination impacted on clinical costs as
the treatments were reduced from four times a week to
twice weekly.
Initially the cream was only applied to the wound edge
and healthy skin. Dressing changes were reduced to
three times per week.
Gradually, as the dressing promoted healing, small
islands of epithelialisation tissue began to appear
randomly, scattered on areas of the wound bed.
Proshield Plus was applied directly onto these areas to
protect the viable skin cells. As the number of islands
increased, Proshield Plus was applied in a thin layer over
the entire circumference of the wound bed. sorbion
sachet EXTRA continued to be applied as the primary
dressing under compression bandaging.
The combination of sorbion sachet EXTRA to ensure
bacteria, exudate and odour were managed and
Proshield Plus for skin protection, produced remarkable
results on a long standing leg ulcer.
Conclusion
After 12 weeks treatment
* sorbion sachet EXTRA
previously known as
sorbion sachet S
Using Proshield Plus skin protectant and sorbion sachet
EXTRA not only promoted wound healing and greatly
improved the patients’ quality of life, but also proved to
be cost effective.
Cleaning with water/baby wipes
Using tough, abrasive wipes or cotton
wool to clean
Hard or too frequent rubbing/wiping
of the skin
Multiple products in use at the same time,
or changed rapidly from one to another.
Products applied too thickly or
inappropriately applied
Highly coloured products used
x
Drying, stinging
x
Abrasive/leaves fibres
x
Friction/abrasion
x
Confusion – staff & parents, unable to
ascertain effective product
Clogged nappies, create further problems/
pain and discomfort
Unable to visualise skin, tendency to
vigorously remove
x
x
Table 3: Changes made to care in perianal dermatitis/excoriation
Use of an aqueous cream to clean bottom

Reduce friction, moisturise, soothing
Use gauze or soft plain wipes

Soft, no shed fibres
Gentle wipe, pat/mop off excess cream

less abrasive
Limit range of products

Better compliance, able to evaluate
effectiveness
Thin application

Allow nappy to work as designed

Better skin assessment reduces number of
changes needed
Where appropriate, use of a transparent
product
Since this case study has been carried out Proshield Plus
is the preferred barrier cream in the clinic to protect
from exudate and maceration.
*Proshield Plus
Photo 2: After barrier
applied
Photo 3: 3 days later
Case study 2
B was a 10 year old boy with Crohns Disease. He had a large anal fissure of 4 years
duration and they had tried ‘everything’, probably several times – nothing worked.
He began to respond almost immediately to the use of the skin protectant and was
delighted with the treatment. His mum wrote saying:
“B suffered for many years with deep fissures and experienced severe pain, we were
always told that there was little that could be done so he learned to tolerate the pain
and discomfort.
After your visit to us it was like a small miracle had occurred...within a week of use B’s
bottom had almost completely healed and has stayed that way! Thank you...”
Case study 3
C was an 18 month old baby with a long term tracheostomy amongst his other
problems. He was having constant problems with both pressure from his trache tapes
and moisture in his neck folds. We started to use the skin protectant to his neck.
It cleared the problems associated with moisture which has, possibly by reducing
drag, improved the skin under his tapes, reducing pressure damage. The product has
subsequently been used under trache tapes on a number of children with long-term
tracheostomies and the results are very positive.
Parents comments
Mrs D, mother of a toddler with Crohns disease, and herself a senior nurse at the
hospital, was desperate. Her son’s behaviour had regressed and he was hiding when he
needed to go to the toilet. She was given the new skin protectant to try on her son’s
nappy rash. She reported back that:
‘The new product changed our son from a screaming 2 year old at nappy change time
to a child who was much happier and more compliant with changes. Within 3 days
the red, blistered and bleeding area had almost completely cleared. I would definitely
recommend it to friends.’
discussion
Problems found in nappy care
• Education of parents and staff – misinformation, no family support
• Lack of knowledge and experience – relatives, everyone an expert, thrush
• Poor communication – literacy, told not shown resulting in poor technique
• Lack of insight/pre-emptive treatment – nurses not anticipating problems associated with
chemo or antibiotic use
• Lack of consistent approach – confusing, develops mistrust, distressed children, poor
compliance
• Multiple concurrent product use with no ability to assess effect.
Using this new skin protectant
• Comfortable, quick response, parents like it
• Ease of product use – more consistency, better compliance
• Parents proactive in seeking product on the wards and continue to use on discharge
• Good company support
Still to iron out
• Availability in the community – GPs are prescribing but some pharmacies delaying supply
• Under and over application - further use is necessary to more accurately gauge the amount
needed
Conclusions
The new dimethicone skin protectant largely worked as well or better than our previous
treatments, though there is still a place for these products in a structured approach. A
hydrocolloid paste remains a strong alternative in some cases. We found the skin protectant to
be a valuable tool in preventing or treating incontinence associated tissue damage in children.
Further usage will definitely help with our understanding of its benefits and limitations.
Presented at EWMA 2012 Vienna, Austria
Supported by an educational grant from H&R Healthcare
1738 H&R_Maxwell-Sinclair_AO_Portrait_Poster.indd 1
11/05/2012 11:23:57
1
IN THE PICTURE
Comfortschoenen ter preventie van diabetische voet
Diabetische voeten verdienen naast een goede wondzorg ook
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paramedische comfortschoenen van de merken Pulman® en Adour®,
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Deze kunnen uiteraard ook preventief gedragen worden.
De modellen ‘New Leiden’ en ‘New Harlem’ zijn specifiek ontwikkeld voor de diabetische voet:
ze vermijden extra druk ter hoogte van de tenen en hebben weggewerkte binnennaden om irritatie
of drukplekken te vermijden.
NEW Gamma
De schoenen van het gamma NEW worden aanbevolen in het geval van diabetes, maar
ook huidletsels, vasculaire letsels, reumatoïde artritis, hemiplegie, spitsvoeten, nagelziekten,
vervormingen en vervormingen van de tenen en de middenvoetsbeentjes.
Leiden New
Harlem New
XTRA Gamma
25 % meer voetruimte dan het gamma NEW.
De schoenen van het gamma Xtra zijn modellen voor zeer dikke verbanden of voor voeten met
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Deze schoenen worden aanbevolen in geval van diabetes, maar ook oedeem, elefantiasis, dikke
verbanden, prothesen en gips.
Leiden X-tra
Harlem X-tra
Ontdek onze andere modellen op www.pulman.be
2
IN THE PICTURE
Beter lopen, Beter leven !
Omdat moeilijke of pijnlijke voeten ook behoefte hebben aan elegantie,
combineren de schoenen van Adour® comfort, elegantie en functionaliteit,
voor gebruik outdoor.
De schoenen van Adour® oefenen geen enkele druk uit op uw voet en kunnen worden
voorzien van een geïntegreerde orthopedische binnenzool.
• De as van de middenvoet van de schoen is naar binnen gebogen. Zo neemt de voet zijn
anatomische positie aan en wordt geen druk uitgeoefend op de tenen.
• De ruimte ter hoogte van de middenvoet is veel groter dan normaal.
• Al deze schoenen kunnen worden versteld ter hoogte van de middenvoet: de sluiting
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• De binnenzolen kunnen worden verwijderd zodat de schoenen ook met een voetbrace
of steunzolen kunnen gedragen worden.
• De buitenste (slijt)zolen zijn licht en slipvast.
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Aire
Douai
Dax
Deze 3 modellen, geschikt voor diabetische voeten, hebben een aantal specifieke eigenschappen:
• Een afgerond voorvoetcompartiment
• Een evolutie in de pijnvrije loopafstand
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• Douai en Dax: verschillende volumes ter hoogte van de tenen
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3
PRODUCT NEWS
Ontdek het Curea P2 verband.
Curea P2 is de volgende stap op weg naar een efficiënte behandeling van sterk exsuderende
chronische wonden.
Dit speciale verband, ontworpen voor gebruik tijdens de tweede fase van het
wondgenezingsproces, bezit een aantal unieke eigenschappen:
•
•
•
•
•
•
•
•
Een geïntegreerde, niet-inklevende wondcontactlaag
Allergeenvrije, absorberende SuperCore® kern op basis van cellulose
Uitmuntende absorptiecapaciteiten
Uitstekende vochtdistributie binnen de kern
Behoud van absorptiecapaciteit, zelfs onder compressiedruk
Minimalisatie van het risico op wondmaceratie
Grote flexibiliteit
Krachtige geurcontrole
Driedimensionale, niet-inklevende wondcontactlaag
Het oppervlak aan de wondzijde bestaat uit een
geïntegreerde wondcontactlaag van polyethyleen
die, dankzij zijn speciale driedimensionale capillaire
structuur, niet gaat inkleven in de wonde.
Dit zorgt ervoor dat het regeneratieweefsel intact blijft.
Aantal/
Verpakking
Referentie
CNK-code Omschrijving
P2-110110-10
3006-228
Super absorberende dressing * 11cmx11cm P2
10
P2-100200-10
3006-210
Super absorberende dressing * 10cmx20cm P2
10
P2-200200-10
3006-236
Super absorberende dressing * 20cmx20cm P2
10
P2-200300-10
3006-244
Super absorberende dressing * 20cmx30cm P2
10
4
AGENDA
Vijfde tweedaags Vlaams Wondcongres
17 januari 2013
Limburghal, Genk.
7-8 februari 2013
‘t Forum, Kortrijk.
17e Conférence Nationale des Plaies et Cicatrisations
20-22 januari 2013 Palais des Congrès, Paris.
Wij wensen jullie prettige feesten!
Marc, Emelie, Sammy, Jurgen, Fanny,
Catherine, Marie-Eve, Charles.
MEER INFORMATIE?
Contacteer:
Catherine Chauvin
+32(0)477 76 05 01
[email protected]
Marc Lens
+32(0)476 86 35 15
[email protected]
Marie-Eve Dutrieux
+32(0)475 78 54 78
[email protected]
Hospithera NV l Klein Eilandstraat 3 l 1070 Brussel
Tel: +32 (0)2 535 03 80 l E-mail: [email protected] l WWW.HOSPITHERA .COM
5