R E V I E W S & A N A LY S E S Skin Integrity, Immobility, and Pressure Ulcers in Class III Obese Patients Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Class III obese patients are identified as having a body mass index greater than or equal Maryann Pagano, MSN, RN, CMS to 401 or weighing 100 pounds or greater than their ideal body weight.2 Class III obese Course Coordinator patients have an increased susceptibility to tissue injury, infections, and altered skin Dixon School of Nursing integrity resulting from the aberrant distribution of dense adipose tissue (e.g., weighted Abington Memorial Hospital skin folds, overlying skin layers) and changes in skin physiology (e.g., moisture from excessive sweating, decreased perfusion).3-9 The increased body mass is associated with functional limitations that predispose the class III obese patient to sitting, lying, or ABSTRACT remaining in a sedentary, immobile position for extended periods of time.10,11 Impaired Immobility, excess adipose tissue, and mobility contributes to the prolonged compression of skin, and without relief of the changes in skin physiology place class pressure through repositioning, injury to the skin and underlying tissues can result. III obese patients at risk for pressure The ability of a class III obese patient to effectively reposition or alleviate the pressure ulcers, skin infections, and cuts, tears, on the skin and underlying tissues is greatly compromised, increasing the occurrence of abrasions, and lacerations. A review sustained, unrelieved pressure, with shearing and friction forces on the skin resulting of five years of class III obese patient in skin breakdown and tissue injury.3,4 skin-related reports submitted to the Pennsylvania Patient Safety Authority ANALYSIS OF PA-PSRS CLASS III OBESE PATIENT EVENT REPORTS identified that 20.7% of all skin-related A query of five years of event reports—from January 1, 2007, through December event reports for class III obese patients 31, 2011—to the Pennsylvania Patient Safety Authority’s Pennsylvania Patient Safety with immobility issues were harmful skin- Reporting System (PA-PSRS) identified that 33.1% (n = 588 of 1,774) of all of the event related events. This percentage is high reports for class III obese patients were skin integrity reports, which is higher than the compared with the percentage of harm- 15.5% (n = 35,454 of 228,835) of skin integrity reports in the general PA-PSRS popula- ful skin-related events (2.3%) out of all tion in 2011.12 The query was conducted on the narrative descriptions using the terms skin-related event reports submitted “obese,” “morbidly obese,” or “bariatric.” A detailed analysis of the 588 skin integrity to the Authority in 2011. Pressure- event reports identified immobility as a factor in 82.8% (n = 487) of the reports, of related reports accounted for 85.0% which 20.7% (n = 101 of 487) were Serious Events (i.e., adverse events resulting in of the skin integrity reports for class III patient harm). This percentage of class III obese patient skin integrity reports that were obese patients with immobility issues, Serious Events is high compared with the 2.3% (n = 800 of 35,454) of Serious Event of which 57.7% were hospital-acquired skin integrity reports in the overall PA-PSRS population in 2011.12 The analysts con- conditions, 37.4% were present on ducted a detailed analysis of the class III obese patient skin integrity event reports in admission, and 4.8% had no indica- which immobility was a factor. tion of the time the event occurred. The development and implementation of PA-PSRS CLASS III OBESE PATIENT SKIN INTEGRITY EVENT REPORTS class III obese patient evidence-based Immobility was identified in class III obese patient PA-PSRS event report narratives skin care protocols and care plans, use when the narrative descriptions indicated patients needed moderate or maximum of bariatric equipment, and effective assistance when turning, transferring, or ambulating or when patients were on bed rest communication are ways to mitigate or had conditions indicative of immobility (e.g., ventilator dependency, recent surgery, the impact of immobility and skin chal- limb infections, limb amputations, preexisting pressure ulcers). lenges in class III obese patients. (Pa The skin integrity event report narratives were analyzed and categorized according to four Patient Saf Advis 2013 Jun;10[2]:50-4.) different types of conditions: (1) pressure-related conditions that were present on admis- Corresponding Author sion or were a hospital-acquired condition; (2) cuts, tears, or lacerations; (3) conditions Lea Anne Gardner involving weight of skin on skin; and (4) skin infections. The analysis of pressure-related conditions, accounting for 85.0% (n = 414 of 487) of the skin integrity event reports for Scan this code this patient population, included all clearly identified pressure ulcers and any type of with your mobile skin injury (e.g., blisters, ecchymotic areas) that occurred as a result of pressure. device’s QR Class III obese patients have a different mechanism underlying the development of a reader to access pressure ulcer. In thin patients, the pressure of the bony prominences injure the tissue the Authority’s toolkit on this covering the bone.13,14 In class III obese patients, the excess adipose tissue creates pres- topic. sure from the weight of the tissue. When skin lays on top of skin, the weight, lack of air circulation, and moisture with poor tissue perfusion set up conditions for a pressure ulcer Page 50 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority to develop.15 For example, the weight of an stage I [skin] breakdown on both upper An extremely obese female patient abdominal pannus can cause skin break- and lower buttocks. Underneath the was admitted to the hospital with down (i.e., a pressure ulcer) over the pubic [abdominal] pannus has stage II-III tenderness in the left flank and area due to the weight of the extra tissue [skin] breakdown and is discolored severe pain in the left lower back. along with the moisture leading to skin (green, yellow). The creases in the arms The patient’s hospitalization was breakdown underneath the pannus. Pres- also have stage II breakdown. complicated by uncontrolled diabetes sure ulcers and pressure-related skin issues mellitus, hypertension, and a possible The patient has a dark purple area predominated the reported skin integrity infection. The patient developed a at the waistline posteriorly from the event issues, followed by cuts, tears, or pressure ulcer on the right buttocks, right lateral side of the mid-back that is lacerations; events involving weight of skin which progressed to stage III during 28 cm wide and 3 cm in length. The on skin; and skin infections (see Table). the hospital stay despite wound care skin is intact, [but the discoloration] Many of the event reports had more than treatment at onset of the skin break- is from folds of tissue compressing the one conditional attribution occurring at the down. [The patient’s] nutritional area. Possible deep-tissue injury. The time of the event report (e.g., many of the status was suboptimal. patient is morbidly obese and is on a events involving weight of skin on skin were [bariatric] bed with low-air-loss surface. also counted as pressure-related events). The HOSPITAL STATEWIDE SURVEY It requires six nurses to turn the patient. Table shows a summary of the event types. When the therapist was preparing In July 2012, the Authority conducted a The majority of the pressure-related hospital statewide survey (35.3% response the patient for therapy, a blood-filled conditions (85.7%, n = 355 of 414) were rate) that included questions about class blister was noted on the right but- identified as pressure ulcers. An analysis III obese patient skin care protocols.16 The tock, which was not present when of the pressure-related event time of occur- survey results identified that 40.7% (n = treatment was given two days prior. rence showed that 57.7% (n = 239) were 24 of 59) of respondents had skin care The patient is alert and oriented hospital-acquired conditions, 37.4% protocols in place, and 20.3% (n = 12) of but immobile due to obesity, [and (n = 155) were present on admission, respondents indicated that there was no their] nutritional status is poor. and the remaining 4.8% (n = 20) did not physical assessment or medical care proto- The patient has been on a bariatric indicate the time the condition occurred. col for obese patients. An analysis of preexisting conditions that plexus mattress since admission. The can contribute to poor skin conditions patient was admitted for wound care treatment of bilateral lower- WAYS TO PREVENT SKIN revealed that 26.7% (n =130 of 487) of the buttock wounds, which are healing in INTEGRITY ISSUES patients had diabetes, 12.3% (n = 60) had venous stasis, 6.0% (n = 29) were inconti- response to established treatment. nent, and 3.9% (n = 19) had poor hygiene. The patient was admitted from another Class III Obese Patient Evidence- facility with cellulitis with a multiple- Based Protocols Skin integrity issues identified in class III stage wound. The patient is obese, with The development of class III obese patient obese patients are described in the follow- most wounds in the folds of skin. The evidence-based protocols helps staff to ing PA-PSRS reports: left hip has a stage III wound, [and] provide safe patient care.17-19 Best practice The patient presented to the hospital the right leg has a stage IV wound in includes performing an initial skin assess- with multiple areas of skin breakdown. the skin folds of the leg. ment followed by periodic reassessment, The patient is morbidly obese and has maintenance of good hygiene, keeping the skin dry, performing a nutritional analysis, repositioning patients, and use of special- Table. Pennsylvania Patient Safety Reporting System Class III Obese Patient Skin Integrity ized bedding and equipment.3,8,20,23-26 Event Reports (N = 487) Coupling skin care protocols with ongoing SKIN INTEGRITY CONDITIONS NO. OF EVENTS % OF EVENTS routine in-service training for staff is essen- Pressure ulcers—hospital-acquired condition 239 49.1 tial to make sure that staff are up to date Pressure ulcers—present on admission 155 31.8 on class III obese patient protocols and Cuts, tears, or lacerations 92 18.9 care pathways.17 In addition to skin-related Weight of skin on skin 75 15.4 protocols and care pathways, sensitivity Infections 27 5.5 training needs to be a part of class III obe- Total* 588 sity skin care protocols.16,21,22 * Total exceeds the number of reports (487) due to multiple conditions occurring in patients. Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 51 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Clinical Skin Assessments skin care routine provides insight into the Patients with reduced mobility need fre- and Care hygiene practices of the patient and pres- quent monitoring, especially in cases in An in-depth, head-to-toe skin assessment ents opportunities for patient education to which bedpans are used. When possible, is imperative, with emphasis on the areas improve future skin hygiene practices.27,29 patients should be offered a bariatric-size of weighted skin folds, excessive moisture One way patients can maintain good skin commode rather than a bedpan to keep or perspiration, and incontinence and hygiene is by having them use long-handled, patients mobile and reduce pressure from on points of increased friction and pres- soft-bristle shower brushes to clean areas a bedpan.30 sure.3,4,19 Inclusion of the Braden scale of their bodies they might otherwise not as part of the skin assessment assists in reach.27 Another aspect of the patient’s Communication identifying patients at risk for the devel- hygiene practice to evaluate is the differ- Clear and effective communication opment of a pressure ulcer.4 The Braden ent approaches used to keep the skin folds among staff and between staff and their scale does not predict the occurrence of clean. Not all skin hygiene approaches may patients is the first step to proactively a pressure ulcer but rather indicates a be beneficial.27 For example, cornstarch- reducing the occurrence of skin integrity heightened risk for the development of a based powder is a home remedy that has issues. Staff-to-staff communication pressure ulcer based on a score that evalu- the potential to incubate yeast and is harm- needs to convey: (1) the patient’s condi- ates six characteristics: sensory perception, ful when managing skin folds.27 tion and any new changes in their skin, moisture, activity, mobility, nutrition, and (2) equipment acquisition issues, and friction/shear.23,24 A study by Swanson Bariatric Equipment Use (3) transferring and repositioning issues, et al. identified that obese patients who Bariatric-size equipment is another way including timing of repositioning, the were assessed with both high-risk mobility to address skin integrity issues. Measur- patient’s capability in participating, and and friction/shear scores had a higher ing the patient’s weight, height, and identifying the number of staff required prevalence of ulcers compared with non- abdominal girth is the first step to ensur- to reposition or transfer the patient along obese patients with both high-risk scores.25 ing that the appropriate-size equipment is with the type of equipment needed to obtained.4,16 Securing the appropriate-size safely move the patient. The clinical care aspect of the care plan needs to focus on keeping all areas of the equipment for class III obese patients can Staff-to-patient communication requires skin dry and free of bodily excretion (i.e., help reduce some of the challenges with sharing information about the patient’s perspiration, excrement, and exudates) and keeping this patient population’s skin condition and plan of care so that everyone on reducing pressure and friction. There safe.27 Pressure-redistribution devices for understands the reasons behind the deci- are specific approaches to address basic skin sitting and sleeping are another way to sions for the patient’s care. Information care protection, incontinence management, reduce pressure for immobile patients.4,26 sharing can occur formally with planned and repositioning.4,26,27 Perineal care needs For example, bariatric beds with low-air- educational materials or informally (e.g., to be performed each time a patient is loss mattresses and specially designed throughout the day, when vital signs are incontinent.4 Creams that have zinc oxide, frames provide comfort for class III obese taken, during the delivery of meals, when dimethicone, or petrolatum provide barriers patients.28 Another type of bed-related patients use their nurse call light). to moist areas.4 Another approach is to use equipment, a trapeze can increase the moisturizers or emollients to prevent fluid patient’s mobility while decreasing fric- LIMITATIONS loss and protect the skin from drying;26 how- tion on skin during movement.4,20 The 487 PA-PSRS class III obese patient ever, falls precautions must be implemented Proper use of equipment is essential in skin integrity event reports identified for if moisturizers or emollients are applied providing safe patient care and is illustrated this analysis underrepresent the actual on or near the feet. Repositioning patients in the following PA-PSRS event report: number of class III obese patients who every two hours can reduce the chance of The patient was noted to have dark- experienced skin integrity events during pressure-related issues.8,28 When reposition- ened (purple) areas to [their] bilateral hospitalization. PA-PSRS event intake ing patients, check and free up all tubes or buttock [with one side worse than forms do not specifically request the catheters that may have become located in the other]. The patient’s skin [was] patient’s weight or body mass index, skin folds or underneath patients.28 reported by the nurse to be “sloughing except for the medication intake form. off” in [several] areas [of the buttocks]. The search of the PA-PSRS event reports Patient Skin Care Routine The patient reported that [she] had relied on the subjective assessments Assessments been put on the bedpan [and left on it provided by the individuals reporting During the clinical assessment of the for a couple of hours during the day]. the events. Limitations associated with patient’s skin, an assessment of the patient’s Wound care was initiated by the nurse. the statewide survey response rate reflect Page 52 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority potential response biases toward hospitals skin physiology has resulted in a high of evidence-based class III obese patient that care for class III obese patients or percentage of pressure ulcers and protocols that address clinical skin care underestimate the number of issues asso- pressure-related issues in class III obese assessments and care plans, equipment ciated with class III obese patients. patients in Pennsylvania. Cuts, tears, or use, hygiene practices, and educational lacerations; issues involving weight of skin programs are ways to proactively address CONCLUSION on skin; and skin infections were also skin conditions, whether the conditions problematic in this patient population. are present on admission or acquired in Immobility coupled with excess skin The development and communication the hospital. and adipose tissue and changes in NOTES 1. National Institutes of Health National 12. Pennsylvania Patient Safety Authority. 2011 21. Puhl RM, Heuer CA. Obesity stigma: Heart Lung and Blood Institute. Clinical annual report [online]. 2012 Apr 30 [cited important considerations for pub- guidelines on the identification, evalu- 2013 Apr 1]. http://patientsafetyauthority. lic health. Am J Pub Health 2010 ation, and treatment of overweight and org/PatientSafetyAuthority/Documents/ Jun;100(6):1019-28. obesity in adults: the evidence report FINAL%202011%20Annual%20 22. Puhl RM, Heuer CA. The stigma of [online]. NIH pub. no. 98-4083. 1998 Sep Report.pdf. obesity: a review and update [online]. [cited 2013 Apr 5]. http://www.nhlbi.nih. 13. National Pressure Ulcer Advisory Obesity 2009 [cited 2012 Nov 7]. http:// gov/guidelines/obesity/ob_gdlns.pdf. Panel (NPUAP). NPUAP pressure ulcer yaleruddcenter.org/resources/upload/ 2. Strum R. Increases in morbid obesity in stages/categories [website]. [cited 2013 docs/what/bias/WeightBiasStudy.pdf. the USA: 2000-2005. Public Health 2007 Apr 19]. Washington (DC): NPUAP. 23. Braden B, Bergstrom N. Braden scale Jul;121(7):492-6. http://www.npuap.org/resources/ for predicting pressure sore risk [online]. 3. Rush A, Muir M. Maintaining skin integ- educational-and-clinical-resources/npuap- 1988 [cited 2013 Feb 19]. http://www. rity bariatric patients. Br J Community Nurs pressure-ulcer-stagescategories. bradenscale.com/images/bradenscale.pdf. 2012 Apr;17(4):154, 156-9. 14. Takahashi M, Black J, Dealey, et al. Pres- 24. Bergstrom N, Braden BJ, Laguzza A, 4. Lowe JR. Skin integrity in critically ill sure in context. In: Pressure ulcer prevention: et al. The Braden scale for predicting obese patients. Crit Care Nurs Clin North pressure, shear, friction and microclimate in pressure sore risk. Nurs Res 1987 Jul- Am 2009 Sep;21(3):311-22. context. London (UK): Wounds Interna- Aug;36(4):205-10. 5. Pokorny ME. Skin physiology and diseases tional; 2010:3-10. 25. Swanson MS, Rose MA, Baker G, et al. in the obese patient. Bariatr Nurs Surg 15. Gallagher S, Arzouman J, Lacovara J, et Braden subscales and their relationship to Patient Care 2008 Jun;3(2):125-8. al. Criteria-based protocols and the obese the prevalence of pressure ulcers in hos- 6. Lowe JR. Skin integrity in critically ill patient: pre-planning care for a high-risk pitalized obese patients. Bariatr Nurs Surg obese patients. Crit Care Nurs Clin North population. Ostomy Wound Manage 2004 Patient Care 2011;6(1):21-3. Am 2009 Sep;21(3):311-22. May;50(5):32-4. 26. National Guideline Clearinghouse. 7. Yosipovitch G, DeVore A, Dawn A. 16. Gardner L, Gibbs C. Class III obese Guideline synthesis: prevention of Obesity and the skin: skin physiology and patients: is your hospital equipped pressure ulcers. In: National Guideline skin manifestations of obesity. J Am Acad to address their needs? Pa Patient Saf Clearinghouse [website]. 2006 Dec Dermatol 2007 Jun;56(6):901-16. Advis [online] 2013 Mar [cited 2013 Apr (revised 2011 Jan) [cited 2013 Feb 20]. 19]. http://patientsafetyauthority.org/ Rockville (MD): Agency for Healthcare 8. Rose MA, Pokorny M, Drake DJ. Prevent- ADVISORIES/AdvisoryLibrary/2013/ Research and Quality. http://www. ing pressure ulcers in the morbidly obese: Mar;10(1)/Pages/11.aspx. guideline.gov/syntheses/synthesis.aspx? in search of an evidence base. Bariatr Nurs Surg Patient Care 2009 Nov;4(3):221-6. 17. McGinley LD, Bunke J. Best practices id=25078&search=prevention+of+ for safe handling of the morbidly obese pressure+ulcers. 9. Camden SG. Obesity: an emerging patient. Bariatr Nurs Surg Patient Care 27. Blackett A, Gallagher S, Dugan S, et al. concern for patients and nurses [online]. 2008 Dec;3(4):255-60. Caring for persons with bariatric health Online J Issues Nurs 2009 Jan [cited 2013 Apr 3]. http://www.nursingworld.org/ 18. Wright K, Bauer C. Meeting bariat- care issues: a primer for the WOC nurse. MainMenuCategories/ANAMarketplace/ ric patient care needs: procedures J Wound Ostomy Continence Nurs 2011 ANAPeriodicals/OJIN/TableofContents/ and protocol development. J Wound Mar-Apr;38(2):133-8. Vol142009/No1Jan09/Obesity- Ostomy Continence Nurs 2005 Nov- 28. Gallagher S. The challenges of obesity An-Emerging-Concern.aspx. Dec;32(6):402-6. and skin integrity. Nurs Clin North Am 10. Ling C, Kelechi R, Mueller M, et al. Gait 19. Arzouman J, Lacovara JE, Blackett A, et 2005 Jun;40(2):325-35. and function in class III obesity [online]. al. Developing a comprehensive bariatric 29. Pokorny ME, Scott E, Rose MA, et al. J Obes 2011 Nov 26 [cited 2013 Apr 3]. protocol: a template for improving patient Challenges in caring for morbidly obese http://www.hindawi.com/journals/ care. Medsurg Nurs 2006 Feb;15(1):21-6. patients: managing activities for daily jobes/2012/257468. 20. Kramer KL. WOC nurses as advocates for living at home. Home Healthc Nurse 2009 11. Del Porto HC, Pechak CM, Smith DR, patients who are morbidly obese: a case Jan;27(1):43-52. et al. Biomechanical effects of obesity on study promoting the use of bariatric beds. 30. Gallagher S. Tailoring care for obese balance. Int J Exerc Sci 2012;5(4):301-20. J Wound Ostomy Continence Nurs 2004 patients. RN 1999 May;62(5):43-6. Nov-Dec;31(6):379-87. Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 53 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recall the definition of a class III The following questions about this article may be useful for internal education and obese patient. assessment. You may use the following examples or develop your own questions. — Recognize the Braden subscale 1. Complete the following sentence. The definition for a person with class III characteristics used to identify class obesity is a person with a body mass index (BMI) greater than or equal to 40 III obese patients who are at risk for or __________________ developing pressure ulcers. a. a BMI of 35 with one comorbidity. — Recognize the appropriate patient b. weighing 100 pounds above his or her ideal weight. assessments for securing the proper c. a BMI of 35 with two comorbidities. type of equipment for class III obese d. weighing 100 pounds or greater than his or her ideal weight. patients. 2. A study by Swanson et al. identified that obese patients who had high-risk scores — Distinguish between treatments that on two Braden subscale characteristics had a higher prevalence of pressure ulcers are and are not beneficial for main- compared with nonobese patients. One characteristic was mobility. Which was the taining good skin integrity in a class second characteristic? III obese patient. a. Activity b. Friction/sheer c. Sensory perception d. Moisture 3. Which of the following actions does not provide useful information when identify- ing and securing bariatric equipment for class III obese patients? a. Measuring the patient’s height b. Measuring the patient’s weight c. Measuring the patient’s skin folds d. Measuring the patient’s abdominal girth 4. Which of the following actions is not a discussed prevention method used to reduce the chance of skin-related problems for class III obese patients? a. Checking and freeing up all tubes or catheters that can get caught in skin folds or under a patient every time the patient is repositioned b. Repositioning the patient every three hours c. Performing a head-to-toe skin assessment d. Securing bariatric-size equipment 5. Which of the following skin treatments is not beneficial for maintaining good skin integrity in a class III obese patient? a. Use of moisturizers or emollients b. Use of zinc oxide creams, dimethicone, or petrolatum c. Use of cornstarch d. Performing perineal care every time the patient is incontinent Page 54 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 1—March 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. 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