Comprehensive Report: Managing Tracheostomized Peristomal Skin Damage

This report delves into the critical issue of managing tracheostomized peristomal skin damage, a common complication in patients with tracheostomies. The study explores the causes of skin breakdown, particularly moisture-associated skin damage (MASD), and examines various treatment approaches. The report provides an overview of the background of the study, literature review, methodology, and results. The research emphasizes the importance of proper skin assessment, the use of barrier creams, and the implementation of effective protocols to prevent and treat peristomal skin damage. It highlights the significance of evidence-based practices and interventions, including the use of specialized dressings and skin cleansing agents, to improve patient outcomes. The report also discusses the importance of collaboration between nursing and respiratory therapy staff in providing comprehensive care for patients with tracheostomies. The findings underscore the need for proactive measures to address peristomal skin damage and enhance the overall quality of care for tracheostomized patients.

Running Head: MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Name of the Student:
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Author Note:

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Abstract:
Periwound maceration is referred to as the wounds that offer local moisture but when existing
with a vast amount and come in contact with the skin, the said moisture can affect the peri-
wound area. Wounds seep out often determinants that are not only is water but also includes
enzymes and cellular debris. Additionally, a leakage in the dressing might leak and due to
that, a continuous exudation might occur on a daily basis leading to the increase in the
moisture content and maceration in the skin, ultimately making the skin more vulnerable to
irritating substances and increase the rate of critical microbial growth. The research paper
below focuses on moisture being the prime reason for damage caused to the skin, especially
focusing on the moisture-associated skin damage (MASD) (1), peri-wound moisture-
associated dermatitis and peristomal moisture-associated dermatitis.

2MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Table of Contents
Introduction:...............................................................................................................................3
Discussion:.................................................................................................................................5
Background of the study:.......................................................................................................5
Literature review:...................................................................................................................6
MASD- overview for the Community Nurses:..................................................................6
Care for the prevention of complications in patients with tracheostomy:.........................7
Management of moisture-associated Dermatitis and Periwound Moisture-associated
Dermatitis:..........................................................................................................................7
Effect of Barrier Cream on the Peristomal skin of Tracheostomized Patients:.................8
Collaborating to improve outcomes related to Tracheostomy Skin Integrity in long term-
acute care hospital:.............................................................................................................8
Management of Moisture associated Skin damage-A scoping review:.............................9
Rationale of the research:.....................................................................................................10
Aims and Objective:.............................................................................................................11
Methodology:.......................................................................................................................12
Research Methodology:...................................................................................................12
Selection of the patients:......................................................................................................13
Procedures followed:............................................................................................................13
Sample Collection:...............................................................................................................14
Skin assessment form:..........................................................................................................14

3MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Analysis of the data:.............................................................................................................15
Dressing performed with the gauze:....................................................................................15
Barrier cream applied with the gauze:.................................................................................15
Effective Pathway Determined:...........................................................................................16
Assessment:......................................................................................................................16
Diagnosis:.........................................................................................................................17
Cause of the skin damage:................................................................................................17
Management:....................................................................................................................17
Presentation of data:.........................................................................................................18
Control group with gauge (n=30).........................................................................................18
Variables..........................................................................................................................18
Results:.................................................................................................................................19
Conclusion:..............................................................................................................................19
References:...............................................................................................................................21

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Introduction:
Skin is one of the largest body organ, which helps in performing several mandatory
functions. The most important role that the skin plays in protecting the body from infectious
pathogenic invasions, obnoxious substances, ultraviolet lights, and prevents loss of fluid and
electrolyte loss. Thereby, the breach in the skin dimensions can result in the occurrence of a
vast range of complications, amongst which some are life-threatening. Excreted bodily fluids
are observed to be mostly responsible for breaching the skin; especially the results of urinary
incontinence or the presence of wound-secreted pus on the skin may produce skin damage.
Most of the common clinical situations, which can cause the damage of the skin, include the
occurrence of the draining wound, using skin adhesive agents, or urinary or faecal particles.
In patients undergoing tracheostomy, a tube is incorporated into the trachea by creating an
opening that helps in providing an allowance to the patency rate in the airway and is regarded
as the primary method of to save a life.
Periwound maceration is referred to as the wounds that offer local moisture but when
existing with a vast amount and come in contact with the skin, the said moisture can affect
the peri-wound area. Wounds seep out often determinants that are not only is water but also
includes enzymes and cellular debris. Additionally, a leakage in the dressing might leak and
due to that, a continuous exudation might occur on a daily basis leading to the increase in the
moisture content and maceration in the skin, ultimately making the skin more vulnerable to
irritating substances and increase the rate of critical microbial growth. According to the
review surveys, tracheotomy-related issues, that eventually raise for around 5% to 40%. They
include mainly pneumothorax, tracheal stenosis, misplacement of the tube, tracheoesophageal
fistula, and obstruction in the airway passage, haemorrhage and peristomal skin damages.
The peristomal skin damages are seen to occur the most at around a tally of 38.5%.
According to various studies, peristomal skin damages tend to display the most commonly

5MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
occurring complications. These complications are seen to further emerge as allergic
dermatitis, peristomal skin irritation, irritant dermatitis, mechanical trauma, infection and
development of granuloma. Inflammation or erosion of the skin, which is mainly caused due
to being exposed to the moisture and their components such as stool or urine or twound
exudate or mucus can lead to the occurrence of Moisture-associated erosion d skin damage
or MASD. The harmful effects water possess when directly being in contact with the skin has
always been known to be adverse and vast. Several reasons for breaking down of skin are
seen in clinical practice and most of them are seen to be caused due to severe skin exposure
to excessive moisture. MASD helps in describing the spectrum of damage caused due to the
result of the prolonged exposure of the skin over a long period of time. The healthy skin acts
as one of the major functions and it applies to maintain the physical state that deals with the
external environment. This, in turn, helps in preventing the entrance of the pathogens along
with the provision of a physical barrier against the outside environment. The research paper
below focuses on moisture being the prime reason for damage caused to the skin, especially
focusing on the moisture-associated skin damage (MASD) (36), peristomal moisture-
associated dermatitis and peri-wound moisture-associated dermatitis. The paper discusses the
management of tracheostomized peristomal moisture-associated skin damage in patients and
eventually creates an effective pathway to implement correct clinical pathway in managing
the damage. The prevention (35) and the protocol for the treatment of moisture associated
skin damage helps in encompassing a variety of the options, which include specialized types
of equipment or surfaces, linens and fabrics that are customized, dressings, incontinence
products and skin cleansing agents. Moreover, implementing barrier creams and moisturizers
for protecting or strengthening the moisturizers to strengthen and protect the skin.
Implementing cost-effective evidence-based practices and interventions that are cost-effective
for preventing or treating moisture associated skin damage should be done, ultimately

6MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
creating a perfect protocol for treating the peristomal moisture associated skin damage in the
patients with recent tracheostomy.
Discussion:
Background of the study:
There had been numerous researches that had been conducted to project the ways to
manage moisture associated skin damage in patients. A tracheostomy is done mainly to
provide airway patency to the patients by placing a tube in the trachea. There have been many
registered pieces of evidence where it has been seen that peristomal skin has been the reason
for various skin complications. There has been a regular rise in the complications related to
peristomal moisture associated skin damage, in tracheostomized patients. Currently,
tracheostomy is conducted with longer intubation that is further followed by observing
intubation to clean the tracheobronchial part. Previous studies that have been conducted for
checking the complications related to peristomal moisture associated skin damage have
projected that the presence of tracheostomy is not without risk. The complications as such
include bleeding, laceration, cervical abscess, tracheoesophageal fistula. Thereby it is very
important to consider the rise in such complications, where the patient is at risk. A survey
projected evidence-based studies that displayed ways to take care of patients suffering from
tracheostomized moisture associated skin damage. However, the study lacked in pieces of
evidence and had a scarcity of productions in relation to the patient. In another study, Karaca
& Korkmaz observed a quasi-experimental study to observe the effect caused by the applying
barrier cream on the peristomal conditioned skin of the tracheotomised patient. Moreover, it
was further observed during the next 7-days follow up session, that peristomal skin was not
compromised at all.

7MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Literature review:
MASD- overview for the Community Nurses:
According to Voegeli (2013), the effects of the application of excessive moisture on
the skin can become the reason for complication amongst many patients. The term MASD
had been implemented as well to explain the range of the damage that happens due to
excessive amount of exposure to the moisture such as urine, perspiration or wound exudate.
The paper also discusses the four distinct conditions of MASD, where each of them has
different aetiologies as such, peristomal moisture-associated dermatitis, incontinence-
associated dermatitis, peri-wound moisture-associated dermatitis, intertrigo. The paper
further evaluates and assesses, which help them in distinguishing between the four types of
moisture associated skin damage along with their appropriate ways preventing the occurrence
of the same. Moreover, the management and the interventions to be implemented are also
observed. Investigating the causes of excessive moisture and effective interventions has also
been observed in the structured skin and the care regime that needs to be followed has also
been implemented.
Care for the prevention of complications in patients with tracheostomy:
The paper analyses the evidence-based study of care to prevent the risk of
complications in tracheostomized patients (8). The study performed in this paper involves a
bibliographical study along with the analysis of articles published in the MEDLINE,
CINAHL and LILACS, between the years 2000 and 2017. The study performed involved a
set of 22 primary studies that were performed in English, Spanish and Portuguese. The results
projected the care that should be implemented during tracheostomy aspiration, dressing
replacement, skin and tube cleaning, saline humidification. Moreover, providing health

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education helped in representing the main strategies that would help in minimizing the risk of
the complications arising from tracheostomy practice.
Management of moisture-associated Dermatitis and Periwound Moisture-associated
Dermatitis:
The paper by Colwell et al (2011) gives an open outlook on moisture associated skin
damage (MASD) and mentions the reasons due to which the said complication arise.
Excessive moisture in stool, urine and wound exudate causes inflammation of the skin,
occurred with or without erosion. The paper also holds a panel discussion conducted by a
group of experts, focusing on peristomal moisture-associated dermatitis and peri-wound
moisture-associate dermatitis. Additionally, the article has an open wide discussion on the
principles that help in addressing the assessment along with discussing the treatment of
MASD affecting the peristomal or peri-wound skin. Lastly, it also gives away a wide outlook
on preventing the occurrences of any such moisture-associated skin damage.
Effect of Barrier Cream on the Peristomal skin of Tracheostomized Patients:
The quasi-experimental study conducted by Karaca (2018) on patients ageing from 18
to 65 years of age. They were hospitalised in the Turkish University Hospital under the ear
nose and throat clinic. The effect of the application of barrier cream or not using a barrier
cream was observed with respect to pH, temperature, moisture, colour, odour, infections and
lesions. The patients were selected on the basis of a sampling method and were further
evaluated. The paper determines a protocol for the nurses to follow in case of the occurrence
of any such complications in tracheostomized patients. The protocol was named as such by
"Nursing Care Steps for Patients with Tracheostomy". The demographic characteristics were
registered for each of the patients along with the assessment in terms with pH, moisture,
temperature and maceration, of the peristomal skin.

9MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Collaborating to improve outcomes related to Tracheostomy Skin Integrity in long
term-acute care hospital:
Hanks and Nix discuss the key problem of tracheostomy management in the given
mentioned paper. It states that assessment of the peristomal skin integrity is considered as a
major issue. Due to excessive moisture seeping from the secretions, frictions and perspiration
occurring from the tracheostomy collar and the breakdown of the peristomal skin may further
occur while stabilizing the ties. The paper further evaluates the surgical technique that is
involved to construct the tracheostomy may cause the incision performed on the patient much
wider than the tube itself resulting in reservoir pool drainage and further adding moisture
seeping issues. The paper helps in understanding the basic principles of taking care of a
wound caused by the breakdown of the skin due to the tracheostomy that had been
performed. Lastly, an effective protocol had been chalked out which helps in decreasing the
cost for the treatment of skin breakdown in tracheostomised patients with skin breakdown
along with showing ways to provide better care and time to the patients.
Management of Moisture associated Skin damage-A scoping review:
Kevin, Beeckman & Chakravarty (2017) discusses the fact that providing protection
to the skin from moisture associated damage is gravely important. This part of taking care of
the comprehensive skin and implementing ways of taking care of a wound is very essential.
The authors based on the previous literature reviewed and proposed new ways and
interventions to promote the protection of the skin from any kind of damage in the skin folds,
areas surrounding a particular wound or stoma or the perineum, which the most prominent
place of skin damage due to leakage in faeces or urine. The main aim discussed in this paper
was to form a review and identify along with providing a successful intervention based on
pieces of evidence, to manage and prevent the moisture-associated skin damage (MASD).
The methodology that was involved included searching the various databases for

10MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
understanding the broader spectrum of the already published and non-published studies in the
English language, in between the years 2005 and 2015. Following this, the findings and the
results were formatted in various different sections and were aggregated into a thematic
description of the given evidence. The results projected an overview of around 37 articles that
were studied and it further included the sectional divisions of 4 types of MASD, along with 7
strategies that were considered as evidence-based interventions for managing moisture
associated skin damage was also observed. The paper concluded by proposing important
interventions that shall help in preventing and protecting moisture associated skin damage by
using barrier ointments, cyanoacrylates for creating a protective layer to maintain the
hydration levels along with blocking external moisture and irritants and by using liquid
polymers.
Rationale of the research:
As per knowledge, amongst all the vital conditions and functions, the functions
performed by the skin by acting as a barrier for protecting the body against any kind of
noxious agents or infectious pathogens, mechanical trauma and excessive fluids. Therefore,
when the skin is overexposed to the moisture, it can break the integrity of the skin and
thereby can disrupt the arrangement of the molecules present in the intercellular region in an
intricate way. Once the cells get damaged the skin is more prone to permeable and being
susceptible to any kind of reaction with any irritant or noxious agents to enter the skin,
further leading to causing inflammation or dermatitis. Moreover, it has been further observed
that wet or moisture-filled skin is more prone to get eroded with friction and further cause
shear damage. The term moisture associated skin damage (MASD) as discussed above,
includes a wide range of injury that is characterised by the erosion or inflammation of the
skin caused from elongated exposure to moisture and elements such as urine, stool, wound

11MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
exudates or perspiration or any kind of ostomy effluent. Additionally, the term moisture
associated skin damage further can be classified into four different categories such as
intertriginous dermatitis, incontinence-associated dermatitis (IAD) (2), peristomal moisture
associated skin damage and peri-wound skin damage. It has been further observed that the
development of a MASD and the severity depends upon the various numbers of intrinsic and
extrinsic factors and their prevention at the initial stage is very necessary. According to
previous studies and evidence-based on working in the long term unit, it was observed that
the patients were incorporated with tracheostomies, because of being kept under ventilation
(18). It was reported that the total number of cases regarding trachea peristomal problem
cases since January 2019, included 113 along with the cases that were registered to wound
care nurse were 481 and the number of the patients admitted from acute care with peristomal
moisture associated skin damage was 384. Thereby, it was evident from the statistics derived
from the research observations that tracheostomy-related complications included peristomal
skin irritation, allergic dermatitis, infection, trauma or development in the granuloma. Based
on the previous studies it is very much evident that with the decrease in the number of the
peristomal skin complications and reducing the factors causing the moisture associated skin
damage can help in preventing the patients to stay longer at the hospitals. Moreover, it will be
cost-effective and would save money of the patients that needed to spent on the interventions.
The first steps of nursing care while dealing with these kinds of patients include maintaining
of the peristomal skin with the use of efficient products.
This has been one of the major issues to find an effective way of maintaining the condition
of the skin, as well as for the tracheostomised patients to prevent the occurrence of any of
such conditions. The aim of this research paper is to find a perfect pathway that is effective as
well as efficient in nature for managing a patient, who had undergone tracheostomy and has
peristomal moisture associated skin damage.