Managing Tracheostomized Peristomal Skin Damage

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

1MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
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

4MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
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

8MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
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.

12MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Aims and Objective:
As discussed in the above section, the main objective that was aimed to achieve, was
to find an efficient and effective pathway for peristomal moisture associated skin damage in
tracheostomised patients and help them to recover faster.
The objectives are as such:
 Identifying the patients who are at high risk of moisture associated skin damage
 Regular inspection to identify any damage caused by being exposed to moisture or
pressure.
 Differentiating the skin assessment damage with using terms as excoriation to explain
an erosion or a liner break along the skin surface or with the term denuded, which
referred to the loss of the epidermis that is caused on being exposed to urine, wound
exudates, body fluids as in this case seeping from the part where the tracheal tube is
inserted or caused due to friction.
 The research study also aimed at forming a protocol to prevent the occurrence of any
kind of moisture associated skin damage to prevent the longer stay of patients at the
long term (17) unit along with making their treatment cost-effective.
 The sources of the moisture due to which the skin damage or the skin erosion might
happen, for there can be many other reasons moisture caused by the seeping around
the peristomal area in the tracheostomy patients.
 With the help of the Braden Scale, the moisture present should be calculated and be
categorized further into sub-categories to help in the better assessment of the patients,
especially with a tracheostomy.
 Finally, finding a perfect skincare regime that needed to be followed to prevent or
manage the peristomal MASD and further, preventing the occurrence of any
occurrence of skin damage.

13MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Methodology:
Research Methodology:
The major problem found while managing tracheostomy was assessing the peristomal
skin integrity. The excessive amount of moisture that has been derived from the secretions,
pressure, friction or from perspiration caused by the presence of the tracheostomy collar has
been observed to aid to the further breakdown of the peristomal skin. The surgical technique
becomes another of the main problem because it causes a difference in the incision of the
tube and may have a wider incision than the tube itself. This has been seen in a maximum of
the patients, ultimately resulting in the seeping of the exudate and forming a pooled drainage.
As the patients are seen to need a tracheostomy for longer mechanical ventilation, they are
often seen to compromise on their health status. The methodology followed during this
particular research project of management of peristomal moisture associated skin damage in
tracheostomised patients included the new foam dressing along with the usage of barrier
cream on the peristomal skin of the patients. The study was conducted and completed by the
nursing and therapy staff in the long term unit of the hospital.
Selection of the patients:
The age ranges for the patients were selected from 18 to 60 years. They were
hospitalized in long term unit and had undergone post tracheostomy surgery. The criteria for
choosing the patients and sorting them for the survey were done with the help of purposeful
sampling method. The participants were chosen and checked whether they had undergone
any other operation for a complication, performed within the next 24 hours post following the
tracheostomy operation.

14MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Procedures followed:
The study was performed in two phases. The first phase was conducted for identifying
the provision of peristomal care to patients. A nursing protocol “Nursing care steps for
patients with a Tracheostomy” was observed. The second part of the study included taking
care of peristomal skin care. The provision of this care post 24 hours of tracheostomy being
performed. The protocol followed included cleaning of the peristomal skin with sterile gauze.
Post saturating the gauze with normal saline, the skin was dried with sterile gauze. Post this,
the assessment of the peristomal skin was performed within the terms of moisture,
temperature, odour, turgor, pH, colour, lesions and the results were registered on the form
stating the peristomal skin assessment. Post cleaning and assessing, barrier cream that is
composed of dimethicone, oils, acrylate terpolymer, paraffin, water, dicapryladipate, PPG-1
stearyl ether and isopropyl palmitate. This cream was applied to the patient's peristomal skin
as a thin layer within an interval of one day and was bandaged with the help of sterile gauze
dressing. Alternatively, for the control group, the gauze dressing was implemented and
altered within a minimum difference of 8 hours. This was done post-cleaning the peristomal
skin. The skincare was provided only once a day for the next consecutive 7 days. Following
this, the gauze dressing directly was applied over the peristomal skin, along with the
application of barrier cream. The patients displayed large amounts of secretion for the first
five days, thereby leading to the change in the sterile gauze dressings by the nurses on the
peristomal skin are.
Sample Collection:
The data was collected and registered into the forms developed for the research. The
observation form was used for the documentation of the provision of the peristomal care
provided to the patients during phase 1 of the study. The form included three open-ended
questions:

15MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
1) steps to follow by the nurses for peristomal care?
2) type of materials used for tracheostomy care?
3) steps followed by the nurses during the period of applying care?
Skin assessment form:
The assessment form for the skin condition was completed as well for monitoring and
recording the peristomal area pH, moisture and temperature along with changes observed in
the lesions, maceration and local symptoms of infection in the peristomal skin for every 24
hours. The surface pH meter calculated the peristomal ph. The moisture of the skin was
checked using the digital skin moisture tester and the temperature was measured with the help
of infrared surface thermometer. The peristomal colour was assessed first as a pale colour and
had progressed to normal or red, which had further progressed from normal as a part of the
healing process for the wound. The odour was differentiated accordingly as existent or non-
existent, turgor was maintained and the presence of lesions was registered as well. This
particular instrument was used along to check and register the microbiological fauna of the
skin by observing the occurrence of the microbes and their specific species. The swab
cultures performed were used both for the interventions on the first and last day of the
tracheostomy peristomal skincare. The collected swab cultures were sent for further
inspection to the laboratory for assessment.
Analysis of the data:
The data collected via the documentation and was transferred and analyzed with the
use of SPSS. The body mass index was calculated and entered for the statistical analysis. The
descriptive survey produced the results that stated the patient’s sociodemographic
specifications and the numerous microbes that were isolated. The variations of the daily

16MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
peristomal area temperature, pH and moisture were checked and analysed daily using the
repeated interventions of analysis of variance with Greenhouse-Geisser correction.
Dressing performed with the gauze: Barrier cream applied with the gauze:
 Microbial sampling (first day)
 Daily assessment of peristomal skin
(as per colour, odour, lesions,
turgor)
 Routine cleaning of the peristomal
skin with 0.9% NaCl solution (needs
to be performed for 3 times a day
for the first 7 consecutive days)
 Assessment of the peristomal skin
post skincare once a day
(temperature, pH, moisture)
 Applying the gauze dressing over
the peristomal skin
 The microbial sampling that was
sent was for culture was checked on
the 7th day.
 Microbiological sampling was done
on the first day
 The daily peristomal skin assessment
was performed to check the colour,
odour, turgor, lesions.
 The routine peristomal skin cleaning
was done in this case also with the
0.9% NaCl solutions. This was
performed once a day for 7
consecutive days.
 The assessment of the peristomal
skin was done after performing the
skincare once a day to check the
pH, moisture, temperature
 Barrier cream was applied over the
peristomal skin followed by the
gauze dressing
 Lastly, the microbial sampling was
performed by culture.

17MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Effective Pathway Determined:
Assessment:
The peristomal skin pH was between 5 to 6 and the moisture was calculated for 40
per cent to 55 per cent. Following this, the temperature ranged from 25 degrees centigrade o
35 degrees centigrade for the next 7 days of the study. The peristomal skin colour had been
observed normal and no growth of any kind of lesions was observed.
Any symptoms of local infection nor any malodour or any maceration were detected
in the peristomal skin. The mean peristomal skin pH was significantly lower with the patients
who had been applied with gauze dressing along with the barrier cream.
Moreover, the growth of S.epidermidis was observed to have been the most cultured
organism in the intervention group. The microorganism S.aureus was the pathological
microorganism that was mostly produced in addition to the flora of the normal skin.
However, the microorganism growth in the peristomal area was not seen to affect any kind of
changes over the study conducted for the next 7 days. Therefore, none of the patients was
administered with any kind of antibiotics during the period of the study.
Diagnosis:
Cause of skin damage:
The reasons that were observed to cause the breakdown of the skin or causing any
kind of peristomal skin damage around the stoma:
 Excessive presence of moisture at the tracheostomy site due to perspiration or copious
secretions)
 Excessive pressure applied from the faceplate

18MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
 Maximum of the patients were observed to be obese and thereby faced difficulty in
stomal construction or the from the presence of any kind of folds
 Tracheostomy construction was performed with a wider incision resulting in a wide
stoma.
 Many of the patients displayed low nutritional status
 Many of the patients faced immunosuppression because of the steroid therapy or from
the chemotherapy)
Management:
The management followed the necessary simple steps:
 Washing of hands and performing hand hygiene, and following the facility guideline
for the infection control
 The supplies had been set up and post this the gloves and appropriate personal
protective types of equipment were applied
 Removal of the soiled dressing and discard the dressing.
 Soiled gloves should be removed post this and hands should be washed.
 The tracheostomy peristomal skin then needs to be cleaned with the normal saline and
patted dry.
 The assessment of the peristomal skin condition and the stoma should be checked for
any signs of infection
 The liquid barrier cream film is applied with a thin layer and let it air dry.
 The dressing is then applied under tracheostomy ties and ensured ties are secured but
not allowing space for one finger under ties
 Lastly, the documents are registered, further assessment are performed, and the
dressing needed to be changed.

19MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
Presentation of data:
Control group with gauge
(n=30)
Control group (Gauze and
barrier cream)
(n = 30)
Variables n (%) n (%)
Diagnosis
Upper respiratory
cancersa
12 (40.0) 11 (36.7)
Stenosisb 3 (10.0) 4 (13.3)
Otherc 15 (50.0) 15 (50.0)
Age (years)
18–33 9 (30.0) 5 (16.7)
34–49 4 (13.3) 7 (23.3)
50–65 17 (56.7) 18 (60.0)
Gender
Female 8 (26.7) 11 (36.7)
Male 22 (73.3) 19 (63.3)
Body mass index
Underweight 3 (10.0) 4 (13.3)
Normal 19 (63.3) 16 (53.3)
Pre-obese 4 (13.3) 7 (23.3)
Obese class 4 (13.3) 3 (10.0)
Type of cannula
Plastic 20 (66.7) 27 (90.0)
Silicone 7 (23.3) 2 (6.7)
Silver 3 (10.0) 1 (3.3)
Smoking habit
Yes 14 (46.7) 15 (50.0)
No 16 (53.3) 15 (50.0)
Chronic disease
Yes 14 (46.7) 16 (53.3)
No 16 (53.3) 14 (46.7)
Results:
The results projected the breakdown in the skin resolved with the eight week
evaluation with the application of barrier cream and application of foam dressing. The
patients and the staff had reported that the application of the film of barrier cream helped in
backing up the new foam dressing and had made the dressing application much easier and
comfortable to slide under the tracheostomy ties. The PRN dressing changes observed on
average dropped from four to one dressing change per patient per day. This was in relation to

20MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
the dressing absorbency and there was a decrease in the secretion of the drainage through the
exterior of the dressing. The foam dressing was also observed to be more comfortable to the
patients and they were also observed to be providing cushioning under the tracheostomy
faceplate and thereby did not adhere to the surface where the wound was present. However,
the application of the barrier cream on the peristomal skin condition of the patient did not
project any kind of changes in the peristomal skin pH or the temperature or the skin moisture.
Conclusion:
The normal function of the skin is to work as a waterproof barrier and thereby,
exposing it to moisture for a prolonged period, will make the skin get soft and ultimately may
break it down. The skin thereby will become more vulnerable and shall be more prone to
fungal or bacterial infections. Therefore, protecting the skin from excessive moisture is very
essential to survive with effective skin and provide better wound care. Implementation of the
comprehensive prevention scheme to prevent the occurrence of any kind of moisture
associated skin damage. This also shall further help in the improvement of the quality of care
provided in the facility. The tracheostomy skin breakdown protocol has been proved to be
more effective for the patients in the long term acute care hospital. The new barrier cream
that was used during the performing of the foam dressing had eliminated the chances of
causing any kind of infection and thereby, acted as infection control through the application
of better containment of the wound exudates. Moreover, the procedures were observed to be
more cost-effective, by decreasing the cost. The procedure was also seen to save time by
observing a gradual decrease in the number of dressing changes, which were required to
manage the exudate. The paper can be concluded with the necessity to promote the protocol
for the management of peristomal moisture associated skin damage in tracheostomized
patients. The staff nurses need to be more aware of the application of the foam dressing along
with the barrier cream and thereby should be more practised. Future studies should be

21MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
performed as well regarding the evaluation of the optimal methods for protecting the
peristomal skins in the tracheostomized patient both in the short period and on a longer
period. Foam dressings have been observed to made out of polymers and have absorbent,
hydrophilic polyurethane centre along with a semi-occlusive outer layer. The foams are
thereby, used moderately in cases where there is heavy exudation from the wounds. The
peristomal and peri-wound moisture associated skin dermatitis are thereby, seen when the
skin is present according to the wound or stoma. The routine assessment of the wound is
much needed. Thereby, the consistent prevention efforts and prompt treatment need o to be
applied to the affected part in order to prevent the moisture associated skin damage from
progressing to further breakdown or totally eroded state.

22MANAGING TRACHEOSTOMIZED PERISTOMAL SKIN DAMAGE
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