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The role of barrier protection in pressure ulcer prevention

AbstractThis article considers the anatomy and physiology of the skin, the natural protection the skin provides in relation to barrier protection and the importance of barrier protection in pressure ulcer prevention. The current national pressure ulcer agenda including high impact actions and the SSKIN care bundle, along with their implementation within one NHS Health Care Trust are discussed.

Key words: Barrier protection ■ Pressure ulcer prevention ■ SSKIN bundle

The�most�significant�role�of�the�skin�is�to�be�a�protective�barrier�against�the�external�environment.�The�skin�is�covered�with�a�naturally�produced�lipid�layer,�which�helps� to�maintain�moisture�balance,�prevents�drying�

and� provides� an� effective� waterproof� barrier.� Normal� skin�pH� is� around� 5.5,� which� significantly� reduces� the� ability�of� bacteria� to� proliferate� (Butcher� and�White,� 2005).� Skin�dryness�may�occur�from�excessive�washing�or�use�of�alkaline�soaps,�which� alters� the� pH�of� the� skin� reducing� its� barrier�function�(Wysocki,�2000).�Bodily�fluids�including�urine�and�faeces� can� waterlog,� macerate� and� corrode� the� outer� layer�of� the� epidermis� (stratum� corneum)� leading� to� weakening�and�breakdown�of�the�skin,�often�painful�in�nature�(Wounds�International,�2010).�As�the�skin�ages,�the�epidermis�gradually�thins� and� the� papillae� that� lie� between� the� epidermis� and�the� dermis� become� flattened,� reducing� the� skin’s� resistance�to�shearing�forces�(Voegeli,�2010)�and�its�ability�to�perform�many�of�its�essential�functions�(Wysocki,�2000).

Skin assessmentIdentifying� early� signs� of� pressure� damage� is� vital� in� the�prevention� of� category� II� and� II� pressure� ulcers.� The�European� Pressure� Ulcer�Advisory� Panel� (EPUAP)� (2009)�and� the�National� Institute� for�Health� and�Care�Excellence�(NICE)�(2005)�advocate�that�essential�skin�assessment�should�be� undertaken� and� should� be� part� of� training� for� health�professionals.� Importantly,� the� need� to� protect� vulnerable�

Jackie Stephen-Haynes

areas�of� the�skin�and�prevent�skin�breakdown�is�considered�to�be�a�cornerstone�of�professional�care�across�all�spheres�of�practice� (Voegeli,� 2008).� Consideration� should� be� given� in�skin�assessment�to�skin�changes�in�the�older�person�(Wounds�UK,�2012)�and�skin�changes�at�life’s�end�(Sibbald�et�al,�2009).�

Newton� and� Cameron� (2003)� advocate� four� essential�aspects� of� skin� assessment:� colour,� texture,� temperature�and� integrity.� The� skin� should� be� observed� for� signs� of�colour� change,� reddening� or� blanching� (white� areas)�in� Caucasian� skin� types� and� for� a� bluish� purple� hue� in�darker� skin� types.� Skin� assessment� should� also� include�observation� for� increased� heat,� swelling,� pain� or� guarding�of� an� area� and� evidence� of� shiny� areas� or� superficial�breaks� owing� to� shearing� forces� against� the� skin.� The�implementation� of� care� rounds� including� assessing� and�monitoring� of� skin� (Bartley,� 2011)� as� part� of� harm-free�care� (Institute� for� Healthcare� Improvement,� 2011)� has� led�to� the� implementation� of� a� visual� skin� assessment� during�each� care� round� (1–2� hourly)� in� community� hospital�and� at� each� district� nursing� visit.� Thomas-Hess� (2000)�proposes�the�following�key�areas�for�skin�management:�

�■ Take� caution� with� the� force� applied� when� washing� the�skin� and� avoid� massaging� areas� that� could� be� easily�damaged

�■ Offer�prompt�attention�when�incontinent�episodes�occur�and�protection�of�skin�with�barrier�protection�

�■ Aim� to� avoid� drying� of� the� skin� through� extremes� of�temperature

�■ Ensure�that�patients�are�positioned,�transferred�and�turned�properly�to�avoid�friction�and�shear�forces

�■ Cleanse�the�skin�at�frequent�intervals,�using�a�pH-balanced�cleansing�agent�followed�by�moisturisers�and�barrier�cream.

Pressure ulcer agenda There� is� a� significant� challenge� in� delivering� high-quality�care�while� improving�its�efficiency�amid�an�era�of�growing�demand�for�healthcare�resources.�In�England,�a�recent�White�Paper,�which�is�centered�on�efficiency�improvements,�outlined�government�strategy�to�address� these� issues�(Department�of�Health� (DH),� 2010a).The� Operating� Framework� for� the�NHS� in�England� for� 2012–13� requires� that� service� quality�and� the�patient�experience�must� improve,� and�productivity�increase� (DH,� 2012).�The� DH� (2010a)� identifies� pressure�ulcers�as�a�future�outcome�indicator,�reporting�that�in�2007/8�there�were�42 995�episodes�of�pressure�ulcers.�Pressure�ulcer�prevention�is�an�area�that�is�recognised�as�having�significant�impact� on� quality� of� care� and� this� has� been� increasingly�elevated�on�political� agendas� in� recent�years.�This� is�owing�

Jackie�Stephen�Haynes�is�Professor�in�Tissue�Viability,�Professional�Development�Unit,�Birmingham�City�University�and�Consultant�Nurse,�Worcestershire�Health�and�Care�NHS�Trust

Accepted for publication: October 2013

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to� the� increasing� emphasis� on�preventative�health� care� and�a� belief� that� pressure� ulcers� are� preventable� (NHS,� 2012).�The� National� Patient� Safety� Agency� (NPSA)� has� been�urging�NHS�organisations�across�England�and�Wales�to�work�towards�preventing�all�pressure�ulcers�(NPSA,�2010a;�2010b).

Pressure ulcer care deliveryCurrent� care� delivery� in� relation� to� pressure� ulcers� is�informed� by� NICE� guidelines� (2005),� EPUAP� guidelines�(2009)� and,� more� latterly,� through� the� introduction� of�High�Impact�Actions�‘Your�Skin�Matters’� (DH,�2010b)�and�the� quality� agenda� Quality,� Innovation,� Productivity� and�Prevention� (QIPP)� (DH,�2010a).�An� initial� target� ambition�was� set�out�aiming�to�prevent�category�III�and�IV�pressure�ulcers;� this� has� been� expanded� by� the� introduction� of� the�elimination�of�avoidable�pressure�ulcers�across�the�Midlands�and�East�in�the�UK�(NHS�Midlands�and�East,�2012).

Several�intrinsic�and�extrinsic�factors�contribute�to�pressure�ulceration� development.� Intrinsic� factors� include� sensory�impairment,� immobility,� age,� poor� nutrition,� incontinence,�and� chronic� illness� (NICE,�2005).�Extrinsic� factors� include�pressure,� shear,� friction,� and� the� impact� of� incontinence�(NICE,�2005;�EPUAP,�2009).�The�significance�of�each�is�not�fully� understood� (EPUAP,� 2009)� and� the� cause� of� pressure�ulcers�has�been�the�subject�of�much�research�and�discussion.�

Pressure�has�been�considered� to�be� the�most� significant�physical� force�responsible� for� the�development�of�pressure�ulceration�(NICE,�2005).�Pressure�over�a�bony�prominence�will� compress� the� capillaries� and� prevent� nutrients� and�oxygen� accessing� the� skin.� Unrelieved� pressure� leads� to�tissue� ischaemia,� with� metabolic� wastes� accumulating� in�the� interstitial� tissue,� ultimately� resulting� in� hypoxia� and�cell�death.�Sample�biopsies� from� tissues� reddened� through�pressure� have� been� demonstrated� to� show� an� increase�in� bacterial� loading� within� the� tissues� as� a� result� of� the�hypoxia� (Sugama� et� al,� 2005).� As� the� amount� of� shear/friction� increases,� the� amount� of� pressure� required� to�cause� ulceration� is� reduced� (Conner� and� Clack,� 1993).�Shear,� friction,� and� microclimate� have� also� recently� been�identified� by� an� expert� panel� as� a� major� cause� of� tissue�damage�(Wounds�International,�2010).�Specifically,�there�is�an�inverse�relationship�between�shear,�friction�and�pressure.�The� cause� of� pressure� damage� and� the� rate� at�which� this�occurs�is�clinically�important�and�clinicians�need�to�be�alert�to� the� reduced� time� for� pressure� damage� to� occur� when�shear/friction� is� a� consideration� (Wounds� International,�2010).�

Importantly,� pressure� ulcers� are� a� considerable� burden�for� the� NHS,� being� a� significant� cause� of� morbidity�and� mortality� (Posnett� et� al,� 2009).� Gorecki� et� al� (2009)�conducted�a�review�of�31 studies,�reporting�the�impact�of�pressure�ulcers�and�pressure�ulcer�interventions�on�health-related� quality� of� life� (HRQoL).� Pressure� ulcers� were�found� to� significantly� affect� physical,� social,� psychological,�and� financial� aspects� of�HRQoL.�Pain�was� identified� as� a�significant� concern� and,� importantly,� patients� attributed�their�pressure�ulcers�to�inadequate�health�care�and�a�lack�of�knowledge�on�the�part�of�health�professionals�regarding�the�prevention�of�pressure�ulceration.

The�financial�cost�of�pressure�ulcers�has�been�estimated�at�£2.3–£3.1�billion�per�year�in�the�UK,�which�would�account�for� 3%� of� the� annual� NHS� expenditure� at� 2005/6� levels�(Posnett� and�Franks,�2007).�The�DH�(2010a)�estimates� that�a� category� III� pressure� ulcer� costs� between� £363�000� and�£543�000�to�treat�and�that�a�category�IV�ulcer�costs�between�£447�000�and�£668�000.�The�majority�of�these�wounds�are�chronic�in�nature�and�are�cared�for�in�the�community�setting�by�GPs�and�community�nurses�(Drew�et�al,�2007).

Once� the� level� of� risk� has� been� ascertained,� the� key�to� reducing� it� relies� on� appropriate� preventative� care�and� treatment� plans� being� developed� and� implemented�(NICE,� 2005).� The� education� of� staff� at� all� levels� and�disciplines� on� risk� assessment� using� validated� tools,� care�planning,� documentation� and� the� implementation� of�appropriate�pressure�reducing�equipment�is�paramount�in�the�identification� and� subsequent� prevention� of� pressure� ulcers�(Institute�for�Healthcare�Improvement,�2008).��

High Impact Actions and SSKIN bundlesThe�high�impact�actions�(DH,�2010b)�indicate�the�majority�of� pressure� ulcers� that� develop� in� NHS-provided� care� are�avoidable,�stating�that�it�is�the�processes�regarding�prevention�that� fail.� It� identifies� that� to� eliminate� pressure� ulcers�requires�input�from�the�multidisciplinary�team.�This�requires�development�of� simple�processes� that�will� reduce�avoidable�pressure�ulcers�(DH,�2010b).

The� latest� guidance� relates� to� the� actual� delivery� of�prescribed�care�in�the�prevention�of�pressure�ulcers�through�the�use�of�SSKIN�bundle�documentation�packages�(Institute�for�Healthcare�Improvement,�2011).�Following�the�successful�implementation� of� the� SSKIN� care� bundle� in� Wales,� it�was� implemented� in�Scotland� in�2011�and� is� supported�by�Healthcare�Improvement�Scotland�(2013).�A�bundle�of�care�is�defined�as�a�structured�way�of�improving�processes�of�care�and� significantly� improving� patient� outcomes� (Institute� for�Healthcare�Improvement,�2011).�

McCarron�(2011)�clarifies�the�crucial�aspect�of�a�successful�care�bundle�as�ensuring�that�every�identified�intervention�is�performed� in� a� sequence� of� steps� and� that� no� component�is� eliminated.� Omitting� any� one� of� the� interventions� in� a�SSKIN� bundle� is� likely� to� result� in� the� development� of� a�pressure� ulcer.� The� critical� difference� between� a� SSKIN�bundle� and� a� traditional� care� plan� is� that� a� bundle� is� an�essential�set�of�steps�in�a�process�where�a�complication�may�arise�if�one�is�missed�(Institute�for�Healthcare�Improvement,�2011).� Bundles� were� initially� used� to� reduce� ventilator-associated� pneumonia� (Resar� et� al,� 2005)� and� are� now�advocated� as� a� structured� method� for� preventing� pressure�ulceration�(Lloyd�Jones,�2012).

The�objective�of�a�bundle�is�to�make�a�process�more�reliable�by� improving� motivation,� compliance� and� implementation�of� a� strategy� for� care� (Stephen-Haynes,� 2011).�Therefore,�SSKIN� care� bundles� are� essential� in� the� prevention� of�pressure�ulcers�and�should�be�implemented�for�every�patient�at�risk�to�achieve�the�elimination�of�avoidable�pressure�ulcers.�

The�SSKIN�bundle� acronym� represents� the� five� essential�elements�of�pressure�ulcer�prevention�(Institute�for�Healthcare�Improvement,�2011):�

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Surface�SkinKeep�moving�Incontinence�Nutrition.All� elements� in� the� bundle� are� based� on� robust� evidence�

and�delivery�of� the�bundle� is�measured� through�compliance�with� every� element.�The� aim� of� the� bundle� is� to� tie� best�practices�together�in�a�reliable�way�to�reduce�the�occurrence�of�a�pressure�ulcer.�Successfully�completing�the�bundle�is�based�on�all�elements�being�carried�out� together�at� the� same�time�(i.e.�at�the�patient’s�bedside�at�2-hourly�intervals)�or�at�every�district�nursing�visit.�The�bundle�encourages�attention�to�detail�through�its�individual�elements�and�helps�establish�good�habits�that� ultimately� impact� on� outcomes� (i.e.� reducing� pressure�ulcers).�The�bundle� therefore�makes� it�easy� for�people� to�do�the�right�thing�at�the�right�time.�Most�importantly,�the�bundle�makes�the�process�for�preventing�pressure�ulcers�visible�to�all.

SurfaceEnsuring� the� appropriate� surface� is� available� within� a�24-hour� period,� that� it� is� being� used� correctly� and� is�clinically� effective� and� fit� for� purpose� with� an� Electro-Biomedical�Engineering�Department�(EBME)�and�Portable�Appliance�Testing�(PAT)�undertaken.�

SkinEarly� visual� inspection� of� skin� with� a� focus� on� early�detection�and�prevention�of�breakdown�or�deterioration�by�early� intervention� of� pressure� relieving� regimes,� cleansing,�moisturising�and�skin�barrier�protection.�

Keep movingEnsuring� patients� are� repositioned� or� encouraged� to�mobilise�independently�at�every�care�round�in�community�hospitals�and�at�every�district�nursing�visit�and�recorded�in�the�SSKIN�care�bundle.�

IncontinenceAt�each�care�round,�staff�ensure�that�the�patient�is�clean,�dry�and� comfortable.� Incontinence� assessments� are� undertaken�and�barrier�protection�is�implemented�both�preventively�and�as�a�treatment�strategy.�

NutritionEnsuring� patients� have� an� appropriate� dietary� and� fluid�intake� to� maintain� their� nutritional� status� and� hydration�levels.�This� should� be� conducted� 2-hourly� as� part� of� care�rounds� within� community� hospitals� and� at� every� district�nursing� visit.� Intake� and� supplement� therapy� is� monitored�and�documented�accordingly.

Following�the� implementation�of� the�SSKIN�bundle,� the�Midland� and� East� have� reduced� the� incidence� of� pressure�ulcers�by�36%�in�6 months�(Ford,�2012).�

Barrier film protection: prevention, treatment and management The�aim�of�a�barrier�film�or�cream�is�to�mimic�the�skin’s�natural�barrier� function� with� the� purpose� of� protecting,� repairing,�

restoring� or� preventing� skin� damage.� The� moisturising�capability� lays� down� a� durable� protective� barrier� affording�the� optimum� protection.�The� use� of� no-sting� barrier� films�began� in� the� UK� in� the� late� 1990s� and� this� has� increased�steadily.�Guest� et� al� (2011)� found� that� despite� barrier� films�being� more� expensive� to� purchase� than� zinc� oxide� and�petroleum-based� products,� the� reductions� in� labour� more�than�offset�the�additional�cost.�According�to�Guest�el�al,�the�potential�savings�in�the�right�care�settings�could�reach�several�millions�of�pounds.

Sorbaderm barrier protection Sorbaderm�No-Sting�Barrier�Film�is�a�non-cytotoxic�acrylate�co-polymer� liquid� film� that� forms� a� flexible� long-lasting�waterproof�barrier�for�the�protection�of�intact�or�the�treatment�of�damaged�skin.�With�its�high-moisture�vapour�transmission�rate,� it� acts� as� a� protective� interface� between� the� skin� and�bodily� fluids,� adhesive� products,� and� mechanical� stress� and�aims� to� mimic� the� body’s� natural� protection� function.�The�barrier� film� can� be� used� clinically� for� incontinence,� peri-stomal� skin� protection,� peri-wound� skin� protection� and�adhesive�trauma�protection.�It�provides�up�to�72 hours�of�skin�protection�depending�upon�the�severity�of�the�corrosive�fluid�or� exposure� and� as� it� does� not� contain� alcohol,� it� does� not�sting.� It� is� transparent,� allowing� for� continuous� visualisation�and�monitoring�of�skin�at�risk�of�breakdown.�

Sorbaderm� No-Sting� Barrier� Cream� is� a� highly�concentrated,�long-lasting�latex�and�fragrance-free�protective�barrier�that�does�not�clog�incontinence�or�dressing�devices,�providing�effective� skin�moisturising�and� long-term�barrier�protection�from�bodily�fluids.

Stephen-Haynes�and�Stephens�(2012)�report�a�study�with�two� arms� involving�95  subjects�within� a�UK�primary� care�organisation.�The� objective� was� to� determine� the� clinical�outcomes� and� acceptability� of� a� no-sting� barrier� film� and�cream�product.�

Study outcomesThe� indications� included� in� the� study� were� peri-wound�protection,�incontinence�and�pressure�ulcers.

The�clinical�indications�explored�were:��■ �Prevention�of�skin�breakdown�■ �Maintenance�of�skin�condition�■ �Peri-wound�maceration�■ �Excoriation�and�incontinence-related�skin�protection�■ �Adhesive�skin�strippingOf�the�95 patients�recruited,�the�barrier�cream�was�evaluated�

in�39 patients�and�the�no-sting�barrier�film�in�53 patients.�

Inclusion criteria�■ Patient�>18�years�of�age�■ Patient�is�willing�to�participate�and�has�capacity�to�consent�■ Patient� has� an� indication� suitable� for� treatment� with� a�barrier�product

�■ Patient�will�be�seen�regularly�by�the�evaluator.

Exclusion criteria�■ Patient�is�<18�years�of�age�■ Patient� does� not� wish� to� participate� or� have� capacity� to�

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also� be� considered� (Clark,� 2010;� Deakin� et� al,� 2010).Economic�models�including�nursing�time�and�material�costs,�favour� the� use� of� barrier� films� and� creams� (Clark,� 2010;�Deakin�et�al,�2010).�

There� is� increasing� evidence� relating� to� the� clinical� and�financial� benefits� of� skin� protection� and,� in� particular,� to�that� of� no-sting� barrier� films� and� barrier� creams� when�compared�with�more�traditionally�used�skin�protection�such�as� petroleum-based� creams� (Stephen-Haynes� and� Stephens,�2012).�The� author� acknowledges� that� the� current� emphasis�on�pressure�ulcer�prevention�led�to�a�low�number�of�patients�with�pressure�damage�taking�part�in�this�95-patient�study.�In�addition,� subjectivity� was� a� limitation� of� the� original� study�due� to� reflective� comparison� to� previous� treatment� regime�rather�than�any�form�of�direct�comparator.

Clinical care studiesFigure 1� shows� a� 67-year-old� female with� a� sacral� pressure�ulcer�with�a�high�exudate�levels�due�to�damage�to�the�peri-wound�skin�caused�by�wound�exudate.�Sorbaderm�No-Sting�Barrier�Film�was�used�for�48�hours.�Figure 2�demonstrates�the�impact�of�the�barrier�film�on�the�peri-wound�area;�the�peri-wound�skin�is�now�intact.�

Figure 3�shows�the�pressure�ulcer�and�damage�to�the�peri-wound�area�of� a�50-year�old�gentleman.�The�pressure�ulcer�occurred�following�a�trauma�injury.�Figure 4�demonstrates�the�improvement�in�his�peri-wound�skin�following�the�application�of�Sorbaderm�No-Sting�Barrier�Film�for�72 hours.�

Figure 5� is�a�photo�of�a�back�ulcer�on�a�74-year-old� lady�who�has� arthritis� renal� failure� and�a� curvature� to� the� spine.�She�has�been�a�very�heavy� smoker� for�most�of�her� life�and�has�a�cough.�On�investigation,�a� tumour�was�noted�but�not�treated�at�her�request.�

This�patient�developed�a�pressure�ulcer� to�her� spine.�This�started�as�a�small�area�with�a�large�area�of�excoriation�to�the�peri-wound� area.�When� the� author� first� saw� this� lady,� the�peri-wound�area�was�excoriated�from�both�exudate�and�the�dressings�being�removed.�The�patient�found�dressing�changes�very�painful�and�sat�upright�in�bed,�uncomfortable�for�many�hours�at�a�time.�This�left�the�skin�on�the�curvature�of�her�spin�vulnerable� and� more� easily� damaged� by� shear� and� friction�from� movement� in� the� bed.� Sorbaderm� No-Sting� Barrier�Cream�was�applied�to�the�peri-wound�and�this�has�improved�the�peri-wound�skin�and�decreased�her�discomfort.

A� 67-year-old� gentlemen� with� Parkinson’s� disease�developed�the�ulcer�shown�in�Figure 6.�His�Parkinson’s�disease�causes�frequent�movement,�resulting�in�shear�and�friction.�He�developed� this� ulcer� following� a� problem� with� his� seating�(he�has�a�moulded�wheelchair).�The�peri�wound�needed� to�be�maintained�during� debridement.�The� excessive�moisture�during� this� period� of� debridement� and� the� involuntary�movements� could� have� resulted� in� extensive� peri-wound�excoriation� and� enlargement� of� the� ulcer.�The� exudate� did�cause� excoriation� as� Figure 6� shows,� but� the� Sorbaderm�No-Sting�Barrier�Film helped�to�reduce�this�(Figure 7).�When�barrier� film� is� applied� to� the�whole�of� the� area,� it� supports�the�dressing�in�place�and�prevents�irritation�and�skin�stripping�from�the�secondary�dressing.

A�72-year-old� lady�acquired�a�category  IV�pressure�ulcer�

Figure 1. Excoriation caused by wound exudate

Figure 3. Excoriation caused by wound exudate

Figure 5. Peri-wound excoriation

consent�■ Patient�not�suitable�for�barrier�product�treatment�■ Instructions�for�the�product�use�cannot�be�followed�■ Any�other�reason�the�evaluator�feels�the�patient�should�be�excluded.

Results In�arm�one,�36 patients�were�evaluated.�There�were�18 males�and�18 females�and�of�these,�6�specifically�related�to�pressure�ulceration,� with� exudate� levels� reported� to� be� moderate�or� high.� None� of� the� six� developed� signs� of� maceration�throughout�the�study�process.�All�(n�=�6)�reported�a�dramatic�visible�improvement�to�skin�condition�within�24–48 hours.�

In� the� second� arm,� the� total� number� of� patients� was� 59;�3 patients�with�shear�and�friction�damage�showed�significant�improvement�following�the�use�of�barrier�protection.�

These� results� are� supported� by� Deakin� et� al� (2010)� and�Clark� (2010)� who� reported� positive� results� in� support� of�Sorbaderm� No-Sting� Barrier� Film� and� No-Sting� Barrier�Cream.� Importantly,� clinical� and� service-user� acceptance,�adoption� strategy� costs� and� educational� requirements� must�

Figure 2. Skin improved after 48 hours application of barrier protection

Figure 4. Skin improved after 48 hours application of barrier protection

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care

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to� her� sacrum� (Figure 8)� following� an� acute� admission� for�breathing�problems�and�dizzy�spells�(she�was�diagnosed�with�Guillain-Barré� syndrome� so� carers� and� relatives� had� been�unable�to�move�her).�This�patient�was�previously�mobile,�very�independent� and� healthy� for� her� age.� She� looked� after� her�husband�who�was�found�to�have�early�dementia.

When�this�patient�was�transferred�to�a�community�hospital,�this� ulcer� had� very� heavy� exudate� and� the� cavity� was� very�large� (12 cm� x� 9 cm� x� 4 cm� deep)� (Figure 9).�The� ulcer,�and� resulting� loss� of� immobility,� caused� this� patient� to� be�depressed� (she� had� loss� of� feeling� in� her� legs� although� this�was�returning�slowly).�

The� author� and� colleagues� had� to� consider� how� to�effectively� manage� the� exudate� while� protecting� the� peri�wound.�Sorbaderm�No-Sting�Barrier�Film�was�commenced�upon�her�admittance�to�the�community�hospital�owing�to�the�high�volume�of�exudate.�

The�wound�was� very� painful� to� dress,� requiring� entonox�(gas� and� air).� Negative� pressure� wound� therapy� was� used�to� dress� the� wound� at� the� beginning;� maintenance� of� the�peri-wound� area� was� very� important� in� order� to� achieve�a� good� seal� and� prevent� the� ulcer� from� getting� bigger.�Following�a�multidisciplinary�team�meeting,�the�team�started�physiotherapy�with�the�patient�and�she�began�to�walk�within�5 weeks.�Her�ulcer�has�now�almost�healed�(Figure 10)�and�she�has�returned�home�with�her�husband.�

ConclusionThe�prevention�of�pressure�ulcers�and�maintenance�of�healthy�skin� integrity� is� a�key�government� agenda�and�a� significant�clinical�challenge�for�health�professionals�and�carers.�Pressure�ulcer�prevention�and�management�are�of�particular�significance�in�an�increasingly�elderly�population�owing�to�mobility�issues,�continence� status� and� skin� changes� that� can� occur� with�ageing,�chronic�illness,�and�at�the�end�of�life.�It�is�essential�for�all�nurses�and�allied�health�professionals�to�consider�pressure�ulcer�prevention�and�be�knowledgeable�regarding�prevention�and� treatment� processes.� Ensuring� fundamental� nursing� is�delivered�and�the�SSKIN�care�bundle�is�implemented�every�time�for�every�patient�is�essential�in�the�prevention�of�pressure�ulcers.�The�evidence�suggests�the�use�of�SSKIN�bundles�and�the�appropriate�use�of�barrier�film�protection�can�contribute�to� the� prevention,� treatment� and� maintenance� of� the� skin’s�barrier�function,�helping�to�protect�and�restore.�� BJN

Conflict of interest: Sorbaderm Barrier Cream and Sorbaderm Barrier

Figure 6. Pressure ulcer with surrounding skin affected by shear, friction and moisture

Figure 10. The improved wound

Film used in the author’s study were supplied by Aspen Medical.

Bartley�A��(2011)�The�Hospital�Pathways�Project.�Making�it�happen:�Intentional�rounding.�The�King’s�Fund�Point�of�Care�and�the�Health�Foundation.�http://tinyurl.com/c7zyohv�(accessed�30�October�2013)

Butcher�M,�White�R�(2005)�The�structure�and�function�of�the�skin.�In:�White�R� (Ed)� Skin care in wound management: Assessment, prevention and treatment.�Wounds�UK,�Aberdeen:�1-16

Clark� M� (2010)� Preventing� skin� breakdown� with� barrier� films� and� creams.�Wounds UK�6(4):�132-8

Conner�L,�Clack�J� (1993)�In�vivo�(CT�scan)�comparison�of�vertical� shear� in�human�tissue�caused�by�various�support�surfaces.�Decubitus�6(2):�20-3,�26-28�

Deakin�A,�Stapleton�M,�Chadwick�K�(2010)�Evaluating�a�skin�barrier�film�in�faecal�and�urinary�incontinence.�Wounds UK�6(2):�107–11

Department� of� Health� (2010a)� The NHS Quality, Innovation, Productivity and

Figure 7. Improvement seen following application of barrier protection

Figure 9. Undermining has improved after 1 week and peri wound is intact

Figure 8. The peri wound is intact following use of the barrier film. Note the undermining at the wound edge

Page 6: The role of barrier protection in pressure ulcer … role of barrier protection in pressure ulcer ... This article considers the anatomy and physiology of the skin, ... responsible

S58� British�Journal�of�Nursing,�2013�(Tissue�Viability�Supplement),�Vol�22,�No�20

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MA

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td

Prevention challenge: An introduction for clinicians.�DH,�London.�http://tinyurl.com/os7xoqn�(accessed�30�October�2013)

Department�of�Health� (2010b)�High Impact Actions for Nursing and Midwifery.NHS Institute of Innovation and improvement.� http://tinyurl.com/peojl3q�(accessed�30�October�2013)

Department�of�Health�(2012).The Operating Framework for the NHS in England 2012/13.�http://tinyurl.com/ax66ola�(accessed�30�October�2013)

Drew� P,� Posnett� J,� Rusling� L� (2007).�The� cost� of� wound� care� for� a� local�population�in�England.�Int Wound Journal�4(2): 149-55

European�Pressure�Ulcer�Advisory�Panel� (2009)�Pressure�ulcer�prevention:�A�quick� reference� guide.� http://tinyurl.com/378oexd� (accessed� 30� October�2013)

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Gorecki�C,�Brown�J,�Nelaon�A�et�al�(2009)�Impact�of�pressure�ulcers�on�quality�of�life�in�older�patients:�a�systematic�review.�J Am Geriatr Soc 57(7): 1175-83

Guest� J,� Greener� M,�Vowden� K,�Vowden� P� (2011)� Clinical� and� economic�evidence� supporting� a� transparent� barrier� film� dressing� in� incontinence-associated�dermatitis�and�peri�wound�protection.�J Wound Care�20(2): 76-84

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McCarron�K�(2011)�Understanding�care�bundles.�Nursing Made Incredibly Easy�

KEY POINTS

n The prevention of pressure ulcers is a key national agenda

n SSKIN bundle implementation is an essential part of the elimination of

avoidable pressure ulcers

n Timely skin assessment, skin care and the use of barrier protection are an

important component of the strategy for pressure ulcer prevention

n An evaluation of barrier films and creams indicates the importance of barrier

protection as an essential component of pressure ulcer prevention

9(2):�30–3.�National� Institute� for�Health� and�Clinical�Excellence� (2005)�The�prevention�

and�treatment�of�pressure�ulcers.�NICE,�LondonNational�Institute�for�Health�and�Clinical�Excellence�(2006)�The�management�

of�urinary�incontinence�in�women.�NICE,�London�National�Patient�Safety�Agency�(2010a)�NHS to adopt zero tolerance approach to

pressure ulcers.�http://tinyurl.com/pn89tw6�(accessed�30�October�2013)National�Patient�Safety�Agency�(2010b)�Serious Incident Reporting and Learning

Framework (SIRL). National framework for reporting and learning from serious incidents requiring investigation.� http://tinyurl.com/2vqkojm� (accessed� 30�October�2013)

Newton�H,�Cameron�J�(2003)�Skin Care in Wound Management. A clinical education in wound management.�Medical�Communications�UK�Ltd,�Holsworthy

NHS�Midlands�&�East�(2012)�Pressure�ulcers.www.stopthepressure.comNHS� (2012)� Harm� Free� Care.� NHS,� London.� http://tinyurl.com/d9r89vw�

(accessed�30�October�2013)Posnett� J,�Franks�P� (2007)�The cost of skin breakdown and ulceration in the UK.

Skin breakdown: the silent epidemic.�Smith&�Nephew�Foundation.�Hull:�6-12Posnett� J,� Gottrup� F,� Lundgren� H,� Saal,� G.� (2009)�The� resource� impact� of�

wounds�on�health�care�providers�in�Europe.�J Wound Care�18(4):�154–61Resar� R,� Pronovost� P,� Haraden� C,� Simmonds�T,� Rainey�T,� Nolan�T� (2005)�

Using� a� bundle� approach� to� improve�ventilator� care�processes� and� reduce�ventilator-associated�pneumonia.�Jt Comm J Qual Patient Saf�31(5): 243-8

Sibbald�R,�Krasner�D,�Lutz�J�et�al�(2009)�SCALE:�skin�changes�at�life’s�end:�final�consensus�statement.�Adv Skin Wound Care�23(5):�225–36

Stephen-Haynes� J� (2011)� Pressure� ulceration� and� the� current� government�agenda�in�the�UK.�Br J Community Nurs�16(Sup5):�S18-S26

Stephen-Haynes� J,� Stephens� C� (2012)� Evaluation� of� clinical� and� financial�outcomes� of� a� new� no-sting� barrier� film� and� barrier� cream� in� a� large�UK� primary� care� organisation.� Int Wound J� doi:� 10.1111/j.1742-481X.2012.01045.x.�[Epub�ahead�of�print]

Sugama� J,� Sanada� H,� Nakatani�T,� Nagakawa�T,� Inagaki� M� (2005)� Pressure-induced� ischemic� wound� healing� with� bacterial� inoculation� in� the� rat.�Wounds�17(7):�157–68

Thomas-Hess�C�(2000)�‘Skin�care�and�wound�prevention�strategies’.� In:�Skin and Wound Care.�Lippincott,�Williams�and�Wilkins,�USA

Voegeli�D�(2008)�The�effect�of�washing�and�drying�practices�on�skin�barrier�function.�J Wound Ostomy Continence Nurs 35(1):�84–90

Voegeli�D�(2010)�Basic�essentials.�Why�elderly�skin�requires�special�treatment.�Nursing and Residential Care�12(9):�422–9

Wounds� International� (2010) Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document.�Wounds� International,�London.�http://tinyurl.com/oj7f6uv�(accessed�30�October�2013)

Wounds� UK� (2012)� Best Practice Statement. Care of the Older Person’s Skin. :�Wounds� UK,� London.� http://tinyurl.com/q9rrt2c� (accessed� 30� October�2013)

Wysocki�A�(2000)�‘Anatomy�and�physiology�of�skin�and�soft�tissue’.�In:�Acute and chronic wounds: nursing management.�Mosby,�St�Louis�

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DermatologyDifferentialDiagnosis