Bariatric patients present a special challenge in terms of skin care and prevention of pressure ulcers. Once damage to the skin occurs, bariatric patients heal more slowly due to decreased vascularity of the skin and reduced perfusion of adipose tissue. Bariatric patients are at high risk for acute wounds, pressure ulcers, venous ulcers, non-healing surgical wounds and diabetic wounds of the foot.

Specific Skin Problems in the Bariatric Population

There are several reasons why bariatric patients are more prone to skin problems/wounds:

• Inadequate blood supply to adipose tissue- this leads to inadequate oxygenation of the tissues
• Poor nutrition- the bariatric patient’s diet often does not include vitamins and nutrients essential for wound healing
• Increased diaphoresis- increased sweating leads to moist skin that may be more prone to skin breakdown and the growth of bacteria and fungi
• Difficulty in keeping the skin clean- skin folds, in particular, may be difficult for the bariatric patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas
• Immobility- difficulty in changing position/repositioning and movement may increase the risk of pressure ulcers in this population; friction and shear damage can occur in unexpected places, such as under the pannus (abdominal fold)
• Tubes and catheters- tubes and catheters can burrow into the skin, causing skin breakdown/ulcer formation

Strategies for Preventing Skin Breakdown

Instituting measures to prevent skin breakdown in the bariatric patient may involve staff education, the use of specialized equipment and multidisciplinary care.

1. Patient Repositioning and Turning
Bedbound patients require regular turning and repositioning to prevent the formation of pressure injuries. For the safe and adequate repositioning of a bariatric patient, it is important for the proper staffing and equipment to be available. Following a turning schedule and coordinating with staff to collaborate to be available at these time to assist in the repositioning of the patient will ensure a compliant, safe patient handling experience and an effective care program to prevent breakdown of the patient's skin.

Specialized equipment including beds, lifts, turning sheets, mattresses, and chairs should be utilized to offload patient weight frequently. Special commodes that can tolerate additional weight may be used to toilet these patients while providing perinea care at the same time. Staff may need education in the use of specialized equipment. (See #5)

2. Proper Skin Cleaning
Skin folds present a challenge in the management of patients with bariatric needs. The weight from excess adipose tissue in skin fold areas can an increased risk of skin injury such as friction, maceration, skin tears and pressure ulcer development.

Skin folds and areas vulnerable to skin injury should be cleaned and dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum powders, should be avoided in these areas. If necessary, dry cloths to absorb moisture can be left in skin folds in between washing and drying of the skin folds.

3. Proper Nutrition and Fluid Intake
A dietician should be consulted to provide a meal plan that maximizes healing potential in existing wounds and preserving the integrity of the skin. Patient hydration should also be considered in the nutrition plan for bariatic patients and the health of their skin.

4. Assessment and Documentation
Bariatric patients should be regularly assessed for areas of potential skin breakdown; in addition, any areas that have already broken down should be noted and a plan for wound management should be implemented.

5. Staff Education
Instituting measures to prevent skin breakdown in bariatric patients may involve additional education of staff. This is critical since no prevention can be obtained without proper training, education, and collaboration in the care of the patient.

Preventing and treating skin breakdown in the bariatric population provides special challenges to clinicians caring for this population. Failure to meet nutritional needs, recognize impending breakdown of the skin and adequately treat preexisting skin breakdown and ulcers can have dire consequences for the patient with bariatric needs.

Sources:
Clark L, Black JM. Keeping the Bariatric Patient’s Skin Intact. Bariatric Times. 2011;8(5):20–23. Available at http://bariatrictimes.com/keeping-the-bariatric-patient%E2%80%99s-skin-…
Cowdell F, Radley K. Skin hygiene for patients with bariatric needs. Nursing Times. 2014;110(24):22-3. Available at http://www.nursingtimes.net/Journals/2014/06/06/p/y/s/110614-Skin-hygie…
Harris H. Nursing care of the morbidly obese patient. Nursing Made Incredibly Easy. 2008;6(3):34-43. Available at http://www.nursingcenter.com/prodev/ce_article.asp?tid=788177
Rush A. Bariatric care: Pressure ulcer prevention. Wound Essentials. 2009;4;68-74. Available at http://www.woundsinternational.com/pdf/content_61.pdf

Editor's Note: This article was originally published on April 4, 2011 and has been updated for accuracy and comprehension.

About The Author
Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS, is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care.