Stephanie Yates, M.S.N., RN, ANP-BC, CWOCN
Incontinence, both fecal and urinary, is a major concern for patients and caregivers. Aside from the embarrassment and isolation often associated with soiling, the skin in (primarily) the buttock, inner thigh, and perineal areas is at risk for damage, which can be painful and lead to other problems.
IAD is a form of irritant dermatitis or inflammation that develops from chronic exposure to urine or liquid stool. IAD is one of four types of moisture-associated skin damage that has been reported.
The skin is a multilayered, self-renewing organ that deserves clinical attention to preserve its barrier protection and other important functions. The mechanisms by which IAD disrupts the barrier structure are believed to be multifactorial, with the two major factors being pH changes and wetness.
The skin’s normal flora of organisms is kept in check when skin pH remains within the usual acid mantle range. When skin pH moves into the alkaline range, pathogenic bacteria counts rise. Repeated exposure to urine and/or feces can lead to changes in skin pH from the normal acidic pH of four to six, to an alkaline pH (>7.5).
Using alkaline soaps can also increase the skin pH. Once the skin pH is raised into the alkaline range, surface skin lipids are altere, and the skin is less able to serve as a barrier to microorganisms. Continuous wetness also weakens skin, leaving it vulnerable to injury.
Friction, shear, and pressure
Aggressive, high-friction cleaning with materials other than soft cloths can also cause skin injury in people with incontinence. Wet skin may also have a higher friction coefficient than dry skin, which increases stress on wet skin when a person moves in their bed or chair, or when someone else is repositioning the patient.
Compression (pressure) and shear in the presence of wetness produces the highest skin “surface loads” compared with compression in a dry environment. These factors support the relationship between IAD and pressure injury development, suggesting prevention of IAD is one way to prevent pressure injuries.
For years, care bundles and formulary products have enabled clinicians to remember key components of care interventions. The essential elements of those interventions are noted to be:
- Timely cleansing following an incontinent episode, using a pH balanced cleanser with a limited number of ingredients (so the likelihood of sensitivities is reduced), and using soft cloths rather than more abrasive washcloths to reduce friction injuries.
- Providing protection to the skin by using a moisture barrier product to shield it from the assaults of incontinence.
- Replenishing lipids that are removed during the cleansing process and restoring the skin barrier to its optimal function.
It is perhaps an obvious strategy that care providers should consider methods to eliminate or reduce episodes of incontinence by using behavioral and practical strategies such as timed voiding, use of toileting aids (e.g., bedside commodes and urinals), and wearing of garments that are easier to remove for toileting, such as those with elastic waistbands rather than zippers or buttons. Dietary interventions, such as limiting fluids in the hours before bedtime or reducing caffeine intake, have also been effective in reducing the number of incontinence episodes.
In addition to the interventions aimed at decreasing the frequency of incontinence episodes, and providing timely and evidence-based skin care, patients and care providers may choose to augment the plan of care using products designed for the containment of incontinence (e.g., briefs, pads, pouches, and external devices for both men and women).
Advancements in technology for these body-worn absorbent products and medical devices have improved the consumer experience exponentially and, when used correctly, can reduce the incidence and severity of IAD. Containment options without compromises in skin integrity are readily available, can be purchased without prescription, and are available for home delivery.
Meeting with a pro
People experiencing incontinence, IAD, or who are having difficulty in tailoring a treatment or management care regimen to their individual situation may benefit from a consultation with a healthcare professional specializing in this area. Since those suffering with incontinence often minimize or fail to report their condition to their provider, delays in referral to those who might make a difference are common.
Certified wound ostomy and continence nurses are valuable resources in the area of incontinence, IAD treatments, and the use of devices and body-worn absorptive products. Patients and care providers alike should consider them as allies.
Stephanie Yates, M.S.N., RN, ANP-BC, CWOCN, President, Wound Ostomy and Continence Nurses Society (WOCN®), [email protected]