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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5256_Библиотеки_им_академика_М_И_Перельмана.pdf
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including the terpolymer acrylates, are synthetic products that may be combined
with other ingredients in various leave-on skin products or applied as a liquid that
dries to form a thin, exible, transparent protective layer over the skin.
Three common ingredients are commonly used in ointments and cream formula-
tions used for prevention and treatment of irritant contact dermatitis, petrolatum,
dimethicone, and zinc oxide (see Table14.1). Petrolatum is a semisolid mixture of
Table 14.1 Ingredients of skin moisturizers and barriers/protectants
Humectants Hydrophilic (attract water)
into the epidermis and from
the dermis and a humid
external environment
oil-repellent
Glycerin (glycerol), propylene glycol, or
70% sorbitol solution, and trihydroxylated
glycerin
Hydrating
agents
Oil repellent protect against
oils, varnishes, and organic
solvents
Oil repellent Sodium bischlorophenyl sulfamine and
Aluminum chlorohydrate
Act as a physical protective
layer
Oil repellent
Inorganic substances such as talc, zinc
oxide, kaolin, and the organoclay
quaternium-18 bentonite
Oil repellent
Prevent absorption of nickel,
chromium, and copper
EDTA (disodiumethylene diaminetetracetic
acid) and pentetic acid (diethylenetriamine
pentacetic acid)
Antioxidant Botanicals such as Vitis vinifera extract and
Rosa canina
Moisturizes skin Urea and allantoin
Moisturizes skin Natural moisturizing factor
Attracts and holds water
maintaining skin hydration
Hyaluronic acid
Wet skin
Protect against irritants
Film-forming polymers soluble or
dispersible in water, e.g., VP/eicosene
copolymer and ammonium
acryloyldimethyltaurate/VP copolymer
Water and oil repellent;
Form a thin lm that does not
clog pores to protect the skin
Synthetic polymers such as FOMBLIN
HC(R)
Emollients Highly occlusive
Water repellent
Protect against acids, alkalis,
soaps, water-soluble irritants,
and detergents
Petrolatum (parafnum liquidum, mineral
oil)
Parafn waxes (petrolatum jelly, white
petrolatum)
Lanolin
Dimethicone
Naturally synthesized for
inclusion in the skin barrier
for healing
Ceramides
Anti-
inammatory
ingredients
Plant derivatives or botanical extracts:
Glycyrrhetinic acid (a root licorice extract),
bisabolol (derived from chamomile), and
Butyrospermum parkii butter (shea butter)
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
308
hydrocarbons obtained from petroleum. It was discovered in 1859 and initially mar-
keted for its healing properties when applied to the skin [46]. It is hydrophobic and
reduces transepidermal water loss from the skin by 99%. Petrolatum exerts multiple
actions that restore the skin’s moisture barrier and enhance repair of skin damaged
by exposure to fecal matter or urine [47]. Dimethicone is one of a family of silicones
(silicas) that are derived from quartz, granite, or sand. Similar to petrolatum,
dimethicone is impermeable to water in its liquid formulation but permeable to
water vapor, which is important in simultaneously protecting the skin from addi-
tional exposure to irritants while maintaining adequate transepidermal water loss
needed to manage the hyperhydration of the skin especially when covered with an
absorptive product. Zinc oxide is a white powder that can be processed to form vari-
ably sized granules; it is mixed with other products to create an ointment or cream-
based paste. Zinc is particularly effective as a barrier to irritants. Disadvantages of
its use are that it may create an opaque white layer blocking visual assessment of
damaged skin and resists removal using soap and water or no rinse cleansers.
Application of topical zinc oxide is considered to have wound-healing properties,
and it is incorporated into a variety of tropical products varying from 1% to 25%
[41]. However, evidence concerning its wound-healing properties is inconclu-
sive [48].
A study in healthy volunteers examined each of these three common ingredients
and found that zinc oxide exerted the most protective effects against exposure to a
standardized irritant, followed by petrolatum and dimethicone [49]. Dimethicone
maintained skin hydration better than zinc oxide or petrolatum. While it is tempting
to use this study as a basis for judging the efcacy of various leave-on products used
to prevent or treat, it must be remembered that skin care products contain other
ingredients, and these results were based on a single ingredient. Clinical studies of
patients with incontinence or irritant contact dermatitis using entire product formu-
lations are lacking. An additional consideration for patients wearing an absorptive
brief to contain incontinence is the potential effect of a topical skin protectant on the
absorptive properties of the brief. Laboratory studies show that different types of
skin protectants differ in clogging pores of absorption products and have mixed
results regarding decreasing the overall absorption capability of these products [50,
51]. Clinical studies are needed to examine the use of skin protectants along with
incontinence-absorption products and the effect on irritant contact dermatitis.
Additional ingredients used to restore the skin’s moisture barrier included emol-
lients and humectants [52] (see Table14.1). Emollients form a lipid or oil barrier on
the skin to protect against loss of water (i.e., water repellent) and irritants and to
supply/restore lipids of the skin barrier. Humectants enhance the skin moisture bar-
rier by attracting moisture to the skin.
There are a variety of commercially available skin care product formulations/
applications that are used to treat and prevent irritant contact dermatitis [38], and
none has proved superior for management of irritant contact dermatitis [17]. For
example, a study of 981 nursing home residents compared ointment and cream-based
formulations to a terpolymer acrylate and found that all improved irritant contact
dermatitis while none emerged as superior based on clinical outcomes alone [17].
M. Gray et al.
309
Innovations in skin care products for irritant contact dermatitis aim to increase
cost effectiveness by decreasing nursing work. As noted earlier, some cleansers no
longer need to be rinsed off with water and a disposable wipe combining a cleanser,
a skin protectant, and ingredients to restore the skin’s moisture barrier was found
more effective than pH neutral soap and water for prevention of irritant contact
dermatitis in nursing home residents [53]. Other important features of skin care
products for treating irritant contact dermatitis relate to whether they contain fra-
grance or alcohol, are hypoallergenic, and their feel on the skin [52]. Important
nursing and patient self-care actions that are components of a skin care protocol are
timely cleansing of soiled skin, gentle cleansing, and complete, gentle drying. Usual
care that relies on nurse preferences can be inadequate and inconsistent as general
nursing staff lack knowledge about the types and use of skin care products available
in their clinical facilities [54].
14.5.2 Managing Incontinence
Because irritant contact dermatitis is associated with fecal or urinary incontinence,
prevention and management of irritant contact dermatitis includes treatment to
reduce incontinence frequency and severity and preventing feces from coming into
contact with the skin [20, 26, 33, 34, 39, 40, 55, 56]. Conservative management,
including use of absorptive products and containment devices, and surgical treat-
ment of fecal incontinence are discussed in detail in other chapters of this book. A
few main strategies are summarized here.
Research shows that more severe irritant contact dermatitis is associated with
more severe fecal incontinence, especially when the patient leaks liquid feces [24].
Therefore, steps to achieve a more formed stool consistency and decrease fecal
incontinence frequency through diet modication, increased dietary ber intake or
medication are part of prevention and management of irritant contact dermatitis
(See Chap. 6).
Several fecal containment strategies may be used to prevent or alleviate irritant
contact dermatitis. A rectal pouch is a type of external collection product comprised
of a skin barrier wafer with a hydrocolloid-based adhesive (similar to a one-piece
ostomy pouching system) that is attached to the perianal skin and a pouch (reser-
voir) that stores fecal materials that leak from the rectum. These pouches have been
found to delay time to onset or occurrence of irritant contact dermatitis when com-
pared to usual care (absorptive products and routine skin cleansing [57, 58]. Another
type of pouch can be irrigated to promote drainage of feces away from the skin and
is attached to wall suction [59].
Several indwelling devices divert or prevent feces from coming into contact with
the skin. They are placed in the rectal vault drain liquid stool into a collection bag;
some allow for rectal irrigation to facilitate drainage. These devices are designed for
short-term use, typically 29days or less, in persons experiencing high volume liquid
stool multiple times daily [60, 61]. They are mainly used in patients in the acute or
critical care setting (see Chap. 10). These devices have been shown to prevent
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
310
irritant contact dermatitis and pressure injuries in patients with fecal incontinence
[62, 63]. Nevertheless, clinical experience demonstrates that these devices move
within the rectum, often resulting in seepage of stool from the anus requiring skin
care and application of skin protectant to the perianal skin [64].
Absorbent products can be used as an adjunct to ongoing continence promotion,
as containment, when continence interventions are not feasible, and as a means to
preserve dignity in persons with incontinence. They are used in acute- and long-
term care settings and by community-living individuals with incontinence [65, 66].
There are numerous styles and designs of absorptive products. They may be catego-
rized based on application (body worn versus on the bed or chair) or their intended
function (intended for light, moderate, or heavy incontinence) [67]. See Chap. 15
for more information about incontinence absorption products.
14.6 Educating Nursing Staff
In addition to increasing their own knowledge and expertise about identifying and
assessing irritant contact dermatitis to support their own practice and consultations,
the advance practice continence nurse may participate in educating nursing staff
about irritant contact dermatitis. Education topics for nursing staff are risks for irri-
tant contact dermatitis and its association with incontinence, assessment of signs,
symptoms, and severity of irritant contact dermatitis, treatment and prevention
approaches, types of skin care products, and benet of using a structured skin care
protocol. In clinical facilities utilizing nursing assistants, nursing assistants should
be prepared to recognize the presence of skin damage and empowered to communi-
cate the information to the nurse who can perform an assessment. The advance
practice continence nurse may be called upon to manage more severe or non- healing
cases. Given turnover rates of approximately 50% of nursing staff in US nursing
homes [68–70], staff education is a continuous need in this setting. An instrument
designed to measure knowledge about incontinence-associated dermatitis/irritant
contact dermatitis has been developed and validated for use in nurses and allied
healthcare professionals [71, 72]. A score of 70 out of 100 on this 18-item instru-
ment indicates adequate knowledge of causes and risk factors for irritant contact
dermatitis, its classication and diagnosis, and prevention and management
strategies.
14.7 Expected Clinical Outcomes
Time to healing of irritant contact dermatitis can vary among individuals and patient
groups. Mild irritant contact dermatitis manifested by pink skin is most common
across all patient groups from community-living residents to critical care patients
[1, 8, 73, 74]. Nearly half of residents in long-term care and acute long-term care
healed irritant contact dermatitis within 2weeks of observation [8, 18, 32]. Median
time to healing irritant contact dermatitis was about 1week in community-living
M. Gray et al.
311
individuals [73] and nearly 2weeks in critically ill patients [18]. Lack of progress
in healing suggests need for a change in approach, which may range from achieving
less exposure of skin to leaked urine and/or feces or using different skin care or
absorbent products. Observations of community-living individuals with fecal incon-
tinence show irritant contact dermatitis reoccurs after healing [1, 2, 4, 5] and sup-
ports the need for prevention after healing. Prevention of irritant contact dermatitis
in nursing home residents with incontinence signicantly reduced the odds of devel-
oping irritant contact dermatitis by about half [73].
14.8 Recommendations forManagement ofIrritant Contact
Dermatitis fortheAdvanced Practice Nurse
• The advanced practice nurse has a role in managing in patients with irritant con-
tact dermatitis in their own practice and when consulting to nursing staff in a
variety of clinical settings.
• The advanced practice nurse should develop expertise in the diagnosis of irritant
contact dermatitis, assessment of its severity, and its treatment and prevention.
• The Assessment and Severity of Irritant Contact Dermatitis due to Incontinence
(ASICDI) instrument can be useful in assessing severity of irritant contact der-
matitis, monitoring worsening or improvement, and educating nursing staff
about irritant contact dermatitis.
• Consultation about irritant contact dermatitis includes evaluating the use and
components of a structured skin care protocol and, as needed, recommending
modications based on the needs of patients, staff, and the care model/setting.
• The advanced practice nurse should be knowledgeable about the options of skin
care and absorbent products available to patients and a clinical facility and their
actions/features.
• Skin care protocols for managing irritant contact dermatitis typically include
products for cleansing skin, replacing water and lipids in the epidermal skin bar-
rier, and protecting skin from losing moisture and from irritants. Maintaining an
acidic skin pH while using skin care and/or absorbent products is
recommended.
• Educating nursing staff about irritant contact dermatitis and the role of the
advanced practice nurse in its care may facilitate better patient outcomes.
• Prevention of irritant contact dermatitis is critical to maintain skin integrity and
to reduce recurrence of skin damage. Prevention protocols are similar to those
for treatment of irritant contact dermatitis.
14.9 Pressure Injury
Incontinence is a risk factor in the development of pressure injury in any healthcare
setting due to the increase in moisture and temperature of the perineal skin making
it higher risk for damage from pressure. Therefore, understanding how pressure
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
312
injury injuries develop, how to identify each patient’s individual risk factors and the
proper management to prevent and treat pressure injuries is part of the comprehen-
sive management of fecal incontinence.
The development of a pressure injury has signicant impact on the quality and
duration of a patient’s life as well as the economic burden for the patient and the
healthcare system. Approximately 60,000 patients die each year from pressure
injury complications [75]. Pressure injury as the cause of death in 80% of people
over 75years of age [75, 76]. Septicemia occurs in 39.7% of pressure injury associ-
ated deaths. The pressure injury mortality rates are higher in African Americans
than in other racial groups [76]. Each year, more than 2.5million people in the
United States develop pressure injuries. These skin injuries cause pain, associated
risk for serious infection, and increased healthcare utilization [77, 78].
The annual cost of a pressure injury treatment in the United States (US) in 2011
was estimated to be as much as $11billion [75]. The annual cost of hospital-acquired
pressure injury in 2016 dollars is estimated to be $26.8billion [79]. For an indi-
vidual patient, the cost of care per pressure injury was $20,900 to $151,700, depend-
ing on its stage. Medicare data reports $43,180 per pressure ulcer [75]. Hospital stay
was longer for patients with pressure injuries, and more than half of these patients
were discharged from a hospital to a long-term care facility/nursing home, which is
three times the rate of hospitalizations for all diagnosis [80]. More than 20% of resi-
dents who have been in long-term care facilities for two or more years will develop
at least one pressure ulcer [81]. The cost of treating pressure injury is 2.5 times the
cost of preventing them [82].
14.10 Pressure Injury Risk Assessment andPrevention
An important role for nurses, especially for continence nurse specialists and
advanced practice nurses, has been to identify the patients at risk for pressure injury
and order or implement a prevention plan targeting the identied risk factors.
Patients should be assessed on admission to any healthcare setting: hospital, acute
long-term care, nursing home, rehabilitation, and home care. At specic intervals
per healthcare setting, the risk assessment should be repeated as an ongoing evalu-
ation. The risk assessment scale provides a score that assists the nurse in identifying
areas of risk in order to implement a prevention plan. There are three validated pres-
sure injury risk assessment tools with scales that are most commonly used: Waterlow,
Norton, and Braden scales [4, 83, 84].
• The Waterlow scale consists of seven items to evaluate risk for pressure injury
development. Those seven areas are height, weight, skin assessment, sex/age,
continence, mobility, and appetite. There are also special risk areas including
tissue malnutrition, neurological decit, medications, and surgery/trauma [84].
• The Norton scale evaluates ve areas of risk: physical condition, mental condi-
tion, activity, mobility, and incontinence [83].
M. Gray et al.
313
• The Braden scale has six subscales identied as key risk factors to predict overall
level of risk for developing pressure injury. The six subscales are sensory, mois-
ture, activity, mobility, nutrition, and friction and shear. It lists the presence of
moisture versus urinary and fecal incontinence per se as other scales do as a
contributing factor [4]. The skin has increased moisture with incontinence, which
weakens the epidermis and with the addition of pressure and/or shear can cause
a pressure injury to develop.
The Braden scale is most widely used in the United States to identify patients
at risk for developing pressure injury in various settings. Therefore, it may be
readily available for the advanced practice nurse to review during an assessment
of fecal incontinence. Based on the overall score [1–23] of a particular patient
and each subscale score (1–4 or 1–3 for friction/shear), an individualized care
plan for prevention can be developed to address the risk factors with appropriate
targeted interventions. A prevention plan can be implemented as a team approach.
A higher score on the Braden scale means a lower risk of developing a pres-
sure injury.
The advanced practice nurse should be cognizant of the strategies needed to pre-
vent the development of a pressure injury in patients that are high risk. A generalist
nurse usually will evaluate the patient on admission to the healthcare setting via a
risk assessment scale such as those noted above and implement prevention mea-
sures based on the results. Nurses are responsible for providing a daily skin care
protocol and assessment, continence care, turning, and repositioning. Because risks
for skin damage can be dynamic, the ongoing assessment and updating of a care
plan are done regularly by the nursing staff.
Incontinence care with skin care products (i.e., cleansers, moisturizers, protec-
tants/moisture barrier) that are gentle and maintain the natural acidic pH of skin is
recommended after every incontinence episode. Interventions that preserve the pro-
tective functions of the skin are crucial for prevention of skin injury in incontinent
patients. Turning and repositioning are currently recommended and should be done
based on patients’ individual needs and at a minimum of every 2h. The turning and
repositioning do not eliminate the pressure but do reduce the duration of the pres-
sure. The amount of time the pressure is present on the skin is a critical element in
the development of the pressure injury.
Prevention involves a multidisciplinary team, and if one is not in place, the
advanced practice nurse can order appropriate consults. For example, a dietician
conducts a nutritional assessment making recommendations to ensure adequate
nutrition and hydration. Physical and occupational therapists implement a plan to
improve the patient’s mobility status and, if needed, recommend a seating surface
and proper equipment for turning and repositioning. The advanced practice nurse
ensures that all areas have been adequately addressed and a treatment plan is in
place for each area assessed as being a risk.
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
314
14.10.1 Nutrition
Nutrition plays an important role in the prevention and healing of pressure injury.
The dietitian or nutritional support nurse’s thorough nutritional assessment and
ongoing review is an important part of the team approach. They assist in screening
for malnutrition risk on admission and for signicant changes in condition after-
ward using a valid and reliable nutritional screening tool. They address nutritional
decits with adequate protein, vitamins, and minerals and adequate hydration
through a comprehensive nutritional plan (see Box 14.1). Assessing uid and caloric
intake may require a 48-h calorie count for accuracy [85]. As many as 56% of resi-
dents in nursing facilities require assistance to eat [86]. Dental problems, ill-tting
dentures, swallowing problems, dementia, depression, and Parkinson’s disease are
all potential reasons for poor nutritional intake [87, 88].
14.10.2 Sensory andMobility
Limitations in mobility and sensory impairments are addressed by an individualized
turning and repositioning schedule and by using a support surface that redistributes
pressure in a chair, wheelchair, and/or bed. There are numerous products that claim
to provide this redistribution of pressure and prevent shearing. Consulting physical
and/or occupational therapy to evaluate the patient’s functional level and make rec-
ommendations is helpful in selecting an appropriate product.
Box 14.1: Nutrition Plan for Patients with or at High Risk for a Pressure Injury
• Screen patients with pressure injury or at high risk for pressure injury for
malnutrition risk.
• Assess nutritional status and intake of these patients.
• Develop and implement a nutrition support.
• Provide and encourage intake of sufcient calories.
• Provide and encourage intake of adequate protein to achieve positive nitro-
gen balance.
• Provide and encourage adequate uid intake for hydration.
• Provide adequate vitamins and minerals, especially vitamin A (protein
synthesis), C (collagen formation), D (immune response), and zinc (colla-
gen formation).
• Reassess nutritional status for pressure injuries that are not progressing in
healing and modify plan according to ndings.
M. Gray et al.
315
14.10.3 Shear andFriction
An example of how a shearing injury can occur is as follows: If the head of the
patient’s bed is elevated greater than 30
o
, and the patient slides down in bed due to
gravity forces, then mechanical damage to the skin and pressure injury can develop.
Shear presents as linear extensions or undermining in a pressure injury. To eliminate
shearing forces, keep the head of the bed elevated less than 30° with the knee area
notched or elevated to prevent sliding down in bed. Lifting or moving a patient with
turning sheets, not dragging, and/or the use of a trapeze or lift equipment will
decrease both friction and shearing.
Friction is the surface damage caused by skin layers rubbing against another
surface. Friction can occur from frequent and aggressive cleansing of the skin after
incontinent episodes. Friction damages the epidermis and top dermal layers of the
skin. It presents in the eshy part of the buttocks as supercial red patchy areas.
Gentle cleansing after incontinent episodes using an appropriate skin cleanser
decreases the risk of friction [89].
14.10.4 Moisture
Moisture has a role in the formation of pressure injury. Skin become waterlogged
(or overhydrated) from frequent exposure to moisture, which results in skin macera-
tion (or thinning). With friction, erosion of macerated skin occurs very easily. Moist
skin is ve times more likely to form a pressure injury than dry skin [90]. Most
commonly, the moisture in an incontinent patient is from fecal or urinary inconti-
nence or both. Additionally, when wearing an incontinent brief, skin pH can increase
(can become alkaline) from the increased heat, occlusion, and exposure to urine and
feces (which have an alkaline pH) [91]. An alkaline skin pH promotes the action of
fecal enzymes in “digesting” the protective lipoprotein matrix of the skin [92].
A management plan for urinary and fecal incontinence is critical for long-term
elimination or reduction of this risk factor. However, in the short term, it is impor-
tant to use a structured skin care program for patients with incontinence, which
includes cleansing, moisturizing, and protecting the skin barrier against moisture
loss. It is also crucial to use high-quality incontinence pads or briefs with moisture
wicking, super absorbency, and air permeability properties and that maintain an
acidic skin pH and offer a good t. Additional risk factors for the development of
pressure injury that need to be managed include extrinsic factors such as limitations
in mobility, movement, transferring, toileting abilities, and cognitive functioning,
decreased circulation, tissue perfusion and oxygenation, and diminished sensa-
tion [93].
14 Management ofSkin Damage Associated withFecal andDouble Incontinence
316
14.11 Description andManifestations ofPressure Injury
Pressure injury is dened by the National Pressure Ulcer Advisory Panel as a local-
ized damage to the skin and underlying soft tissue, usually over a bony prominence
or under a medical device caused by pressure or pressure with shear [13, 15]. Signs
of pressure injury can range from intact non-blanchable erythema of the skin to full-
thickness skin loss. The tolerance of the skin for pressure and shear injury can be
affected by nutrition, perfusion, comorbidities, microclimate, and condition of the
skin at the baseline.
The staging of pressure injury (from 1 to 4) is differentiated by the degree of tis-
sue damage at the wound base [92] (see Box 14.2). Pressure injuries are the only
wounds that are staged. Other types of wounds are described as partial-thickness or
full-thickness wounds. Since the correct staging of pressure injury requires an eval-
uation at the base of the wound, if the wound base is covered with necrotic tissue
(either slough or eschar), the wound is considered an unstageable pressure injury. A
deep tissue injury is also not staged because it is a persistent non- blanchable deep
red, maroon, or purple intact skin discoloration. This area may resolve or evolve
into a stageable pressure injury.
Box 14.2: Stages of Pressure Injury [13, 15]
• Stage 1 pressure injury is intact skin with non-blanchable erythema. The
damaged skin may have changes in temperature and rmness compared to
adjacent tissue. Stage 1 may difcult to determine on darker skin tones.
• Stage 2 pressure injury is partial-thickness skin loss. Partial thickness is
damage to the epidermal skin, which can extend into the dermal layer but
not through the dermis. Stage 2 pressure injury heals through epithelializa-
tion, which means the tensile strength is not affected. Stage 2 pressure
injury may easily be confused with irritant contact dermatitis if relying on
appearance only, so knowing the etiology (i.e., if pressure was a factor) is
important.
• Stages 3 and 4 are full thickness tissue injuries. Stage 3 pressure injury
extends through the dermis into the subcutaneous tissue. A stage 4 involves
muscle, fascia, tendon, and possibly bone. Full thickness wounds leave a
healed area weakened because they heal with scar formation. The healed
area never reaches more than 70% tensile strength and therefore is at risk
to recur.
M. Gray et al.