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maximizing SAPs have enhanced all-in-one absorption to 87oz of uid and
underpads to 9500mL, reducing the number of items per day for patients with
moderate-to-severe fecal, urinary, or double incontinence and thereby reducing
nancial burden and lessening the environmental carbon footprint.
2. Qualitative research by Raepsaet etal. [77] revealed the characteristics of the
user prole, technical requirements, circumstances, and possible advantages of
incorporating sensor technology into disposable BWAPs. Results include the
following:
(a) Residents with cognitive impairment and those who are bedridden or have
severe mobility limitations were identied as the two categories that com-
prise the user prole. The analyses revealed the following (technical)
requirements: a small, thin, oval/circular sensor; a exible or front-facing
sensor attachment on the absorbent product; a real-time indication of the
absorbent product’s saturation; leak detection; liquid stool detection; auto-
matic data recording related to incontinence; a robust, easily sterilizable
sensor; and the ability to receive notications on a wearable device.
(b) A reliable connection between the wearable and the sensor, precise mea-
surements, an easy-to-use interface, clear instruction, reasonable prices, and
data security were among the requirements.
(c) Reduced burden, better resident and staff comfort, more person-centered
care, higher-quality care, less skin injury, and/or nancial (i.e., lower
expenses from fewer changes to highly absorbent products) and/or envi-
ronmental (i.e., reduced waste) benets were among the possible
advantages.
3. Creation of “smart diapers” with a Bluetooth sensor or a printed sensor with a
transmitter clipped to the BWAP that alert carers via an app on their “smart
phone” the absorbent product is soiled. A less expensive option is a moisture
sensor with a passive radio frequency identication (RFID) tag that detects and
communicates wetness to a nearby RFID reader, which then informs a caregiver
when it’s time to change the absorbent product.
4. The development of an electronic urinary continence assessment system that is
“smart” by recording voiding times, urine volumes, and continence patterns
using a 72-h assessment sensor in BWAP.After being moved to a secure server,
the data is examined, and a straightforward graph is generated. In their evalua-
tion of the technology’s efcacy with nursing home residents, Rajabali etal. [78]
observed that it allowed staff to determine individual toileting times and the need
for pad changes, which reduced the number of needless wet checks that could be
upsetting for the patient and inefcient for the caregiver. It decreased the absor-
bency level and frequency of improper pad use, particularly at night, and incon-
tinence. These similar results were conrmed by another study [79].
5. The odors emanating from human feces and urine possess unique characteristics
that are easily identiable by humans, even at extremely low levels of concentra-
tion [80]. Concealing, reducing, and/or eliminating embarrassing odor is highly
desirable and a chief requested feature by users of BWAPs, especially active
adults living in the community concealing this embarrassing and life-altering
J. Ermer-Seltun and K. Borchert
359
problem [4, 5, 50, 59]. Researchers and engineers are working hard to accom-
modate this need, but they have yet to create the ideal odor-resistant or elimina-
tor solution for consumers. Fader etal. [5] describe signicant new initiatives
with varied degrees of evidence, or efcacy can be classied into two categories:
(a) ingestible items that reduce the production of foul atus previously discussed
and (b) products that trap or absorb emitted malodorous gas through microbial-
treated fabrics [81], the use of activated charcoal [60] or odor neutralizing tech-
nology [73]. An interesting innovation that is still in its early stages is the creation
of a portable “smart” device for detecting, distinguishing, and notifying odors
associated with urine and feces. The device communicates with a mobile phone
via Bluetooth, delivering raw data from the smell sensor to the smart device for
analysis and notication [66].
15.13 Priorities forResearch
Despite recent technological breakthroughs in absorptive product features, signi-
cant progress is still required to develop a product designed to contain stool (light
and moderate fecal incontinence with and without urinary incontinence), particu-
larly liquid stool, minimize odor, and improve perigenital skin health. Furthermore,
it is necessary to improve the design of eco-friendly disposable items that are effec-
tive, discreet, and efcient in minimizing medical solid waste and the environmental
impact. Fader etal. [5] list the following research priorities:
• Creating absorbent products (body worn or underpads) that protect perigenital
skin and can eradicate, lessen, or conceal the smell of atus, urine, fecal, or
double incontinence.
• Comparing washable and disposable absorbent products for community users
who rely on caregivers.
• Developing disposable products that are more appealing and effective, especially
for men.
• Creation of reusable (washable) items that are more aesthetically pleasing and
effective, especially for women and for usage at night.
• Although they are extensively used, disposable underpads have a limited role in
managing incontinence. Examining how patients feel and think about their use
could help highlight their shortcomings, especially in terms of skin health.
15.14 Conclusion
Absorbent products (body worn and underpads) can greatly enhance dignity, quality
of life and are an essential component of containment management for individuals
with urinary, fecal, or double incontinence in all settings. However, the use of absor-
bent products should not take the place of a thorough assessment and evidence-
based interventions to enhance continence status.
15 Absorbent Products: Types, Selection, andPros andCons
360
Although BWAPs are essential for containment, there are drawbacks. Absorptive
products can compromise perigenital skin health because of occlusion, increased
heat, which raises skin pH, and compounded by the addition of other alkaline
sources of moisture (urine, feces, double). If incontinent of feces, especially if
loose, the protective lipid-protein matrix of the skin is further “digested” by fecal
proteolytic enzymes activated by an alkaline skin pH. Plus, overhydrated skin
increases friction (drag) between the skin and BWAP, especially if it is wet.
Unfortunately, BWAPs design and features are inadequate to manage fecal
incontinence; yet it is the best available option for containment presently. The cur-
rent rst-line recommendation for light fecal incontinence for ambulatory people
regardless of gender is to insert a cotton gauze dressing or an absorbent buttery-
shaped pad with gentle adhesive strips against the anus that is held in place by the
buttocks. For the ambulatory individual with moderate-to-heavy daytime FI, the
rst-line recommendation is a pull-on with SAP technology. Remember, there is not
a single “right” BWAP that applies to everyone. Users should be advised that differ-
ent design combinations may be more appealing and cost-effective depending on
whether they are at home versus out in public, where discreetness and product per-
formance are priorities, or during the day when toilet access is easily accessible
versus at night, where avoiding leaking in bed may be the goal. APNs can inform
consumers that using less expensive, smaller, and discrete products can mean they
have to assume a larger risk of product leakage. As a result, when choosing a BWAP,
it is critical to take the user’s priorities into account.
Despite recent technological breakthroughs in absorptive product features, sig-
nicant work remains to be done to develop a product intended to contain feces
(light/moderate/heavy fecal incontinence with and without urinary incontinence),
particularly if liquid, eliminate odor, and improve the health of the perigenital
skin area.
Once the APN is familiar with the design categories, features, and performance
requirements of absorbent products presented in this chapter, the authors hope
APNs will be equipped with evidence-based knowledge and skills to assist inconti-
nence consumers and other community stakeholders in selecting the BEST absorp-
tion product for optimal performance, t, ease of use, comfort, aesthetics, odor
control, skin health, cost, and environmental impact.
Boxes 15.1 and 15.2 describe the pros and cons of absorptive product selection
and the care provided by an advanced practice nurse case scenario of patients with
fecal incontinence.
Box 15.1: Case Scenario Illustrating Pros of Absorbent Products
Jeannette (as she prefers to be called) is a 68-year-old woman who completed
adjunctive chemotherapy and radiation therapy for adenocarcinoma of the
rectum. She comes into the outpatient clinic with complaints of fecal urgency,
frequency, liquid bowel movements with at least one to two episodes of mod-
erate-to-large fecal incontinent episodes per day. Using a night-time inserted
(continued)
J. Ermer-Seltun and K. Borchert
361
Box 15.1 (continued)
menstrual type of pad in her underwear but still must change her clothes with
each fecal incontinence episode. Loose stools started 1week ago following
chemo/radiation treatment. Taking loperamide 2mg once a day but it does not
help. Experiencing severe perianal burning and pain, using “diaper rash”
cream but it hurts to apply.
• Presents with reduced appetite and lost 10 pounds in 2weeks. Following a
low residue diet, small frequent meals. Oral intake: one 8oz. protein sup-
plement per day, i.e., Ensure; 4 cups of water, 2 cups of orange juice.
• Review of Systems: Increase fatigue, mild dizziness when going from a
sitting to standing position; urinating every 4–6h, dark yellow urine. No
incontinence. Schedule for an abdominoperineal resection in 2weeks.
• Medical history: adenocarcinoma of rectum, completed adjunctive chemo-
radiation therapy, chemo-induced neuropathy of hands/feet.
• Medications: Loperamide 2mg prn, chewable multivitamin, Alpha lipoic
acid 600mg/day for neuropathy.
The advanced practice continence nurse specialist performs the assessment
and interventions and evaluation below.
Focused Exam: Vital signs: afebrile, pulse 94, respirations 18, blood pressure
100/68 sitting and 96/65 standing. Weight 138 pounds (63 kgs). Loss of
10% of body weight<30days.
General: Well-developed, thin, fatigued appearing female, dress and hygiene
appropriate. Ambulatory without assistive devices.
Mentation: Alert, pleasant, cognitively intact.
Oral: mucous membranes dry, good dentation.
Cardiovascular: Regular rate and rhythm without murmur. No lower extrem-
ity edema.
Respiratory: Lungs clear to auscultation.
Abdomen: Non-distended, hyperactive bowel sounds, soft and non-tender
with palpation.
Genital: Labia without redness or rash. Perianal skin tender to touch, ery-
thema with erosion of skin into the anal verge. Gluteal cleft with mild
erythema without erosion of skin. Digital rectal exam deferred.
Assessment and Plan
1. Radiation-induced diarrhea with fecal urgency, frequency, and full fecal
incontinence.
(a) Instruct about using Bowel diary to describe stools and symptoms
including illustrations of stool consistency (see Chap. 5). Bring the
completed diaries to the next visit.
(continued)
15 Absorbent Products: Types, Selection, andPros andCons
362
Box 15.1 (continued)
(b) Take loperamide 2mg, 1–2 tablets 30 min before breakfast, lunch,
supper, and one tablet before bed. May take up to 8 tablets a day. Omit
if stool consistency is formed or rm.
(c) Stop hyperosmolar beverages (Ensure & orange juice) since this will
make diarrhea worse. Start whey-isolate or plant-based protein mixed
with lactose free milk, 8oz two times a day. This is low carbohydrate
and gentle on digestive system. Add 1 tablespoon of psyllium in each
shake to help thicken stool.
(d) Provide handouts and education on how foods/beverages affect the
stool characteristics. Promote foods that will thicken stool. Stay away
from simple sugar products, i.e. juices, Jello, desserts, syrups.
(e) APN will notify oncologist and dietician of today’s ndings and plan
of care and need for further nutritional evaluation.
2. Irritant contact dermatitis to perianal skin with erosion
(a) Gently cleanse with pH-balanced surfactant incontinence cleanser and
soft, disposable wipe after every loose stool. May perform warm sitz
baths for cleansing if too tender.
(b) Apply zinc oxide paste generously to perianal skin and into the anal
verge after every loose stool. May switch to cream-base barrier once
perianal skin pain and burning is resolved.
3. Containment needed for fecal incontinence
(a) Measure waist and hip circumference in inches and give to patient.
Whichever is greater is the sizing reference to use when selecting a
body-worn absorbent product (BWAP).
(b) BWAP design recommendations per BWAP.WOCN.ORG [68]: First-
line recommendation is the use of disposable underwear, i.e. Pull-on
design. Understand this product is limited in its ability to contain stool
and odor so must be changed as soon as soiled. Other options: if an
inserted pad design is preferred, it would be advantageous to nd a
product with extra protection and extra-wide rear coverage and elasti-
cation worn with close-tting underwear. All-in-ones (diaper) design
may contain odor better due to outer plastic cover but will be bulkier
and more time to apply.
(c) Instruct Jeannette she may nd different types of BWAPs for different
occasions to be benecial, i.e., different design for home vs out of
the home.
(d) Provide online resources: Continence Product Advisor [43], Home
Delivery Incontinence Supply, and National Association for
Continence [52].
(e) If fecal incontinence reduces to a small amount (anal seepage or
smears), consider the use of an absorbent, buttery-shaped dressing
placed between the buttocks to absorb the seepage.
(continued)
J. Ermer-Seltun and K. Borchert
363
Box 15.1 (continued)
4. Mild dehydration
(a) Labs: Basic metabolic panel to determine uid & electrolyte
imbalance.
(b) Measure urine output X 24h. If less than 1200mL/day, this is an early
sign you are dehydrated. May stop measuring urine output if urinating
every 3–4h light yellow urine.
(c) Drink 10–12 cups of uids per day which includes protein shakes.
Start with 4 cups of water, and 4 cups Oral Rehydration Solution
recipe of choice. Recipes provided. May stop ORS if no loose stools
and urine is light yellow.
Box 15.2: Case Scenario Illustrating Cons of Absorbent Products
Roberto is an 88-year-old long-term Latino resident who speaks broken
English. He has mild-to- moderate dementia and is non-ambulatory due to a
stroke but toiletable during the day. He has been experiencing increasing epi-
sodes of moderate-to-heavy double incontinence during the day and some-
times during the night. He was recently placed in an all-in-one body-worn
absorbent product (BWAP) design with extra absorbency with an integrated
plastic outer cover to prevent soilage of his clothes during the day. Roberto
became increasingly agitated throughout the afternoon and into the evening,
pulling at his undergarments, and yelling he wanted “it” (BWAP) off because
it hurt, stunk, and demanded to have his own underwear put back on. To calm
Roberto down, the evening shift staff toileted him, provided pericare, and
replaced the BWAP with a pull-on design during the night which seemed to
appease Roberto. Staff frequently woke him up at 3AM to change his soiled
undergarment to reduce the redness and irritation of his perigenital skin. In
addition, the staff also changed his entire bedding since the pull-on design
often leaked urine and feces around the leg gathers onto the bed linens. It took
staff 45 min to complete the task. Staff and Roberto were frustrated and
exhausted with this process. It was not unusual for Roberto to refuse to get up
for breakfast because he wanted to sleep. He began to lose weight.
Family members who came to see Roberto remarked that he regularly fell
asleep during their visits, avoided eye contact, and appeared distant, with-
drawn, and less involved in conversation, even with his great grandchildren,
who have always brought delight and a smile to his face. Roberto’s children
were extremely concerned with his behavioral changes and requested an
urgent evaluation by his long-time healthcare provider, an Advanced Practice
Nurse (APN).
(continued)
15 Absorbent Products: Types, Selection, andPros andCons
364
Box 15.2 (continued)
The APN surmised Roberto’s inability to communicate his distress effec-
tively due to his dementia and language barrier, his agitation was often misin-
terpreted by staff as behavioral issues rather than a response to his discomfort
and desire for dignity in wearing his own underwear. Given his history, the
APN conducted a thorough assessment. The combination of increased agita-
tion, frequent skin irritations, and his withdrawal from activities all signaled a
need for immediate attention.
The APN, who was familiar with Roberto’s baseline, quickly recognized
that these changes could be attributed to the use of inappropriate absorbent
product designs, resulting in physical discomfort from irritant contact derma-
titis due to incontinence and the wet, bulky absorbent product, a lack of sleep,
emotional distress, and a loss of dignity while wearing an all-in-one (diaper-
like) design during the day. Addressing this, the APN recommended a better-
suited product to normalize the toileting experience during the day and
another BWAP design to enhance containment and produce less disturbance
during sleep hours. Since Roberto is non-ambulatory but toiletable, a design
that appeared to be more like underwear was chosen, a pull-on male design
(absorbent core in the front for urine) with an additional use of a backless pad
for better rear coverage for fecal containment. The APN measured Roberto’s
waist circumference (it was greater than his hip circumference) to determine
proper sizing to maximize a close t especially around the legs gathers. Staff
then were instructed to offer daytime toileting and pericare with the use of pH
balance surfactant-based skin cleanser and application of barrier cream every
2–3h. However, if a fecal incontinent episode occurred, staff were directed to
remove the soiled BWAP and perform proper hygiene as soon as possible. For
night-time use, the APN chose a super absorbent all-in-one design to provide
greater absorbency and ease of removal and re-placement provided by the
front tab closure system. In addition, a disposable bed pad with SAPs was
placed under Roberto to avoid changing bed linens if his undergarment leaked
to reduce staff time and sleep disturbance.
This intervention improved Roberto’s comfort, sleep, and dignity while
reducing his distress and agitation, as well as easing his children’s worries.
The APN provided staff with the electronic WOCN
®
BWAP Guide, allowing
them to condently select appropriate BWAPs for any of their incontinent
residents. The tool will aid in an objective assessment of the incontinent indi-
vidual to obtain the best match between the user and BWAP design.
In this case scenario, the use of an unsuitable BWAP created a chain reac-
tion of negative consequences, all preventable with a thorough assessment of
the incontinent individual to select the best BWAP design for day and night-
time use in a non-ambulatory but toiletable individual with limited cognition
and ability to voice his concerns and preferences.
J. Ermer-Seltun and K. Borchert
365
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15 Absorbent Products: Types, Selection, andPros andCons