Cath Lab Digest

I ncontinence has a major impact on health and quality of life. In the general population, fecal incontinence affects approximately 2% of adults and urinary incontinence affects approximately 30% of adults.^1,2 Dermatitis is a common problem for individuals experiencing incontinence. This skin condition affects all age groups, races, and genders. Up to 30% of hospitalized adult patients have been reported to have perineal dermatitis.³ Additionally, experts cite incontinence as a major risk factor in the development of pressure ulcers. The presence of pressure ulcers increases hospital stays up to five times longer than when none are present and can cost up to an additional $35,000 for treatment depending on the severity and stages of the wounds.⁴

Perineal skin injury resulting from incontinence has been found in as many as 33% of hospitalized adults.³ Products such as underpads and adult briefs commonly used with incontinent patients contribute to perineal skin injury by trapping moisture against the skin.⁵ To address the problem of perineal skin injury, the Perineal Assessment Tool (PAT) was developed through literature review. The PAT is a four-item instrument (see Table 1). The framework for the PAT is based on four factors that are determinants in perineal skin breakdown. These constructs include duration of irritant, intensity/type of irritant, perineal skin condition, and contributing factors that may cause diarrhea. Each subscale reflects degrees of risk factors. All subscales are rated from 1 (least risk) to 3 (most risk). Each rating has a descriptor and a description of each level of the scale. Total scores can range from 4 (least risk) to 12 (most risk).

Literature Review

Duration of irritant refers to the amount of time the skin is exposed to an irritant (ie, urine and/or stool). Skin wetness has been defined as fluid in contact with the skin for 2 or more hours.⁶ The Braden Scale for predicting pressure ulcers has a subscale for moisture. The Braden subscale definition for moisture is "degree to which skin is exposed to moisture." The Braden Scale further defines degree to which skin is exposed by frequency of garment/linen change: constantly moist (dampness is detected every time patient is moved or turned); often but not always moist (linen changes at least once a shift); occasionally moist (linen change once a day); and rarely moist (skin is usually dry).⁷

Intensity of irritant refers to the strength and ability of the irritant to cause epidermal barrier disruption in human skin. Factors that correlate with barrier disruption include moisture, increased pH, and invasion of microorganisms. Moist or wet skin has a higher pH than dry skin and is more permeable to irritants and bacteria.^6,8 Stool from the large bowel is usually formed and has less moisture. In contrast, small bowel discharge is liquid and reported to be a strong irritant to the skin.⁹ Studies show that prolonged occlusive exposure to digestive enzymes in feces causes erythema and epidermal barrier disruption in humans. Digestive enzymes with higher pH have been associated with more severe skin alterations.¹⁰ The intestine is a natural reservoir of microorganisms that are exposed to the skin through feces.⁸