A Review of Perineal Skin Care Protocols and Skin Barrier Product Use

  • 12/1/2004
  • 1 Comments
  • 17707 reads
Author(s): 
Denise Nix, RN, MS, CWOCN; and JoAnn Ermer-Seltun, RN, MS, ARNP, CWOCN

P erineal skin damage secondary to incontinence is painful, preventable, and occurs in as many as 33% of hospitalized adults and 41% of adults in long-term care.1,2 Despite the importance of perineal skin care protocols that seek to improve quality of care through evidence-based interventions for various conditions,3 the quality of and compliance with these protocols have not been examined in current literature. To address this dearth of information, a convenience sampling study was conducted to 1) determine the extent to which 76 perineal skin care protocols are consistent with Wound, Ostomy and Continence Nurses (WOCN) Society Clinical Practice Guidelines; and 2) calculate and estimate the level of compliance related to the use of protective perineal skin barriers to prevent skin breakdown for individuals with incontinence to treat pressure ulcers.

Literature Review

Exposure to urine and/or feces leads to perineal skin damage. Sgadari et al4 reported the prevalence of incontinence in nursing home residents using a Minimum Data Set-derived from a cross-national database. In this sample of 279,191 residents, the prevalence of urinary incontinence was 46.4%, fecal incontinence was 29.5%, and a combination of urinary and fecal incontinence was 25.6%. Fecal incontinence is estimated to affect 16% to 66% of hospitalized elderly.5

Perineal skin damage secondary to incontinence ranges in severity and may include erythema; swelling; oozing; vesiculation; and crusting and scaling in the groin, perineum, and buttocks region.5 Multiple potentially harmful variables work together to cause perineal skin injury. Moisture from incontinence alters the skin’s protective pH and increases the permeability of the stratum corneum. An intense irritant such as feces contains bacteria that can permeate the stratum corneum, allowing for secondary infections. The need for frequent cleansing can lead to further pH changes and damage from friction.5,6 Damaged skin is indicative of reduced blood flow or the loss of collagen or elastic fibrous connective tissues — conditions that affect skin nutrition, elasticity, and strength.7 Perineal skin injury may rapidly progress to ulceration and bacterial (Staphylococcus) and yeast (Candida albicans) infections that lead to discomfort and increased treatment costs.8 Additional problems associated with perineal skin damage include diminished quality of life (QOL), increased pain and costs, and pressure ulcer development.6,8-12

Quality-of-life issues. Incontinence negatively affects QOL by causing vast psychosocial disabilities that influence careers, social experiences, and sexual relationships.9,10 It produces emotions such as fear (of accidents), anxiety, frustration, embarrassment, and depression. Persons with incontinence, especially the elderly, also fear the loss of independence and institutionalization. When the severity of the incontinence increases, emotional distress amplifies, as well as behaviors to conceal it.13 The psychosocial consequences of urinary and fecal incontinence are substantial, distressful,11 and measurable using QOL instruments such as the Incontinence Impact Questionnaire and Urogenital Distress Inventory.10 The dissemination and use of such tools is encouraged because increasing awareness of the consequences of incontinence may alter negative attitudes and behavior toward those who suffer from the condition; plus, healthcare providers might be motivated to seek and implement incontinence prevention and management programs.13

References: 

1. Lyder C, Clemes-Lowrance C, Davis A, Sullivan L, Zucker A. A structured skin care regimen to prevent perineal dermatitis in the elderly. J ET Nurs. 1992;12:12–16.
2. Lyder CH. Perineal dermatitis in the elderly. A critical review of the literature. J Gerontol Nurs. 1997:23(12):5–10.
3. Fenner SP. Developing and implementing a wound care program in long-term care. J WOCN. 1999;26(5):254–260.
4. Sgadari A,Topinkova E, Bjornson J, Bernabei R. Urinary incontinence in nursing home residents: a cross-national comparison. Age Aging. 1997;26(suppl 2):49–54.
5. Brown DS, Sears M. Perineal dermatitis: a conceptual framework. Ostomy Wound Manage. 1993;39:2–26.
6. Nix, D. Prevention and treatment of perineal skin breakdown. In: Milne C, Corbett L, Dubuc D, eds. Wound, Ostomy, and Continence Nursing Secrets: Wound, Ostomy, and Continence Secrets. Philadelphia, Pa.: Hanley & Belfus, Inc.;2002:373–377.
7. Scardillo J, Aronovitch SA. Successfully managing incontinence-related irritant dermatitis across the lifespan. Ostomy Wound Manage. 1999;45(4):36–44.
8. Warshaw E, Nix D, Kula J, Markon CE. Clinical and cost effectiveness of a cleanser protectant lotion for treatment of perineal skin breakdown in low-risk patients with incontinence. Ostomy Wound Manage. 2002;48(6):44–51.
9. Wagner TH, Patrick DL, Bavendam TG, et al. Quality of life of persons with urinary incontinence: development of a new measure. Urology. 1996;47(1):67–72.
10. Ubersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess quality of life and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurol Urodyn. 1995;14:131–139.
11. Lewis-Byers K, Thayer D, Kahl A. An evaluation of two incontinence skin care protocols in a long-term care setting. Ostomy Wound Manage. 2002;48(12):44–51.
12. The Characteristics of Long-Term Care Users. AHRQ Research Report. AHRQ Publication no. 00-0049, January 2001. Agency for Healthcare Research and Quality, Rockville, Md.
13. Fiers S, Thayer D. Management of intractable incontinence. In: Doughty DB. Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby;2000:183–207.
14. Acute Pain Management Guideline Panel. Clinical Practice Guideline: Acute Pain Management: Operative or Medical Procedures and Trauma. Rockville, Md: U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; February 1992. AHCPR Pub. No. 92-0032.
15. Shannon ML, Lehman CA. Protecting the skin of the elderly patient in the intensive care unit. Crit Care Nurs Clin North Am. 1996;8(1):17–28.
16. Comprehensive Accreditation Manual for Hospitals. The Official Handbook (CAMH). Joint Commission on Accreditation of Healthcare Organizations. 1999.
17. Maklebust J, Magnan MA. Risk factors associated with having a pressure ulcer: a secondary data analysis. Advances in Wound Care. 1994;7(6):25,27–28,31–34 passim.
18. Robinson C, Gloekner M, Bush S, et al. Determining the efficacy of a pressure ulcer prevention program by collecting prevalence and incidence data: a unit-based report. Ostomy Wound Manage. 2003;49(5):44–51.
19. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md.: U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research, 1992. AHCPR Publication 92-0047.
20. Pompeo MQ. The role of “wound burden” in determining the costs associated with wound care. Ostomy Wound Manage. 2001;47(3):65–71.
21. Clever K, Smith G, Bowser C, Monroe K. Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy Wound Manage. 2002;48(12):60–67.
22. Lyder CH, Shannon R, Empleo-Frazier O, McGeHee D, White C. A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes. Ostomy Wound Manage. 2002;48:52–62.
23. Wound, Ostomy, and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series. Glenview, Ill.: WOCN Society;2003:14.
24. Nix D. An evaluation of 52 incontinent skin care protocols. 18th Annual Clinical Symposium on Advances in Skin & Wound Care. Chicago, Ill. October 16-19, 2003.
25. Incontinent Ointment/Barriers: Skin Care (90-354) in HPIS Trend Report (Dollars) Physician/Alternative Site Markets Class Summary. Spring House, Pa.: Healthcare Products Information Services, Inc.;2002.
26. Makofsky D, Cone JE. Installing needle disposal boxes closer to the bedside reduces needle-recapping rates in hospital units. Infect Control Hosp Epidemiol. 1993;14(3):140–144.

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  Anonymoussays:
  September 20.2011 at 05:52 am
  
I was looking everywhere and this popped up like nohtnig!

  

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