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