Incontinence: Risk factors for skin breakdown and assessment
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history to identify and address risk factors for skin breakdown in incontinent patients: moisture, increased skin pH, microbial colonization and friction and shear. | Level of Evidence Not Assessed |
| Address Patient-centered Concerns | ||
|---|---|---|
| 2 | Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life. | Level of Evidence Not Assessed |
| 3 | Provide information and advice on treatment options available in both primary and secondary care. | Level of Evidence Not Assessed |
| 4 | Use a validated quality of life and incontinence severity questionnaire. | Level of Evidence Not Assessed |
| Provide Local Care | ||
|---|---|---|
| 5 | Recommend containment products and reassess their suitability. | Level of Evidence Not Assessed |
| 6 | Consider absorbent products as: - a coping strategy pending definitive treatment - an adjunct to other ongoing therapy - long term management of urinary incontinence only after other treatment options have been explored | Level of Evidence Not Assessed |
| 7 | Assess perineal skin carefully and regularly to identify signs of irritation, infection, contact dermatitis and skin excoriation. | Level of Evidence Not Assessed |
| 8 | Develop individualized skin care plans for patients with incontinence and intact or irritated skin, based on regularly cleansing, moisturizing and protecting the perineal skin. | Level of Evidence Not Assessed |
| 9 | Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams. | Level of Evidence Not Assessed |
| 10 | Treat infected skin or other skin complications appropriately. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 11 | Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. | Level of Evidence Not Assessed |
Background
Incontinence increases the risk of developing skin irritation, ulceration and infection, as does the use of incontinence containment products, such as diapers. The risk is further increased in patients who have received perineal radiation and in those with limited mobility. Specific risk factors for skin breakdown are the following:• Moisture: Overhydration can result from incontinence and from pads or briefs that trap urine or liquid feces against the perineal skin, increasing perspiration. Skin barrier damage allows water and chemical absorption and bacterial overgrowth.
• Skin pH: Urine may be acidic or alkaline; and incontinence may upset the normal skin pH. Ammonia from urine and urea from both urine and overgrowth of fecal bacteria may increase skin pH above 8. Highly acidic urine may develop in people with poorly controlled diabetes.
• Microbial colonization: Prolonged perineal exposure to moisture due to incontinence allows bacterial overgrowth. Obesity, immune-compromise, diabetes and exposure of damaged skin to gastrointestinal flora and digestive enzymes all increase the risk of infection, which further damages the skin barrier. Candidiasis is the most common infection, but normal skin or gastrointestinal flora may also cause infection.
• Friction and shear: The movement of clothing, bedding, or incontinence containment devices against moist or wet skin causes friction that may erode the stratum corneum. Erosions, while generally superficial, may involve large perineal skin areas. Repositioning an immobile incontinent patient may produce shearing forces resulting in tissue injury.
It is important to inspect the perineal area for skin integrity and evidence of infection. In males, this includes inspecting the glans penis, retracting the foreskin (if present). In females, thorough assessment includes pulling back the labia majora and minora to allow inspection of the distal vaginal vault. Inspection of the anal area in all patients involves separating the buttocks and any skin folds, as these folds may be overlooked during cleansing and are likely to perspire, especially in the obese individual.
References
| Essential Publications |
|---|
| 1 | Incontinence and skin injury |
Quality Indicator
|
Type: Prevalence study |
| Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. JWOCN 2007;34(3):260-9. | |||
| The purpose of this study was to analyze the prevalence of skin injury in areas exposed to incontinence. 19.7% of the 608 patients surveyed were incontinent of urine and 17.6% were incontinent of stool. The researchers found that fecal incontinence was associated with hypoalbuminemia, poor nutritional status, and a higher skin injury rate. | |||
| 2 | Perineal assessment tool |
Quality Indicator
|
Type: Validation study |
| Nix DH. Validity and reliability of the perineal assessment tool. Ostomy Wound Management 2002;48(2):43-6, 48-9. | |||
| The purpose of this study was to evaluate the validity and reliability of the Perineal Assessment Tool. The Perineal Assessment Tool was designed to determine the risk of perineal skin injury in hospitalized patients by measuring four risk factors: duration of irritant, intensity and type of irritant, perineal skin condition, and contributing factors that may cause diarrhea. The scale was evaluated by comparing the scores assessed using the tool by wound, ostomy and continence nurses with the scores calculated by staff registered nurses and licensed practical nurses using the same tool. The researcher found that there was a very good correlation between the expert and staff nurses’ scores (r = 0.97, p < 0.0001), indicating that the Perineal Assessment Tool may be valid and reliable. | |||