Offsetting natural 'poisons'.

Incontinent residents require vigilant, gentle skin care

FLORENCE NIGHTINGALE MAY NOT HAVE UNDERSTOOD AS MUCH about skin care as we, but she certainly knew the damaging effects of excretions on the skin. Not washing perspiration or excretion off the skin properly interfered with health as much as giving the patient a dose of poison, she wrote in her book, Notes on Nursing in 1859. [1]

Now fast forward to today. Although we don't usually refer to the harmful effects of urine and stool on the skin as "poison," we are well aware of the threats posed by their presence, particularly by incontinence. The Agency for Health Care Policy and Research identified incontinence as one of the risk factors in the development of pressure ulcers and made recommendations for preventing incontinence dermatitis that could lead to ulcer formation.

Some of their suggested measures included regular skin inspection; gentle cleansing with a mild cleansing agent immediately after soiling; avoidance of force and friction during cleansing; use of absorptive briefs or pads; use of topical barriers to protect the skin from moisture; and minimizing skin injury caused by friction and shear through proper positioning, turning, and transfer techniques. [2]

While Nightingale had only water, strong soap, and rough towels in her supply kit, today's nurses have the benefit of a wide array of products to aid in maintaining skin integrity. Selection of the right product, however, is dependent on knowing the relationship between incontinence and skin breakdown.

The purpose of skin

Skin serves several purposes including the secretion of oils to moisturize and protect against bacteria and fungi, and the protection of underlying tissue from drying and injury. Skin pH, normally between 4 and 6.8, provides an acidic environment that deters bacterial colonization and promotes moisture retention in the epidermis. As we age, the protective abilities of these mechanisms gradually decrease. Noticeable results are drying of the skin, reduction of oil production, loss of elasticity, slowed healing process, and visible crevices in which bacteria can grow. When a resident is incontinent there is a cycle of moisture, friction, bacteria, and breakdown. Moisture alone makes the skin more susceptible to breakdown. Rubbing moist skin on sheets, diapers, and clothing leads to denuding of the skin and increases its permeability to irritants. Bacteria from urine or feces enter skin crevices causing infection; as bacteria grow, ammonia is produced, upsetting the pH of the skin and causing chemical irritation . [3] Pressure from resident immobility compounds the problem.

Keep in mind three simple rules--clean it, repair it, and protect it--when selecting skin-care products. The products are essentially of three types: cleansers, moisturizers, and barrier protectants. Cleaning should occur after each incontinent episode but bar soap is not recommended because of drying, residue and pH disruption effects, and the friction effects of rubbing. Suggested instead are skin cleansers. Some are norinse; they are sprayed on, wiped gently with a cloth, and left on the skin for protection and conditioning. Alkaline pH, detergents, fragrances, and alcohol are undesirable cleanser ingredients. [3,4]

Moisturizing the skin helps repair damage from incontinence episodes as well as condition it against future damage. Lotions and creams are examples of moisturizers; their thickness depends on the proportion of water to solid moisturizing agents. Protect the skin through use of harrier products that give a protective coat or skin film to repel the moisture of perspiration, feces, and urine, and prevent friction from linens and pads. Petrolatum and antimicrobials are common ingredients of barrier products; some contain antifungals. [3,4]

Disposable absorbent briefs used for incontinence need to be evaluated for absorbency, skin protection, comfort, and ease of changing. Some products currently available contain high-absorbency polymers that wick away from the skin, softer outer coverings to reduce noise during movement, and resealable tabs.

It is possible to keep skin of an incontinent resident intact with vigilant care. Given the high cost of skin breakdown--psychologically, physically, and financially--it is important to choose--and use--skin-care products appropriately.

References

(1.) Nightingale F. Notes on Nursing. Philadelphia, Lippincott Co., 1946, facsimile of 1st edition, 1859, p.53.

(2.) Agency for Health Care Policy and Research. Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md., May 1992, p.1520.

(3.) Fiers S. Breaking the cycle: the etiology of incontinence dermatitis and evaluating and using skin-care products. Ostomy/Wound Management. April 1996;42(3):32-43.

(4.) Kennedy K. Skin care for the "incontinent" skin. Quality Care, spring 1997;15(2):l-2.