When skin is overhydrated, its ability to protect underlying structures is compromised and its own integrity is placed at risk. Skin that is damp or wet is more permeable to irritating substances and more readily colonized by microorganisms (Zimmerer, 1986). Furthermore, less friction is required to abrade or blister skin when it is damp (Leyden, 1977; Sulzberger, 1966; Zimmerer, 1986).
It is important to note that these negative outcomes are the result of the skin being damp - regardless of the source of moisture. Whether skin is damp because the patient is incontinent, has a fever and is perspiring, has a leaking gastrostomy tube or has a draining wound, nurses should anticipate that the integrity of the skin will be compromised.
Findings suggest that much of the skin breakdown associated with urinary incontinence is due to the water content of urine rather than its content of ammonia (Leyden, 1977). Friction also may play a role, especially in the sacral breakdown seen in patients who are incontinent of urine. Many patients who are incontinent of urine may have decreased mobility or strength and be unable to lift their body to avoid dragging their buttocks and sacrum across bed linens. Although urine alone can be mildly irritating to the skin during prolonged exposure, moisture and friction combine to macerate, abrade, and blister the skin over the buttocks and sacrum (Berg, 1986).
In Figure 1, the arrows point to white and silver areas of overhydrated skin overlying the sacrum. This macerated tissue is friable and easily torn when friction is generated in the sacral area. When stool is present with urine the negative effect of the water content of urine can be augmented by a complex interaction between enzymes in the stool and urea in the urine.
Figure 1 . White and silver areas of overhydrated skin lie over the sacrum.
Figure 2. Skin breakdown secondary to drainage from a gastrostomy tube that leaked around the insertion site.
In an attempt to model the etiology of diaper dermatitis, investigators who studied the effects of infant urine and stool on the skin of mice constructed a sequence of events that results in enzymes in the stool converting urea into ammonia and increasing the pH in the "diaper" area (Buckingham, 1986). This rise in pH increases the activity of fecal proteinases and lipases. These fecal enzymes not only irritate the skin directly, but also (like water) make the skin more permeable to other irritants, such as bile salts. Results from a study of a small sample of geropsychiatric inpatients suggest that this complex interaction between urine and stool also might contribute to perineal dermatitis in elderly incontinent patients (Lyder, 1992).
When caring for patients who are incontinent of both urine and stool, nurses face the challenge of managing the detrimental effects of moisture as well as the negative effects of irritants within the stool. Leaking gastrostomy tubes and draining enterocutaneous fistulas also pose a dual threat to the skin. Figure 2 illustrates the skin breakdown that can occur secondary to drainage from a gastrostomy tube that leaks around the site of insertion.
Further, nurses should remember that moisture alone from any source - even perspiration - can contribute to skin breakdown. The water in perspiration can overhydrate the skin and promote the growth of such microorganisms as Candida aibicans, resulting in a candidiasis along with the dermatitis. The arrow in Figure 3 highlights the red satellite papules at the periphery of the central area of erythema that often are seen in candidiasis.
INTERVENTIONS _________ ____
The secondary goal of nurses who care for patients at risk for skin breakdown is to keep the skin dry and free of irritants. Given that what we know about protecting the skin is still evolving, the level of success nurses will realize in achieving this goal will depend greatly on the resources available to them and the extent to which caregivers are able to comply with the plan of care.
First, nurses must make every effort to control the source of moisture. There are many strategies and techniques to help nurses achieve this objective; however, it is beyond the scope of this article to discuss them. I will refer the reader to comprehensive reviews for the details.
When caring for patients whose skin is damp because they are incontinent of urine, nurses should work closely with physicians and nurse specialists to diagnose and treat the cause of the incontinence. The Urinary Incontinence Guideline Panel (1992) completed an extensive review and critique of the literature on acquired urinary incontinence in adults and developed recommendations for diagnosis and treatment. These recommendations are available free of charge from the Agency for Health Care Policy and Research Publications Clearinghouse (PO Box 8547, Silver Spring, MD 20907).
The directors of the Enterostomal Therapy (ET) Nurse Education Programs have compiled a series of texts to serve as the core curriculum for educating ET nurses. Among the numerous topics discussed are strategies for treating urinary and fecal incontinence, and techniques for managing draining wounds and leaking tubes (Bryant, 1992; Doughty, 1991).
Nurses who care for patients who present with these types of problems should ask their nurse managers to lobby for reference libraries that include these types of comprehensive texts. If nurse specialists in urology, enterostomal therapy or rehabilitation are accessible, then nurses should consult them for advice and guidance. We need not allow ourselves to be isolated from resources that can help us improve the care we provide.
Although this article does not focus on how to treat the primary problem that is causing the patient to be wet, it does cover an important secondary concern - how to keep the skin dry and free from irritants. In those cases in which the primary problem can be resolved, these interventions will be only temporary measures to protect the skin. In cases in which the primary problem cannot be resolved, or only a partial solution is obtained, these interventions may become long term.
Underpads and Briefs
Underpads and briefs that are designed to absorb moisture and present a quick-drying surface to the skin can be used to decrease wetness (Ranel for the Prediction, 1992). Studies with infants and adults indicated that products designed to absorb moisture and present a quick-drying surface to the skin keep the skin drier and are associated with a significantly lower incidence of skin rashes than cloth products (Campbell, 1987; Seymour, 1987; Stein, 1982; Zimmerer, 1986).
It is important to note how the product is designed and not whether it is disposable or reusable. Reusable products made of fabric that absorb moisture and present a quick-drying interface with the skin are available and appear to be effective (Silberberg, 1977; Williams, 1981). Additionally, incontinent adults or infants who use these products still may develop perineal dermatitis; however, the condition is not likely to be as severe as when cloth products are used. No matter what product is used, nurses should establish a written schedule for checking patients who are likely to be exposed to moisture so that wet linens, underpads, briefs, or dressings can be replaced frequently. No product can eliminate the need for increased vigilance on the part of the caregiver.
Unlike briefs, incontinence underpads are not a tight impermeable covering. If the perineal dermatitis seen with the use of diapers or briefs is associated with the occlusive nature of these products, it may be possible to decrease the incidence of dermatitis by alternating the use of briefs with incontinence underpads. When patients who are lying on absorbent incontinence pads are turned, the area of skin that was in contact with the pad is now exposed to the air, which should allow moisture to evaporate and dry the surface of the skin. Reserving briefs for times when the patient is being walked, transported to another department or sitting in a chair, and using underpads when the patient is in bed may help decrease the incidence or severity of perineal dermatitis.
Experience in treating soldiers with warm-water immersion foot syndrome suggests that allowing the skin to dry between episodes of exposure to water prevents the acute inflammatory dermatitis that characterizes this syndrome (Willis, 1973). Randomized, controlled, clinical trials comparing the incidence and severity of dermatitis in patients managed with briefs and those managed with underpads would help to evaluate whether this strategy of alternating products would decrease the incidence of perineal dermatitis.
Using briefs that limit the amount of skin covered with a moisture impermeable covering also may help reduce the severity of perineal dermatitis (Hu, 1989, 1990). One strategy for preventing perineal dermatitis is placing bed linen between the patient and the absorbent underpad. Following this practice, however, hinders the design of the underpads by reducing them to products for protecting the bed linens rather than the patient's skin.
The briefs and underpads that are recommended are those designed to absorb moisture and present a quickdrying surface to the skin. When these products are used, however, the patient still must be checked and changed frequently. Keeping the skin dry is the best way to minimize the incidence and severity of perineal dermatitis associated with moisture.
Topical Skin Barriers
Topical skin barriers also can be used to keep the skin dry and free from irritants. With these products, success is likely to be linked to how they are formulated and the type of irritants contained within the source of moisture. Over the years, nurses have used a variety of ointments and pastes to protect skin exposed to urine, stool, and wound drainage. The extent to which these products will function as a barrier between these sources of moisture and the skin will be influenced by the degree to which these products are hydrophobic. If an ointment or paste is easily removed with the water used to cleanse an area, then it is not likely to provide a durable barrier to urine, liquid stool, or drainage - all which contain large amounts of water.
When powder is added to ointments, pastes are created. Pastes are thicker and more durable than ointments alone (Spraker, 1991). Indeed, when nurses use pastes as skin barriers, they often complain because the paste is difficult to remove from the skin. Given that the paste is intended to act as a physical barrier for the skin, as long as an intact layer of paste is covering the underlying skin, nurses need not struggle to remove the paste each time they wash the area. When working with zinc oxide paste, nurses should use mineral oil rather than water to remove paste that no longer forms a protective layer.
Liquid plastic skin sealants also can be applied to the skin as a physical barrier. Before applying any ointment, paste, or skin sealant to a patient's skin, nurses must read the manufacturer's information thoroughly for directions on how to apply the product and any precautions or contraindications. It also is important to note whether the product is limited to use on intact skin.
Figure 3. Red satellite papules at the periphery of the central area of erythema.
Although in theory it would appear that topical skin barriers that repel moisture should protect the skin from the detrimental effects of wetness and irritants, there is little research on these products in clinical populations. Investigators who studied a sample of 28 infants reported a lower incidence of diaper dermatitis in infants whose skin was treated with a water-repellent petroleum-based ointment than infants whose skin was cleansed only with water (Kramer, 1988). Although the infants were randomly assigned to the two groups, the results were not tested for statistical significance.
Investigators who examined the extent to which a liquid copolymer skin barrier was instrumental in protecting or healing skin exposed to ostomy effluent or diarrhea reported data that suggests a beneficial outcome (Snipes, 1981, 1983). Because the samples were small and the results were not tested for statistical significance, however, the results must be viewed cautiously. To help select skin barriers with some degree of confidence, nurses need randomized, controlled clinical trials that vary not only the formulation of the products compared, but also the source of moisture (eg, urine, stool, wound drainage).
Protecting the skin of patients who are incontinent of liquid stool or have a wound or tube that is draining or leaking effluent from the gastrointestinal tract is a special challenge. In these situations nurses are faced with protecting the skin not only from moisture, but also from numerous irritating chemicals. When considering interventions, select one that you are fairly confident will work. The chemical irritants contained in effluents from the stomach and small intestine can denude the skin quickly, leaving weeping skin - to which few products will adhere.
Figure 4. Covering a large area surrounding a wound with a water-type skin barrier can protect the underlying skin.
If ointments, pastes, or skin sealants are selected to protect the perineal skin of patients who are incontinent of liquid stool, nurses should select products that will withstand high volumes of water. Should breakdown occur despite efforts to protect the skin, several investigators have reported therapeutic effects for ointments containing the bile-binding resin cholestyramine (Moller, 1987; Rodriquez, 1976). Clinical trials to examine whether these ointments have a role in preventing skin breakdown would be a useful next step.
Fecal Incontinence Collectors and Wafer-Type Skin Barriers
When liquid stool is a problem, an alternative to topical skin barriers is a fecal incontinence collector. Several companies manufacture these devices, which consist of a self-adhering skin barrier and a drainable pouch (Myers, 1986). When using fecal incontinence collectors, establish a routine schedule for changing them so that they are likely to be replaced before, rather than after, they leak. They tend to be technique sensitive, so it is important to follow the manufacturer's directions and have adequate help in controlling the effluent and positioning the device.
Although pouching may be the preferred technique for managing draining wounds and leaking tubes, a lack of resources, knowledge, and experience may make it a difficult solution to implement in some situations. In these situations, covering a large area surrounding the wound with a wafertype skin barrier can protect the underlying skin (Figure 4). With this approach, nurses continue to use conventional dressings to absorb the drainage while the wafer keeps the wet dressings from lying on the skin.
This technique also can be used to protect the healthy margins of a pressure ulcer or wound that is being packed with moist gauze. Although these types of wounds do not produce the caustic drainage associated with enterocutaneous fistulas, they do produce a serious drainage that, when combined with the solution being used to dress the wound, can macerate the surrounding healthy skin. The wafer acts as an effective physical barrier between the wet dressings and the skin. To prevent the wafer from macerating the skin, replace it when the edges of the wafer that are next to the wound become moist.
Reduction of Friction
As mentioned earlier, patients whose skin is damp also are likely to be exposed to injury caused by friction. Because it takes less friction to abrade or blister damp skin, nurses must intervene to decrease friction. Interventions to decrease friction will be important when the skin of the back and buttocks is damp. Patients who are perspiring, are incontinent, or have drainage that will accumulate in these areas fall into this category.
Patients who have difficulty lifting their lower torso to prevent dragging the skin across bed linens but who can use their arms would benefit from a trapeze. This group of patients, as well as those who are totally dependent upon nurses to reposition them, will benefit from lifting devices, such as bed linens. In addition to recommending lifters to decrease friction, the Panel for the Prediction and Prevention of Pressure Ulcers in Adults (1992) recommended the use of lubricants and protective films /dressings to decrease skin injury due to friction.
Finally, the panel recommends maintaining the head of the bed at the lowest elevation (consistent with the patients' medical condition and other restrictions) and limiting the amount of time the head of the bed is elevated. This recommendation is especially important for patients who do not have the strength to maintain an upright position in bed. Such patients slide down in bed when the head of the bed is elevated - a maneuver that not only increases friction, but also creates a shearing force that can injure soft tissue.
When caring for patients whose skin is likely to be moist, nurses must include strategies to keep the skin dry and free of irritants in their plan of care. Although there are many products that claim to protect the skin from the injurious effects of moisture, research supporting these claims is limited.
In light of this paucity of scientifically sound data, nurses must be inquisitive and vigilant when selecting products. They must ask manufacturers and distributors to provide evidence from randomized controlled, clinical trials to support their claims. When using these products, nurses must establish a schedule that will ensure that they assess the patient's skin routinely and systematically. By carefully monitoring the skin, nurses can quickly ascertain whether an approach is working and initiate additional or alternative strategies when necessary.
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