Skin Care In Bladder And Bowel Dysfunction Wendy Ness Colorectal Nurse Specialist

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1 Skin Care In Bladder And Bowel Dysfunction Wendy Ness Colorectal Nurse Specialist

2 Function Of The Skin Healthy skin serves several purposes it protects the internal organs physically, chemically and biologically Protects against physical and mechanical damage Prevents the diffusion of water in or out of the body Detects external stimuli through touch pressure and pain Skin damage can happen easily in different ways resulting in a wound Protective function lost

3 The Skin

4 What Happens To The Skin In The Older Person Changes in ageing skin thinning of epidermis, reduced vascularity and elasticity, dehydration, decreased sensation Impedes skins primary function of protection Rapidly weakened if the individual experiences bouts or faecal or urinary incontinence even worse if both The normal PH of the skin is 5.5 which is slightly acidic and known as the acid mantle PH of skin changes to be more alkaline and ideal for bacterial proliferation, resulting in dermatitis tissue excoriation and possible infection The interaction of urine and faeces decreases the PH of the skin and increases permeability of the skin

5 What Happens To The Skin In The Older Person Patients cared for in nursing home (1) 29% incontinent of urine and 65% doubly incontinent If urine or faeces is left in contact with the skin for a prolonged length of time it will lead to incontinence associated dermatitis (IAD) and possible skin breakdown A patient with diarrhoea who has faecal incontinence is more likely to have skin breakdown because of the digestive enzymes in the faeces Like having a chemical burn 1) Bale et al (2004) the benefits of implementing a new skin care protocol in nursing homes, Journal of tissue viability 14, (2) 44-50

6 What Happens To The Skin Is Similar To A Burn

7 Major Concern Incontinence has a number of detrimental effects upon skin integrity. It is linked to an increased risk of developing pressure ulcers. It is also a major cause of other types of skin damage particularly IAD NICE /RCN, 2005; Le Vievre, 2002

8 What Is Incontinence Associated Dermatitis (IAD)? IAD is defined as an inflammation of the skin that occurs when urine or faeces comes into contact with perineal skin Skin damage from IAD the injury starts on the skins surface and works inward. Located where the skin lays in contact with urine or faeces Early injury is bright red, then bright red and weepy When skin is broken can sometimes be mistaken for a grade one pressure ulcer

9 IAD Risk Factors Urinary incontinence Faecal leakage Prolonged skin exposure to urine / faeces Compromised mobility Enforced bed rest Physical disability Chronic health problem Co morbidities Disposable containment product misuse Inappropriate skin cleansing product use Nursing care not being evidence-based.

10 Risk Assessment Important to carryout a risk assessment on each individual and consider these risk factors Good assessment to establish cause of incontinence whether it be urinary or faecal Treat the incontinence where possible Nurses have a role to play in assessing and preventing skin breakdown (1) Correct diagnosis between IAD and Pressure ulcer is imperative to get the right treatment 1) Flynn, D. and Williams, S. (2011) Barrier creams for skin breakdown nursing and residential care vol 13 no 11 Suppl

11 Which Of These Is IAD And Which Is A Pressure Sore?

12 Management Tips Often managed passively (pads) End of life care aim is to improve QOL Treating the incontinence which may be causing the skin problem Frequency of defecation and abrasion from harsh frequent wiping will damage the skin Don't over use dry toilet paper as abrasive, may cause skin damage Not ideal to use soap and water as dries skin making damage even more likely Careful when drying as may cause friction Foam cleansers better as clean, protect and moisturise Don t over apply barrier creams

13 Management Tips For those patients with incontinence, protecting skin is just as important as cleansing and moisturizing If faecal soiling is a frequent problem the use of cleansing, moisture impregnated cloths, such as those made by Clinell or an all in one cleanser such as Proshield can reduce the risk of IAD (1) Proshield Plus can be used directly on IAD thus reducing the associated pain and discomfort. 1) End of life Document, 2011

14 The Aim Of Good Skin Care The over-riding aim of skincare is to clean, protect and moisturise the patient s skin thus avoiding skin breakdown. IAD Prevention Remove irritants, preserve skin s moisture barrier protect from subsequent exposure IADTreatment Remove irritant, preserve moisture barrier and protect from additional exposure while skin heals Cleanse, moisturize and protect using products with active ingredients to promote healing

15 The Aim Of Good Skin Care When frequent bathing necessary, current evidence suggests. Gentle cleansing: No scrubbing (1,2) Select a cleanser with ph close to acid mantle of skin Select product that minimizes potential irritants, scents, etc. Avoid towel drying when possible, consider no rinse alternatives for frequent bathing (2) 1. Gray M et al. Journal of Wound, Ostomy & Continence Nursing 2007; 34(2): Voegeli D. Journal of Wound, Ostomy & Continence Nursing 2008; 35(1).

16 Kings College Hospital Study Carried Out By Ruth Baadjies And Sue Foxley In 2009 Compared 2 products for treating IAD Firstly Shield barrier cloths = 25p each 2.50 a day if 10 cloths used Secondly Tena 3:1 wash cream = 7p 35p a day (average use x5) Both products are used to clean, moisturise and protect the patients skin following an incontinent episode

17 Kings College Hospital Study Carried Out By Ruth Baadjies And Sue Foxley In 2009 The study suggested that Where patients are at risk of developing IAD Tena 3:1 product should be used to maintain skin integrity. In those patients compromised by their medical condition and where the Tena product has proved ineffective Shield should be used to cleanse, moisturise and protect the skin from any breakdown which could lead to pressure ulcer development.

18 Other Products For Skin Cleansing And Protection

19 Containment For Urinary Incontinence Consider ways of containment to reduce the risk of urine coming in contact with skin More options for men If all other options considered a correctly fitted pad could be used

20 Reasons For Insertion Of Catheterisation At End Of Life Risk assessment needs to be carried out to ensure that advantages out ways disadvantages of catheterisation Management or prevention of wound damage, for example sacral pressure ulcers and or fungating wounds or soreness of the anus, perineum, vulva and penis Painful physical movements due to frequent changes of bed linen caused by incontinence Pain or difficulty for female patients getting in and out of bed to use a commode When the use of sheaths or a bottle for a men is not an option Never be used for nursing convenience!! End of Life Document, 2011

21 Containment For Faecal Incontinence If individual has passive faecal incontinence consider a Coloplast anal plug If faecally incontinent of type 7 stool and patient is bed bound it may be appropriate to use a faecal collection system. Available are Flexiseal (Convetac), Actiflow (Hollister) and Dignicare (Bard) Also available is Hollister faecal collector

22 Conclusion Good assessment to establish the cause of the incontinence and treat if possible The elderly more at risk of skin breakdown Important to carry out a risk assessment on each individual and consider the risk factors Aim of skincare is to clean, protect and moisturise the patient s skin thus avoiding skin breakdown and improve quality of life Never catheterise for nursing convenience!

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