Pressure ulcers must have pressure and/or shear present. Pressure ulcers normally occur over a bony prominence and may be full or partial thickness. A Stage I pressure ulcer will be unbroken reddened skin that is nonblanchable. A Stage II pressure ulcer is a partial-thickness wound involving the epidermis. Unlike moisture-associated skin damage, a pressure ulcer usually has distinct edges. In full-thickness pressure ulcers, necrotic tissue may be present. Although moisture may also be present, the underlying cause of the wound is pressure-related skin damage.17
Treatment starts with identification of the moisture source. Test to determine the type of urinary incontinence or if there are underlying causes of fecal incontinence such as Clostridium difficile or tube feeding–related diarrhea. Note the time of day the incontinence occurs and monitor that for patterns. Foods such as caffeine, carbonated beverages, spicy foods, or acidic foods such as citrus products and fruit juices may trigger bladder spasms that lead to incontinence. Some incontinence cases can be treated surgically or with medication. Remember that medication may cause constipation, which can worsen the incontinence by straining at stool or because the rectal vault is full of hard stool that is pressing on the bladder. The incidence of fecal incontinence is increased if stool is liquid. Fiber added to food may help, or active yogurt cultures, such as lactobacillus, may be given.18 If the diarrhea is related to tube feeding, the dietitian should be consulted to adjust the rate or type of formula (Table 4).
Next, the skin needs to be protected from exposure to further irritants. Skin should be cleansed gently using a no-rinse skin cleanser with a pH similar to normal skin.2,12 These types of cleansers are as effective as soap and water in removing both Gram-negative and Gram-positive bacteria from the skin.
After cleansing, a barrier ointment or a no-sting barrier film should be applied to protect the skin from the constant moisture. 10,20–22 Products should be applied according to the manufacturer’s directions or after each incontinent episode and cleaning. Keeping the patient clean and dry, changing underpads or briefs after soiling, and using barrier creams or ointments are usually all that is required for moisture-associated dermatitis to resolve.23 It is helpful to keep the individual off the affected area to promote dryness and reduce potential friction. If a secondary infection is present, appropriate treatment should be implemented. In some cases, diversion devices, such as Foley or condom catheters, or fecal containment devices are used to keep the skin dry. However, use of these devices also has risks, including bladder infection, ulceration of the penis, or anal mucosal erosion. Be sure to monitor for such complications.
Older adult skin is particularly susceptible to moisture-related damage. Skin becomes drier, thinner, and less elastic. The epidermis and dermis are no longer attached, and friction-related tearing becomes more problematic. Bladder changes also occur. The bladder empties less effectively and becomes less elastic. Women may have weakened pelvic floor muscles from childbearing. Consequently, the combination of physiologic changes in skin and bladder function, multiple medical comorbidities experienced during aging, and age-related mobility problems leads to an increased risk of incontinence and moisture-related skin damage.24
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. Last accessed February 24, 2012.
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