Assess for the presence of fungal infection and yeast. The literature often clumps together true dermatophyte fungus and yeast as fungus, but clinically they are distinct. True fungus (dermatophytes) has a red active margin, and yeast (Candida) is associated with satellite papules and pustules. For Candida, look for an area with a confluent red center and the presence of satellite lesions (Figure 4). Research indicates that fungus occurs in persons with IAD. Campbell et al22 report fungal presence in 32% (12/38) of patients with IAD, whereas Gray and Giulano23 report that 14.8% (169/1,140) of patients with IAD had a fungal rash.
The maintenance of clean, dry skin is a fundamental principle in skin care. There is wide acceptance for recommendations in the literature supporting the move from cleansing the skin with soap and water51 and phasing out wash basins that present an infection control hazard.52 Surfactants lower the surface tension and act as detergents to remove debris from the skin. Skin should be cleansed with a pH-balanced cleanser1 to maintain the acid mantle. A pH-balanced cleanser reduces skin irritation and dryness, reducing the risk of impaired skin integrity.1,2 Despite expert opinion, many laypersons and professionals alike are unfamiliar with this practice recommendation and rationale. Consequently, those with urinary and fecal incontinence (as well as those caring for them) routinely endorse skin care that is tradition and assumption based rather than evidence based, that is, washing with harsh, deodorant soaps in an attempt to kill bacteria and rid the skin of odors. This practice is known to elevate the pH of the skin, making it more susceptible to bacterial and fungal overgrowth.
Soaps and cleansers with numerous ingredients, such as preservatives, fragrances, and dyes, increase the potential for skin sensitivities and reactions. Selecting products with fewer ingredients may improve skin integrity for vulnerable populations.
Fortunately, advancements in technology continue to be translated into newer products that are available for patient use “Older” body-worn products intended to contain urinary or fecal incontinence are not the same as the new products that are now available. With advances in science, clinicians may need to unlearn previous beliefs about absorbent products.55
Skin assessments and characteristics should provide guidance and help clinicians when determining the care plan for prevention and healing of IAD-damaged skin. There are three basic components to the plan of care: cleansing (described previously), moisturizing, and protecting the skin. Products needed to achieve this care may consist of these three components individually or as products that combine two or three of these components in one product. Products with fewer ingredients (dyes, fragrances, preservatives) may be an option to avoid allergies. Therefore, it is imperative that clinicians know the composition of the products they use for skin care. Some studies support a single-step intervention (where cleanser, moisturizer, and skin protectants are incorporated into a single product such as a soft washcloth) for efficiency and staff adherence to the skin care regimen.56,58
There is little to guide the care provider in terms of frequency of application for incontinence care products; most manufactures direct the caregiver to reapply products following each episode of incontinence. Newer, long-lasting barriers such as those in the cyanoacrylate class are believed to maintain their barrier function after repeated contact with urine, feces, and dual incontinence and the subsequent cleansing of the skin for several days.64
More study is needed in this area, but if the claims can be substantiated, some of the burden of caregiving would be alleviated. There is evidence to support that adherence to a structured skin care regimen using products that cleanse, moisturize, and protect in combination with timely incontinence care using soft cloths reduces the incidence of IAD.20
In late 2008, a large Midwest academic medical center initiated a newly defined skin care regimen. The purpose was to standardize incontinence and skin care throughout the hospital for adult and pediatric populations. This initiative involved several new products that were introduced simultaneously to aid in the prevention of IAD, but this case study will focus only on skin care; the other products are beyond the scope of this article.
The program included transitioning to a standardized one-step product that cleansed, moisturized, and protected the skin. Prior to this defined skin regimen, traditional soap and water and a one-step spray cleanser were available for staff to use to cleanse patients with incontinence. After introduction of the new product, there continued to be variability in skin cleansing technique and product use. Some staff continued to use soap and water, whereas others would use the prepackaged moistened cloths meant for bathing. It became apparent that a defined, standardized skin regimen was necessary to improve patient care.
As the defined regimen was standardized, the product manufacturer representatives provided education to all shifts. This education was provided over a 3- to 4-day period in an effort to roll out the new program and standard of practice to all staff simultaneously.
As with the introduction of any new product or process, there were some barriers to change that required repeated education to all nursing staff, including nursing assistants. Skin care champions were an integral part of maintaining the change in practice at the forefront of daily care. A “Save Our Skin” education program was offered twice a year for both nurses and nursing assistants. Informational flyers were distributed frequently to the units. Information about the skin care products was included in the unit’s tool kits for easy access. The same information is available on the skin care committee’s intranet site. Most recently, online competency presentations on skin care have been developed and implemented for annual review by all inpatient nursing staff.
As the defined skin care regimen was being initiated, a new electronic medical record was launched. The wound, ostomy, and continence nursing team worked with the information technology department to develop documentation on IAD prevention and treatment. This documentation comprised a portion of the safety interventions that were linked to the Braden subscale scores. If the patient was identified as at risk within the moisture subscale, the IAD documentation was automatically populated as a visual cue to initiate prevention strategies. Currently, the electronic medical record is undergoing optimization to more effectively document MASD and IAD. Further, the wound, ostomy, and continence nurses developed flowsheet documentation within the electronic medical record called a navigator that enables them to quantify the number of patients they assess and treat with IAD.
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