Practice development Innovations Practice development How to... References 8. Driver DS. Perineal dermatitis in critical care patients. Critical Care Nurse 2007; 27(4): 42–46
9. Gray M. Preventing and managing perineal dermatitis: a shared goal for wound and continence care. J Wound Ostomy Continence Nurs 2004; 31(1 suppl): S2–9
10 Fleur M. World Wide Wounds. Available at:
http://www.worldwidewounds.com/2009/September/ Flour/
vulnerable-skin-1.html (accessed 12 September, 2012)
11.
Beeckman D, Schoonhoven I, Verhage S, Heyneman A, Defloor T. Prevention and treatment of incontinence-associated dermatitis: literature review. 2009; J Adv Nurs 65(6): 1141–154
12. Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care 2002; 15(4):170–78
13. Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers hospital complications and disease severity: imact on hospital costs and length of stay. 1999; Adv Wound Care 12(1): 22–30
14. Ousey K. The identification and management of moisture lesions. Wounds UK 2012; 8(2 Suppl): S3
15. Bianchi J. Top tips on avoidance of incontinence-associated dermatitis. In: The Identification and Management of Moisture Lesions. Wounds UK 2012; 8(2 Suppl): S6-8
16. Bianchi J, Johnstone A. Moisture-related Skin Excoriation: a retrospective review of assessment and management across 5 Glasgow hospitals. 2011; EPUAP meeting, Oporto
THE CONSEQUENCES OF FAECAL INCONTINENCE The physiological changes that occur due to faecal incontinence are thought to be a result of an increase in the pH of the skin. The normal pH of the skin varies from person to person but, in the normal state, the skin is acidic with a mean pH of 5.5–5.9. Changes in the external pH of the skin affect the fatty acid content of the skin and impair the barrier formed by the skin cells[9,10]
.
Normal stool is alkaline, with a typical pH of 7.0–7.5. Exposure to faeces contributes to an abnormally high skin pH. In addition to damaging the barrier function of the skin cells, an increased pH encourages bacterial colonisation, most often by Candida albicans and Staphylococcus from the perineal skin and the gastrointestinal tract[11]
. Overgrowth
of these or other microorganisms can lead to skin irritation or infection, which can further weaken the skin's defence mechanisms. The excess moisture also makes the skin
susceptible to mechanical damage, friction and shearing forces[9]
. In liquid stool, lipidolytic and
proteolytic enzymes also damage the skin by breaking down the epidermis[11]
.
Excoriation: erythema (redness) skin not broken. Caused by irritant fluids, urine and/or sweat. Skin is shiny and wet in appearance. Most commonly occurs in skin folds, natal cleft and peri-anal area. Likely to have irregular edges
Moisture lesions: superficial lesions caused by irritant fluids, ie urine, faeces and wound exudate. Found in skin folds natal cleft, and the peri-anal area — may present as diffuse spots, kissing ulcers and are likely to have irregular edges. Superficial or partial thickness skin loss is common and infection may be present. The wound may also be macerated. White colouration may be due to fungal infection and green areas could be caused by bacterial infection
Pressure ulcers: tissue damage caused by pressure, shearing and friction or a combination of these factors. Damage can be superficial or deep, often present over bony prominences. Tissue types may vary from erythema to black necrosis. Edges are more distinct than in moisture lesions
Combined lesions: one or more wounds/skin lesions caused by a combination of pressure, shear, friction and moisture. May occur over bony prominences and there may also be skin damage in the perineal area, the natal cleft and between the thighs. The lesions may be partial or full thickness in appearance and may range from non-blanching erythema to necrotic and sloughy wounds. These wounds are at risk of infection so may appear green in colour depending on the types of bacteria present
Table 2. Different lesion types caused by faecal incontinence (taken from Bianchi, J. 'The use of faecal management systems to combat skin damage'. Wounds UK 8[2] Supplement).
In addition to the local damage caused by faecal incontinence, there is an increased risk of systemic infection such as urinary tract infection and microbial skin infection[12]
.
Pressure ulcer development is associated with increased morbidity and mortality. Other consequences include a higher risk of nosocomial infections and other hospital complications, and increased length of stay[13] Moisture lesions, moisture ulcers, perineal
.
dermatitis, diaper dermatitis and IAD all refer to skin damage caused by excessive moisture[14]
of faecal incontinence. Nix[7]
and are potential consequences suggested that IAD develops in one-
third of patients who are faecally incontinent — this correlates with a study carried out by Bliss et al[1]
who found that, in a study
population of elderly residents in nursing homes, all of the patients who developed IAD also had faecal incontinence. Bliss et al[1]
defined the different levels of IAD as: n Mild: light redness, intact skin, slight discomfort
n Moderate: medium redness, presence of skin peeling or flaking, small areas of shallow broken skin or small blisters
n Severe: dark or intense redness, presence of rash, deeper skin peeling or erosion, large blisters or weeping skin and pain.
16 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012
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