The identification and management of moisture lesions - Wounds UK SUPPLEMENT - Stop the Pressure
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SUPPLEMENT
Wounds UK
The identification
and management
of moisture lesions
Karen Ousey, Janice Bianchi,
Pauline Beldon, Trudie Young
®
In association with
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CONTENTS
Wounds UK © Wounds UK Limited,
A Schofield Healthcare
Wound digest s4 Media Company
A look at the latest research on moisture lesions and IAD
All rights reserved. No part of this
publication may be reproduced,
Top tips on avoidance of incontinence-associated dermatitis s6 stored in a retrieval system or
Janice Bianchi transmitted in any form or by any
means, electronic, mechanical,
The causes and clinical presentation of moisture lesions s9 photocopying, recording or
Trudie Young otherwise without prior permission
from the publishers.
The use of faecal management systems to combat skin damage s11
The views expressed in this
Janice Bianchi
document are those of the authors
and do not necessarily reflect those
The latest advances in skin protection s17 of Wounds UK. Any products
Pauline Beldon referred to should only be used as
recommended by manufacturers’
data sheets.
To reference this document, cite the
following:
Wounds UK (2012) Moisture Lesions
Supplement. Wounds UK, London
INTRODUCTION
M
oisture lesions, moisture ulcers, perineal dermatitis, diaper dermatitis and incontinence associated dermatitis (IAD) all
refer to skin damage caused by excessive moisture. Yet there is often confusion between pressure ulcers and this kind of
lesion. Distinguishing between the two is of clinical importance since prevention and treatment are quite different for
each (Defloor et al, 2005a). Due to the location of moisture lesions, they are often mistaken for pressure ulcers (Defloor et al, 2005b),
however, skin damage as a result of excessive moisture is defined as being associated with incontinence and not pressure or shear
(Defloor et al, 2005a), although moisture can contribute to the formation of pressure ulcers (EPUAP and NPUAP, 2009).
Gray et al (2012) defined IAD as erythema and oedema of the surface of the skin, sometimes accompanied by bullae with serous
exudate, erosion, or secondary cutaneous infection. The risks of developing pressure ulcers or other problems with the skin increase
where there is faecal and/or urinary incontinence, often resulting in maceration of the skin and friction (Cutting and White, 2002). This
leads to the protective barrier of the skin being breached, allowing enzymatic attack (Wishin et al, 2008). It is of paramount importance
that clinicians are able to correctly identify this and implement strategies for the prevention and/or treatment of these lesions.
The significance of correct identification and classification has never been more central, with many trusts identifying that moisture
lesions are often incorrectly categorised as category 2 pressure ulcers. There are a range of tools that can be used for evaluation of IAD,
including the Perineal Assessment Tool (Nix, 2002); the Peri-rectal Skin Assessment Tool (Storer-Brown, 1993); IAD Skin Condition
Assessment Tool (Kennedy et al, 1996); and the IAD and its severity instrument (Borchert et al, 2010).
Proactive protection of the skin from maceration should be a priority, with regular skin inspection and cleansing and accurate recordings of
skin assessment and frequency of incontinence episodes (Ousey and Gillibrand, 2010). A structured skin cleansing regimen that does not deplete
the skin of moisture should be implemented. Nix (2006) recommended the use of as humectants, such as glycerine, esters, lanolin, cetyl or stearyl
alcohol, and mineral oils, as they prevent the loss of natural moisture from the skin. Treatment goals recommended by Gray et al (2012) include
protection of the skin from further exposure to irritants, establishment of a healing environment, and eradication any cutaneous infection.
Karen Ousey, June 2012
Borchert K et al (2010) The incontinence-associated dermatitis and its severity instrument: development and validation . J Wound Ostomy Continence Nurs 37 (5): 527-
535; Cooper P (2002) Incontinence induced pressure ulcers. Nurs Residential Care 5(4): 16-21; Cutting KF, White RJ (2002) Maceration of the skin: 1: the nature and
causes of skin maceration. J Wound Care 11(7): 275–8; Defloor T et al (2005a) Pressure ulcer classification differentation between pressure ulcers and moisture lesions.
Available at: http://www.epuap.org/archived_reviews/EPUAP_Rev6.3.pdf; Defloor T et al (2005b) The effect of a pressure-reducing mattress on turning intervals in
geriatric patients at risk of developing pressure ulcers. Int J of Nurs Stud 42(1): 37–46; EPUAP/NPUAP (2009) Prevention and treatment of pressure ulcers: quick reference
guide. Available: http://www.epuap.org/archived_reviews/EPUAP_Rev6.3.pdf; Gray M et al (2012) Incontinence-associated dermatitis: A comprehensive review and
update. JWOCN. January/February; Kennedy K et al (1996) Cost-effectiveness Evaluation of a New Alcohol-free, Film-Forming Incontinence Skin Protectant . White paper.
St Paul, MN: 3M Healthcare; Nix DH (2002) Validity and reliability of the Perineal Assessment Tool . Ostomy Wound Manage 48 (2 ): 43–49 . Nix D (2006) Skin matters:
Prevention and treatment of perineal skin breakdown due to incontinence. Ost Wound Man 52(4): 26–8; Ousey K, Gillibrand W (2010) Using faecal collectors to reduce
wound contamination. Wounds UK 6(1): 86–91; Storer-Brown D (1993) Perineal dermatitis: can we measure it? Ostomy Wound Manage 39(7): 28–31. Voegeli, D
(2008) The effect of washing and drying practices on skin barrier function. J Wound Ostomy Continence Nurs 35(1): 84–90; Wishin J et al (2008) Emerging options for the
management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs 35(1): 104–10.
Wounds UK 2012, Vol 8, No 2 S3
RESEARCH UPDATE
SELECTED PAPERS OF
INTEREST
Wound digest
1. Prevalence, management and
clinical challenges associated with
In each Wounds UK supplement, the digest summarises,
acute faecal incontinence in the ICU in turn, recent key papers in the areas of leg ulcers,
and critical care settings: The FIRST™ moisture lesions, pressure ulcers and complex wounds.
cross-sectional descriptive survey.
2. Efficacy of an improved absorbent
1
pad on incontinence-associated
dermatitis in older women: cluster Prevalence, management and underestimated problem, which is
randomized controlled trial. clinical challenges associated associated with a high use of nursing time.
with acute faecal incontinence
in the ICU and critical care settings: Bayón García C, Binks R, De Luca E, Dierkes C,
The FIRST™ cross-sectional Franci A, Gallart E, Niederalt G, Wyncoll D (2012)
descriptive survey Prevalence, management and clinical challenges
associated with acute faecal incontinence in the ICU
Credits: Hyunseok Michael Knight; Fields of View; Cherry Cyanide, on Flickr.
Readability and critical care settings: The FIRST™ cross-sectional
Relevance to daily practice descriptive survey. Intensive Crit Care Nurs. 2012
Novelty factor Feb 29. [Epub ahead of print]
2
This paper sought to investigate
and evaluate the prevalence, awareness Efficacy of an improved absorbent
and management of acute faecal pad on incontinence-associated
incontinence with diarrhoea (AFId) in dermatitis in older women: cluster
the intensive care unit. randomized controlled trial
The design incorporated a cross-
sectional descriptive survey of intensive Readability
care units across Europe, including Relevance to daily practice
Germany, Italy, Spain and the United Novelty factor
Kingdom.
Nine-hundred and sixty two This study examined the efficacy of
questionnaires were completed by nurses an absorbent pad against incontinence-
(60%), physicians (29%) and pharmacists associated dermatitis (IAD).
or purchasing personnel (11%). Most older adults with urinary
The estimated prevalence of AFId incontinence use absorbent pads. The
ranged from 9–37% of patients on the perineal skin region is a key risk area for
specific day the survey was performed. the development of IAD.
The majority of respondents reported A cluster randomized controlled
a low-to-moderate awareness of the design compared two absorbent pads
problems of AFId. in female inpatients aged 65 years
Patients with AFId often and over. Healing rates of IAD and
demonstrated compromised variables of skin barrier function, such
skin integrity, including perineal as skin pH and skin moisture, were
dermatitis, moisture lesions or sacral compared.
pressure ulcers. Thirteen patients (43.3%) from
Reducing the risk of cross-infection the test absorbent pad group and four
and ensuring skin integrity were rated patients (13.3%) from the usual absorbent
as the most important clinical priorities. pad group recovered completely from
To compile the digest a Medline search Forty-nine percent of respondents said IAD. Moreover, the test absorbent pad
was performed for the three months there was no hospital protocol or guideline group healed significantly faster than the
ending in June, 2012 using the search for AFId management in their area. usual absorbent pad group (p = 0.009).
term ‘moisture lesions’. Papers have been There was a poor awareness of how
chosen on the basis of their potential long nurses spent managing AFId — 60% Sugama J, Sanada H, Shigeta Y, Nakagami G, Konya
interest to practitioners involved in of respondents estimated that 10–20 C (2012) Efficacy of an improved absorbent pad on
day-to-day wound care. The papers minutes with two to three clinicians are incontinence-associated dermatitis in older women:
were rated according to readability, necessary for each AFId episode. cluster randomized controlled trial. BMC Geriatr.
applicability to daily practice and The report concluded that AFId 2012 May 29;12(1):22. [Epub ahead of print]
novelty factor. in the critical care setting may be an
244 Wounds
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Visit the new wOunds uK MOisture lesiOns e-acadeMy Wounds UK has released its latest innovation in online learning with the new moisture lesions e-academy. Featuring practical step-by-step guidance on diagnosing and managing moisture lesions, the new e-academy provides a vital resource for tissue viability nurses, nursing home staff, link nurses and anyone else who comes into contact with moisture lesions on a regular basis. www.e-academy.wounds-uk.com
HOW TO
Top tips on avoidance
KEY POINTS
of incontinence-
It is essential that when
presented with a patient who
is incontinent, clinicians take a
associated dermatitis
full history and carry out a full
assessment.
This article looks at methods for avoiding the
In some cases, timely and
development of incontinence-associated dermatitis
appropriate skin cleansing and (IAD) and provides some useful tips for practice.
protection can prevent and
heal incontinence-associated
dermatitis (IAD).
INTRODUCTION periwound maceration (skin breakdown as
The aim of skin protection A systematic approach to assessment a result of exposure to wound exudate) and
products is to isolate exposed of IAD helps with early recognition of pressure ulcers.
skin from harmful or irritant whether a patient is at increased risk of
substances. complications. It also helps healthcare Gray (2007) observed that IAD associated
practitioners to identify when prevention with urinary incontinence tends to occur
strategies should be put into place. This in the skin folds and the labia majora in
section describes the important elements women or the scrotum in men, whereas
of both assessment and prevention IAD associated with faecal incontinence
strategies which should be employed to tends to originate in the perianal area. In
avoid IAD. severe cases, the erythema may extend
to the lower abdomen and sacrum
(Beldon, 2008). Candidiasis is a common
1 RISK ASSESSMENT complication of IAD and will manifest itself
It is essential that when presented with a as a macropapular rash with satellite lesions.
patient who is incontinent, clinicians take
a full history and carry out a full assessment
to ensure that an effective treatment plan 3 GRADE THE LEVEL
can be implemented (Bardsley, 2008). OF DAMAGE
Clinicians should also consider whether any When reviewing the language clinicians
of the procedures that will be carried out, or use to describe the degree of IAD, Bianchi
prescribed drugs, have the potential to cause and Johnstone (2011) found there was no
loose bowel movements. consistency. In order to help clinicians to
accurately grade the degree of skin damage
and suggest management strategies, the
2 ROUTINE SKIN ASSESSMENT National Association of Tissue Viability
If the risk assessment has indicated that Nurses Scotland (NATVNS) developed
the patient is high risk of developing IAD, an excoriation grading tool, which includes
the skin should be inspected routinely. clinical images, grades the level of excoriation
IAD is characterised by inflammation of and offers management advice This tool may
the surface of the skin with erythema, also help to encourage a consistent approach
oedema and in some cases bullae in care of patients with IAD.
(vesicles) containing clear exudates. In
severe cases, erosion of the epidermis can 4 CLEANSING ROUTINE
also be seen. Kennedy and Lutz (1996) In some cases, timely and appropriate
noted that the erythema may be patchy or skin cleansing and protection can prevent
consolidated (Figure 1) . and heal IAD. Soap and water should be
avoided. Soap is made up of a mixture of
Observation of the distribution of alkalis and fatty acid. The alkalis in soap are
JANICE BIANCHI these symptoms will help clinicians to thought have the potential to raise the pH of
Medical Education Specialist at JB differentiate from other types of tissue the skin damaging the acid mantel (Beldon,
Med Ed Ltd; Honorary Lecturer at damage, including intertrigo (inflamed skin 2008). Perineal skin cleansers are the best
University of Glasgow folds caused by exposure to perspiration, choice for individuals with IAD. They come
friction and bacterial or fungal bioburden), in different formats including emulsions,
244 Wounds
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foams and sprays. They combine detergents including:
and surfactant ingredients to loosen and Acrylate polymer-based liquid film
remove dirt of irritants. Many are also Petroleum ointment (43%)
pH balanced and/or contain moisturising Zinc oxide in 1% dimethicone (12%)
agents, which restore or preserve optimal Petroleum ointment (98%).
barrier function.
With all of the regimens, Bliss et al (2005)
5 SKIN PROTECTION found that the incidence of IAD was low
The aim of skin protection products is and there was no significant difference in the
to isolate exposed skin from harmful or development of IAD between them. These
irritant substances. In the case of IAD, results suggest the use of a defined skin care
skin protectors isolate the skin from regimen using quality skin care products will
excessive moisture, urine or faeces. prevent the occurrence of IAD.
Liquid barrier films and moisture barrier
creams or ointments are frequently used If the IAD does not improve using these Figure 1: Erythema may be patchy or
products. Bliss (2005) compared four skin measures, the recommendations for consolidated.
care regimens in the prevention of IAD, napkin dermatitis in babies and children
Table 1
Common causes of incontinence
Possible causes of faecal incontinence
Anal sphincter damage or weakness
Obstectric trauma to anal sphincter muscles; surgery e.g. latertal sphincterotomy,
haemorroidectomy, anal stretch
Neurological conditions
Spinal chord injury; multiple sclerosis; Parkinson’s disease; spina bifida; stroke
Impaction with overflow
Frail or immobile patient; cognitive impairment, e.g. dementia; immobility/physical
disability
Ano-rectal pathology
Rectal prolapse; congenital abnormalities; anal/recto-vaginal fistula
Diarrhoea/intestinal hurry
Chron’s disease; ulcerative colitis; drugs, e.g. antibiotics
Possible causes of urinary incontinence
Stress incontinence
Pelvic floor muscles damaged or weakened
Urethral sphincter damage
Urge incontinence
Urinary tract infection
Neurological conditions as above
Bladder cancer
Increasing age References
Bladder outlet obstruction/stones Bardsley A (2008) An introduction to faecal in-
Benign prostatic hypertrophy (men) continence. Continence Essentials 1: 110–16
Unknown cause Beldon P (2008) Faecal incontinence and its
impact on wound care. Continence Essentials
Overflow incontinence 1: 22–27
Enlarged prostate gland (men) Bianchi J, Page B, Robertson S (2011) Com-
Bladder stones mon skin conditions in children. In: Bianchi J,
Constipation Page B, Robertson S (eds). Your Dermatology
Surgery to the bowel or spinal cord Pocket Guide: Common Skin Conditions Ex-
plained. NHS Education Scotland: Edinburgh
Weak bladder muscles
Nerve damage Bianchi J, Johnstone A (2011) Moisture-related
skin excoriation: a retrospective review of as-
Some medications sessment and management across five Glasgow
Medications associated with urinary incontinence Hospitals. Oral presentation 14th Annual
Alpha-adrenergic agonists; alpha-adrenergic blockers; angiotensin-converting enzymes; European Pressure Ulcer Advisory Panel
meeting. Oporto, Portugal
diuretics; cholinesterase inhibitors; some medications with anticholinergic effect;
hormone replacement therapy; opioids; sedatives and hypnotics.
Wounds
Wounds
UK 2012,
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HOW TO
may be an appropriate route to follow. faecal fluid or where the skin is already
Published literature suggests that when damaged by IAD.
napkin dermatitis does not improve
using barrier products, a weak topical Faecal management systems: In cases
steroid such as 1% hydrocortisone cream of severe or high-volume diarrhoea,
or ointment can be applied twice a day IAD and widespread skin breakdown
for 3–5 days. If candidiasis is present, 1% can occur very rapidly. In this instance it
clotrimazole cream is recommended, or may be appropriate to consider the use
a combined hydrocortisone/clotrimazole of a faecal management system (Figure
cream when both dermatitis and 2). These temporary faecal containment
candidiasis are present (Hunter et al, 2002; devices consist of a soft flexible silicone
Bianchi et al, 2011). catheter, which is inserted digitally into
the rectum and held in place by a low
pressure balloon cuff that is inflated
6 TREATMENT AND with saline or water. The catheter is then
Figure 2: A faecal management system MANAGEMENT OF INCONTINENCE attached to a closed-ended collection bag,
in situ. The ultimate goal for any clinician which enables accurate fluid balance to
caring for an individual with urinary be maintained. These appliances are vital
or faecal incontinence is to alleviate if the patient is at risk of dehydration. The
and control bowel/bladder function device can be left in situ for 29 days and
(Cooper, 2011). Causes of incontinence is a cost effective way of managing acute
are numerous and multifactorial (see diarrhoea (Johnstone, 2005). While there
Table 1). A multidisciplinary approach is a paucity of evidence for their use at the
may be required, with the continence present time, if there is a risk of cross-
advisor included in the team of clinicians infection with Clostridium difficile or
involved in planning care. Norovirus, faecal management systems
may reduce risk to other patients due to
their ability to contain faecal matter.
7 CONTAINMENT OF URINE
OR FAECES 8 DOCUMENT FREQUENCY
In individuals where bladder and or bowel OF EPISODES OF INCONTINENCE
control is not possible, there are a range of AND STOOL CONSISTENCY
containment products available. It is important to observe for changes
in frequency of faecal or urinary
Body worn pads: these disposable pads incontinence as this may indicate
come in various sizes depending on the an increase in risk status. Equally if
volume of fluid expected. They are made incontinence is becoming infrequent,
References
of super-absorbent material, which turns the patient may be at less risk of skin
Bliss DZ (2005) An economic evaluation of to a gel when it comes into contact with breakdown. The Bristol stool chart
skin damage prevention regimesamongst
home residentswith incontinence: labor costs. fluid, helping to lock the fluid away from should also be to classify the form of
J Wound Ostomy Continence Nurs 32 (Supp the skin. It is essential to change soiled the faeces.
3): 51 products on a regular basis.
Cooper P (2011) Skin Care: managing the skin 9 EDUCATION OF PATIENTS
of incontinent patients. Wound Essentials 6: Urinary catheters: urinary AND/OR CARERS
69–74
catheterisation is not without risk Education should be based around the
Gray M (2007) Incontinence-related skin and should not be carried out unless use of a structured skin care programme,
damage: essential knowledge. Ostomy Wound
Manage 53: 12: 28–32
there is a sound rationale. In the case including skin cleansers, skin protectors
of uncontrolled urinary incontinence and continence management. It is
Hunter J, Slavin J, Dahl M (2002) Eczema and
dermatitis. In: Hunter J, Slavin J, Dahl M (eds.)
with skin damage, the clinician should important for the clinician to be aware of
Clinical Dermatology. Blackwell Publishing carry out a risk assessment to determine the possible causes of faecal and urinary
Ltd, Oxford whether short-term catheterisation with incontinence. This knowledge will aid
Johnstone A (2005) Evaluating Flexi-Seal® FMS: an indwelling catheter is the best course early identification of risk and timely
a faecal management system. Wounds UK 1: of treatment for the individual. intervention.
3: 110–14
Kennedy KI, Lutz I (1996) Comparing the ef- Anal bags: These disposable CONCLUSION
ficacy and cost effectiveness of three skin pro-
containment bags are applied to the If clinicians adopt the tips described
tectants in the management of incontinence
dermatitis. In: Proceedings of the European peri-anal area. The skin-friendly here they may be able to reduce the
Conference on Advances in Wound Manage- adhesive holds the product in situ. number of patients developing IAD
ment. Amsterdam While they are useful, they may not and the associated pain, discomfort and
be appropriate for high output of embarrassment. Wuk
244 Wounds
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Vol8,12,
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CLINICAL UPDATE
The causes and clinical
presentation of
moisture lesions
Excessive moisture from perspiration, urine, faeces,
wound exudate or a combination of these factors, can
begin to erode the integrity of the skin. The author looks at
References
how the clinician can best identify moisture lesions. Beeckman D, Schoonhoven L, Verhage S,
Heyneman A, Defloor T (2009) Prevention and
treatment of incontinence-associated dermati-
T
he skin provides the body with (Beeckman et al, 2009). In this situation, tis: literature review. J Clin Nurs 65(6): 1141–54
an external protective layer. the skin is at risk of developing a Beldon P (2008) Problems encountered manag-
ing pressure ulceration of the sacrum. Br J
However, this layer is susceptible secondary infection in the injured
Comm Nur 13(Suppl 12): S6–10
to damage and trauma from external epidermis (Beldon, 2008).
Bianchi J, Johnstone A (2011) Moisture-related
elements, one of which is chemical skin excoriation: a retrospective review of as-
damage in the form of excessive moisture Incontinence sessment and management across five Glasgow
from perspiration, urine, faeces, wound Urinary incontinence alone can hospitals . Poster presentation. Harrogate,
exudate, or a combination of these cause moisture damage, however, it is Wounds UK
factors (Cooper et al, 2006; Evans and exacerbated when combined with faecal Cooper P, Clark M, Bale S (2006) Best Practice
Stephen-Haynes, 2007). incontinence (Vogeli, 2010). Initially the Statement: care of the older person’s skin.
Wounds UK, London
skin may be able to maintain its integrity
SKIN DAMAGE against the physical and chemical assault, Defloor T, Schoonhoven L (2004) Inter-rater
reliability of the EPUAP pressure ulcer classifi-
After exposure to excessive moisture, the however, the intensity, duration and cation system using photographs. J Clin Nurs
skin becomes damp, soggy and clammy frequency of exposure to the irritants will 13: 952–59
and eventually saturated. At any point influence the speed of the breakdown Defloor T, Schoonhoven L, Fletcher J, et al
in this trajectory, the skin’s permeability (Nix and Haugen, 2010). (2005) Pressure ulcer classification differentia-
can be breached and it is susceptible tion between pressure ulcers and moisture
lesions. EPUAP Review 6(3) 81-5
to physical damage from friction and Extrinsic factors may exacerbate the
shearing forces (Beeckman et al, 2009). proble, for instance, the side effect of Evans J, Stephen-Haynes J (2007) Identification
of superficial pressure ulcers. J Wound Care
some medications includes diarrhoea 16(2): 54-56
The outer layer of the epidermis consists (Nix and Haugen, 2010).
of 70% protein, 15% lipids and 15%
water and is attacked by lipidolytic and Microclimate
proteolytic enzymes. These are found The role of the microclimate is being
in the highest quantity in liquid faeces increasingly recognised as an influence on
(Beeckman et al, 2009). the humidity of the skin. Regulation of the
microclimate, which includes controlling
The enzymes break down and destroy the temperature and moisture of the skin,
the intercellular ‘cement’ and disrupt are seen as pivotal in protecting the skin
the physical construction of the stratum from external damage (Langoen, 2010).
corneum, resulting in erosion of the
epidermis and its subsequent barrier MOISTURE LESIONS
capabilities. There are many causes of and many
ways to describe moisture-induced skin
This may be further compounded by damage, however, the most common term
an increase in the normal acidic pH of is moisture lesion.
the skin (4–6.8) due to the alkalinity
of urine and faeces (Cooper et al, Incontinence-associated dermatitis is one
2006). The increase in the pH of the cause of moisture lesions (Langoen, 2010). TRUDIE YOUNG
skin encourages bacterial colonisation, One literature review of incontinence- Lecturer, Bangor University (Hon);
most often with Candida albicans associated dermatitis identified 18 Tissue Viability Nurse, Aneurin Bevan
and Staphylococcus from the perineal different terms for the condition Health Board (Hon)
skin and the gastrointestinal tract (Beeckman et al, 2009).
Wounds UK 2012, Vol 8, No 2 S9
CLINICAL UPDATE
Gray et al (2007) defines a moisture IDENTIFICATION
References lesion as ‘reactive responses of the skin Tools have been devised to assist with
Gray M, Bliss D, Doughty D, Ermer-Seltum J, to chronic exposure to urine and faecal the identification of moisture lesions,for
Kennedy-Evans K, Palmer M (2007) Incon-
matter, which could be observed as instance there is a skin excoriation
tinence-associated dermatitis: a consensus. J
Wound Ostomy Continence Nurs 34: 45–54 an inflammation and erythema with grading tool, however, their integration
Kottner J, Halfens R (2010) Moisture lesions:
or without erosion and denudation’. into clinical practice has not been fully
interrater agreement and reliability. J Clin Nurs Typically there is loss of the epidermis achieved (Bianchi and Johnstone, 2011).
19: 716–20 and the skin appears macerated, red
Langoen A (2010) Innovations in care of the broken and painful (Cooper et al, 2006; The European Pressure Ulcer Advisory
skin surrounding pressure ulcers. Available at: Gray et al, 2007). Panel (EPUAP) suggest six questions/
http://www.woundsinternational.com/prac- statements to consider when identifying
tice-development/innovations-in-care-of-the-
skin-surrounding-pressure-ulcers (accessed 29
Pressure damage the cause of a lesion:
May, 2012) The link between incontinence and Check the (wound) history in the
Nix D, Haugen V (2010) Prevention and man- pressure damage has already been patient’s record
agement of incontinence-associated dermatitis. established. This is demonstrated Ascertain what measures have been
Drugs Aging 27(6): 491–96 by the inclusion of incontinence in taken/care provided so far
Vogeli D (2010) Moisture-associated skin dam- the majority of pressure ulcer risk What is the skin condition at the
age. Nurs Res Care 12(12): 578–83 assessment tools (Braden — www. different pressure points?
bradenscale.com). In addition, pressure Check whether movement, transfers
ulcers (categories 2 and 3) are most and changes in position may have
commonly confused with moisture caused the lesion
lesions (Defloor and Schoonhoven, If a patient is incontinent, consider
2004). whether the damage is a moisture
lesion or not
Exclude other possible causes (Defloor
Table 1 and Schoonhoven, 2004).
Clinical presentation of moisture lesions and pressure ulcers
Characteristic Moisture lesion Pressure ulcer Along with the questions above, Table
1 can help clinicians identify moisture
Cause Moisture must be present (e.g. Pressure and/or shear must
lesions, however, they do not provide a
shining, wet skin caused by uri- be present
watertight process for reaching the correct
nary incontinence or diarrhoea)
diagnosis (Kottner and Halfens, 2010).
Location May occur over bony If not over bony prominence Also, the prevention and treatment of
prominence then unlikely to be a pressure ulcers and moisture lesions require
Perineum, buttocks, inner thigh, pressure ulcer different clinical interventions, therefore, it
groin Equipment related – under is essential that clinicians can differentiate
Skin folds a device/tube between the two conditions. If confusion
Skin folds (combination) exists, this may result in suboptimal use
Shape Diffuse differential areas/spots Circular wounds of limited resources, such as pressure-
Kissing ulcer Regular shape redistributing equipment and nursing
Anal cleft-linear intervention (Beeckman et al, 2009).
Depth Superficial partial thickness Dependent on category of
skin loss ulcer CONCLUSION
Can enlarge if infection It is important to establish the prevalence
is present of moisture lesions in different care
settings as this will assist in the
Necrosis No necrosis Dependent on category of
development of a strategy and allocation
ulcer
of resources to tackle the problem.
Edge Diffuse and irregular edges Raised edge (chronicity)
Colour of the wound Non uniform redness Erythema In addition, the pathophysiological
bed Pink/white surrounding skin Slough mechanisms that cause moisture lesions
(maceration) Necrosis require further exploration in order for
Peri-anal redness Granulation tissue the exact relationship between cause
Epithelial tissue and effect to be established. Once this
Dressing residue is better understood, it will be possible
Infection to begin providing support in the form
Distribution Confluent or patchy Isolated individual lesions of an unambiguous clinical definition
and a validated observation instrument
Adapted from Defloor et al (2005), Nix and Haugen (2010)
(Beeckman et al, 2009). Wuk
S10 Wounds UK 2012, Vol 8, No 2PRODUCT UPDATE
The use of faecal
management systems to
combat skin damage
Incontinence is a relatively common feature of the
ageing patient, and can present as urinary, faecal or
both. This article examines the different types of skin
damage caused by incontinence, as well as outlining a
new management tool to minimise this risk.
‘The skin normally
provides an
excellent protective
I barrier against
ncontinence-related skin developed by a group of UK experts.
lesions, sometimes referred to as This guide is designed to help clinicians
incontinence-associated dermatitis, identify the levels of moisture damage physical and
(Cooper et al, 2008), are extremely
painful areas of skin damage in which
present, how to manage each level of
damage and also how such damage can
chemical damage’
the chemicals and enzymes present in be prevented.
urine and/or faeces are allowed to erode
the surface of the skin (Beldon, 2008). In This tool will be presented below,
some cases the damage caused is severe however, in order to understand the
and debilitating for the patient. mechanism of incontinence-related skin
injury, it is helpful to first understand the
The skin normally provides an excellent function of the skin.
protective barrier from physical and
chemical damage (Timmons, 2006). FUNCTIONS OF THE SKIN
As people age, the protective barrier of The skin plays a variety of roles in
the skin changes and the loss of elasticity the maintenance of a person’s overall
and appearance of wrinkles can increase health, including:
the skin’s susceptibility to pressure Protection: the skin serves as the
shearing and friction damage, while the body’s main protective barrier,
simultaneous loss of sebum exposes the preventing damage to internal tissues
skin to chemical damage. from physical trauma, ultraviolet
(UV) light, temperature changes,
For patients who are exposed toxins and bacteria (Butcher and
to incontinence, which may be White, 2005)
compounded by pressure shear and Sensation: the nerve endings in the
friction, the skin undergoes a number of skin allow the body to detect pain as
attacks that will undoubtedly result in well as changes in temperature, touch
loss of the superficial skin layers. and pressure
Thermoregulation: the skin allows
The presence of urine and faeces on the the body to respond to changes
skin represents a significant threat to in temperature by constricting or
its integrity and the best way to avoid dilating the blood vessels within it.
problems is to identify the at-risk patient The sweat glands produce sweat,
and act to prevent any damage. Nor is which stays on the skin allowing
this often unseen problem rare — in the body to cool down. When the
2007, Houwing et al estimated the body is cold, the erector pili muscles
prevalence of incontinence-associated contract, raising the hair and trapping
skin lesions in Dutch healthcare warm air next to the skin JANICE BIANCHI
institutions to be 11%. Excretory function: the skin excretes Medical Education Specialist at JB
waste products in sweat, which Med Ed Ltd; Honorary Lecturer at
A clinical guide to incontinence- contains water, urea and albumin. University of Glasgow
related skin damage has recently been Sebum is an oily substance excreted
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2012,
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VolVol No122 245
12,8,No S11PRODUCT UPDATE
by the sebaceous glands, helping to One study in the US found that 48% of
lubricate and protect the skin women aged over 50 had experienced
Metabolism: when UV light is urinary incontinence, 15% suffered
present, the skin produces vitamin from faecal incontinence and 9.4 %
D, which is required for calcium had experienced both (Roberts et al,
absorption 1999). These figures suggest a significant
Non-verbal communication: the skin problem, both in terms of quality of
can convey changes in mood through life for patients, but also in relation to
colour changes, such as blushing. costs for healthcare services. It could,
KEY WORDS therefore, be assumed that incontinence
The acid mantle in the elderly is a significant problem,
Incontinence The pH of the skin normally stands which is set to grow as the numbers of
Skin at between 4.4 and 5.5, which is why elderly patients continue to rise.
Moisture lesions this protective mechanism is known as
Faecal management the acid mantle. This is the protective
layer that is created by the presence
of sebum, which creates a barrier to
chemical damage and also protects ‘The pH of the
against some types of bacteria. The acid skin normally
mantle of the skin provides significant
resistance against dehydration, as well stands at between
as bacterial invasion. 4.4 and 5.5,
Changes in ageing skin which is why
There are a number of changes that this protective
occur in the skin of elderly patients,
which may predispose them to skin mechanism is
damage: known as the acid
Skin becomes drier and sebum
production slows down mantle’
Skin can crack due to dryness, which
makes it more vulnerable
Collagen depletion leaves the skin Faecal incontinence
thinner, there is a loss of elasticity and Faecal incontinence can be acute
the skin becomes more fragile or develop into a chronic problem
Decreased sensory perception due to depending on the underlying pathology.
reduction in nerve fibres can mean Investigations should always be carried
that patients may not feel pain in out to determine the exact cause of
areas exposed to pressure. the problem. Diarrhoea could be due
to infection in the bowel or some form
THE PREVALENCE OF of chronic inflammatory disease, such
INCONTINENCE as Crohn’s disease or ulcerative colitis
References
As people age, the likelihood of (Beldon, 2008). Overflow diarrhoea is
Bardsley A, Binks R, Kiernan M, Beldon P incontinence increases — the bladder also common in the elderly due to bowel
(2007) Management of Faecal Incontinence:
A guideline for the healthcare professional. becomes more irritable, will hold less impaction as a result of constipation.
Continence UK, Aberdeen fluid and may empty less efficiently This should be investigated prior to
Beldon P (2008) Moisture lesions: the effect of (Millard and Moore, 1996). commencing treatment for constipation,
urine and faeces on the skin. Wound Essentials as aperients and enemas should not
3: 82–87 If these natural age-related changes are be given to patients with disease or
Berg RW, Buckingham KW, Stewart RL (1986) also compounded by concurrent illness, infection (Beldon, 2008).
Etiologic factors in diaper dermatitis: the role such as dementia or local surgery, then
of urine. Pediatr Dermatol 3: 102–06
there is a likelihood that incontinence Clostridium difficile is an anaerobic
Butcher M, White R (2005) The structure and may develop (Farage et al, 2007). bacteria that normally lives in the
functions of the skin. In: White R, ed. Skin
Care in Wound Management: Assessment,
large bowel of some healthy patients
Prevention and Treatment. Wounds UK, The prevalence of incontinence in those and is subdued by the action of other
Aberdeen aged over 65 is said to be in the region of commensal bacteria in the bowel.
Cooper P, Gray DG, Russell F (2008) Compar- 7% (Soffer and Hull, 2000), although this However, in certain situations, such as
ing Tena Wash Mousse with Clinisan Foam figure is likely to be an underestimate as the presence of antibiotics, the numbers
Cleanser: the results of a comparative study, the condition is often under-reported due of commensal bacteria are reduced,
Wounds UK 4(3): 12–21
to the attached stigma (Beldon, 2008). which leads to the proliferation of C.
S12 Wounds UK 2012, Vol 8, No 2difficile bacteria. The toxins released with a towel after they have showered.
by this virulent bacteria create an Farage et al (2007) suggest that once the
1
inflammatory response within the bowel skin integrity is breached, both bacteria
causing damage to the mucosa, which and fungal infection may occur. Faecal
leads to diarrhoea (Bardsley et al, 2007). material contains a large number of
bacteria that are not normally in contact
The effects of incontinence on the skin with the skin, however, when present
Roberts et al (1999) suggest that in the vicinity of a moisture lesion,
‘Skin damage
incontinence may exist as a transient are in danger of causing an infection
problem, possibly as a result of illness, (Whitman, 1991).
but if allowed to progress beyond six
For example, Candida albicans is a
caused by
incontinence
months it can become chronic and more
difficult to resolve. common fungus, which thrives in the
environment created within moisture is variously
referred to as
The structure of the skin and the lesions.
presence of the acid mantle are key
to providing protection from external Farage et al (2007) also highlight the moisture lesions
or incontinence
factors, such as urinary or faecal role of occlusion when poor quality
incontinence. In patients with urinary, incontinence pads or pants are used.
faecal or combined incontinence, the
skin is exposed to the harmful effects of
Occlusion is likely to exacerbate
the impact of incontinence on the
dermatitis’
the chemicals and toxins within the fluid, skin’s barrier function and encourage
which may then begin to disturb the maceration.
protective function of the skin.
The role of shearing and friction in the
Farage et al (2007) describe the effects formation of moisture lesions is unclear,
of incontinence as chemical irritation, however, the predominance of lesions
mechanical injury and increased on the buttock area and the natal cleft
susceptibility to infection. would suggest that these sites are prone
to friction, which may combine to create
When urine breaks down it forms further tissue damage.
ammonia, which is an alkaline substance,
this increasing the pH of the skin, which Once the skin has been breached, the lesion
results in disruption of the acid mantle. that forms may cover a large area and begin
This effect can be compounded if there with mild erythema, which, if left untreated,
is also faeces present, which contains may deteriorate into blistering and in time
References
proteolytic enzymes. These enzymes are erode the skin’s surface. Skin damage
Farage MA, Miller KW, Berardesca E, Maibach
reactivated by the increase in pH on the caused by incontinence is variously referred
HI (2007) Incontinence in the aged: contact
skin, which leads to further irritation and to as moisture lesions or incontinence- dermatitis and other cutaneous consequences,
skin breakdown (Berg, 1986). associated dermatitis. Contact Dermatitis 57: 211–17
Houwing RH, Arends JW, Canninga-van Dijk
The presence of the excessive moisture MOISTURE LESIONS/ MR, Koopman E, Haalboom JRE (2007) Is the
that accompanies urinary and faecal INCONTINENCE- distinction between superficial pressure ulcers
incontinence leads to the skin becoming ASSOCIATED DERMATITIS and moisture lesions justifiable? A clinical-
pathological study. SKINmed 6: 113–17
over-hydrated or macerated, this also Moisture lesions and incontinence-
Mathison R, Bianchi J, Bateman S, Harker J,
makes the skin more susceptible to associated dermatitis are both terms used Johnstone J (2011) Skin Integrity: A clinical
bacterial infiltration (Beldon, 2008). to describe areas of skin damage caused guide to ‘best practice’. Wounds UK Harrogate
Once the skin is over-hydrated it is also by urinary and/or faecal incontinence. Poster Presentation. Available at: http://www.
more prone to physical damage — twice Skin damage in the perineal area and the wounds-uk.com/case-series/harrogate-poster-
presentations-2011 (accessed 22 May, 2012)
as much friction energy is required buttocks can cause the patient significant
to damage dry skin, compared with skin discomfort (Farage et al, 2007). Millard RJ, Moore KH (1996) Urinary incon-
tinence: the Cinderella subject. Med J Austr
that has been exposed to moisture for 165: 124–25
prolonged periods (Sivamani et Moisture lesions are often associated [AQ13: Please supply Diagram 1
Morris C (2011) Flexi-Seal faecal management
al, 2006). with increased age and decreased - Static
system Stiffness
for the preventionsIndex formula]
and management of
mobility, as well as the presence of moisture lesions. Wounds UK 7(2): 88–93
In order to reduce skin damage, those incontinence. Roberts RO, Jacobson SJ, Reilly WT, Pember-
involved in caring for patients with ton JH Leiber MM, Talley NJ (1999) Prevalence
incontinence should be aware of the In addition to these factors, the patient’s of combined faecal and urinary incontinence:
a community based study. J Am Geriatr Soc
need to avoid excessive rubbing of the overall health, cognitive impairment
47: 837–41
skin, for instance, when drying a person and concurrent medications may
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2012,
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VolVol No122 245
12,8,No S13PRODUCT UPDATE
also play a part in the development The key differences between the types of
KEY WORDS of moisture lesions/incontinence damage are shown in Figure 2.
dermatitis. The pattern of skin damage
Barrier films
is reflective of the flow of urine and
Barrier creams
Incontinence pads
faeces around the perineal area and often MANAGEMENT OF
Faecal management systems
appears like a superficial burn. INCONTINENCE AND
MOISTURE LESIONS
Once superficial damage occurs, Manageing the skin of patients with
bacteria from the stool can colonise incontinence begins with regular skin
the skin and increase the inflammation inspections. Without this, there is a risk
present, increasing the size and depth of that skin damage may occur or existing
the lesion. skin damage may deteriorate.
A new clinical tool to aid assessment Any skin inspection should include all
of moisture lesions or incontinence the areas that can be affected by urine
dermatitis and faeces — the perineal area, the natal
Assessment of skin lesions is a key cleft, in between the thighs, any skin
consideration if treatment and folds and the buttocks.
management protocols are to be
employed effectively. Using the appropriate skin cleanser is
another important step in managing
Wounds on the sacrum are often the skin of the incontinent patient.
classified as pressure ulcers regardless Cleansers with an acidic pH, which do
of the cause of the lesion. not require rinsing off the skin, will
help to maintain the acid mantle and
Similarly, moisture lesions may be prevent further damage (Cooper et al,
mistaken for pressure damage due 2008). Avoiding the use of soap and
water is also considered to be helpful,
as soap is alkaline and can further
‘Managing the skin
disturb the acid mantle.
of incontinence Foam cleansers are available and these
patients begins
assist in skin cleansing by breaking down
the active components within the urine
with regular and faeces, further preventing skin
skin inspections.
damage. The pH-balanced formulation of
these products also helps to maintain the
Without this, there slightly acidic pH of the skin (Cooper et
is a risk that skin
al, 2008).
damage may occur’ The skin should be cleansed after each
episode of loose stool, using non-rinse
skin cleansers and soft wipes, which will
help to prevent excessive friction on the
to the position and the type of tissue skin (Beldon, 2008; Cooper et al, 2008).
damage present (Morris, 2011).
References When possible, ‘air drying’ of the skin is
Sivamani RK, Wu G, Maibach H I, Gitis NV It is also important for clinicians to preferable and avoids rubbing the area
(2006) Tribological studies on skin: measure-
be able to recognise when lesions with towels, which can cause friction
ment of the coefficient of friction. In: Serup
J, Jemec GBE, Grove GL (eds). Handbook of may be caused by a combination of and damage to the epidermis (Farage et
Non-Invasive Methods and the Skin. 2nd edi- incontinence and pressure. al, 2007).
tion. Boca Raton, Taylor and Francis: 215–24
Soffer E, Hull T (2000) Faecal incontinence: A group of UK clinicians have developed Barrier creams can also be used to help
a practical approach to evaluation and treat- a tool that can be used to help identify the form a protective layer on the skin
ment. Am J Gastroenterol 95(8): 1873–79
type of skin damage present (Mathison et between episodes of incontinence,
Timmons JP (2006) Skin physiology and al, 2011) (see Figure 1). Using this chart although it is important to avoid build-
wound healing. Wounds Essentials 1: 8–17
can help clinicians to identify the type and up of these products and they should be
Whitman DH (1991) Intra-Abdominal level of tissue damage present and choose rinsed off at each episode of incontinence
Infections: Pathophysiology and Treatment.
Hoechst, Frankfurt, Germany the correct skin care regimen to best (Beldon, 2008). Liquid barrier films, which
manage the patient. contain a solvent, that dries on the skin,
S14 Wounds UK 2012, Vol 8, No 2are also available, although they cannot be
used on broken skin. SKIN INTEGRITY: A CLINICAL GUIDE TO ‘BEST PRACTICE’
RACHEL MATHISON, Medical Affairs Manager, ConvaTec Rachel.mathison@convatec.com
Co-Authors: Janice Bianchi, Independent Medical Education Specialist and honorary lecturer Glasgow University janice.bianchi@gmail.com
Sharon Bateman, Lead Nurse Wound Care, South Tees Hosp NHS Foundation Trust, The James Cook University Hospital sharon.bateman@stees.nhs.uk
Judy Harker, Nurse Consultant Tissue Viability, The Royal Oldham Hospital judy.harker@pat.nhs.uk,
The use of appropriate incontinence Alison Johnstone, Tissue Viability Specialist, Glasgow Royal infirmary alisonjohnstone@ggc.scot.nhs.uk
pads is also an important part of Introduction: Maintenance of good skin integrity is everyone’s business. To distinguish the difference between a pressure
ulcer (PU) and other forms of skin damage can be extremely challenging for all Clinicians. Wounds to the sacrum are often
classified as a PU without any consideration to other causes. There are other reasons why wounds occur in this area which are
Method: A focus group meeting was sponsored by ConvaTec to explore current clinical challenges in the identification and
management of skin damage caused by moisture, pressure, shear, friction, &/or a combination of these factors. Results: A
table to illustrate differences between Excoriation [E], Moisture Lesion [M], Pressure Ulcer [P], Combined Lesion [C] has been
often related to moisture, either from wound exudate or more significantly unresolved or mismanaged urinary or faecal developed [Fig: 1] to educate and encourage ‘Best Practice’ Skin Integrity management. Conclusion: The overall objective
managing patients with moisture- incontinence. Accurate diagnosis is imperative as prevention & treatment strategies differ largely and the patient consequences
of the outcome are extremely important. Bianchi & Johnstone (2011)1 indicated that despite guidelines and grading tools being
available to staff across NHS GGC, uptake was poor, only 36% of patients who should have been assessed for use of a Faecal
was to develop a clinical differential diagnosis tool which is simple & easy to use to promote good skin integrity and assist in
the prevention of excoriation and timely intervention of moisture induced skin damage management. Clinicians often wait until
excoriation is very severe, sometimes with bleeding before optimal intervention is considered incurring increased costs and
related skin damage (Farage et al, 2007). Management System actually were. Although this percentage is low, it is not unusual. In a literature review literature, Gethin
et al (2011)2 also found use of guidelines for patient care was limited to between 17- 54% .Gethin also indicated dissemination
should be multifaceted, and clinicians want a simple tool. With this in mind a group of lead Clinicians in collaboration with
patient associated problems. A recommendation made by the group is if the associated moisture problem is due to faecal
incontinence (FI) to assess the suitability of the patient and then consider use of a faecal management system eg: Flexi-seal.
It is widely known FI can be debilitating and intensely embarrassing to those affected and in many cases it has a profound
ConvaTec decided to develop a ‘simple easy to use guide’ to reinforce and build on the latest EPUAP documentation3 and impact on the patients’ quality of life4. Early intervention is essential to prevent further deterioration and induce increased
Superabsorbent, breathable pads should assist in management and the differential diagnosis between healthy skin, excoriation, moisture lesions and pressure damage.
Excoriation [E] Moisture Lesion [M]
management costs for all.
Pressure Ulcer [P] Combined Lesion [C]
be used as these minimise moisture Fig: 1
contact with the skin, locking away
incontinence and avoiding occlusion
of the skin, which may exacerbate the Definition Erythema (redness), no broken skin
Superficial lesions caused by irritant fluids i.e: urine, faeces,
wound exudate.
Area of localised damage to the skin & underlying tissue caused
by pressure, shear, friction, &/or a combination of these factors.
One or more wounds with elements of damage to the skin &
underlying tissue caused by pressure, shear, friction, &/or a
combination of factors plus moisture
Irritant fluids / Moisture is present, eg urine, faeces, wound
problem.
Causes Irritant fluids / Moisture is present, eg: urine; shining wet
exudate
Pressure, shear, friction, &/or a combination Pressure, shear, friction, &/or a combination plus moisture
Location Skin folds, anal cleft, peri-anal area Skin folds, anal cleft (sharp edge), peri-anal area Bony prominences Bony prominences & peri wound area (i.e: peri-anal area)
One spot, circular or regular or irregular wound edges combined
Shape Diffuse. Irregular shape Diffuse superficial spots, ‘kissing’ ulcers, irregular wound edges One spot, circular or regular wound edges
with diffuse superficial spots
Partial – full thickness [from Category / Grade 2– 4] Generally
Depth No broken skin Superficial – partial thickness skin loss (infection)
deeper than moisture wounds
Partial – full thickness [from Category / Grade 2–4]
The use of a faecal management system Necrosis None No necrosis or eschar Necrosis likely Necrosis likely
Distinct edges over bony prominence, irregular margins to
Edges Diffuse or irregular edges Diffuse edges and irregular lesions Distinct edges. Clear demarcation
satellite lesions
to prevent incontinence dermatitis
Red but not uniformly distributed, pink or white skin Red but not uniformly distributed, pink or white surrounding skin Non-blanchable erythema, necrosis and slough. Red, yellow, Non-blanchable erythema, necrosis and slough. Red, yellow,
Colour [macerated], red with white [fungal infection] [macerated], red with white [fungal infection], green [infected] green [infected], black. green [infected], black.
Complete assessment: Complete assessment: Complete wound assessment: Complete wound assessment:
Review Bristol Stool Chart* Review Bristol Stool Chart* Refer to EPUAP 2009 Pressure Ulcer Definitions* Review Bristol Stool Chart*
Faecal incontinence is a problem that
Clean skin with pH balanced cleanser Clean skin with pH balanced cleanser Refer to local wound care formulary guidelines Refer to EPUAP 2009 Pressure Ulcer Definitions*
Manage moisture: Use skin protectors: Eg: durable barrier Manage Moisture: Use skin protectors: Eg: durable barrier cream Ensure all assessments are completed and pressure relieving Refer to local wound care formulary guidelines plus consider
cream or barrier film spray. or barrier film spray. equipment is provided. management of surrounding skin as per Moisture Lesion [M]
Control urinary & faecal incontinence: use of pads. Control urinary & faecal incontinence: use of pads. guidance. Ensure all assessments are completed and pressure
can severely affect the dignity of a patient
Clinical recommendations: Clinical recommendations: relieving equipment is provided.
• If Bristol stool 6 or 7 & prolonged (ie: more than 3 • If Bristol stool 6 or 7 & prolonged (ie: more than 3 episodes):
Management episodes): Intervene early - consider use of faecal Intervene early - consider use of faecal management system
management system eg: Flexi-seal eg: Flexi-seal
and is a great source of embarrassment • If patients medical status &/or medication is known to
cause diarrhoea: Intervene early - consider use of faecal
management system eg: Flexi-seal
• If severe excoriation is present due to faecal incontinence:
• If patients medical status &/or medication is known to cause
diarrhoea: Intervene early - consider use of faecal
management system eg: Flexi-seal
• If severe excoriation is present due to faecal incontinence:
and stigma. Coupled with the consider use of faecal management system eg: Flexi-seal consider use of faecal management system eg: Flexi-seal
If damage is due to wound fluid refer to local wound care
formulary guidelines for management of exudate.
psychological ramifications are the
Report & Recording In line with local Trust policy In line with local Trust policy In line with local Trust policy In line with local Trust policy
This ‘simple easy to use’ clinical management tool is to be produced and disseminated by ConvaTec. All images sourced from ConvaTec slide library. ConvaTec wish to acknowledge the support and extend their thanks to the lead Clinicians for their time and input into this documentation.
References: 1.Bianchi J& Johnstone A (2011) Moisture related skin excoriation: a retrospective review of assessment and management across 5 Glasgow Hospitals. EPUAP Oporto. 2.Gethin G, McIntosh C, Cundell J (2011) The dissemination of wound management guidelines: a national survey.
damaging effects of faeces on the skin,
JWC 20:7;340-345 3.European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Treatment of Pressure Ulcers: Quick Reference Guide. Washington D C; 2009. 4. Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in adults. Lancet 2004;364(9434):621-32 . /TM indicates a trade mark of ConvaTec Inc. ConvaTec Ltd an authorised user.
5.* Bristol Stool Chart: Lewis SJ, Heaton KW (1997). "Stool form scale as a useful guide to intestinal transit time". Scand. J. Gastroenterol. 32 (9): 920–4. The presentation costs of this poster were sponsored by ConvaTec Inc.
© 2011 ConvaTec Inc.
which if left untreated will result in the Figure 1: Tool to be used for identifying skin damage.
development of moisture lesions.
Reducing wound infection
Flexi-Seal® Faecal Management System Reducing cross-infection in cases of
(ConvaTec) has been designed to be infective diarrhoea
inserted into the rectum, allowing Improving patients’ quality of life.
faeces to be drained through a tube and
collected in a drainable bag.
The system is designed as a temporary
containment device, which can be used
to treat immobile patients with liquid or ‘Faecal
semi-liquid stools (Morris, 2011). incontinence is a
In addition to protecting the patient’s problem that can
skin from breakdown, Flexi-Seal severely affect the
can help to divert faeces away from
wounds, which would normally become dignity of a patient
contaminated. and is a great source
The Flexi-Seal system is designed with of embarrassment
soft silicone material and is retained and stigma’
in the rectum using a water balloon,
providing a gentle method of retention.
The tubing also has a sampling port from
which faecal specimens can be removed CONCLUSION
safely and without risk of contamination. For patients with urinary and faecal
incontinence, the risk of developing skin
Morris (2011) discusses the outcomes damage is one that clinicians should be
of a service audit and subsequent aware of.
evaluation of the use of the system,
listing its benefits as: Moisture lesions or incontinence
Reducing risk of moisture lesion dermatitis is painful and traumatic for
development patients, many of whom are likely to be
Reducing nursing costs involved in suffering from concurrent illnesses.
cleaning incontinent patients
Reducing cost of cleansers, wipes and Regular skin inspection and preventative
barrier creams treatments should be employed to
Wounds UK 2012, Vol 8, No 2 S15You can also read
