art & science tissue viability supplement Management of tissue excoriation in older patients with urinary or faecal incontinence

Copson D (2006) Management of tissue excoriation in older patients with urinary or faecal incontinence. Nursing Standard. 21, 7, 57-66. Date of acceptance: August 21 2006.

The epidermal layer is the rough outer surface Summary that consists of many layers of epithelial celis. As This article discusses good skin care in relation to the management new epithelial cells are made the old ones die and of incontinence. It outlines the structure and functions of the skin slough (iff the skin, providing an impermeable yet and describes how the skin changes as we age. It examines how renewable barrier. The epidermis is maintained incontinence can damage the skin and provides an overview of the by diffusion as nutrients contained in interstitial current management methods that are used to prevent tissue tissue fluid pass through the dermal blood vessels. excoriation. It also suggests an effective alternative that could be This process supplies the epidermis with essential used if previous strategies have failed and the skin begins vitamins, minerals and oxygen for regeneration. to breakdown, that is, the use of a silver regimen. The underlying dermal layer is vascular connective tissue that receives one third ofthe Author body's circulating blood volume (Flanagan and Dale Copson is tissue viability nurse specialist, Nottingham Culieyl996). University Hospitals NHS Trust, Nottingham- The subcutis, often referred to as subcutaneous Email: [email protected] tissue, provides support for the dermis and consists of adipose (fat) tissue, connective tissue Keywords and blood vessels (Gawkrodger 1997, Graham- Older patients; Skin care; Tissue viability Brown and Bourke 1998). These keywords are based on the subject headings from the British Healthy skin serves several purposes: it Nursing Index. This article has been subject to double-blind review. protects the internal organs chemically, physically For related articles and author guidelines visit our online archive at and biologically (Stepheii-Haynesand Gibson www.nursmg-standard.co.uk and search using the keywords. 2005) (Box 1). Skin secretions and melanin provide chemical protection. A plethora of commensal bacteria and yeasts cover the skin's THE SKIN is the largest body organ and one ofthe surface; the acidity ofthe skin's secretions reduces most important (Torcora and Anagnostakos 1990, tbeir proliferation and controls possible Gawkrodger 1997). It is an outer protective overgrowth. It has also been suggested that covering that is usually unbroken. It has a surface sebum (an oily substance secreted by the area of approximately l.Sin'nnd weighs sebaceous glands) contaitis chemicals that can approximately 3kg. It hosts a variety of appendages destroy some bacteria. Melanin is a chemical such as blood vessels, nerves., swear glands, pigmentthat protects vulnerable tissue from sebaceous (oil) glands and sensory receptors, over-exposure tothe sun's harmful ultraviolet makingir a complex and multifunctional organ. rays (Graham-Brown and Bourke 1998). The The skin varies in its thickness depending on epidermis is hard, wbich means that the skin also the region of the body; it is thinner over the protects against physical and mechanical damage eyelids (0.6mm) and thicker (3mm or more) on such as abrasions or accidental injury. It also the back, palms and soles {Gawkrodger 1997, prevents the diffusion of water and/or water- Stephen-Haynes and Gibson 2003). It consists of soluble compounds (electrolytes and proteins), three separate layers, the epidermis, dermis and thus safeguarding both their loss out of and entry subcutis (Figure I). These distinct layers are into the body (Mairis 1992). attached to each other, but arc segregated by an The skin controls the body's temperature undulating or wavy borderline known as the Rete through a process called thermoregulation ridge (Powell and Soon 2002). (Tortora and Anagnostakos 1990). For example,

NURSING STANDARD October 25 :: vol 21 no 7 :: 2006 57 Tbe skin plays a pivotal role in tbe syntbesis of art & science tissue viability supplement vitamin D. Epidermal cells contain molecules of cbolesterol, which can be irradiated by ultraviolet ligbt and converted to vitamin D when there is a decrease in the external (Tortora and Anagnostakos 1990). Vitamin D is temperature and the skin becomes cold, the carried in the derma! vessels to other parts of tbe dermal vessels constrict keeping; blood closer to body and plays a precursory role in calcium thebody'score. We may Starr to shake to metabolism, since calcium cannot be absorbed generate heat energy and experience 'goose witbout tbis vitamin. bumps'; these are caused by the erector pili The skin allows us to detect external stimuli muscles contracting, forcing tbe bairsto stand on through touch, prL'ssurc and pain. The skin end to provide an insulatinglayerof air attbe contains numerous nerve endings and tactile surface of the skin. These responses are an receptors. If activated, the receptors send attempt to conserve body beat and maintain a impulses to the brain to evaluate whetber a tactile safe body temperature {Toole and Toole 1991). response is required (Clark 1993). Forexample, Alternatively, when the external temperature if we were to toucb an extremely bot object, tbe rises, tbe dermal blood vessels dilate and our tactile response from the brain would be to appearance may become flushed as blood passes instantaneously remove the part of tbe body in closer to the surface ofthe skin. The swear glands contact with tbe heat source to prevent skin may increase their secretory activity, resulting in damage. increased perspiration (sweating). The arrector In summary, the skin is a metabolically active pili muscles relax, causing the hairs to lie fiat. A organ. Unlike most other organs in tbe body, its cooling effect is obtained when sweat evaporates cells are constantly dying and being replaced off the surface of the skin, thus preventing us tbrougbout life, itconsists of tissues structurally from overheating (Clark 1993). joined together to perform specific tasks. Tortora and Anagnostakos (1990) note tbat Maintaining skin integrity is a complex removal of waste products is made easier by tbe process and one tbat is often taken for granted skin. Although the majority of nitrogen- until damage occurs. Skin damage can bappen containing waste Is expelled from tbe body as easily in many different ways, and whatever tbe urine, small amounts of urea, uric acid and cause, the end result is often a wound. When ammonia are excreted from the body in sweat. wounds occur tbe protective function of tbe skin

FIGURE 1 Structure of the

Sweat duct Hair shaft Arrector pili muscle Stratum corneum {horny layer)

Stratum granulosum (granular cell layer)

Stratum spinosum (prickle cell layer)

Stratum basale {basal cell layer)

Cutaneous circulation

Nerve fibres

Sweat giand

Sebaceous gland

Hair follicle

58 October 25 :: vol 21 no 7:: 2006 NURSING STANDARD art & science tissue viability supplement FIGURE 2 Severe excoriation as a result of urinary and faecal incontinence is breached. It is therefore importanr to close the defect as quickly as possible, thereby preventing infection and iillowing normal skin function to occur (Timmons 2006). Skin and ageing There are a number of factors that may aftect skin function (Holloway and Jones 2005), all of which may be exacerbated by ageing. As we get older the skin undergoes many structural changes, which may make it susceptible to disease and damage. Such changes include (Desai 1997): • Thinning of the epidermis. • Reduced vascularity. 29 per cent of residents were incontuient of urine, 65 per cent were doubly incontinent and 6 per y Reduced elasticity. cetit were catheterised. Little evidence exists of • Dehydration due to loss of water contetit. the prevalence of incontinence in the acute setting (Lyder 1997, Hughes2002). Skincareof • Decreased sensation. incontinent patients is a significatit challenge for • Reduced sebum production. practitioners (Cooper 2000). Continuousorprotonged exposure of the skin Alt of these changes have the potential to impede to urine and/or faeces can result in loss of barrier the skin's primary function of protection. function and epithelial breakdown. This is due Furthermore, this protective function can be to rhe skin becoming too moist and fragile rapidly weakened if the individual experiences (macerated) and changes in its pH (Gray?/J/ bouts of faecal and/or urinary incontinence. 2002).ThepHof healthy skin is usually between 4.0 and 5..5 (Cooperand Gray 2001), making it Incontinence and its effect on skin slightly acidic and inhibitingthe growth of bacteria (Anthony 1993}.The mixture of urine Involuntary loss of control ofthe bladder, bowels and faeceson the skin alters the pH, making it or both, more often referred to as incontinence more alkaline and ideal for bacterial (Clooper and Gray 2001), is a condition that proliferation (Neander 1990). The prolonged mainly affects older patients (Department of effects of this can result in local dermatitis, tissue Health (DH) 2000). It has been suggested that excoriation (Figure 2), irritation and/or pain, an faecd! incontinence may affect 1 per cent of increased risk of pressure ulceration and possible adults in their own home and one in four in infection (Rcrge/*?/1986, Barbenelefd/1997, nursingand residential accommodation (DH Cooper 2000). 2000). Recent data .suggest chat .50 percent of nursing home residents in Britain and Northern Management of compromised skin Ireland have urinary incontinence (Durrant and Snape 2003). Bale etal (2004), in a study of older The first and most common method of managing patients cared for in a nursing home, found that the skin of incontinent patients is with soap, warm water, a flannel or soft wipe and towel to dry. It is still not known what effect water temperature has on the integrity of chc skin Main functions of the skin {Voegeli 2005). For the patient who has • Protection occasional incontinence this method may be acceptable. However, the frequency of washing • Immunity will be increased ifthe patient is continuously • Excretion wet and/or soiled. For this reason practitioners should be aware of the potential detrimental • Temperature regulation effects that some soaps may have on the skin. • Reception of stimuli Most soaps are known to have a drying effect • Synthesis of vitamin D because they decrease the natural sebum content of the epidermis (Cork 1997). They may also (Tortora and Anagnostakos 1990) leaveresidueson the skin and if they are

60 October 25 :: vol 21 no 7 :: 2006 NURSING STANDARD these situations is 'bow often should Cavilon® be art & science tissue viability supplement applied?' Faecal collectors are useful in tbese situations, however, not every patient is suitable for or perfumed there is rhe possibility of chemical willing to bave these devices fitted. For this reason irritarion, which may lead to skin breakdown Nottingham University Hospitals NHS Trust bas {Wort/.man l99KKirsnerandFroelich 1998}. adopted an alternative approach to managing Friction damage from repeatedly drying the skin skin excoriation caused by incontinence. after cleansing may also reduce the integrity of the epithelium, thus exacerbating the problem An alternative approach to managing {Huh etallQQl). Therefore, if soap is to be used excoriation to cleanse the skin of an incontinent patient, a mild, pH-balanced and non-scented product When asked to describe the feeling of tissue should be used, for example, baby soap or excoriation to tbe tissue viability nurse, many shampoo. older patients describe it as 'an agonising burning Foam cleansers are another popular product sensation', 'dreading tbe thought of being advocated in healthcare settings (Cooper 2000), cleanedagain','Ican't bear to be touched'and '1 Cooper and Gray (2001) found these products just want the pain to go away'. As excoriation is were far better at maintaining the skin of caused by a chemical reaction damaging the incontinent patients than soap and water. They surface of tbe skin (Cooper and Gray 200!), the reduced the potential for friction damage, as well effect is, in essence, a chemical burn. as preventing the skin from drying out because of For many years burns patients have been their emollient concent, which moisturised the treated with a cream containing silver, which is skin thus maintaining its hydration after renowned for its broad-spectrum antimicrobial cleansing. However, it is recommended that the properties (Russell and Hugo 1994, Lansdown practitioner understands how these products 2002a,Tboniasand McCubbin 2003). should be used because a common error observed Flamazine® is a common example. It is a white in clinical practice is the incorrect application of creamcontainingsilversulfadiazine 1% w/vina the foam. The simple mistake of applying the semi-solid oil in water emulsion. Its main cleanser onto a soft wipe instead of directly onto therapeutic indications are for the prophylaxis tbe patient's skin is often made. By doing this the and treatment of infection in burns wounds (Holt practitioner will reduce tbe efficacy of the 1998,Howell 1998). it is also used in the product because it must be in contact with the treatment and management of leg ulcers and skin if it istoreducethepHandrehydrateand pressure ulcers and abrasions (British National moisturise it. Formulary 2006). Barrier creams are often used in conj unction Locally, this product has been successful in with a suitable cleansing regimen, for example, rapidly reducing tbe effects of tissue excoriation Sudocrcm®, Metanium® and Cavilon® Durable associated with incontinence. However, there is Barrier Cream. These are topical preparations no publisbed evidence to date tbat promotes the manufactured to provide a protective harrier use of silver sulfadiazine 1% cream for this between the skin and the irritant effects of urine condition. and/or faeces. This barrier is achieved by After every episode of incontinence the skin applying a thin layer over compromised skin and should be gcntlyclcanscdwith an appropriate intact skin that is at risk of tissue damage. cleansing agent and allowed to dry. A thin layer However, over-application of these products may of Flamazine® cream should then be applied to reduce the effectiveness of continence pads if the affected atea(s); this should be carried out worn by clogging or interfering with tbcir afterevery incontinent episode, or up to four absorbency (Williams 2001. Newton and times a day until general cleansing or barrier Cameron 2005), thus increasing the risk of creams or films c;ui be used to manage tbe maceration and possible excoriation. problem. If, after two weeks, the problem is not Protection of broken skin may be achieved resolving tben an alternative method of through the use of a film barrier, for example, managing the incontinence should be sought, for Cavilon® No Sting Barrier Film, an alcohol-free example, a faecal collection system or skin protector that, once applied, can last for up catheterisation, if this has not previously been to 72 hours (Williams 1998). In many cases this considered. The benefits of using this product are product is effective in managing damaged skin. usually observed in 24 to 48 hours, and most However, if the patient has antibiotic or patients will state that they feel much more parenteral nutrition-induced faecal incontinence comfortable and that the pain bas reduced. or Closiridittm difficile., he or she can be washed Generally, silver sulfadiazine is well tolerated, several times an hour. The question to be asked in but there have been occasional teports of

62 October 25 :: vol 21 no 7 :: 2006 NURSING STANDARD art & science tissue viability suppletnent riGURE3 Skin before application of Flama2ine^ cream

irritancy,argyria (staining, a dull blue or grey colouration of the skin) and associated stinging (Lansdown and Williams 2004). However, this is more common when using silver nitrate compounds (Lansdown 2002b). To be systemically roxic. silver must be absorbed in sufficient amounts to evoke irreversible changes in a target organ such as the kidney or liver. Coombes etal (1992) documented that there were no measurable changes in serum silver levels (normal level less than2.3mcg/l) in two volunteers exposed to daily topical applications (3-5mm depth) of silver sulfadiazine for two weeks. As only a thin layer (less than 1mm depth) of cream is applied to the incontinent patient Skin one week after application of using the Flama/ine® regimen, it could be argued Flamazine" cream that the risk of high levels of silver being absorbed systemically is low. Flamazine® is relatively thin in texture. The advantage of this is that it is almost painless on application and a small amount can be spread over a large area. It also provides a soothing effect (Kagan and Smith 2000). The risk of infection is also reduced because ofthe antimicrobial propertiesof tbe silver in the cream. An example of the benefits ofthe Flamazine® cream method is outlined in Box 2. Figure 3 shows the skin before the application of

Case study of excoriation treated with FIama7-ine®cream and Figure4 demonstrates Flamazine' cream skin improvementafterone week of applying the cream. Til .11 91-year-old female, presented willi While the author does not recommend that severe tissue excoriation caused by a two-week the silver sulfadiazine regimen be instigated as episode of faecal incontinence as a result of antibiotic soon as incontinence becomes a problem, he does therapy for a recent chest infection. Her skin was not recommend that staff in local trusts and care responding to a regimen of general cleansing (soap, warm water and towel drying and Caviion-- No Sting settings develop a skin care protocol that Barrier Film). accommodates this method if skin damage, pain and riskof infection are evident. At present there The patient was commenced on a Flamazine''' cream is a lack of evidence to support the use of this regimen after every episode of incontinence. She was regimenanditsefficacy if used for longer than then nursed using continence pads and pants. Figure 3 two weeks. Tlie only way its benefits can be shows the patient's skin before commencing the Flamazine* cream regimen. The patient's skin was dry, promoted are through continued use and possibly due to the effects of soap, it was discoloured publicationof findings, which the author and had localised excoriation with supei-ficial broken recommends. All of the management techniques areas that were hypersensitive to touch and cleansing. described in this article are secondary to Figure 4 shows the significant improvement of the establishing and addressing the cause ofthe patient's skin one week later. The skin was well patient's incontinence. hydrated and supple and almost all ofthe superficial broken areas had healed. The patient niso stated a decrease In pain and discomfort during cleansing. The Conclusion patient's skin was subsequently managed using a general cleansing regimen (soap, warm water and Skin care is a fundamental aspect of nursing. For towei drying) and the application of a barrier cream. nurses to be effective at this they should have a sound knowledge of the skin's structure and

64 October 25 ;: vol 21 no 7:: 2006 NURSING STANDARD art & science tissue viability supplement pH-balanced soap, warm water and a soft wipe. However, other methods are available if the skin becomes further compromised, for example, barrier creams and films. Tbis article provides an function. They also need to be aware of skin overview of the current management methods changes as a result ofthe ageing process, and the that could be used to prevent tissue excoriation. It damage that faecal and/or urinary incontinence also suggests the use of silver sulfadiazine may cause to the protective function that tbe skin 1 % cream as a simple yet effective alternative that provides. The mainstay of treatment for could be used if previous strategies bave failed managingcompromiscdskiniswitha mild and the patient's skin begins to breakdown NS

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