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Incontinence Associated Objectives Dermatitis • The participant will be able to: Faculty – Discuss the function of skin Jacqueline Giddens, RN, MSN, CWCCN, WOCN – Identify the three layers of skin Nurse Consultant BfHdCitSiBureau of Home and Community Services – Identify common skin problems Alabama Department of Public Health related to incontinence Satellite Conference and Live Webcast Wednesday, January 22, 2014 – Discuss prevention and treatment 2:00 – 4:00 p.m. Central Time strategies for skin breakdown due Produced by the Alabama Department of Public Health Video Communications and Distance Learning Division to incontinence

Skin is an Organ Skin is an Organ • Did you know the skin is an organ? • 1 square inch of the skin contains: – Largest organ – 100 sebaceous glands – Heaviest organ – 65 hairs • 15% of body weight – 78 yards of nerves – In a 150 pound person, the skin – 650 sweat glands weighs about 12 pounds and can – 19 yards of blood vessels cover 18 square feet

Skin is an Organ Skin Layers – 9,500,000 cells • Epidermis – 1,300 nerve endings • Dermis – 20,000 sensory cells • Subcutaneous tissue – 32,000,000 bacteria

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Skin Layers Epidermis • There are 5 layers in the Epidermis – Stratum corneum – Stratum licidum – Stratum granulosum – Stratum spinosum – Stratum basale

Stratum Corneum Epidermal Layer • Outside layer • Provides protection • Sloughs off about every 2 weeks • Call the “horny” or “crusty” layer

Horny layer Layers of the Dermis (stratum corneum) • Papillary Clear layer (stratum lucidum) – Contains a thin arrangement of Granular layer (stratum granulosum) collagen fibers • Reticular Prickle-cell layer (stratum spinosum) – Thicker and made of thick collagen fibers that are arranged parallel to Basal layer the surface of the skin (stratum basale)

Basal membrane

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Specialized Cells Specialized Cells and Structures and Structures • Hair follicles Papillary Reticular • Muscles on each hair follicle • Oil, sebaceous, and sweat glands • Blood vessels • Lymph vessels • Nerves

Subcutaneous Tissue Subcutaneous Layer • Primarily consists of fat cells • Shock absorber and heat insulator • Structures – Muscl es attach hded to h hifllilair follicles – Sweat glands Fat layer – Blood vessels in skin – Lymphatic system – Nerves

Incontinence What Causes Incontinence? • The involuntary leakage of urine • Constipation or stool • Diet • Urinary • Gastrointestinal disease – Loss of bladder control • HiblHormone imbalance • Fecal • Weakness or loss of pelvic – Loss of bowel control muscle function • Loss of mobility

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What Causes Incontinence? Incontinence • Mental changes • Chronic exposure to moisture • Prostrate disease • Breaks down alkaline pH • Spinal cord injury • Overgrowth or infection with pathogens • Urinary track infections • Friction

Problems Caused Skin Infection: By Incontinence Yeast / Fungal • Infections • Any area, usually skin fold – Bacterial and yeast • May create its own moisture • Incontinence Associated Dermatitis • Fiery red, white coated (IAD), skin excoriation, and skin • Satellite lesions breakdown – Red spots scattered at the edges • Pressure ulcers

Skin Infection: Management Incontinence • Keep skin and folds clean and dry Associated Dermatitis “Skin inflammation manifested as • Maximize air to the area redness with or without blistering, • Use antifungal powder or cream erosion, or loss of the skin barrier • Oral antifungal ftithtfunction that occurs as a consequence of chronic or repeated exposure of the skin to urine or fecal matter”

– Michael Gray defined PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN

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Incontinence Incontinence Associated Dermatitis Associated Dermatitis • Located where skin is in contact • No satellite lesions unless also has with urine or feces fungal • Initiallyyy may be bri ght red and wee py • Not confined over a bony • Later dark red / purple, or white prominence • Dry peeling skin like sunburn • Burning, itchy, tingling, or painful

IAD: Management Pressure Ulcer • Treat cause of incontinence • Pressure ulcer • Prevent skin breakdown – Over bony prominence – Daily skin check – Coccyx, usually round or oval – Prompt cleaning – Sacra l or i schi um, b utt erfl y or oval if only on one side – Protect skin at risk – Well defined edges, no satellite • Treat skin breakdown lesions

Pressure Ulcer Pressure Ulcer Management • Relieve or reduce pressure • Keep wound clean • Maintain moisture in the wound bed • PttProtect woun ddd edges • Do not massage

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Prevention and Treatment Treatment: of Skin Breakdown Urinary Incontinence • TREAT the incontinence • Assessment • DAILY check the skin • Determination of type of incontinence • PROMPTLY clean the skin • Address the root cause • Effective management

Prevention and Treatment Linens, Diapers, Chux… of Skin Breakdown • Limit linen usage under patient • GENTLY wipe skin when cleaning – No more than 2 layers • USE product with acidic pH like • No diaper normal skin – Keeps moisture against the skin – 5.5 – Only use when up in chair • PROTECT with moisture barrier or walking

Linens, Diapers, Chux… Check the Skin • Chux (blue) pads • Check the skin daily – They wick moisture away so skin • Observe skin in perineal area on can dry all patients – Patient needs to lie on top of pad – Take spppecial note of patients who are bed or chair bound • Do NOT put pad under linen – Take special note of patients who are incontinent • Do NOT use pad as diaper • Report any changes to caregiver and supervisor

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Clean the Skin Clean the Skin • Clean skin immediately after urine or • Rinse well fecal leakage • Pat dry the skin and skin fold • Use disposable perineal wipes or – Do not rub mild soap and warm water • Frequent b ath s will remove nat ural • Do not rub or scrub oils and increase skin dryness – pH balanced body cleansers – Soap

Clean the Skin Protect • Cleanse only when soiled • Moisturized skin = healthy skin • Bath water should be warm • Loss of moisture from epidermis – Not hot! causes dryness • Mini mal f orce • Moisturizing prevents itching – No vigorous scrubbing • Apply lotion to damp skin – Locks in moisture – Apply daily

Protect • Use emollients to soften and soothe skin but do not macerate – Add too much moisture • Expose the area to air for 30 minutes , 2 - 3 times a day • Apply skin protectorant – Dimethicone, petrolatum, or zinc oxide

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