Prevention Of Pressure Sores Due To Incontinence

By Diane Berardi, Gerontologist

Incontinence is a common risk factor for pressure ulcers, especially in bed-bound and elderly.

Urine and feces are caustic to the skin. Warm, moist skin is the perfect breeding ground for disease and can lead to rapid skin breakdown and the development of a pressure ulcer.

Unless they are immediately removed and the affected area thoroughly cleaned and dried, the skin will begin to break down immediately. Irritating substances in feces cause inflammation of the skin; repeated or prolonged wetness from leaked urine causes skin cells to swell and thus become compromised. Leaking urine and feces together causes more damaging than either one alone.

Disposable diapers alone are not the answer. Wearing an absorbent brief or pad for prolonged periods makes the skin even more prone to damage.

Have you ever had to wear Band-Aid for any period of time? Think about how your skin looks after you take it off. The skin under the bandage is pale, wrinkled, moist and thin. Incontinence briefs and pads have a similar effect on the skin because they keep air from circulating to the covered areas and drying them. This also creates an ideal environment for certain types of bacteria or fungi to grow, causing a rash or urinary tract infections.

The skin damage of inflammation appears as redness that can vary in shade from light pink to brown-red. In darker-toned skin, inflammation may appear as redness or as patches of darker or lighter coloring.

Damaged skin may also look shiny and wet, with local swelling or fluid buildup.

In cases of more severe damage, the top layer of skin can wear away, exposing the skin underneath to the effects of the urine or feces. With the top layer of skin gone, bacteria or fungi can more easily invade the underlying tissues, causing a rash. If damage to skin goes untreated, it can worsen to become an open wound.

Damaged skin may cause soreness, pain, burning or itching. Although some people with Alzheimer’s disease or dementia may not complain about these symptoms, they may show other signs of discomfort (e.g., tugging at their clothes, scratching, squirming, wincing or grimacing when they sit down). Even people who show no obvious signs of discomfort may be very uncomfortable, and that may manifest as something as simple as grouchiness.

There are many strategies that can reduce the risk of pressure ulcer formation…

Here’s a simple 3-step process.   

Cleanse the skin regularly–

Cleansing and drying the skin as soon as possible after it is soiled with urine or feces is critical for preventing damage or helping to heal.

Gently clean and dry the skin with a soft, non-irritating cloth as soon as possible after it is wet or soiled. Don’t use soap, which can dry out the skin. Instead, use a mild cleanser that says it is “pH balanced” on the label. Many of these gentle cleansers do not require the use of water, making them very convenient. Some products also combine a cleanser and a protective cream so you can clean and protect in one step.

If you use disposable cleansing wipes that contain a moisturizer or a protectant, the protectant that remains on the skin from these wipes may work well for prevention and treatment of minor skin damage, but this is certainly not enough for treatment of more severe damage.

The skin may be patted gently dry using a soft cloth (don’t ever scrub the skin).

After patting the skin dry, apply a protectant (e.g., ointment or cream) as a barrier
against moisture and other irritants. Apply it to the genitals, on and between the
buttocks and on the inner thighs.

Several kinds of products are available to prevent skin damage and promote healing.

Look for these active ingredients on the label: petrolatum, dimethicone or zinc oxide.

Examples of these types of products are A+D® Ointment, petroleum jelly (e.g., Vaseline®) or zinc oxide skin protectant (many generics and brand names).

A clear, non-stinging acrylic film (e.g., 3M™ Cavilon™ No Sting Barrier Film or Spray) may also be used very effectively. You can find these online or your local pharmacy or surgical supply store may be able to order them for you.

Many of the same products can be used for both prevention and treatment of
skin damage, however, a greater amount of some active ingredients (like zinc oxide) in a product also makes that product better for treatment. And, products containing zinc oxide or the non-stinging acrylic promote healing.

But here are a few things to keep in mind:

· Remove the protective ointment and reapply it after each cleansing.

If removal or application is difficult, you can try applying an acrylic film. Acrylic films do not need to be applied as often and can remain on the skin through several cleanings.

An acrylic film may need to be used only once a day or once every other day. Keeping a regular schedule of application is a good idea.

· If the skin is dry and your cleanser or protectant does not contain a moisturizer, you can apply a moisturizer before applying the protectant. Dry, cracked skin is more prone to bacteria. Some products contain a combination of cleanser, moisturizer, and protectant.

· Don’t apply baby powder. Baby powder can actually abrade the skin more, and because it raises the pH of the area, it enables fungus and bacteria to more easily grow. That’s not a good thing.

· If your aging parent’s skin is severely inflamed, an open wound has formed or you feel you can no longer manage it, contact his or her healthcare provider immediately. Don’t put this off. Pressure sores can get out of hand very quickly.

Examine the skin routinely–

It is important that the skin covered by incontinence products be examined regularly for signs of redness, irritation or skin breakdown. This includes the coccyx, the buttocks, and the perineum. Any signs of irritation or redness should be addressed immediately and monitored carefully for progression.

Address incontinence–

This may perhaps be the most obvious strategy to prevent pressure ulcer formation resulting from incontinence- try to reduce incidents of incontinence.

There are many ways in which incontinence can be reduced, here are a few:

Review all medications- Medications may contribute to incontinence by increasing the amount and/or frequency of urination or decreasing awareness of the need to void. Medications such as diuretics, blood pressure medications, sedatives, hypnotics, and opioids may affect continence. Although it may not be possible to stop all of these meds, a medication review may reveal the likely culprit and a better alternative may be available.

Avoid constipation- incontinence can be worsened by constipation. When the colon is full of hard stool, the pressure is placed on the bladder and urethra, which may increase incontinence. A good bowel routine can help to reduce episodes of incontinence. Geriatricians recommend adding dietary fiber to the diet. The easiest to use are the ones that dissolve easily in a small amount of liquid such as Benefiber—I personally buy the Wal-Mart generic equivalent, it seems to work just as well.

Monitor fluid intake- It may seem counterintuitive to push fluids in order to control urinary incontinence, but drinking too little fluids can lead to concentrated urine, which can increase the urge to void, in addition to making urine more alkaline and likely to damage the skin.

But be careful of the timing. Drinking too much fluid, especially right before bed, can increase incontinence and lead to skin breakdown.

Encourage Kegel exercises- many patients can learn to perform Kegel exercises, which strengthen pelvic floor muscles. In women, weak pelvic floor muscles from pregnancy, childbirth, and menopause can contribute to incontinence. Kegel exercises are easy to teach and perform and, over time, can improve continence.

Scheduled toileting/bladder training- whether individuals live in aged care facilities or at home, regularly scheduled bathroom breaks can “train” the bladder. For individuals without cognitive issues, the length of time can be gradually increased between bathroom breaks until the individual can hold their urine for a reasonable amount of time.

Screen for conditions that may contribute to incontinence- if incontinence is new or worsening, it may be worthwhile to screen the individual for conditions that might influence continence, such as a bladder infection, stones in the urinary tract or diabetes.

Although incontinence is a risk factor for pressure ulcer formation, pressure ulcers due to incontinence can be easily avoided using the above strategies.