Dorothy Doughty

Incontinence-associated dermatitis: a consensus.

Incontinence-associated dermatitis (IAD) is an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin. Little research has focused on IAD, resulting in significant gaps in our understanding of its epidemiology, natural history, etiology, and pathophysiology. A growing number of studies have examined clinical and economic outcomes associated with prevention strategies, but less research exists concerning the efficacy of various treatments. In the clinical and research settings, IAD is often combined with skin damage caused by pressure and shear or related factors, sometimes leading to confusion among clinicians concerning its etiology and diagnosis. This article reviews existing literature related to IAD, outlines strategies for assessing, preventing, and treating IAD, and provides suggestions for additional research needed to enhance our understanding and management of this common but under-reported and understudied skin disorder.

Incontinence-Associated Dermatitis: A Comprehensive Review and Update

In 2009, a multinational group of clinicians was charged with reviewing and evaluating the research base pertaining to incontinence-associated dermatitis (IAD) and synthesizing this knowledge into best practice recommendations based on existing evidence. This is the first of 2 articles focusing on IAD; it updates current research and identifies persistent gaps in our knowledge. Our literature review revealed a small but growing body of evidence that provides additional insight into the epidemiology, etiology, and pathophysiology of IAD when compared to the review generated by the first IAD consensus group convened 5 years earlier. We identified research supporting the use of a defined skin care regimen based on principles of gentle perineal cleansing, moisturization, and application of a skin protectant. Clinical experience also supports application of an antifungal powder, ointment, or cream in patients with evidence of cutaneous candidiasis, aggressive containment of urinary or fecal incontinence, and highly selective use of a mild topical anti-inflammatory product in selected cases. The panel concluded that research remains limited and additional studies are urgently needed to enhance our understanding of IAD and to establish evidence-based protocols for its prevention and treatment.

Incontinence-associated Dermatitis: Consensus Statements, Evidence-based Guidelines for Prevention and Treatment, and Current Challenges

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.

A Rational Approach to the Use of Topical Antiseptics

The proper application of antiseptics to the open wound is controversial. With the goal of creating an optimal environment for wound repair, consideration of a topical antiseptic includes both its bactericidal activity and its potential cytotoxicity when applied to the healing wound in varying concentrations. This discussion reviews the events of wound healing, including the key cells that mediate this process, the significance of bacteria in the wound bed, and the impact of infection. Specific antiseptics, including povidone-iodine, hydrogen peroxide, acetic acid, and Dakins solution are reviewed, emphasizing their bactericidal potential and their cytotoxic properties.

Issues and challenges in staging of pressure ulcers.

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.

Peristomal moisture-associated skin damage in adults with fecal ostomies: a comprehensive review and consensus.

Approximately 1 million persons living in North America have an ostomy, and approximately 70% will experience stomal or peristomal complications. The most prevalent of these complications is peristomal skin damage, and the most common form of peristomal skin damage occurs when the skin is exposed to effluent from the ostomy, resulting in inflammation and erosion of the skin. Despite its prevalence, research-based evidence related to the assessment, prevention, and management of peristomal moisture-associated skin damage is sparse, and current practice is largely based on expert opinion. In order to address current gaps in clinical evidence and knowledge of this condition, a group of WOC and enterostomal therapy nurses with expertise in ostomy care was convened in 2012. This article summarizes results from the panels literature review and summarizes consensus-based statements outlining best practices for the assessment, prevention, and management of peristomal moisture-associated dermatitis among patients with fecal ostomies.

A physiologic approach to bowel training

Bowel training is an effective management option for many patients with dysfunctional bowel elimination patterns and neurogenic fecal incontinence. To be effective, a bowel training program must be based on sound physiologic principles and must be individualized for each patient. This article includes a review of the structures and physiologic processes controlling normal defecation and the physiologic principles governing bowel training. The steps involved in successful implementation of a bowel training program are discussed, and case studies are used to illustrate the principles.

History of ostomy surgery.

Development of Colostomy: Indications and Construction Only sporadic accounts of ostomy surgery can be found before the 1700s. Throughout the 18th century, accepted management of intestinal perforation was to close any open abdominal wound and “hope for the best.” This treatment plan was (not surprisingly) associated with extremely high mortality rates. The earliest stomas were actually fistulas that developed spontaneously following bowel perforation; one surgeon noted the correlation between spontaneous fistula development and patient survival and stated in his journal that perhaps surgeons should “take a lesson from Mother Nature” and construct planned stomas in such cases.1,2 Any surgical advance during this period was significantly complicated by the absence of anesthesia and asepsis, which of course resulted in extremely reluctant patients and dismal outcomes. In the late 18th century (1793), an innovative surgeon performed a colostomy on a 3-day-old infant with an imperforate anus; to prepare for the procedure, he practiced on the bodies of dead babies he obtained from the city’s poorhouse. The surgery was successful, and the patient lived to the age of 45, though we lack any data as to how he actually managed the stoma.1,2 Following the development of anesthesia during the mid-1800s, surgery became a realistic treatment option; surgeons in the mid-1800s to late-1800s used diverting colostomy to manage bowel obstruction and also tried to cure patients with rectal cancer by surgical excision of the rectum (narrow abdominal perineal resection of rectum [APR]). Unfortunately, these early attempts to cure rectal cancer with APR were associated with a 100% recurrence rate, because only the rectum and anal canal were removed. Surgeons learned quickly from these failures, and in the early 1900s surgeons Mayo and Miles modified the APR procedure to include radical resection of the perirectal tissue and lymphatics as well as the rectum and anal canal.1-4 During the early 1900s, surgeons also found that proximal colostomy could be used to protect a distal anastomosis and to reduce postoperative complications.1 Early decompressive and protective colostomies were typically constructed as skin-level “loop” ostomies. They provided effective decompression of an obstructed bowel but only partial diversion of the stool, and they proved quite difficult to manage. In 1888, the support rod was introduced to prevent retraction of the loop stoma until it had granulated to the abdominal wall. The use of rods was a major advance, in that it produced a protruding stoma that provided almost complete diversion of the fecal stream.1,5 At this time, the standard of care was to leave the loop stoma closed until several days following surgery, at which point the anterior wall of the loop was opened with cautery at the patient’s bedside. The procedure was not painful but it frequently was traumatic since the patient could smell the burning tissue, and it meant that the stoma had to “self-mature” via gradual self-eversion to expose the mucosal layer of the bowel. This changed in the 1950s, when Dr Bryan Brooke made surgical maturation the standard of care for ileostomy; subsequently surgical maturation became the standard of care for colostomy construction as well.1,5,6 Henry Hartmann popularized the concept of delayed anastomosis (and the Hartmann’s Pouch) when he lectured in America during the early 1900s on his technique for managing obstructing sigmoid tumors: removal of the involved segment of bowel, closure of the distal stump, and formation of an end colostomy.1,5 Mikulicz-Radecki proposed another option for temporary diversion following bowel resection; he recommended bringing the proximal and distal segments of the bowel out as 2 side-by-side skin-level stomas, and he further recommended using a crushing clamp to create a fistula between the 2 loops of bowel (and thus restore intestinal continuity) once it was deemed safe for stool to pass through the distal bowel. He

Role of the enterostomal therapy nurse in ostomy patient rehabilitation.

Enterostomal therapy (ET) nurses specialize in the management of patients with urinary and fecal diversions, draining wounds and fistulas, fecal and urinary incontinence, and chronic wounds such as pressure ulcers and vascular ulcers. ET nurses have much to offer in the management of patients with cancer. Such nurses play a major role in the rehabilitation of patients undergoing fecal or urinary diversions. Preoperative services include: counseling regarding planned surgical procedure, the impact of an ostomy on the patients life, and the basics of ostomy management: sexual counseling; and stoma site selection. Postoperatively, the ET nurse instructs the patient and family in ostomy care, dietary and fluid alterations, and ways to incorporate ostomy management into the patients life. The ET nurse also provides long‐term follow‐up care in outpatient settings: such care includes ongoing counseling, education, and surveillance for complications requiring medical intervention. ET nurses can recommend appropriate measures to prevent and manage skin breakdown that is related to immobility, friable skin, incontinence, and/or radiation therapy. They also can assist in correcting or containing fecal or urinary incontinence and in cost‐effective management of draining wounds and fistulas.

Integrating advanced practice and WOC nursing education.

The increased use of advanced practice nurses (APNs) in all health care settings provides new practice options for WOC nurses and new challenges for WOC nursing education. A number of WOC nurses are moving into APN roles, and APNs who are not WOC specialists are providing much of the primary care for patients with wounds, ostomies, and incontinence. New educational approaches are needed to prepare APNs for specialty practice in wound, ostomy, and/or continence care. In addition, the need exists to incorporate key WOC nursing content into the core curriculum for APNs who provide primary care for patients with or at risk for wounds or disordered elimination. This article explores potential strategies for meeting these new demands.