VOL: 98, ISSUE: 04, PAGE NO: 58
Sarah Le Lievre, RGN, CMB, FETC, Cert.H.Ed, is clinical nurse specialist, continence, Health and Social Services, Jersey, Channel Islands
Faecal incontinence affects more than 1% of the adult population (Nelson et al, 1995), but the exact figure is unknown, as many hide the problem owing to embarrassment. Faecal incontinence has a more dramatic effect on the skin than urinary incontinence (Fiers, 1996), and therefore extra care should be taken to prevent skin problems occurring.
Aetiology of skin problems
The main reasons why skin problems occur with faecal incontinence is that it causes an increase in the pH of the skin, excessive hydration and increased permeability. Skin problems occur more often with double incontinence and in those who have particularly loose stools. A study carried out by Marchette et al (1991) showed that people with faecal incontinence had an increase in skin redness and significant incidence of skin ulcers.
When urine and faeces are mixed, ammonia is produced from the breakdown of urinary urea and faecal urease. The resulting high pH of the skin allows increased activity of the faecal enzymes. These enzymes can lead directly to skin damage but also increase susceptibility to other irritating factors (Campbell et al, 1987; Davis et al, 1989; Berg, 1988; Buckingham, 1986; Wilson and Dallas, 1990).
A rise in pH of the skin also occurs with occlusion of the skin. Therefore patients who wear incontinence pads are found to have a higher skin pH (Berg et al, 1986; Wilson and Dallas, 1990).
Sixty per cent of faecal matter is made of bacteria (Whitman, 1991), and these pathogens destroy the skin’s cellular defence, which can lead to skin breakdown and infection. These bacteria can also track upwards towards the urethra, causing urinary tract infections.
Excessive hydration of the skin occurs with urinary incontinence and diarrhoea. Those with liquid faecal incontinence have a much higher risk of developing skin problems, such as incontinence dermatitis, as not only is there the problem of the loose stool adding fluid to the area but also the faecal enzymes that cause skin damage. The elderly are particularly at risk as they have a thinner epidermal layer. Older skin produces less sebum than younger skin, which affects the barrier function of the skin (Keller et al, 1990). Soap is known to strip the skin of sebum, therefore overzealous washing of the skin with excessive amounts of soap renders skin more at risk. Older women are at greater risk of skin breakdown due to a reduction in oestrogen production that results in more fragile skin.
A study carried out by Whittingham and May (1998) into cleansing regimens in elderly people used a new generation of skin cleansers that do not contain soap. They concluded that there were potential benefits in using these cleansers, not only for skin conditions but also in cost and patients’ views.
Frictional damage will occur more readily when the barrier function of the skin is impaired, and in particular if the skin is overhydrated (Leyden, 1986; Keller et al, 1990; Berg, 1988).
Assessment of faecal incontinence
Before deciding on the prevention or treatment methods to be used in caring for the skin, the patient’s incontinence status should be thoroughly assessed and investigated. When the cause of faecal incontinence has been discovered it can usually be treated. In fact, most incontinence can be cured or greatly improved, thus negating the need for any further skin care intervention.
There are many reasons for faecal incontinence and diarrhoea, ranging from constipation, constipation/overflow, inflammatory bowel diseases, influenza, infection, cancer, ileal anal reservoir, diabetes, liver failure, cancer therapies and medication, the most common being antibiotics (Haugen, 1997). Within the continence assessment skin condition should also be assessed and documented. If there are no skin problems it is still important to assess if the patient is at risk of developing skin problems in the future. As mentioned earlier, greater problems will occur if the patient is elderly, immobile, malnourished, has poor dexterity or is not using the appropriate continence aids.
Cleansing the skin
Skin should be washed gently immediately after episodes of faecal incontinence, with small amounts of unperfumed soap ensuring that it is well rinsed. If the skin is very dry or already irritated an emollient can be used as a soap substitute - for example, aqueous cream.
Other skin cleansers are also available and some are reported not to effect the pH of the skin or strip it of sebum. They usually contain moisturisers and some contain antimicrobial agents and no rinsing is required. These products may be useful when dealing with frequent incontinence episodes. However, some people may show an allergic reaction to some products.
Drying the skin
The skin should be dried thoroughly, especially in skin folds. Gentle patting is the preferred method, as too vigorous rubbing can lead to friction damage.
Talcum powder is not advised, as this can form encrustations, in particular in the groin area when mixed with faeces, urine or sweat. It can also affect the absorbency of incontinence pads.
Barrier creams should be applied sparingly and never rubbed into the skin, but gently layered on in the direction of the hair growth. Moisturisers lubricate normal skin, but for those with dry skin they not only lubricate but also hydrate. Creams again can effect the absorbency of incontinence pads.
Care should be taken when choosing an incontinence aid for faecal incontinence. There are two main aids for containing faecal incontinence - incontinence pads and faecal collectors.
Pads are not ideal for containing faecal incontinence as, although they will absorb the liquid from liquid faeces, more solid faeces will remain on the surface of the pad and therefore be in constant contact with the skin. It is essential that pads are always changed immediately and the skin cleaned. If the patient has frequent faecal incontinence episodes this will have financial implications and become very costly in materials as well as nursing time and can be degrading for the patient (Bosley, 1994).
Faecal collectors (perineal pouches) consist of a round adhesive foam pad with a circular opening in the centre, this adheres to the skin around the anus. A clear, plastic collection bag allows for the collection of stool in the bag away from the skin. It has a tap at the end to allow emptying without removing the collector. The collectors come in two sizes - 500ml and 1,000ml. If the amount of faeces is copious and very liquid the collector can be connected to a continuous gravity drainage collection bag (Bosley, 1994). It can remain in place as long as is needed, provided it is cleaned with water and no leakage takes place.
Addison (1987) collected data on using a faecal collector by six patients; one of these kept the same collector in place for seven days with no detrimental effects.
There are both advantages and disadvantages when using collectors, and it would appear that they are most successful with patients who are confined to bed.
One of the advantages of collectors is that liquid stool can be emptied and measured to ensure accurate output records. Another advantage is that the entire device can be removed, the adhesive ring can then be folded on itself and disposed of as one unit, preventing the spread of infectious disease to care givers through faecal contaminants (Bosley, 1994). The collectors are also very effective in controlling unpleasant odours, which is a bonus for both patients and those surrounding them. The main disadvantage reported is the difficulty in maintaining the collector’s seal, but this could be due to poor technique when applied.
Leaking between the adhesive and the seal is a particularly common problem for more mobile or restless patients. Collectors can fall off or literally be blown off due to an accumulation of gas or stool in the collector.
Karaya paste can be used with the barrier to fill in the cracks and crevices and provide greater security. To ensure the successful use of the collector it is essential that the skin is prepared correctly. It should be clean, free from soap residues and thoroughly dry. Creams and talcum powders of any kind should not be used under the barrier (Addison, 1987).
Faecal incontinence has a cause, and careful assessment can result in diagnosis and successful treatment. If this should be found to be impossible for whatever reason, the mainstay of skin care is to ensure a nutritious diet, mobility and that the skin is kept dry, hydrated and clean.
Every attempt should be made to prevent faeces coming into contact with the skin. If, however, this should occur the skin should be gently cleaned immediately. Some patients might find the use of collectors very acceptable and satisfactory in keeping faeces off the skin and prefer them to incontinence pads.