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Incontinence and Skin Care Management for Improved Long-Term Care

June 20, 2013

Perspective of Nursing Care from Past to Future by Matron Marley

By Margaret Heale, RN, MSc, CWOCN

Well, I was a matron such a long time ago when we still had candy stripers and you swallowed tablets or wrote on them with chalk. My granddaughter is doing some work at a local nursing home and offered to show me around. I held my breath as we entered, to assess the OOS (odor offense scale), something I learned when doing nursing home assessments way back when. A breath out and a slow even breath in through the nose and- mmm! Most unexpected, it must be almost lunchtime. Quite different from my day. Today's chat is about why.

A very common reason for nursing home admission is incontinence. Morrison and Levy 2006 found between 6% and 10% of admissions were solely due to incontinence. One way we dealt with incontinence in the past was with a catheter. Today if catheters are used to deal with continence, the criteria has to be clear and a rationale given. One acceptable reason for catheter placement is to prevent the soiling of sacral pressure ulcers. Some dressings will protect the wound and skin but most succumb within a day to excess moisture, plus cleansers and protectants loosen the adhesives. Dressings end up rolled or displaced, exposing the wound. The possibility of fecal contamination is high, so placing a catheter makes sense for people with even small sacral wounds. A continence retraining program/scheduled voiding should, however, be a practical consideration before resorting to a catheter for pressure ulcer healing. There are ways to improve the chances of a dressing remaining intact on the sacrum:

1) Use a semi-occlusive border style dressing, ensuring there is full skin contact (an extra hand may help).
2) Hold in place for a full minute, pressing not rubbing (shear shreds adhesives).
3) Picture frame the border dressing with semi-occlusive strips (don’t cover completely with a second semi-occlusive layer as this reduces the water vapor transmission rate and will macerate the wound (Barry et al).
4) Dust over the intact semi-occlusive dressing with baby powder (this reduces any stickiness at the skin dressing border and makes the dressing surface slippery and less likely to 'catch').
5) Make a plan of care that details ways to reduce friction and shear when lifting and moving the patient. This may entail the use of rolling, slide sheets or positioning devices.

Another acceptable criteria for urinary catheter use is patient choice. Some patients have always used a catheter and even when fully informed of the risks, will continue to do so. Documentation of their informed consent is important.

Ultrasound imaging, in my day, was a procedure for pregnant women but it is now a way of determining the need for straight catheterizing for people who struggle with retention. Catheterizing people receiving hospice care may help some but catheters are uncomfortable to place and many find the discomfort from them too much to tolerate. Today in a facility with 100 beds there might be only two residents with a catheter, where just ten years ago this number would have been much higher. Having to give an acceptable rationale within a plan of care has had the desired effect. Planned individualized voiding schedules may not be quite at the level needed in some facilities but others are doing exceptionally well making them virtually 'brief free'. I was so pleased the word diapers has been dropped when referring to adult absorbent products, definitely a good step.

We all know stale urine smells dreadful and the importance of properly cleansing the skin has become so much better with the cream, foam and impregnated cloth cleansers now available. I so wish we had had the helpful mantra of Dr Mikel Gray in my day, "clean, dry, moisturize and protect." I wonder how much damage we did with soap, hot water and rubbing (I admit I never rubbed hard, it just seemed to be wrong…and it is, as the shear produced can lead to tissue injury).

The way contaminated items are dealt with by immediate disposal out of the room is fundamental to keeping odor under control. Some consideration to using biodegradable cellophane bags will ensure too much plastic isn't the result of our need for clean! The easy clean furniture, carpets and effective housekeeping products available today allow for efficient and, more importantly, effective management of the accidents that are bound to occur. Lastly, educating staff and allowing them to develop and be part of changes that need to happen will produce a proactive workforce proud of what they do and the dignity given to the residents they help care for.

It is hardly surprising that there was a smell of urine in homes when there were 'rubber kippers' for leg bags and cloth briefs in need of changing. Used linen carts in hallways didn't help. If you had told me when I was a student that it was possible to have two residents with catheters, few briefed residents and no stale urine odor I would have laughed. Today it is different and the changes taking place will benefit more than just the residents - our noses will be grateful too. I might stay and volunteer a while as I want to see what they do for 'recliner butt' (sorry, moisture-associated skin damage!). But, where are the recliners! I will write again soon.

Barry, P. Fram, P.J. Phillips. The effect of temperature and humidity on the permeability of film dressings (2011) S. Thomas, L. Journal of Wound Care 20(10): 484 - 489

Morrison. A. Levy, R. 2006 Fraction of Nursing Home Admissions Attributable to Urinary Incontinence. Value in health Volume 9, Number 4, 2006

About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.