Moisture-Associated Skin Damage: Its Impact in a Critical Care Setting

Moisture-associated skin damage (MASD) is becoming increasingly prevalent in today’s health care system. Often associated with discomfort and pain, MASD ultimately negatively impacts quality of life. MASD is usually broken down into 3 or 4 categories, most commonly incontinence-associated dermatitis (IAD), intertriginous dermatitis, periwound dermatitis, and peristomal dermatitis.¹ In this blog, I focus on the prevention and treatment of IAD and subsequent pressure injuries in critical care through a nurse-led approach.

What Is Incontinence-Associated Dermatitis?

IAD is a type of irritant dermatitis caused by exposure to moisture (most commonly urine or stool) and is defined as erythema and edema of the surface of the skin. Skin irritation can sometimes be accompanied by bullae, secondary cutaneous infection, red rash, denuded skin, desquamation, and pain. IAD is a significant risk factor for pressure injury development and can at times be difficult to manage, especially in a critical care setting.¹

Identifying the Cause of Incontinence-Associated Dermatitis

The incidence of IAD is highest among patients with fecal incontinence or diarrhea. As we are aware, stool contains a high amount of digestive enzymes that are caustic to the skin and can quickly cause erosion and skin damage when the skin is left unprotected. Critically ill patients are more prone to diarrhea because of the severity of their disease processes, specialized treatments or conditions, enteral nutrition, increased intra-abdominal pressure that can be caused by mechanical ventilation, and drug-induced alterations of the intestinal flora.¹ Literature reports the prevalence of fecal incontinence in critical care to be as high as 78%, with the prevalence of diarrhea at 13%, thereby increasing the incidence of IAD among critically ill patients to 20% to 37%.¹

Establishing Standardized Skin Care Protocols, Treatment, and Prevention Plans

In our critical care unit, we designated “Wound Wednesday” as the day of the week where our Wound Treatment Associate – Certified® skin champion would complete routine head-to-toe skin assessments, rounding, stocking of treatment and prevention carts, and ensuring that items used for treatment and prevention were readily available at the bedside and/or on the unit.

Having a standardized prevention, treatment, and education routine (protocol, day of the week, systematic approach) has been proven to decrease pressure injuries in our specific critical care unit. The success of implementing and sustaining routine skin and prevention rounds is owed to the presence of designated tasks, a trained staff, a specified day of the week, a routine, and the support of leadership and management. Literature has shown that a structured skin care protocol typically results in positive outcomes.¹ Additionally, by preventing IAD, we are ultimately preventing damage to the skin that can easily lead to a hospital-acquired pressure injury.

Protocols for Incontinence-Associated Dermatitis Treatment and Prevention

Evidence has shown us that skin should be assessed at routine intervals and a risk assessment should be performed. Interventions should be put into place based on the risk assessment score. With IAD, skin should be cleansed with a gentle pH-balanced cleanser. Literature suggests a nonionic surfactant and normal saline to cleanse any broken skin. Barrier wipes, spray, film, and/or ointment without alcohol are often utilized based on the presentation of the skin.¹

It is helpful to identify routine treatment guidelines, for example, including a protocol for prevention, first-line treatment, advanced treatment, and follow-up. Consulting with all members of the interdisciplinary team (providers, therapy, nutrition, wound care specialist, etc) will lend to a holistic plan of care and consistency in the applied protocols according to unit needs. Documentation, follow-up, and recording of the results are also important elements of follow-through and closing the loop while ensuring that either the treatment/prevention plan was effective or revisions or updates need to be put into place.

Education and Assessment

The initial steps of any successful protocol or new directive implementation include educating those involved. It is important that frontline staff are trained on the protocol, skin inspections, prevention measures, evidence, and so on. After educating those involved, the next steps in the protocol are inspection and assessment.

Clinicians need to determine which patients are at risk and why they are at risk and then put specific interventions into place. It is important to understand the different risk factors and patient populations in each care area (eg, critical care, long-term care, emergency, acute medicine, operating room). Each population will have different risk factors and needs.

Conclusion

Complete, comprehensive, and correct nursing evaluation is key to high-quality patient care.¹ Literature discusses that patient evaluation is 1 of the 9 core competencies a nurse should possess.¹ Because IAD may develop rapidly in the presence of risk factors, the correct use of evaluation and risk assessment tools will help standardize nursing care and ensure that evidence-based interventions are put in place early with the hope of preventing significant skin breakdown, pain, and ultimately a decrease in quality of life.¹

Utilizing protocols that identify the different stages of IAD and treatment for each stage, including cleansing and protection, helps to provide a background for nurses to administer appropriate and evidenced-based nursing care.¹ Ultimately, the literature reviewed and the practice we implemented yielded similar results. Staff training, standardized protocols, prevention measures, and routine rounding, as well as follow-up with a standardized approach, resulted in positive patient outcomes related to pressure injury prevention by managing and treating IAD early through the use of a standardized approach.

Reference

1. Zhang X, Wang X, Zhao X, Zhang Y. A structured skin care protocol for preventing and treating incontinence-associated dermatitis in critically ill patients, Adv Skin Wound Care. 2022;35(6):335-342. doi:10.1097/01.ASW.0000828972.70137.8a

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse specialist at VA Northeast Ohio Healthcare System in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately ten years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.