SKIN DISORDERS AND MOISTURE IN INCONTINENT NURSING-HOME RESIDENTS - INTERVENTION IMPLICATIONS

OBJECTIVE: To provide data needed to design an intervention trial to p revent or treat skin disorders in a high risk, incontinent nursing hom e population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trai ned observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under conti nent and incontinent conditions. RESULTS: All subjects had at least on e skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, whi ch occurred in 94% of the subjects, predominantly in the front and bac k regions that were closest to the urethra and rectum. Twenty-one perc ent of residents developed either a Stage 1 (nonblanchable erythema) o r 2 pressure ulcer. All skin conditions were transient when measured e very 3 weeks with the exception of blanchable erythema, which showed s tability. Stage 3 or greater pressure ulcers and edema were not observ ed, and interrater reliability for the measure of papules was poor. Me asures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mob ility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin mo isture levels in the back perineal farthest from the rectum (periphera l) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient natu re of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be as sociated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of var ious interventions on the incidence of pressure ulcers and other relat ed skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greates t benefit from an intervention trial to reduce moisture caused by inco ntinence.