Incidence and Characteristics of Incontinence-Associated Dermatitis in Community-Dwelling Persons With Fecal Incontinence.

PURPOSE: Little is known about the incidence and characteristics of incontinence-associated dermatitis (IAD) in community-living individuals with fecal incontinence. The primary aim of this study was to describe the incidence and characteristics of self-reported IAD among community-living individuals with fecal incontinence. The study also examined whether IAD was associated with older age, sex, presence of urinary incontinence, or fecal incontinence severity. DESIGN: Secondary data analysis was performed using a prospective cohort design. SUBJECTS AND SETTING: Data were drawn from community-living adults (n = 98) with fecal incontinence (76% female, 34% aged ≥65 years, 90% white) who participated in a study about dietary fiber supplementation and were free of IAD at the start. Thirty five percent also had urinary incontinence. METHODS: Subjects assessed their skin for IAD daily for 52 days, reporting types of IAD damage (redness, rash/fungal infection, and skin loss), location of IAD, and symptoms. They reported fecal incontinence on a diary for the first and last 14 study days. RESULTS: The incidence of IAD was 41% (40 of the 98). The fecal incontinence severity score for subjects developing IAD was 1.2 higher than those who never had IAD (P < .001). There was no significant association of IAD with age, sex, or dual fecal and urinary incontinence. Incontinence-associated dermatitis developed within 2 weeks and healed in approximately 1 week. The most common sign and symptom were redness (60% patients) and soreness (78% patients), respectively. Most subjects (85%) had IAD in one location. CONCLUSIONS: Assessing for IAD in community-living patients with fecal incontinence is important as IAD is common and causes discomfort. The relatively mild severity of IAD offers WOC nurses the opportunity for improving patient outcomes by preventing and managing this problem.

Refinement of an instrument for assessing incontinent-associated dermatitis and its severity for use with darker-toned skin.

PURPOSE: The purpose of this study was to refine an instrument for assessing incontinence-associated dermatitis (IAD) and its severity for use on lighter- and darker-toned skin, the Incontinence-Associated Dermatitis and its Severity Instrument-D (IADS-D), and to test its validity and reliability among WOC nurses. METHODS: Revisions to the existing instrument included examples of colors of normal and IAD-damaged skin that would be observed on light-, medium-, and dark-toned skin using pixels from patient photographs, additional photographs of IAD manifestations on different skin tones, and training materials. Four certified WOC nurse consultants and 2 WOC nurse clinical experts assessed the face and content validity of the IADS-D instrument. The IADS-D instrument was tested for criterion validity and interrater reliability using photo cases by attendees at the Wound, Ostomy, and Continence Nurses Society 2012 conference. RESULTS: The IADS-D instrument had good face and content validity. The overall average intraclass correlation coefficient (ICC) of IADS-D scores for all photo cases of testers (n = 266, 95% female, age 53.0 ± 7.9 years, mean ± SD) and those of investigators, experts, and consultants serving as the criterion was 0.90. The overall ICC for interrater reliability between all nurse testers was 0.99 and the ICC for tester skin tone was 0.99. CONCLUSION: The IADS-D instrument has excellent validity and interrater reliability among WOC nurses. Its refinement for use with lighter- and darker-toned skin addresses the lack of a much-needed instrument in nursing practice and research. Results support continued development and evaluation of the instrument's use in clinical and research settings.

Incontinence-associated dermatitis in critically ill adults: time to development, severity, and risk factors.

PURPOSE: The purpose of this study was to determine the time to development, severity, and risk factors of incontinence-associated dermatitis (IAD) among critically ill patients with fecal incontinence. SUBJECTS AND SETTING: Forty-five patients with a mean age of 49.4 ± 18.5 years (mean ± SD) in the surgical/trauma critical care unit (ICU) of 1 of 3 urban hospitals who were free of any perineal skin damage at study start participated in the study. The majority (76%) were male. METHODS: Surveillance of skin for IAD and chart review of data initially and daily. RESULTS: Incontinence-associated dermatitis developed in 36% of patients. The median time to onset of IAD was 4 days (range, 1-6). Eighty-one percent of patients still had IAD at discharge from the ICU and at the end of their surveillance (median time = 7 days, range, 1-19 days). The severity of erythema associated with IAD was mild, moderate, or severe for 13%, 11%, or 4% (means) of the time patients were observed. Denudement occurred 9% of the observed time. Frequent incontinence of loose or liquid stools and diminished cognitive awareness were significant independent risk factors for development of IAD sooner. CONCLUSION: Incontinence-associated dermatitis develops in critically ill patients with fecal incontinence relatively quickly and does not resolve in most before their discharge from the ICU. Early monitoring and prevention of IAD, especially in patients with diminished cognition or with frequent leakage of loose or liquid feces, are recommended to promote skin health.

Dry skin in older adults.

Dry skin is a common problem in the older individual due to physiological changes of the aging process as well as chronic health conditions. Dry skin can worsen if management is inappropriate or lacking. Nursing management of dry skin in the elderly is comprehensive including applying topical products to replenish lipids and reduce water loss, maintaining or increasing fluid intake, limiting sun exposure, and reducing symptoms of chronic illnesses.

Comparing community and specialty provider-based recruitment in a randomized clinical trial: clinical trial in fecal incontinence.

Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). In the Fiber Study, a randomized controlled trial on symptom management for FI, we successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported.

Conservative management of fecal incontinence.

OVERVIEW: Although fecal incontinence can be both emotionally and socially debilitating, the embarrassment associated with it is so great that it often prevents patients from seeking much needed help from their health care providers. Nursing care begins with case finding and continues through conservative management, which has greatly improved over the past 15 years. This article summarizes the strategies that have proven most effective in uncovering and combating this prevalent yet seldom acknowledged condition. KEYWORDS: : defecation, diarrhea, fecal incontinence, feces, incontinence, incontinence of stool.

Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients.

AIM: This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea. BACKGROUND: Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause. METHOD: This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance. FINDINGS: The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea. CONCLUSION: As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Prevalence and correlates of perineal dermatitis in nursing home residents.

BACKGROUND: Perineal dermatitis is an adverse outcome of incontinence, which is common in older nursing home residents; yet knowledge about perineal dermatitis in this population is sorely lacking. OBJECTIVES: To determine the prevalence and significant correlates of perineal dermatitis in older nursing home residents. METHODS: Assessment data from 59,558 records in the Minimum Data Set (MDS) were linked with 2,883,049 orders in the medical record which enabled definition of variables related to perineal dermatitis, identification of cases, and determination of the prevalence of perineal dermatitis. Data from two subsamples, each with the records of 10,215 older nursing home residents, were analyzed using logistic regression to identify the significant correlates of perineal dermatitis. RESULTS: Perineal dermatitis was found in 5.7% (n = 3,405) of residents and 73% of these were incontinent. Having perineal dermatitis was significantly associated with (a) impairments in tissue tolerance (i.e., more health problems, presence of a fever, requiring nutrition support, and having more problems of diminished perfusion or oxygenation); (b)problems of the perineal environment (i.e., having fecal incontinence only, double incontinence, and more items associated with mechanical chafing); and (c) altered toileting ability from daily use of restraints. DISCUSSION: Several correlates of perineal dermatitis (mechanical chafing, fecal and double incontinence, and use of restraints) appear modifiable through nursing intervention. Clinical interventions should consider the complex health status of this population.

Community-based recruitment and enrollment for a clinical trial on the sensitive issue of fecal incontinence: the Fiber study.

The recruitment of community-living participants for clinical trials of sensitive topics, when the population is largely hidden and reluctant to self-identify, and the study protocols and procedures intensive, creates significant challenges to researchers. The Fiber Study is an ongoing randomized controlled clinical trial conducted to compare the effectiveness of three dietary fibers with different levels of fermentability for symptom management in community-living adults with fecal incontinence. The researchers developed a staged approach to recruitment using three primary recruitment methods and a three-phase approach to the enrollment process. We have been successful in reaching, recruiting, and enrolling participants in a clinical trial, as well as in effectively managing study resources and staff time.

Diet strategies used by women to manage fecal incontinence.

Fecal incontinence occurs in community-living women who are elderly, as well as younger women, particularly after vaginal childbirth. Little is known about how women manage fecal incontinence in their everyday lives. Ten women who had fecal incontinence for at least 1 year participated in an audio-taped interview in a phenomenological study. Diet modification was identified as a key strategy for managing fecal incontinence. Various food types were avoided, restricted, or used as remedies. The meanings that the women applied to the diet strategies for managing fecal incontinence had 4 themes: restricting diet and eating patterns, eating and dealing with the consequences, treating fecal incontinence with foods and fluids, and lacking therapeutic guidance regarding diet modifications for fecal incontinence. The results of this study suggest that the continence nurse specialist recognize the important role and meaning of diet as a self-care strategy for women with fecal incontinence and address diet in their assessment and management recommendations.

Preparing a grant proposal--Part 5: Organization and revision.

Translating a research idea into a well-written grant proposal takes planning and commitment. This Spotlight is the fifth in a series by the members of the Center for Clinical Investigation (CCI) of the Wound, Ostomy and Continence Nurses (WOCN) Society. The aim of this series is to facilitate high-quality grant writing and encourage submissions to WOCN's grants program. This article provides guidance on the development of a grant proposal and the revisions necessary to result in a polished final product.

Managing fecal incontinence: self-care practices of older adults.

Little is known about the ways in which community-dwelling elderly individuals manage fecal incontinence (FI) in their daily lives. In this study, community-dwelling elderly individuals were surveyed at clinics of a health maintenance organization (HMO) to describe the self-care practices used to manage FI and to examine factors that influenced the number of self-care practices used and the reporting of FI to a health care practitioner. Responses of 242 elderly individuals who reported that they had FI several times per year were analyzed. The self-care practices used most commonly were changing diet, wearing a sanitary pad/brief, and reducing activity or exercise. Elderly women and those with a greater severity of FI and more chronic health problems engaged in more self-care practices. Factors associated with reporting FI to a clinician were considering FI to be a problem, uncertainty about the cause of FI, and changing diet to avoid FI. There is a need to promote effective management strategies for FI to older individuals living in the community.

Searching the literature by design.

Current nursing knowledge has been generated by studies whose designs range from exploratory to experimental. Searching the literature for a study illustrating a particular design can be a perplexing process. This article explains strategies that are useful in identifying research studies according to the designs used in their methods. The suggested search strategies assist in identifying the most relevant search results and can save time. Outcomes of such a search can be instructional about the implementation of a design in its classic form or some variation. They can provide practical illustrations of the advantages and limitations of a design when applied in a particular area of interest.

Dietary fiber in conservative management of chronic renal failure.

Conservative management of chronic renal failure has included a variety of dietary manipulations. Supplementation of dietary fiber to reduce adverse symptoms is a novel approach, but whether it can make an effective clinical impact is yet undetermined. This commentary accompanies a brief report of improved well-being during fiber supplementation. It explains some of the background thinking and early trials of fiber supplementation in chronic renal failure patients.