ABSTRACT

Keywords: Control, elderly patients, incontinence-associated dermatitis, structured skin care plan structured skin care plan was used to improve the condition of elderly patients with IAD, with good results achieved.

INTRODUCTION

Incontinence-associated dermatitis (IAD) refers to the skin inflammation caused by local skin injury in the vulva, perianal,and buttocks due to long term or repeated exposure to urine and feces, mainly manifested as erythema, rash, maceration,and erosion, with or without blisters.[1,2]IAD is one of the common skin complications in patients with incontinence,most likely to occur in elderly patients, and increases the risk of secondary infections and pressure ulcers or injuries.[3]If the treatment and care of IAD is not applied timely, the patient’s condition will be further aggravated, which greatly increases the nursing workload, treatment costs, the time of patient staying at hospital, and other social burdens.[4]Therefore,how to effectively alleviate dermatitis associated with senior incontinence is worthy of attention. In this article, the

MATERIALS AND METHODS

Diagnostic criteria, inclusion criteria, and exclusion criteria

Elderly IAD patients who were hospitalized in the Department of Nephrology, Dongfang Hospital, Beijing University of Chinese Medicine, from January 2018 to December 2019 were selected as the research objects. The diagnostic criteria of Western medicine for IAD were skin inflammation caused by local skin exposed to urine or feces in the long term,mainly occurred in of the vulva, perianal, and buttocks and manifested as erythema, rash, maceration, and erosion, with or without blisters.[1]Inclusion criteria were (1) age 60 years old, (2) conforming to Western medicine diagnostic criteria for IAD, and (3) patients who voluntarily participated in this study and signed an informed consent form. Exclusion criteria were (1) allergic to external application of the test agent on the inner forearm of both upper limbs, (2) those with skin injuries (pressure injury) caused by nonmaceration in the perineum, sacrococcygeal region, buttocks that affect skin observation or who did not cooperate during the treatment;and (3) patients with other serious life-threatening diseases.

Grouping

According to the random number table, 66 IAD patients were divided into the experiment group of 32 cases and the control group of 34 cases. The control group was given conventional nursing care, while the experiment group received a structured skin care plan.

Nursing interventions

The patients in the control group were given routine nursing care, as follows: the patient’s local skin was washed with warm water and wiped with a soft towel after every urinary and fecal incontinence. Then, 3M liquid dressing (mainly containing acrylate copolymer, methyl disiloxane, and polyethyl methicone) was sprayed 5–10 cm away from the skin with IAD to form a layer of skin protective film on the damaged skin surface. If there are wrinkles in the skin of the sprayed part, it is suggested to gently unfold the wrinkles with your hands and then spray evenly. After the skin protective film is completely dry, restore the natural position of the skin. If the perianal or perineal skin is damaged, it is suggested to first apply stoma powder (mainly containing sodium carboxymethyl cellulose) evenly on the affected area and then spray 3M liquid dressing. 3M liquid dressing and stoma powder are used twice daily. If the skin is contaminated again by the stool, it is suggested to gently clean with warm water to avoid damaging the protective film.

Patients in the experiment group were performed with a structured skin care plan of integrated Chinese and Western medicine. (1) Set up an IAD group consisting of 6 experienced nurses, 1 specialist nurse for wound stoma, 1 physician,and 1 nutritionist. (2) After the patient was admitted, the responsible nurse made a comprehensive assessment of the patient’s skin of the whole body to understand the patient’s condition, including the risk of pressure ulcers, degree of incontinence, and IAD level. The nurse of each shift was responsible for preparation of the skin care labels at patients’bedsides, recording the patient’s specific situation and meanwhile making an assessment of the perianal, perineal,and sacrococcygeal skin of patients every 2 h. (3) Traditional Chinese Medicine (TCM) dietary guidance: The nutritionist made a scientific diet plan to give the patients specific dietary guidance, and helped the patients to reasonably arrange their diet during treatment. (4) Moxibustion: The responsible nurse implemented moxibustion for patients with IAD for 5 min at 9:00 am in every morning after cleaning the skin and using 3M liquid dressing and/or stoma powder. In addition to moxibustion for the affected area, the specific acupoints including Shenshu, Pangguangshu, Dachangshu,Qihai, Guanyuan, Zhongji, Tianshu, and Zusanli were selected based on the theory of TCM meridians and collaterals,[5]and then, the mild moxibustion was done 2–3 cm away from those acupoints, 3 min for each acupoint. During the process of performing mild moxibustion, the responsible nurse should put his or her index and middle fingers on both sides of the patient’s acupoints to feel the temperature of moxibustion and prevent burns. Moxibustion was first performed on the acupoints in one side of the body, and alternately on the other side on the next day. (5) Dynamic skin management:The duty nurse did a skin test on a regular basis to assess the skin conditions and recorded the assessment results,and adjusted nursing methods according to the recovery of the patients.

Efficacy evaluation

The skin assessment tool (SAT) score: The SAT is a tool designed by Kennedy and Lutz[6]in 1996 for assessing the severity of skin damage caused by incontinence. This tool includes three dimensions: the extent of skin damage, the level of skin redness, and the depth of erosion. The extent of skin damage and the level of skin redness are scored on a scale ranging from 0 to 3 points, while the depth of erosion is scored ranging from 0 to 4. The total score of the scale is ranging from 0 to 10. The higher the score, the more serious the skin injury. The scale was Chinesized by Bao et al.[7]The re-test validity of the Chinese version of SAT was 0.775,the Cronbach’s α of internal consistency was 0.836, the content validity index was 0.93, and the cumulative variance contribution rate was 78.561%, showing good reliability and validity. Therefore, it is suitable for assessing the severity of IAD.Curative effects: The diagnostic standards of therapeutic evaluation conform to Guiding Principles for Clinical Study of New Chinese Medicines.[8](1) Recovery: Skin intact,without redness, ruptures, and other discomforts, SAT score is 0 or score reduction ≥95%. (2) Significant effect: Small amount of skin damage, SAT score reduction ≥70%. (3)Improvement: A small amount of skin damage, SAT score reduction ≥30%. (4) Invalid: No improvement or even deterioration occurred in the damaged skin after treatment, SAT score reduction ＜30%. Total effective rate= (recovery + significant effect + improvement) cases/total number of cases × 100%. Healing days: It refers the time from the beginning of treatment for IAD patients to complete wound healing.

Safety evaluation

During the moxibustion process, if there is any adverse event such as burns, blisters, vomiting, and nausea, it will be recorded and the relationship with moxibustion should be analyzed. Meanwhile, the treatment plan should be adjusted if the adverse event is a serious one.

Statistical methods

SPSS 20.0 statistical software (IBM, Armonk, New York,USA) was used to analyze data. The measurement data were described by means ± standard deviation or median. The counting data were described by frequency and composition ratio. T-test was used when measurement data conformed to normal distribution, and nonparametric test was used for nonnormal distribution. The nonparametric test was used for comparison of the ranked data. The difference was statistically significant when P ＜ 0.05.

Ethical statement

This study complied with the medical ethics requirements and was approved by the hospital ethics committee, batch number: JDF-IRB-2018030901. Before implementation, all patients or their family members signed informed consent to inform the purpose and significance of the experimental study in written. The patients’ information was promised to keep strictly confidential. Patients had the right to withdraw from the study at any time during the research process.

RESULTS

No patient withdrew from the study and 66 patients finished the treatment. The baseline characteristics of the two groups were as follows: in the control group, there were 14 (43.8%) males and 18 (56.2%) females; patients aged 80.19 ± 4.90 years; in terms of type of incontinence,13 cases were of fecal incontinence, 13 cases were of urinary incontinence, and 6 cases were of double incontinence; the SAT score was 5.18 ± 2.30. In the experiment group, there were 16 (47.1%) males and 18 (52.9%) females; patients aged 79.44 ± 6.94 years; in terms of type of incontinence,12 cases were of fecal incontinence, 15 cases were of urinary incontinence, and 7 cases were of double incontinence;the SAT score was 4.84 ± 2.67. There was no statistically significant difference between the two groups regarding age (t = 0.483, P = 0.631), gender (χ2= 0.073, P = 0.787),type of incontinence (χ2= 0.199, P = 0. 905), and SAT score(Z = ?0.241, P = 0.809).

The total effective rate was 97.1% for the experiment group and 78.1% for the control group, and the difference was statistically significant (χ2= 3.913, P = 0.048) [Table 1].

The SAT score of patients was 0.56 ± 1.58 in the experiment group and 1.75 ± 2.46 in the control group after intervention,and the difference was statistically significant (Z = ?2.401,P = 0.016). The healing time was 7.29 ± 4.76 days for the experiment group and 10.69 ± 6.36 days for the control group, the difference was statistically significant (Z = ?2.280,P = 0.026). No adverse events such as vomiting, nausea,scalds, and blisters occurred in the experiment group during the process of moxibustion.

DISCUSSION

As for hospitalized senile patients with urinary and fecal incontinence, the local skin exposed to a wet environment in the long term causes reduced skin barrier function and thus leads to the occurrence of IAD. In recent years,structured skin care plan has been gradually developed and has attracted the attention of the medical workers.[9,10]According to the recommendations of expert consensus for IAD,[11]the treatment of IAD should follow three steps of the structured skin care plan, including identification of types of incontinence, cleansing of the skin, and protection of the skin. Previous studies showed the use of 3M liquid dressing and stoma powder as main skin protective agents to isolate urine and feces and often in different types of IAD,[12-14]with obvious therapeutic effects obtained in prevention and treatment of IAD.[15-17]

TCM believes that the pathogenesis of IAD lies in the blocking of meridians and collaterals, and deficiency of Qi and blood.Therefore, to better improve the patients’ skin condition,shorten healing time, and enhance patients’ comfort, in this study, we integrated TCM characteristics, including TCM dietary guidance and moxibustion, into the routine structured skin care plan to form a new structured skin care plan. A reasonable TCM diet plan could alleviate the symptoms of diarrhea andincontinence of feces and urine. In diet, patients were guided to avoid raw food, cold food, and stimulating food such as beef, mutton, and crab. Meanwhile, moxibustion, as the highlight of this study, was performed for patients. In addition to moxibustion for the local inflammatory skin, Shenshu,Pangguangshu, Dachangshu, Qihai, Guanyuan, Zhongji, Tianshu,and Zusanli acupoints were also performed with moxibustion for patients. Moxibustion can improve humid conditions for skin by the heat while burning, dredging meridians, tonifying Qi,and activating the blood through stimulation on specific sites and own medicinal properties, thus accelerate wound healing.From modern medicine, it was explained that moxibustion could accelerate the proliferation of vascular endothelial cells in wound surface, promote the release of vascular endothelial growth factor, regeneration of granulation tissue, and accelerate wound healing.[18,19]The results of this study showed that patients in the experiment group had a higher total effective rate, lower SAT score, and shorter healing time than those in the control group, indicating that the skin condition of the experiment group was significantly improved through the implementation of integrated traditional Chinese and Western medicine structured skin care plan in the elderly patients with IAD. Meanwhile, the patients’ comfort experience and satisfaction were increased.

Table 1: Comparison of curative effects between the two groups

As TCM classics General Treatise on the Cause and Symptoms of Diseases stated, urinary and fecal incontinence is mainly caused by deficiency of kidneys and bladders, so the treatment of them should take measures of tonifying Qi and kidney and controlling the primordial Qi of lower energizer. An research of Zhang et al.[20]proved that the operation of moxibustion can achieve the effect of warming Yang Qi of kidney, spleen,and heat, controlling nocturnal emission, dispelling coldness,tonifying deficiency, and dredging the meridians through its warm stimulation on acupoints while burning, thus regulating the disequilibrium of the whole body. Therefore, in this study,Pangguangshu, Shenshu, and Dachangshu acupoints on the Bladder Meridian of Foot Taiyang for moxibustion were selected to regulate the functions of the kidneys, bladders, and large intestine. Qihai and Guanyuan acupoints on Ren-meridian were selected to treat urinary incontinence and difficult urination through invigorating kidney yang and tonifying the primordial Qi of lower energizer. Zhongji acupoint was selected for treating disorder of bladder function, and Zusanli acupoint was selected for strengthening the spleen and regulating water passage.Tianshu combined with Dachang was used for regulating gastrointestinal function and making defecation normally.Together, the combination of acupoints on the Bladder Meridian of Foot Taiyang and Ren-meridian has effects of warming meridians and invigorating kidney yang, dredging meridians,and collaterals through stimulation on those acupoints by heat produced by moxa burning.[21]It should be noted that moxibustion is easy to cause scalds for patients’ skin during the operation, so patients’ feelings and skin temperature changes should be paid attention to at any time.

CONCLUSION

In summary, structured skin care plan of integrated Chinese and Western medicine can significantly decrease the healing time, improve the skin condition of hospitalized patients, and also can be used as an effective intervention of promoting the rehabilitation of IAD patients. Moreover, it is easy to perform for patients, with few adverse reactions. Therefore,this plan with good therapeutic effect, short healing time,and increased comfort is worth of clinical promotion. In addition, because the present study is a single-center study with small sample size and short-term observation, the in-depth research should be further conducted on the basis of expanded sample size and long-term efficacy observation.

Declaration of patient conform

Informed consent has been obtained from all patients included in this study. In the form, the patients have given their consent for clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study is supported by the Young Teacher Project of Beijing University of Chinese Medicine (No.: 2018-JYB-JS134).

Conflicts of interest

There are no conflicts of interest.