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Perineal and Incontinence Care Providing perineal and incontinence care are two of the most important responsibilities entrusted to caregivers in long-term care facilities. Thorough care provides comfort and reduces odors and helps residents maintain their dignity and feeling of self-worth. Careful perineal/incontinence care also preserves skin and helps prevent perineal dermatitis. Providing good perineal care can have a positive effect on the well-being and self-esteem of your residents.

Perineal Dermatitis Perineal dermatitis is often associated with incontinence and ranges in severity from redness to areas with open abrasions. Urinary incontinence rates between 30-50% have been reported for long-term care residents.1 Up to half of elderly long-term care residents are incontinent of stool.1 Perineal dermatitis develops in a third of patients with fecal incontinence. 1 Perineal dermatitis causes itching and pain and can increase the risk for urinary tract infection, skin infection, and pressure ulcers.

Perineal Dermatitis In one study, 56.7% of patients with pressure ulcers also had fecal incontinence, making fecal incontinence one of the most common risk factors for pressure ulcers.1 The clinical practice guidelines of the Wound, Ostomy, and Continence Nurses Society (WOCN) recommend keeping the skin clean and dry and applying an incontinence skin protectant after each episode of incontinence.2 Residents at risk for perineal dermatitis should have routine perineal skin care that includes gentle cleansing and the application of a moisture barrier.

Perineal Skin Damage Even though painful and preventable, perineal skin damage occurs in as many as 41% of adults in long term care.3 Perineal skin damage may progress rapidly to ulceration and secondary infection including bacterial and yeast infections which increase discomfort and treatment costs, and compromise quality of life.3 Preventive cleansing and application of a protectant reduce the incidence of pressure ulcers by as much as 59%.1

Perineal and Incontinence Care Accepting help with something as personal as perineal or incontinence care can represent a loss of privacy and self-esteem to the resident. Respect the resident’s dignity: Keep the door closed Talk with the resident and explain what you are doing Expose only the area to be cleansed

Perineal and Incontinence Care Optimal perineal/ incontinence care requires: The right product The right process Staff compliance

Perineal and Incontinence Care Basics Preserve the resident’s skin: Use warm, not hot water Avoid force or friction – be gentle Fold the washcloth to provide a softer surface for cleansing Use Standard Infection Control Precautions: Always wear gloves for perineal/incontinence care – add an apron or gown per facility policy While wearing gloves, avoid contaminating environmental surfaces and supplies Put on clean gloves to apply perineal cream or ointment Minimize opportunities to spread contamination: Remove excess fecal material with diaper or disposable wipe Cleanse from the area of least contamination to the area of most contamination Refold and change cloths to prevent spreading contamination

Standards of Care in Long-term Care Facilities (LTCFs) Regulations from the Centers for Medicare and Medicaid Services (CMS) establish standards for LTCFs Regulations are divided into 2 parts Written regulatory statements are labeled by F-tags and a number. F-tag is jargon for the actual regulation as published in the Federal Register.* Interpretative Guidelines are used for enforcing the regulations. These consist of an explanation of the intent of the regulation, definitions of terms, and instructions for determining compliance with the regulation. Interpretative Guidelines are continually revised by CMS and are used during surveys of long-term care facilities. *The Federal Register is the official journal of the Federal Government of the United States and contains proposed rules, new regulations, and public notices of government agencies.

CMS F-Tag 314: Pressure Sores Residents who enter facility without pressure sores do not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Identify risk factors including exposure of skin to urine and fecal incontinence.

CMS F-Tag 315: Urinary Incontinence Skin related complications: Frequent washing with soap and water can dry the skin, use of perineal rinse may be indicated. Moisturizers help preserve the moisture in the skin by either sealing in existing moisture or adding moisture to the skin. Moisturizers should be used sparingly – if at all – on macerated (soggy) or excessively moist skin.5

PROVON® 3 in 1 Wash Cream A single product for complete, no-rinse bathing and perineal care Cleans, moisturizes and helps reduce odors in one step Gentle cleansing agent loosens dirt, urine and stool from the skin and reduces the amount of force or friction needed during bathing and incontinence care Moisturizes the skin with 10 conditioning agents pH balanced Dermatologist tested and dye-free

PROVON® 3 in 1 Wash Cream Perineal Cleansing Prepare cloth(s) by adding 2-3 pumps of product to each warm, damp cloth Males Cleanse the penis - tip to base For uncircumcised male, gently push foreskin back, cleanse tip of penis, and replace foreskin Refold cloth to unused surface, cleanse groin, then scrotum - wipe toward rectum Use additional cloths as necessary Place cloths in soiled linen bag Females Cleanse groin and both outer labia Refold cloth to unused surface Separate labia and cleanse downward, wiping toward rectum Use additional cloths as necessary Place cloths in soiled linen bag .

PROVON® Perineal Wash Perineal Cleansing Remove excess fecal matter. Apply product to warm damp wash cloth(s). Gently clean entire perineal area, always wiping from front to back. Repeat with additional washcloths as needed. Benefit of not using basin of water for perineal cleansing – proven to be reservoir for bacteria and potential source of transmission of healthcare acquired infections.4

PROVON® Perineal Skin Protectant Ointment with 99% Petrolatum Water-resistant skin protectant that acts as a moisture barrier Barriers shield skin from exposure to irritants and moisture. Provides temporary barrier to urine and fecal matter. Helps protect red, irritated skin. Contains petrolatum (skin protectant), skin conditioning agents and fragrance. Non-greasy

PROVON® Perineal Skin Protectant Ointment with 60% Petrolatum Creamier consistency than Perineal Skin Protectant Ointment with 99% Petrolatum. Water-resistant skin protectant that acts as a moisture barrier. Barriers shield skin from exposure to irritants and moisture Provides temporary barrier to urine and fecal matter Helps protect red, irritated skin Contains petrolatum (skin protectant), skin conditioning agents and fragrance Non-greasy

Applying PROVON® Perineal Skin Protectant Ointment with Petrolatum Apply after skin has been cleansed and patted dry. Apply a continuous, light film to the perineum, buttocks, and especially to the sacrum. Apply with a gentle touch – no aggressive rubbing.

References Driver DS. Perineal dermatitis in critical care patients. Critical Care Nurse 2007;27:42-46. Wound, Ostomy, and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. WOCN Clinical Practice Guideline No. 2. Glenview, IL: Wound, Ostomy & Continence Nurses Society; 2003. Nix, D. (2010). Prevention and Treatment of Perineal Skin Breakdown Due to Incontinence. Ostomy Wound Management 52(4). Johnson, D. et.al. (2009) Patients’ bath basins as potential source of infection: A multicenter sampling study. American Journal of Critical Care 18(1) 31-40. http://www.cms.gov/manuals/Downloads/som107ap_pp _guidelines_ltcf.pdf p.195 Pressure Sores; p. 232 Urinary Incontinence

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