Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings

The choreographies of the elimination of faeces-An ethnographic study of the institutionalized body care practices of older people in different health care settings

AIM

To explore the choreographies of the elimination of faeces of older people to gain insight into the institutionalized practices of body care of older people in hospitals and long-term care settings.

DESIGN

A qualitative ethnographic study, drawing on a perspective of socio-material theory. Reported in accordance with the Standards for Reporting Qualitative Research.

METHODS

A total of, 30 women and 11 men aged 80 years and above needing assistance with body care in a hospital ward, 2 nursing homes and home care and 32 care workers participated. Four individual interviews with older people and three focus group interviews with care workers were conducted, in addition to 135 h of participant observations, from December 2020 to September 2021. Data were analysed using a situational analysis approach.

RESULTS

The assistance with the elimination of faeces is a multiplicity of ongoing dynamic practices where different actors interrelate. Dominating actors are time, space, materialities, different ideals and professional knowledge. The choreographies aim at order the elimination of faeces to happen at the right time at the right place, to provide dignified care.

CONCLUSION

To assist older people with the elimination of faeces is complex institutionalized practices. The study argues for a greater focus on the ongoing relations between human and non-human actors to provide new understandings of an underexplored phenomenon in nursing.

IMPACT

What problem did the study address? The elimination of faeces of older people as part of body care is an underexplored phenomenon in nursing, often subject to stigma and taboo, and delegated to other healthcare workers than registered nurses. Internationally, there are challenges in the delivery of fundamentals of nursing care to older people across healthcare settings. Few studies have explored body care as an institutionalized practice across different settings, taking into consideration the contextual aspects of care as well as the involvement of non-human actors in the care practices. What were the main findings? Multiple human and non-human actors are involved when older people need assistance with the elimination of faeces. Time, space, materialities, different ideals and professional knowledge are important actors. The elimination of faeces is not a homogeneous practice but ongoing, dynamic, and multiple practices. The context of care practices related to the elimination of faeces is not an outer macro level distant from care, but part of the ongoing daily practices of body care. Where and on whom will the research have an impact? The findings can inspire researchers and clinicians to develop a new understanding of fundamental care needs. The study offers a critical perspective on possibilities for providing care, since political ideals and governance are active actors in daily care practices.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. The study was conducted during the COVID-19 pandemic; restrictions limited the access to involving patients and care workers in the research process. An advisory board consisting of leaders from the different settings was a part of the design process and in the interpretation of data.

RECOMMENDATIONS FOR FURTHER RESEARCH

The socio material theoretical perspective has a potential to unfold the complexities in nursing care practices focusing on aspects that are underexplored in nursing research.

Impact of hydrocolloid dressings in the prevention of pressure ulcers in high-risk patients: a randomized controlled trial (PENFUP)

It is uncertain whether hydrocolloid dressings, a more costly intervention than offering standard care with petrolatum, is superior to prevent pressure ulcers among hospitalized high-risk adults. Randomized, parallel-group, open-label, superiority trial with an active control group, blinded for investigators, event validators, and analysts (December 1, 2015 to December 12, 2017). Eligible patients were ≥ 18 years of age with intact skin judged as high-risk for skin ulcers (Braden scale), admitted to surgical or medical wards of two tertiary-level hospitals. Participants were randomized (1:1) to protection with hydrocolloid dressings or petrolatum. The primary outcome was the first occurrence of pressure ulcers (with post-injury photographs adjudicated by three judges) under intention-to-treat analysis. Based on prior cost analysis, and the available resources (assumed incidence of 6 ulcers/1000 patient-days in controls), inclusion of up to 1500 participants allowed to surpass a one-sided superiority threshold > 5% based on a target efficacy > 40% for dressings. We planned an economic analysis using a decision tree model based on the effectiveness of the study results from a perspective of the third payer of health care. After inclusion of 689 patients (69 events), the trial was stopped for futility after a planned interim analysis (conditional power < 0.1 for all scenarios if the trial was completed). Pressure ulcers had occurred in 34 (10.2%) patients in the intervention group [9.6 per 1000 patient-days] and 35 (9.9%) participants in the control group [7.9 per 1000 patient-days], HR = 1.07 [95% CI 0.67 to 1.71]. The estimated incremental cost for dressings (a dominated strategy) was USD 52.11 per patient. Using hydrocolloid dressings was found similar to petrolatum for preventing pressure ulcers among hospitalized high-risk patients. As it conveys additional costs, and in this study was unlikely to demonstrate enough superiority, this strategy did not overcome conventional skin care.Trial registration: ClinicalTrials.gov identifier (NCT number): NCT02565745 registered on December 1, 2015.

Meaning of hygiene care for patients as perceived by clinical nurses through an interactive care process: A grounded theory approach

AIM

This study aimed to explore the meaning of hygiene care for patients from the perspective of nurses, who provide them with care through an interactive process.

METHODS

Sixteen registered nurses working in general wards for over 5 years were selected through purposive and snowball sampling. Individual semi-structured interviews were conducted between May and August 2021. Data were analyzed using a grounded theory approach, and the Consolidated Criteria for Reporting Qualitative Research was used to ensure quality and transparency.

RESULTS

The participants recognized the core category "realizing oneself alive here," where hygiene care energized patients and promoted their realization of "feeling alive." Hygiene care created "time of relief, temporarily forgetting the illness," and "restoring a sense of oneself." A situation of care also created an "opportunity to treat each other as unique individuals," "opportunity to face self," and "encouraging the recovery and disease-fighting process."

CONCLUSIONS

This study highlights the value of hygiene care provided by nurses to patients. The meaning of hygiene care conceptualized in this study should help build a conceptual framework for understanding the patient's experience and reaffirming the value of hygiene care.

[Eczema of wound surroundings : Genesis, diagnostics and treatment]

Skin changes in the surrounding areas of wounds are a frequently occurring multidisciplinary challenge in the care of patients with wounds, especially in older people. These are often inflammatory skin diseases like eczema that can be caused by various factors. These include allergens, noxa, incorrect skin care or prolonged contact with moisture. In the diagnostics, detailed medical history, clinical examination and allergological tests play important roles. Eczema can mostly be treated symptomatically with topical glucocorticoids. Calcineurin inhibitors are an alternative treatment, especially for longer term topical applications. In cases of impetiginized lesions, appropriate antimicrobial therapy should also be carried out. For long-term and preventive treatment the adequate use of skin care and skin protection products that help to strengthen or restore the skin barrier is decisive as well as the education of the patients and, if necessary, their relatives.

Improving skin health of community-dwelling older people: a scoping review protocol

INTRODUCTION

Ageing is accompanied by an age-related decrease in mobility or cognitive and sensory functions; in addition, physiological changes in the skin occur with age. Therefore, the skin requires appropriate care and observation in order to prevent or manage a variety of dermatological diseases and conditions, and to prevent or minimise effects on the quality of life.Globally, most older people live at home, and the need to establish sustainable structures and processes to support and to care for people at home for as long as possible has been emphasised. The body of evidence supporting screening, diagnosis and management of skin conditions in older people living at home has not been collated and summarised to date. The aim of this scoping review is to describe and summarise the extent and nature of the available body of evidence in this regard.

METHODS AND ANALYSIS

This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Eligibility criteria were developed using the Population, Concept and Context framework, and the search will focus on systematic and scoping reviews as well as clinical practice guidelines. Two reviewers will conduct systematic searches, screen and select identified evidence as well as extract and chart data, independently. Finally, data will be systematically analysed and summarised descriptively to map existing evidence and identify gaps.

ETHICS AND DISSEMINATION

Due to the nature of research, not involving humans or unpublished secondary data, approval of an ethics committee is not required. The dissemination of findings is planned via professional networks and publication in scientific open access journals.

Barriers and facilitators to delivering everyday personal hygiene care in residential settings: A systematic review

INTRODUCTION

Globally, the population is ageing, and more people live in residential care. Best practice in personal hygiene care may reduce distressing and debilitating skin and oral problems and improve resident outcomes. Although there is guidance on personal hygiene care, implementation may be a challenge.

AIM

To identify barriers and facilitators to delivering personal hygiene care for older persons in residential care settings.

METHODS

Systematic review reported according to PRISMA 2020 guidance. Databases MEDLINE, CIHAHL and PsychINFO were systematically searched using terms and synonyms 'barriers', 'facilitators', 'hygiene', 'older adults' and 'residential care'. Only empirical studies, reporting everyday skin and oral care, in English, peer reviewed and published from 2000 to 2021 were included. Due to methodological heterogeneity, a narrative synthesis was conducted.

RESULTS

Sixteen papers yielded nine categories of barrier or facilitator. Five related to skin and oral care: (i) knowledge, (ii) skills relating to hygiene care, (iii) skills relating to supporting 'uncooperative' behaviours, (iv) lack of resources and (v) time, workload and staffing levels. The remainder related only to oral care: (vi) resident, family or carer motivation, (vii) dislike of hygiene care, (viii) carer attitudes and beliefs and (ix) social influences and communication. Six papers reported interventions to optimise care.

CONCLUSION

This review highlights the persistent dearth of research into everyday personal hygiene practices, in particular skin hygiene in residential care. Existing literature identifies a range of barriers; however, there is a mismatch between these and reported interventions to improve practice.

RELEVANCE TO CLINICAL PRACTICE

Advances in implementation science to support optimal care have yet to be applied to interventions to support hygiene practices in care homes and it is imperative this is addressed. Future interventions should involve: (i) systematically and theoretically assessing barriers, (ii) application of tailored behaviour change techniques (iii) using these co-design pragmatic, locally acceptable strategies.

Wearable Sweat Loss Measuring Devices: From the Role of Sweat Loss to Advanced Mechanisms and Designs

Wearable sweat sensors have received significant research interest and have become popular as sweat contains considerable health information about physiological and psychological states. However, measured biomarker concentrations vary with sweat rates, which has a significant effect on the accuracy and reliability of sweat biosensors. Wearable sweat loss measuring devices (SLMDs) have recently been proposed to overcome the limitations of biomarker tracking and reduce inter- and intraindividual variability. In addition, they offer substantial potential for monitoring human body homeostasis, because sweat loss plays an indispensable role in thermoregulation and skin hydration. Previous studies have not carried out a comprehensive and systematic review of the principles, importance, and development of wearable SLMDs. This paper reviews wearable SLMDs with a new health perspective from the role of sweat loss to advanced mechanisms and designs. Two types of sweat and their measurement significance for practical applications are highlighted. Then, a comprehensive review of advances in different wearable SLMDs based on hygrometers, absorbent materials, and microfluidics is presented by describing their respective device architectures, present situations, and future directions. Finally, concluding remarks on opportunities for future application fields and challenges for future sweat sensing are presented.

Two New Dexpanthenol-Containing Wash Gels: Skin Hydration, Barrier Function and Cosmetic Performance upon Single and Repeated Usage in Subjects with Dry Skin

Two novel body/face wash gels enriched with emollient ingredients (including dexpanthenol) were developed for the daily care of dry skin. Two similarly designed 2-week studies (N = 42 each) were conducted to assess the biophysical and cosmetic performance of each of the new wash gels in healthy adults with dry skin. Instrumental measurements quantified the effects of the wash gels on stratum corneum (SC) hydration and transepidermal water loss (TEWL) (with and without a previous sodium lauryl sulfate (SLS) challenge) after single and repeated usage. Following single and repeated applications of the face wash gel to facial skin, as well as to dry SLS-undamaged and SLS-damaged skin of the forearm, skin hydration significantly increased. Similarly, after single and repeated usage of the body wash gel to dry SLS-undamaged and SLS-damaged skin of the forearm, skin moisturization increased significantly from baseline; comparisons with control areas provided inconsistent results for SLS-undamaged skin. No effects on TEWL were observed for either product. Both wash gels were well tolerated and the cosmetic performances were appreciated by the subjects. The study results suggest that daily use of the new wash gels was associated with significant skin-moisturizing effects without adversely affecting skin barrier function and repair.

Effectiveness of bed bath methods for skin integrity, skin cleanliness and comfort enhancement in adults: A systematic review

Aim

To evaluate the effectiveness of bed bath methods for skin integrity, skin cleanliness and comfort enhancement in adults.

Design

A systematic review based on the PRISMA guidelines.

Methods

We searched for quantitative studies published between 2004–2020, using the PubMed, MEDLINE and CINAHL. The remaining 25 studies were appraised by the JBI tool.

Results

Only four of the included studies were of high quality. Studies of above moderate quality demonstrated that disposable towels were as effective as cotton towels for skin lesions and bacterial removal. Applying a hot towel maintained the skin barrier function and provided warmth; cotton towels were effective for cleaning even with weak pressure, and post‐bed bath moisturizer treatment contributed to skin integrity.

Conclusion

Although various methods have been examined, the available evidence is inadequate for establishing best practices. It is necessary to verify empirical research with rigorous methodology involving elderly inpatients and to develop instruments that measure patients' comfort.

Effect on autonomic nervous activity of applying hot towels for 10 s to the back during bed baths

BACKGROUND

Bed baths are a daily nursing activity to maintain patients' hygiene. Those may provide not only comfort but also relaxation. Notably, applying a hot towel to the skin for 10 s (AHT10s) during bed baths helped to reduce the risk of skin tears and provided comfort and warmth in previous studies. However, it is still unclear whether autonomic nervous system is affected by bed baths. Thus, this study investigated the effect on the autonomic nervous activity of applying hot towels for 10 s to the back during bed baths.

METHODS

This crossover study had 50 participants (25 men and women each; average age 22.2 ± 1.6 years; average body mass index 21.4 ± 2.2 kg/m2) who took bed baths with and without (control condition: CON) AHT10s on their back. Skin temperature, heart rate variability (HRV), and blood pressure (BP) were measured. Subjective evaluations and the State-Trait Anxiety Inventory in Japanese were also performed.

RESULTS

A significant interaction of time and bed bath type on skin surface temperature was observed (p < .001). Regarding the means of skin surface temperature at each measurement time point, those for AHT10s were significantly higher than those for CON. Although the total state-anxiety score significantly decreased in both the bed bath types after intervention, the mean values of comfort and warmth were higher for bed baths with AHT10s than for CON (p < .05) during bed baths; AHT10s was significantly higher in warmth than CON after 15 min (p = .032). The interaction and main effects of time on HRV and BP and that of bed bath type were not significant.

CONCLUSION

Bed baths that involved AHT10s caused participants to maintain a higher skin temperature and warmer feeling than under the wiping-only condition; they also provided comfort during the interventions. However, the bed baths with AHT10s did not allow participants to reach a relaxed state; moreover, there was no change in autonomic nerve activity. This may be due to participants' increased anxiety from skin exposure and the intervention being limited to one part of the body.

End-of-Life Care for Neonates: Assessing and Addressing Pain and Distressing Symptoms

One of the most essential components of end-of-life (EOL) care for neonates is assessing and addressing distressing symptoms. There is limited evidence to guide neonatal EOL symptom management and therefore significant variety in treatment (1-4). EOL neonatal palliative care should include identifying and relieving distressing symptoms. Symptoms to manage at neonatal EOL may include pain using both non-pharmacologic and pharmacologic comfort measures, respiratory distress, secretions, agitation and neurologic symptoms, nutrition and gastrointestinal distress, and skin care. Also of equal importance is communication surrounding familial existential distress and psychosocial care (1, 5-7). Institutions should implement a guideline for neonatal EOL care as guidelines have been shown to decrease variability of interventions and increase use of pharmacologic symptom management (4). Providers should consult with palliative care teams if available for added multidisciplinary support for family and staff, which has been shown to enhance EOL care in neonates (8, 9).

Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings

BACKGROUND

Ageing has a degenerative effect on the skin, leaving it more vulnerable to damage. Hygiene and emollient interventions may help maintain skin integrity in older people in hospital and residential care settings; however, at present, most care is based on "tried and tested" practice, rather than on evidence.

OBJECTIVES

To assess the effects of hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL, up to January 2019. We also searched five trials registers.

SELECTION CRITERIA

Randomised controlled trials comparing hygiene and emollient interventions versus placebo, no intervention, or standard practices for older people aged ≥ 60 years in hospital or residential care settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. Primary outcomes were frequency of skin damage, for example, complete loss of integrity (tears or ulceration) or partial loss of integrity (fissuring), and side effects. Secondary outcomes included transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema, and clinical scores of dryness or itch. We used GRADE to assess the quality of evidence.

MAIN RESULTS

We included six trials involving 1598 residential care home residents; no included trial had a hospital setting. Most participants had a mean age of 80+ years; when specified, more women were recruited than men. Two studies included only people with diagnosed dry skin. Studies were conducted in Asia, Australasia, Europe, and North America. A range of hygiene and emollient interventions were assessed: a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave-on body lotion; bed bath with "wash gloves" containing numerous ingredients; and application of a hot towel after usual care bed bath. In five studies, treatment duration ranged from five days to six months; only one study had post-treatment follow-up (one to eight days from end of treatment). Outcomes in the hot towel study were measured 15 minutes after the skin was wiped with a dry towel. Three studies each had high risk of attrition, detection, and performance bias. Only one trial (n = 984) assessed frequency of skin damage via average monthly incidence of skin tears during six months of treatment. The emollient group (usual care plus twice-daily application of moisturiser) had 5.76 tears per month per 1000 occupied bed-days compared with 10.57 tears in the usual care only group (ad hoc or no standardised skin-moisturising regimen) (P = 0.004), but this is based on very low-quality evidence, so we are uncertain of this result. Only one trial (n = 133) reported measuring side effects. At 56 ± 4 days from baseline, there were three undesirable effects (itch (mild), redness (mild/moderate), and irritation (severe)) in intervention group 1 (regimen consisting of a moisturising body wash and a moisturising leave-on lotion) and one event (mild skin dryness) in intervention group 2 (regimen consisting of body wash and a water-in-oil emulsion containing emollients and 4% urea). In both groups, the body wash was used daily and the emollient twice daily for eight weeks. There were zero adverse events in the usual care group. This result is based on very low-quality evidence. This same study also measured TEWL at 56 ± 4 days in the mid-volar forearm (n = 106) and the lower leg (n = 105). Compared to usual care, there may be no difference in TEWL between intervention groups, but evidence quality is low. One study, which compared application of a hot towel for 10 seconds after a usual care bed bath versus usual care bed bath only, also measured TEWL at 15 minutes after the skin was wiped with a dry towel for one second. The mean TEWL was 8.6 g/m²/h (standard deviation (SD) 3.2) in the hot towel group compared with 8.9 g/m²/h (SD 4.1) in the usual care group (low-quality evidence; n = 42), showing there may be little or no difference between groups. A lower score is more favourable. Three studies (266 participants) measured SCH, but all evidence is of very low quality; we did not combine these studies due to differences in treatments (different skin care regimens for eight weeks; wash gloves for 12 weeks; and single application of hot towel to the skin) and differences in outcome reporting. All three studies showed no clear difference in SCH at follow-up (ranging from 15 minutes after the intervention to 12 weeks from baseline), when compared with usual care. A clinical score of dryness was measured by three studies (including 245 participants); pooling was not appropriate. The treatment groups (different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days) may reduce dryness compared to standard care or no intervention (results measured at 5, 8, and 56 ± 4 days after treatment was initiated). However, the quality of evidence for this outcome is low. Outcomes of erythema and clinical score of itch were not assessed in any included studies.

AUTHORS' CONCLUSIONS

Current evidence about the effects of hygiene and emollients in maintaining skin integrity in older people in residential and hospital settings is inadequate. We cannot draw conclusions regarding frequency of skin damage or side effects due to very low-quality evidence. Low-quality evidence suggests that in residential care settings for older people, certain types of hygiene and emollient interventions (two different standardised skin care regimens; moisturising soap bar; combinations of water soak, oil soak, and lotion) may be more effective in terms of clinical score of dryness when compared with no intervention or standard care. Studies were small and generally lacked methodological rigour, and information on effect sizes and precision was absent. More clinical trials are needed to guide practice; future studies should use a standard approach to measuring treatment effects and should include patient-reported outcomes, such as comfort and acceptability.