Original Investigation
A Structured Skin Care Protocol for Preventing and
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Treating Incontinence-associated Dermatitis in Critically
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Ill Patients
Xiaoxue Zhang, MSc, RN; Xinran Wang, MSc; Xiaowei Zhao, BSc, RN; and Yu Zhang, MSc, RN
ABSTRACT
OBJECTIVE: To examine the effectiveness of a structured skin care protocol for
preventing and treating incontinence-associated dermatitis (IAD) in critically ill
patients.
METHODS: Participants were drawn from the ICUs of three teaching hospitals
between January 2016 and December 2017. Patients were eligible if they
were ≥18 years old, had idiopathic fecal incontinence, had diarrhea but were unable
to sense it, and were expected to stay in the ICU for at least 72 hours after
developing incontinence. A total of 143 patients were enrolled: 79 in the
experimental group and 64 in the control group. In the first phase of the study, routine
skin care measures were used; in the second phase, three ICU caregivers were
trained to provide a structured skin care protocol. Trained research team members
conducted the data collection and analysis. The TREND (Transparent Reporting of
Evaluations with Nonrandomized Designs) Statement Checklist was followed in
reporting the study results.
RESULTS: Application of the structured skin care protocol reduced the incidence of
IAD from 35.9% in the control phase to 17.7% in the intervention phase (χ2 = 6.117,
P < .05) and also decreased the severity of IAD (z = −2.023, P < .05). Further, IAD
developed later (z = −2.116, P < .05) in the intervention group than in the control
group. In addition, the nursing times to prevent or manage IAD did not differ
significantly between the groups (t = −0.258, P > .05; t = −1.190, P > .05).
CONCLUSIONS: Use of the developed structured skin care protocol for IAD in
critically ill patients lowered the incidence and severity of IAD and delayed IAD
development.
KEYWORDS: critically ill patient, incontinence-associated dermatitis, incidence,
skin care protocol
ADV SKIN WOUND CARE 2022;35:335–42.
DOI: 10.1097/01.ASW.0000828972.70137.8a
In the General Surgery Department at Xuanwu Hospital, Capital Medical University, Beijing, China, Xiaoxue Zhang is Nurse; Xinran Wang is Head Nurse and Professor; and Xiaowei Zhao is Head Nurse.
Yu Zhang is Nurse, Urinary Surgery Department, Beijing Hospital. Acknowledgments: This work was supported by the Beijing Municipal Administration of Hospitals Incubating Program (grant PX2016037)
and the Chinese Nursing Association Project (grant ZHKY201711). The authors gratefully acknowledge the financial support of the Beijing Municipal Administration of Hospitals Incubating Program and
Chinese Nursing Association Project. They also thank the nurses in three ICUs for their effort in the protocol implementation. The authors have disclosed no other financial relationships related to this
article. Submitted May 6, 2021; accepted in revised form July 23, 2021.
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INTRODUCTION
Incontinence-associated dermatitis (IAD) is a challeng-
ing clinical condition and a major risk factor for pressure
injury development.1,2 It is essentially an irritant derma-
titis caused by exposure of skin to urine or stool3 and is
defined as erythema and edema of the surface of the
skin, sometimes accompanied by bullae with serous
exudate, erosion, or secondary cutaneous infection; it
is characterized by red rash, skin impregnation, and
desquamation accompanied by burn, pain, pruritus,
or pricking, with or without infection.4 Because IAD is
often associated with extreme discomfort and pain, it
can negatively affect patients’ quality of life.5 Moreover,
IAD symptoms are aggravated in the case of secondary
infection, thereby making its management more difficult
for nursing staff.
Among patients with incontinence, the incidence of
IAD is highest among those with fecal incontinence or
diarrhea, indicating that these patients represent a high-
risk group for IAD.6,7 Stool contains a large number of
digestive enzymes,8,9 which are highly destructive to
skin. Critically ill patients are more prone to diarrhea be-
cause of the severity of disease and specialized treat-
ment conditions (eg, enteral nutrition),10,11 increased
intra-abdominal pressure caused by mechanical ven-
tilation,12 and drug-induced alteration of the intestinal
flora. The prevalence of fecal incontinence in the ICU
has been reported to be as high as 78%, and the preva-
lence of diarrhea has been reported to be 13%.13,14 In pa-
tients with fecal incontinence or diarrhea, skin integrity
is likely to be impaired, leading to a high incidence of
IAD among critically ill patients, at percentages of up
to 20.4% to 37%.2,15–17
Interventions aimed at IAD prevention have been
explored previously. However, in their systemic review,
Beeckman et al18 found that there is little evidence
335 ADVANCES IN SKIN & WOUND CARE • JUNE 2022
 regarding the effects of interventions for preventing and
treating IAD in adults; the evidence that does exist is of
low to moderate quality. Although a structured skin care
regimen for IAD was put forth in Best Practice Principles,
Incontinence-Associated Dermatitis: Moving Prevention For-
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ward,19 this regimen does not provide specific guidelines
for IAD prevention and control among critically ill pa-
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tients. In addition, few studies have investigated this
topic, and very few specific protocols have been re-
ported thus far for IAD interventions in critically ill pa-
tients.20 Some investigators used measures with the best
available evidence in critically ill patients and reported
that these measures help lower the incidence of IAD
and delay the occurrence of IAD. However, there are
some limitations to the use of preventive care measures
once IAD has already developed. Therefore, it is neces-
sary to develop and test a structured skin care protocol
for treating IAD that includes skin care measures that
can be applied after the occurrence of IAD.
Aims
This study aimed to (1) develop a structured skin care
protocol for preventing and treating IAD in critically ill
patients and (2) examine its effectiveness in reducing
the incidence and severity of IAD in critically ill patients.
METHODS
Sample and Setting
This research was carried out in three ICUs at three teach-
ing hospitals, including two comprehensive ICUs (an ICU
including all disciplines) and one surgical ICU. The three
ICU departments agreed to participate in this investiga-
tion, and the relatives of patients provided oral informed
consent for study participation.
Patients were included in this study if they were admit-
ted to the ICU during the study period, were ≥18 years of
age, had idiopathic fecal incontinence or urinary inconti-
nence, and would remain in the ICU for ≥72 hours after
the start of incontinence. For the purposes of this research,
incontinence meant that the patient could not control def-
ecation and urination and was experiencing diarrhea,
causing repeated irritation of the local skin, but was un-
aware of this condition because of mechanical ventilation
or impaired consciousness. Patients were excluded if they
had an existing skin injury in the perineum (eg, IAD,
pressure injury, skin avulsion); had prolapse of the anus,
neoplasms, or a perianal abscess; or had IAD prior to or
on admission to the ICU.
Based on a pilot test that investigated the effect of the
structured skin care protocol on the incidence of IAD
in critically ill patients, the sample size was calculated
according to an incidence decrease from 37% to 16%,
an α level of .05, and a power of 80%. The sample size
ADVANCES IN SKIN & WOUND CARE • JUNE 2022
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needed was estimated to be 66 participants in each
group (Figure 1).
Intervention and Control Procedures
For the control group, the standard skin care protocol was
followed, with nurses assessing the perineal and perianal
skin of the patient every shift. Patients were given daily
warm water baths and topical cleansing with water when
stool or urinary incontinence occurred.
The intervention group was managed with a new, struc-
tured skin care protocol (outlined in Tables 1 and 2) in addi-
tion to standard skin care interventions. The protocol was
initiated after the patient developed incontinence. Skin
integrity was assessed on admission and during hospi-
talization. Patients were bathed in bed once a day using
a basin bowl of water and pH-balanced soap.
Training
A special team was formed for the application of IAD
skin care in the intervention group. The team had the
head nurse of the surgery department as the team leader
and the ICU head nurse and ICU physician leader as
deputy team leaders. The other team members included
the ICU physician, the teaching secretary of the surgery
department, a wound professional nurse, and an ICU spe-
cialist nurse. The team provided protocol training for the
nursing staffs in the form of a workshop. The training ses-
sion was held every month to account for the rotation
of nurses, thereby ensuring that all nurses were familiar
with and experienced in implementing the protocol.
In the control group, the skin management team of the
department provided training on skin care for patients.
There were no physicians or clinical teachers among the
skin management team members. A training session was
held every month.
Data Collection
Researchers used a self-designed form to collect patient
data until patient transfer, death, or complete resolution
of dermatitis. The form included two parts: (1) general
demographic and clinical data of the patient and (2) data
regarding incontinence and IAD. These data were collected
by a research team member who had received special train-
ing for the purpose. Assessments of IAD severity were
made jointly by the research team member and the ICU
charge nurse to ensure accuracy of the evaluation results.
The nursing time was measured by another nurse in the
ICU using a stopwatch.
Assessment Tools
Activities of Daily Living. The Modified Barthel Index21
is a universally accepted scale to rate 10 activities of daily
living: feeding, bathing, grooming, dressing, bowel con-
trol, bladder control, toilet use, movement from bed to
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 Figure 1. STUDY FLOW DIAGRAM
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chair, level walking over a 50-m distance, and walking
up and down stairs. The total score is 100, with higher
scores indicating greater ability to live independently
with less dependency.
APACHE II Scale. The Acute Physiology and Chronic
Health Evaluation II (APACHE II) is a severity of disease/
injury classification system that consists of three parts: 12
acute physiologic variables, age, and chronic health status.
It was designed to predict an individual’s risk of dying in
a hospital.22
Braden Scale. The Braden Scale is a risk assessment tool
used to assess a patient’s risk of pressure injury development.
It is based on six common risk factors, including sensory
function, moisture, activity, mobility, nutrition, shearing
force, and friction.23
Nutrition Risk Screening 2002. The Nutrition Risk
Screening 2002 is a screening tool for malnutrition estab-
lished for the medical inpatient population. It includes
assessment of the patient’s nutrition status (based on
weight loss, body mass index, and general condition or
food intake) and disease severity (stress metabolism due
to the degree of disease) and is associated with higher risk
for adverse outcomes.24
The Bristol Stool Scale. According to this scale, stool
is classified into 7 types: types 1 to 4 are solid stool, type
5 is semisolid, and types 6 and 7 are liquid stool.25

Table 1. STRUCTURED SKIN CARE PROTOCOL FOR IAD PREVENTION AND MANAGEMENT APPLIED IN THE
INTERVENTION GROUP
Item Condition Measurement
Skin In case of IAD risk (incontinence) Evaluate the perineal skin every shift (8 h) to determine the existence of IAD
evaluation
Skin cleaning Clean the perineal skin after each defecation or Clean the skin with nonionic surfactant skin cleansing agent; use normal saline to clean the wound in case of
episode of incontinence skin defect
Skin Perineal skin is in good condition without Apply a skin barrier spray without alcohol to protect the skin from irritation of stool in case of stool types 1–5;
protection redness apply a skin barrier film to protect the skin in case of stool types 6–7
Skin appears pink or red, or a red rash appears Apply a skin barrier film without alcohol plus hydrocolloid dressings. The transparent or translucent dressings
might be applied on the edge of hydrocolloid dressings to prevent leakage of excrement or turned edge
Skin defect is observed If the skin is not infected, apply foam dressings to promote the absorption of seepage; if the skin is infected,
apply silver ion dressings that release silver ions with bioresistance for better wound healing
Perianal skin is broken and ulcerated Apply leakproof cream on the side of hydrocolloid dressings near the anus and on the exposed skin close to the
anus to prevent leakage and protect the skin from irritation of excrement
Record Nursing record is made according to IAD severity Record the evaluation result
evaluation result
Abbreviation: IAD, incontinence-associated dermatitis.

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 Table 2. PREVENTIVE MEASURES APPLIED IN THE CONTROL GROUP
Item Condition
Skin evaluation In case of IAD risk (incontinence)
Skin cleaning Clean the perianal skin after each defecation or episode of incontinence Use fresh water to clean the skin and dry it with paper
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Skin protection No IAD (the perianal skin is in good condition without redness)
Occurrence of IAD (IAD of each degree)
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Nursing record Recorded as perianal skin redness
Abbreviation: IAD, incontinence-associated dermatitis.
Risk of Incontinence-Associated Dermatitis. The Per-
ineal Assessment Tool assesses IAD risk. It includes four
items: the intensity of exposure to irritants, the duration
of exposure, the patient’s perineal and perigenital skin
condition, and other contributing factors.26 A higher score
indicates a greater risk of IAD.
Incontinence-Associated Dermatitis Severity. The
IAD severity evaluation tool (IADS) is used to evaluate the
severity of IAD.27 The Cronbach α coefficient and content va-
lidity for the Chinese version of the IADS scale have been
reported to be .875 and .93, respectively, which suggests
that the Chinese version of the IADS scale has good reli-
ability and validity.28 The scale covers 14 domains, with
each domain rated across four degrees of severity (pink,
red, red rash, and skin defect) that are assigned corre-
sponding points. The severity of IAD is determined by
the total score for all 14 domains, with a higher number
of points indicating more severe IAD (Figure 2).
Outcome Indicators
The primary outcome was the incidence of IAD. Second-
ary outcomes included the time to IAD development
and nursing time for skin care related to incontinence
and IAD.
Figure 2. AREAS AFFECTED BY INCONTINENCE-ASSOCIATED DERMATITIS
ADVANCES IN SKIN & WOUND CARE • JUNE 2022
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Measurement
Evaluate the perianal skin every shift (8 h) to determine the existence of IAD
Apply skin protectant
If the skin is not infected, apply a skin repairing product; if the skin is infected,
apply the skin-repairing product plus an anti-infective drug
Record the area of redness and whether any skin defect is present
Ethical Considerations
This study was approved by the ethics committees of the
hospitals involved in the study, and the research ob-
jective and methods were explained to the patients
and their families before oral consent was obtained for
study participation.
Data Analysis
All statistical analyses were performed using SPSS soft-
ware, version 23.0 (IBM Corp, Armonk, New York). Data
for parameters showing normal distribution were expressed
as mean (SD) and were analyzed with t tests. Other pa-
rameters without normal distribution were represented
as median and interquartile range and analyzed by non-
parametric tests. The numerical data were expressed in
percentage and analyzed using the χ2 test.29 P < .05 sug-
gested statistical significance.
RESULTS
Of the 3,747 patients assessed for eligibility in three ICUs
at three teaching hospitals between January 2016 and
December 2017, 145 patients treated met the inclusion
criteria for the study. Of these, 79 participants were in the
intervention group, and 64 were in the control group; 2
338 WWW.ASWCJOURNAL.COM
 patients had incomplete information. Comparison of intervention group developed IAD, an incidence of 17.7%.
the two groups revealed no statistically significant in- The difference in IAD incidence between the two groups
tergroup differences in terms of their demographic was statistically significant ( P < .05). The IADS scores in the
and clinical characteristics ( P > .05, Table 3). control group and intervention group were 2 (1.00, 3.00)
In the control group, 23 patients developed IAD for and 1 (1.00, 1.25) points, respectively, with a statistically
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an incidence of 35.9%. By comparison, 14 patients in the significant intergroup difference (z = −2.023, P < .05).
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Table 3. DEMOGRAPHIC AND CLINICAL DATA OF PATIENTS (N = 143)

Variable Control Group (n = 64) Intervention Group (n = 79) Statistics P
Male, n (%) 40 (62.5) 50 (63.3) χ = 0.009
2
.922
Age, mean (SD), y 69.38 (17.42) 70.13 (15.17) t = −0.276 .783
Body mass index, mean (SD), kg/m2 23.13 (4.20) 23.75 (3.67) t = −0.684 .496
Disease diagnosis, n (%) χ = 5.152
2
.525
Cerebral infarction 3 (4.7) 9 (11.4)
Cerebral hemorrhage 3 (4.7) 4 (5.1)
Cerebral trauma 5 (7.8) 3 (3.8)
Pancreatic disease 5 (7.8) 8 (10.1)
Infectious diseases 7 (10.9) 14 (17.7)
Cancer 7 (10.9) 7 (8.9)
Others 34 (53.1) 34 (43.0)
State of consciousness, n (%) χ2 = 0.675 .411
Conscious 40 (62.5) 44 (55.7)
Unconscious 24 (37.5) 35 (44.3)
Underlying disease, n (%) 52 (81.3) 70 (88.6) χ2 = 1.528 .216
Temperature, n (%) χ2 = 2.966 .397
36–37.2° C 44 (68.8) 48 (60.8)
37.3–38° C 12 (18.8) 24 (30.4)
38.1–39° C 6 (9.4) 6 (7.6)
39.1–41° C 2 (3.1) 1 (1.3)
Barthel Index, median (IQR) 12 (0, 28) 15 (0, 30) Z = −0.213 .831
APACHE II score, mean (SD) 16.34 (6.72) 16.36 (5.78) t = −0.020 .984
Braden Scale score, mean (SD) 11.81 (1.745) 12.37 (2.107) t = −1.688 .094
NRS 2002 score, median (IQR) 4 (3, 6) 4 (3, 6) Z = −0.470 .638
Serum albumin level, n (%) χ2 = 1.522 .217
35–55 g/L 8 (12.5) 16 (20.3)
<35 g/L 56 (87.5) 63 (79.7)
Nutrition support pattern, n (%) χ2 = 3.171 .205
Enteral nutrition 36 (56.2) 48 (50.8)
Parenteral nutrition 17 (26.6) 12 (15.2)
Enteral + parenteral 11 (17.2) 19 (24.0)
Types of antibiotics, n (%) χ2 = 1.504 .681
0 4 (6.3) 4 (5.1)
1 26 (40.6) 40 (50.6)
2 29 (45.3) 29 (36.7)
≥3 5 (7.8) 6 (7.6)
Application of sedatives, n (%) 15 (23.4) 20 (25.3) χ2 = 0.068 .795
Mechanical ventilation, n (%) 30 (46.9) 31 (39.2) χ2 = 0.842 .359
Abbreviations: APACHEII, Acute Physiology and Chronic Health Evaluation II; IQR, interquartile range; NRS, Nutrition Risk Screening.

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 Table 4. IAD INCIDENCE IN THE CONTROL AND INTERVENTION GROUPS
Intervention Group (n = 79) Control Group (n = 64) Statistics (χ2/z) P
IAD incidence, n (%)
No IAD 65 (82.3) 41 (64.1) 6.117 .013a
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Occurrence of IAD 14 (17.7) 23 (35.9)

IAD severity (points) 1 (1, 2.5) 2 (1, 3) −2.023 .043a
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Occurrence site, n (%) 0.862 .353

One site 9 (64.3) 18 (78.3)
Multiple sites 5 (35.7) 5 (21.7)
Perianal skin 3 23 22.522 <.01b
Gluteal fold 14 5
Genitalia 4 1
Buttocks 2 5
Groin fold 1 2
Thigh 0 1
Lower abdomen 0 0
IAD formation time, median (IQR) 8 (6, 12.25) 2 (1, 10) −2.116 .036a
Abbreviations: IAD, incontinence-associated dermatitis; IQR, interquartile range.
a
P < .05.
b
P < .01.

Similarly, the time to the development of IAD in the in-
tervention group was significantly longer than that in
the control group (z = −2.116, P < .05), thereby indicating
a delay in the onset of IAD. However, no significant dif-
ferences were noted between the two groups in terms of
the site of occurrence of IAD (χ2 = 6.117, P > .05; Table 4),
although as seen in Figure 3, the area in which IAD oc-
curred in the experimental group after preventive
measures was limited to a certain extent and less likely
to spread to the thigh area than in the control group
with a statistically significant intergroup difference
(χ2 = 22.522, P < .01; Table 4).
The difference in nursing time devoted to care for
incontinence and IAD between the intervention group
and the control group was not statistically significant
(t = −0.258, P > .05; t = −1.190, P > .05; Table 5). No adverse
events associated with the intervention were observed
during the study.
DISCUSSION
The present study describes a structured management
protocol for preventing IAD in critically ill patients ad-
mitted to the ICU. This protocol was applied in practice
by providing appropriate training to medical personnel,
and a total of 12 training sessions were completed during
the research phase. The results indicated positive outcomes
from the protocol, with significantly lower incidence
and lower severity of IAD in the intervention group com-
pared with the control group. However, the intervention
and control groups did not show any statistically signif-
icant differences in terms of the duration of nursing care
for incontinence and IAD.

Figure 3. DISTRIBUTION OF AREAS AFFECTED BY INCONTINENCE-ASSOCIATED DERMATITIS BY GROUP

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Table 5. NURSING TIME FOR TREATMENT OF
INCONTINENCE AND IAD
Control Group Intervention Group
Mean (SD) Mean (SD)
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Time spent on patients with 18.39 (9.39) 17.71 (6.52)
IAD, min
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Time spent on patients without 8.77 (1.38) 7.56 (1.53)
IAD, min
Abbreviation: IAD, incontinence-associated dermatitis.
Critically ill patients are at a high risk for IAD because
they have many specialized care needs. For example,
some patients may require purgative therapy, a type of
a therapeutic method for eliminating retained intestinal
objects with purgation, which induces diarrhea. Various
studies report different values for the incidence of IAD.30,31
With this structured skin management protocol, the inci-
dence of IAD in critically ill patients was only 17.7%, sig-
nificantly lower than the rates reported in other studies20
and 18.2% lower than that of the control group.
The intervention and control groups differed with re-
spect to the severity of IAD as well, with the disease being
less severe in the intervention group. Coyer et al20 found
that a skin care bundle effectively reduced IAD incidence
although the IAD that developed was more severe than
that observed with conventional intervention strategies.20
However, a variety of skin-protective dressings were used
in this study. Different skin protection products and mea-
sures were used according to the clinical manifestations
in different stages of IAD. A skin protective film was used
to avoid direct contact with the exudation of the stool,
whereas foam dressing was used to protect areas where
skin was missing. These approaches have been reported
to significantly reduce wound healing time, exudate and
secretions, and the required number of dressing replace-
ments, as well as to decrease the extent of damage to the
healing epithelium during dressing changes.32 For in-
fected wounds, silver ion dressing was used, which pro-
vides both foam dressing for protection against exudate
and the antibacterial action of silver ions. Studies have
shown that the bacteriostatic action of the dressing can
exert its protective effects within 30 minutes for up to
7 days, thereby providing enhanced control of wound in-
fection and wound healing.33 These measures together
play a role in preventing the progression of dermatitis.
Currently, intervention for IAD in clinical practice relies
only on the consensus of experts based on experience; how-
ever, it is necessary to develop a specific protocol for pre-
venting and treating IAD to ensure standardized nursing
care. The present study reports a new clinical care plan for
IAD in critically ill patients, which was developed based
on the researchers’ clinical experience as well as globally
accepted management protocols. The two key points in
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the prevention and control of IAD are treatment of inconti-
nence and a structured skin care protocol. Specifically, the
protocol encompasses steps for evaluation, skin cleaning,
T P and skin protection. Evaluation of the patient in terms of
−0.258 .798 care required is a fundamental prerequisite of nursing.
Complete, comprehensive, and correct nursing evaluation
−1.190 .237
ensures the administration of high-quality nursing care,34
and patient evaluation is one of the nine core competencies
a nurse should possess.35 Because IAD develops rapidly in
the presence of risk factors, the IAD evaluation tool included
as part of this protocol helps standardize nursing care
and aids nurses in applying appropriate nursing inter-
ventions according to the severity of IAD. In the structured
skin care protocol, specific care methods were defined for
different stages of IAD, combining the two principles of skin
cleaning and skin protection, which provides a back-
ground for nurses to administer appropriate care.
Limitations
The nonblinded, pre/post design limits interpretation of
the results because confounders (eg, changes in staff, the
evolution of care over time) were not controlled, treat-
ments were not randomized, and outcome assessors were
not blinded. Further, the lack of follow-up of the complete
course of IAD in the patients precluded an analysis of the
progression and outcomes of the condition. Additional
studies are necessary to overcome these limitations and
confirm the potential benefit and applicability of this
structured skin care protocol and testing in other inten-
sive care populations.
CONCLUSIONS
The present study demonstrated that application of the
structured skin care protocol decreased the incidence
and severity of IAD in ICU patients and delayed IAD
development to some extent. Use of this method is ex-
pected to reduce the nursing time required for the man-
agement of IAD, although further studies are warranted
for confirmation. •
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1. Coleman S, Nixon J, Keen J, et al. A new pressure ulcer conceptual framework. J Adv Nurs 2014;70:
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