Ms. Nix is an associate director for the webWOC Nursing Educational Program in partnership with Metropolitan State University, Minnesota. Her experience includes implementation and ongoing coordination of a hospital wound and skin care program, lecturing, publishing, consultation and clinical research related to wound, ostomy, and continence issues. Wounds1 recently spoke with Ms. Nix about the details of bathing and moisturizing.
Wounds1: First of all, what is a WOC Nurse?
Ms. Nix: Wound, Ostomy and Continence (WOC) Nurses manage conditions such as stomas, draining wounds, fistulas, vascular ulcers, pressure ulcers, neuropathic wounds, urinary incontinence, fecal incontinence, and functional disorders of the bowel and bladder. There are an estimated 750,000 persons with ostomies in North America, and more than 70,000 new ostomy surgeries are performed annually in the United States and Canada. Urinary incontinence affects more than 10 million Americans. Up to 50% of patients in nursing homes experience fecal incontinence, and the condition is found in two to three out of 100 patients in hospitals. More than one million new cases of pressure ulcers occur each year, and 60,000 deaths per year are attributed to this problem. WOC nurses are recognized for delivering high quality, cost effective care that is essential in today's health care environment. Their role includes: consultation, education for patients, families and staff, product selection, counseling, program development for the prevention of skin breakdown and in some cases research. Studies show that WOC Nurse involvement can help shorten hospitalization by an average of 3 days.
Wounds1: Does type of cleanser really matter?
Ms. Nix: Yes. It depends on the need of the person using the product. The ideal skin cleanser should remove unwanted germs without the need for aggressive scrubbing that could damage the skin. An elderly person living at home or in a nursing home will require a gentle product with a pH between 4 to 7 for general bathing. The healthcare worker will need an acceptable pH for washing their hands, however, an antimicrobial ingredient will also be needed to combat frequent exposure to contaminants. A cleanser for incontinent clean- up will need to be gentle and easy to use. There are perineal cleansers that require rinsing and some that do not. Some perineal cleansers will leave an ingredient behind that will protect the skin such a petrolatum or dimethicone. Again a pH from 4 to 7 is recommended for perineal cleansers. Choice between rinse and no- rinse, or an added protecting ingredient, depends on personal preference and budget.
Wounds1: What is pH and why is it important?
Ms. Nix: Healthy skin is acidic with a pH of 5.5 to discourage bacteria from growing. The pH of a skin care product influences the skin’s pH. For example, repeated washings with an alkaline soap will increase the pH of the skin. A product with a pH of 4 to 7 is recommended for skin cleansing particularly for the elderly patient because their skin is drier, more prone to cracking, and slower to recover from the effects of alkaline substances when compared to the skin of younger adults.
Wounds1: Should I use an antibacterial cleanser to keep all of the bacteria off my skin so I don’t get sick?
Ms. Nix: Actually, we all have a certain amount of normal bacteria on our skin that helps to prevent sickness. The normal skin organisms or normal flora is a normal and necessary part of our immune system. The bacteria on our skin or normal flora resists invasion from other types of bacteria that can make us sick. I’m over- simplifying this process. It’s actually very complex and like so much of what our body does, completely amazing.
Wounds1: When should an antibacterial soap be used?
Ms. Nix: Researchers raise concerns that regular use of antimicrobials may increase the risk of germs developing that can become resistant to the products intended to remove or destroy them. Therefore antimicrobial cleansers are not recommended for general bathing. An antimicrobial cleanser is recommended for health care providers with a high frequency of handwashing (8 or more times per day).
Wounds1: Which are better, liquid or bar cleansers?
Ms. Nix: Some experts on infection control state that bar soaps are frequently misused because they are stored carelessly in contact with moisture. In some cases, this may be responsible for the transfer of bacteria from one user to another. Other researchers have disputed these claims. Many bar cleansers have a pH between 7 and 11. Ingredients can be added to products to adjust for a high pH but the ingredient can cause the bar to form a gelatinous material creating an excellent place for bacteria to grow. There is an attempt to compensate for this by adding a filler such as dextrin or starch, which can create a rough surface texture. The Center for Disease Control (CDC) recommends placement of bar soap on drainable racks to keep it dry and minimize bacteria. Not all liquid cleansers have the right pH and bacteria can grow in the containers if they are not replaced or refilled without properly cleaning the container. My opinion is that there are fewer potential problems with the use of liquid cleansers.
Wounds1: Is there such a thing as cleansing my skin too often?
Ms. Nix: The concern is dry skin that can occur with frequent bathing. The frequency of skin cleansing should be individualized according to need. One should avoid hot water and use a mild cleansing agent. During the cleansing process, care should be taken to minimize the force and friction applied to the skin so washcloths should be soft. Dry skin should be treated with moisturizers. Better yet, prevent dry skin by moisturizing. A cleanser with a moisturizer in it may not be enough, so follow-up bathing with moisturizing.
Wounds1: If dry skin does not bother me, why is it a problem?
Ms. Nix: Your skin is the dividing line between you and the environment. It is a vital part of our immune system and protects us from harmful agents in the environment. Dry, cracked skin is a place for unwanted bacteria to live. Dry skin is weak skin and can increase the risk for skin tears and pressure ulcers in vulnerable individuals. At least 1.5 million skin tears occur each year in institutionalized adults. Researchers have emphasized the importance of the maintenance of tissue hydration including the use of lotion for the prevention of skin tears.
Wounds1: What is the difference between sealants, creams, and emollients?
Ms. Nix: Creams are water in oil. Ointments are oil in water emulsions. Barrier pastes are ointments mixed with a fine powder. Skin sealants are liquid barrier films made of polymers and solvents. The solvent evaporates after the product is applied to the skin, leaving behind a protective film.
Wounds1: What about alcohol? Shouldn’t that ingredient be avoided?
Ms. Nix: Not always. Alcohols are a diverse group of products and have a variety of effects depending on their specific formulation. Some alcohols act as antimicrobial agents, others function as a preservative. Surprisingly, cetyl or stearyl alcohols serve as emollients and thickening agents when added to moisturizers or lubricants. When used in this context, they safely enhance the total formula of the product and are not drying or irritating to the skin.
Wounds1: Should skin care products include preservatives?
Ms. Nix: Yes. Preservatives help prevent the product from breaking down and from becoming contaminated with bacteria. Chloroxylenol (PCMX), triclosan, methyl, benzoic acid, and sorbic acid are just a few examples of preservatives. As preservatives, these products are effective against certain types of bacteria in the package and are NOT designed to remove the same bacteria from the skin.