ABSTRACT
OBJECTIVE:
To explore the efficacy of a double-pocket fecal catheter system combined with camellia oil application in the prevention and treatment of irritant contact dermatitis (ICD) due to incontinence among patients in the intensive care unit (ICU).
METHODS:
A total of 248 patients admitted to the integrated ICU of the authors’ hospital between January 1, 2022, and December 31, 2023, were selected. Among them, 204 high-risk patients with ICD due to incontinence were identified using the perineal assessment tool. The high-risk patients were divided into research group 1 (camellia oil application), research group 2 (double-pocket fecal catheter system combined with zinc oxide ointment application), research group 3 (double-pocket fecal catheter system combined with camellia oil application), and the control group (zinc oxide ointment application). The incidence, time of onset, severity, daily treatment cost, nursing efficiency, and healing time of ICD due to incontinence were compared among different groups.
RESULTS:
Different treatment methods had varying effects on the incidence (χ2=14.211, P<.001), time of onset (F=5.521, P=.013), severity (P=.023), daily treatment cost (F=9.607, P<.001), nursing efficiency (P=.037), and healing time of ICD due to incontinence (F=3.907, P=.028). The performance of research group 3 in terms of ICD due to incontinence onset and healing times was superior to that of the other groups, with statistically significant differences (P<.001).
CONCLUSIONS:
Camellia oil combined with a double-pocket fecal catheter system exhibits high efficacy in the prevention and treatment of ICD due to incontinence among patients in the ICU.
KEYWORDS: camellia oil, double-pocket fecal catheter system, intensive care unit, irritant contact dermatitis
INTRODUCTION
Irritant contact dermatitis (ICD) due to incontinence is an inflammation of the skin associated with exposure to urine or stool caused by uncontrolled urination and defecation, manifested as erythema, red rash, maceration, erosion, and even skin peeling, and it can occur at any age. The affected skin areas include the perineum, sacrococcygeal region, buttocks, groin, and medial and posterior thighs.1,2 Healthy skin serves as a major natural barrier against environmental factors and irritants, such as excessive moisture and absorbed substances. Among patients in the intensive care unit (ICU), various factors such as trauma, restricted frictional activity, medication, incontinence, and malnutrition can damage the skin barrier function. In addition, due to weakened cognitive and sensory functions, most patients are unable to fully respond to pain induced by compression or moisture stimulation, thereby promoting ICD due to the occurrence of incontinence.3–5 The ICU is a place for the centralized monitoring and treatment of critically ill patients. The prevalence of ICD due to incontinence among inpatients is 5% to 7%, with the highest incidence in ICU wards (up to 36% to 50%), where elderly patients are at the greatest risk.6 Irritant contact dermatitis due to incontinence is the most common complication among elderly patients in ICUs,7 with a prevalence of 14%. Of these cases, 5.5% are accompanied by pressure injuries (PIs) and 11.3% by mycotic dermatitis,8 mainly occurring in patients with urinary or fecal incontinence. Excessive moisture on the skin surface can lead to skin maceration, induce chemical and physical irritation, enhance skin permeability, and damage the skin barrier function.9
The key to preventing ICD due to incontinence is the early identification and management of the causes of incontinence, as well as defining high-risk and vulnerable populations and developing targeted skin care plans. Skin cleaning and protection are crucial measures for preventing and managing ICD due to incontinence.10 Currently, one of the most important indicators for evaluating community-accredited hospitals is reducing skin damage, such as PIs. Nursing staff lack not only an evaluation system for ICD due to incontinence but also a mature understanding of it. Once skin problems occur in patients, developing an effective skin care plan becomes particularly important. The prevention of ICD due to incontinence is more important than its treatment, and the key to prevention is effective skin care by maintaining cleanliness and a normal skin environment. Skin cleaning can prevent irritation and damage caused by urine and stool. The prevention and treatment of ICD due to incontinence mainly involve 3 aspects: cleaning, moisturizing, and using skin protectants. A programmatic and standardized skin care plan that involves those aspects can effectively decrease the incidence of ICD due to incontinence; delay its onset; improve nursing efficiency; save nursing time, workload, and costs; and enhance patient satisfaction.11,12
The double-pocket fecal catheter system consists of feces-catching pockets made from circular membrane material with dual pockets. It drains and stores patients’ loose or formed stools in a collector while maintaining the normal physiological function of the anus. This system is characterized by its convenient and safe clinical application. Camellia oil is an edible oil obtained by pressing the mature seeds of Theaceae plants. This oil is widely used externally in dermatology and is easily absorbed by the skin; it has lubricating effects without being greasy.13 Camellia oil is mainly composed of unsaturated fatty acids, such as oleic, linoleic, and linolenic acids, as well as a small amount of saturated fatty acids. It has excellent skin affinity and permeability, protecting the skin and moisturizing it, thereby improving patient comfort.14
Most existing research is limited to local skin care after ICD occurrence without paying attention to its evaluation and preventive interventions.15 Moreover, there is relatively little research on the double-pocket fecal catheter system or camellia oil in ICD prevention. Therefore, a research question was posed: What is the effect of the double-pocket fecal catheter system combined with camellia oil application in preventing irritant contact dermatitis? Building on this, this study focuses primarily on local skin care for preventing ICD due to incontinence in patients in ICUs. It explores the efficacy of a double-pocket fecal catheter system and the local application of camellia oil for skin protection and clinical ICD prevention in this population.
METHODS
Participants
Using the convenience sampling method, 248 patients admitted to the integrated ICU of the authors’ hospital between January 1, 2022, and December 31, 2023, were selected. Among them, 204 high-risk patients with ICD due to incontinence were identified using the Perineal Assessment Tool (PAT). Based on a random number generator, the high-risk patients were divided into research group 1 (camellia oil application), research group 2 (double-pocket fecal catheter system combined with zinc oxide ointment application), research group 3 (double-pocket fecal catheter system combined with camellia oil application), and the control group (zinc oxide ointment application). The specific operation was as follows: SPSS 26.0 software was used to generate 204 random numbers corresponding to the ascending order from 1 to 204. These 204 random numbers were then randomly coded as 1, 2, 3, or 4. Numbers coded as 1 were assigned to research group 1, those coded as 2 were assigned to research group 2, those coded as 3 were assigned to research group 3, and those coded as 4 were assigned to the control group. The inclusion criteria were as follows: (1) age ≥18 years; (2) critically ill and bedridden patients in ICU wards; (3) 3 or more episodes of urinary incontinence (involuntary leakage of urine from the urethra), fecal incontinence (inability to control gas or fecal discharge from the anus, type 5, 6, or 7 on the Bristol Stool Form Scale, a scale of stool types ranging from the hardest, type 1, to the softest, type 7. Types 1 and 2 are considered abnormally hard stools, whereas types 5, 6, and 7 are considered abnormally loose/liquid stools)16 or double incontinence within 24 hours; (4) intact skin in the perineum, perianal area, and buttocks; (5) no ICD occurrence at admission; and (6) admission time ≥24 hours. The exclusion criteria were as follows: (1) presence of ICD; (2) allergic dermatitis caused by other reasons; (3) allergy to zinc oxide or camellia oil; (4) patients with incontinence with diabetes and malignant tumors; (5) current PIs; (6) other skin diseases; (7) deep skin pigmentation in the measurement area; (8) erythema of the groin, thighs, buttocks, or scrotum that required local treatment; (9) inability to tolerate or persist in the experiment; and (10) transfer or death.
Ethical Approval
This study was conducted in accordance with the Declaration of Helsinki. The studies involving human participants were reviewed and approved by the First Affiliated Hospital of Gannan Medical University, Jiangxi (approval No.: LLSC-2023 No. 292). The patients/participants provided their written informed consent to participate in this study.
Research Methods
Perineal Assessment Tool
The risk of ICD due to incontinence was assessed in all individuals using the PAT, as shown in Table 1. This tool consisted of 4 parts: type of irritant, stimulation time, perineal skin condition, and constituent factors. Scoring was performed on a 3-point Likert-type scale, with each subscale ranging from 1 point (lowest) to 3 points (highest), resulting in a total score range of 4 to 12 points. A higher score indicated a higher risk of developing ICD due to incontinence.
TABLE 1.
GENERAL DATA
| Item | Research Group 1 (n=51) | Research Group 2 (n=51) | Research Group 3 (n=51) | Control Group(n=51) | F/χ2 | P |
|---|---|---|---|---|---|---|
| Sex, n (%) | 1.198 | .753 | ||||
| Male | 31 (60.78) | 29 (56.86) | 33 (64.71) | 28 (54.90) | ||
| Female | 20 (39.22) | 22 (43.14) | 18 (35.29) | 23 (45.10) | ||
| Age, y | 55.32±4.21 | 56.87±4.55 | 56.61±3.98 | 57.08±4.04 | 4.829 | .747 |
| Height, m | 1.67±0.26 | 1.65±0.24 | 1.68±0.21 | 1.67±0.28 | 2.574 | .136 |
| Weight, kg | 55.24 ±5.07 | 54.77±4.81 | 55.95±6.21 | 56.09±6.10 | 2.851 | .112 |
| PAT | 9.51±2.30 | 9.33±2.17 | 9.14±1.98 | 9.46±2.11 | 1.168 | .802 |
| Incontinence type, n (%) | 1.259 | .974 | ||||
| Fecal incontinence | 17 (33.33) | 19 (37.25) | 15 (29.41) | 16 (31.37) | ||
| Urinary incontinence | 16 (31.37) | 16 (31.37) | 18 (35.29) | 15 (29.41) | ||
| Double incontinence | 18 (35.29) | 16 (31.37) | 18 (35.29) | 20 (39.22) |
Abbreviation: PAT, Perineal Assessment Tool.
Classification of ICD Due to Incontinence Severity
According to the Incontinence-Associated Dermatitis Guidelines, the severity of ICD was classified as mild, moderate, or severe.17 Mild ICD: the affected skin was dry and intact, with no defects or blisters, slight redness, unclear boundaries, and a slightly elevated skin temperature upon palpation. Patients reported a burning sensation or mild pain. Moderate ICD: the affected skin was not intact, showing small-area defects and a reddish or deep red color. The skin was also shiny and moist with blisters, local damage, spotting, exudation, and bleeding. Patients complained of significant pain. Severe ICD: the skin was seriously damaged, with large-area defects and a deep red, yellowish-white, or even purple color. The partially defective area was accompanied by blood and fluid oozing.
Nursing Methods
Control Group
After each bowel movement, the perineal skin was rinsed with warm water at 37 °C to 39 °C to ensure that all skin wrinkles were cleaned. The remaining moisture was then absorbed using a clean, soft towel, and the area was dried. Bed sheets and urine pads were promptly replaced to maintain a clean and dry bed unit. Following standardized care of the perineal skin, zinc oxide ointment was applied. Prepared zinc oxide ointment was applied with a cotton swab, starting from the perineum and extending outward, avoiding the urethra, vagina, and anus. The application extended 2 cm beyond the area affected by dermatitis, with the thickness of the ointment just covering the skin. Gentle massaging was performed after each application, which was done twice per day, with the ointment left on for more than 2 hours each time.
Research Group 1
After standardized care, the perineal skin was treated with Gannan camellia oil from the Gannan region of Jiangxi. A cotton swab was used to apply the prepared camellia oil, starting from the perineum and extending outward. The application covered the perianal region, avoiding the urethra, vagina, and anus, extending 2 cm beyond the area affected by dermatitis. The oil was applied to achieve an oily layer on the skin. Gentle massaging was performed after each application, which was done twice per day, with the oil left on for more than 2 hours each time.
Research Group 2
After standardized care of the perineal skin, the patients were positioned in the left lateral decubitus position on the right edge of the bed, with both legs bent and the anus exposed. Zinc oxide ointment was applied before inserting the airbag. The inner ring was inserted into the anus while the patient was in the lateral position, and the inner airbag was inflated with ~12 mL of air at a pressure of 30 cm H2O. The fecal catheter system was gently pulled to straighten it and expose the outer airbag, which was then inflated with about 8 mL of air at a pressure of 30 cm H2O. The fecal catheter system (Figure) was then fixed to the anus and connected to the feces catcher pockets. Airbag pressure was measured every 6 hours to prevent air leakage. If the airbag pressure remained stable, it was measured once a day. Perianal care was performed twice daily to keep the perineal region dry, and contaminated dressings were replaced promptly. The catheter was replaced once a week by pulling it out after emptying the airbag while the patient remained in the lateral decubitus position. The stool collector was replaced based on its filling condition. Observations included feces discharge, catheter detachment, leakage, and obstruction.
FIGURE.
PHOTO OF THE FECAL COLLECTION DEVICE
Research Group 3
Based on the method in research group 2, zinc oxide ointment was replaced with camellia oil.
Research Indicators
Incidence of ICD due to incontinence: the ratio of patients with ICD due to incontinence to total patients in each group was calculated.
Time of ICD due to incontinence onset: the time of onset of ICD due to incontinence was defined as the time from patient enrollment to the presence of ICD due to incontinence, with “d” as the unit.
Severity of ICD due to incontinence: according to the 2015 Guidelines for Classification of ICD due to incontinence severity,17 the severity of ICD due to incontinence was determined as mild, moderate, and severe.
Treatment cost: daily treatment cost=(total cost per fecal incontinence episode × number of episodes + total cost of ICD due to incontinence treatment)/d.
Nursing efficiency of ICD due to incontinence: the efficacy of the nursing methods applied to patients with ICD due to incontinence in the intervention groups was evaluated. Effective outcomes included “cured” and “effective.” The effective rate was calculated as follows: (effective cases + cured cases)/total cases of ICD due to incontinence in each group × 100%. Cured had the following characteristics: moist, swollen, and erythematous skin recovered without obvious itching or any skin discomfort. Effective had the following characteristics: moist, swollen, and erythematous skin was reduced, and skin itching and other symptoms were significantly alleviated. Participants had the following characteristics: moist, swollen, and erythematous skin was unchanged or enlarged; symptoms and signs did not significantly improve or worsen and complications increased.18
Healing time of ICD due to incontinence: the healing time of ICD due to incontinence was measured from onset to recovery, with “d” as the unit.
Statistical Methods
The data were statistically analyzed using SPSS 26.0. Measurement data were expressed as ±s and analyzed by the F test. Enumeration data were described as frequency (n) or rate (%). The satisfying data were analyzed using the χ 2 test, whereas the nonsatisfying data were analyzed using the Fisher exact probability test. The significance level was set at α=0.05.
RESULTS
General Data
The skin risk of the 248 patients admitted to the ICU was screened using PAT, and 204 patients showed a PAT score of 7 to 12, suggesting that 82.26% of them were at risk of developing ICD due to incontinence. Among the high-risk patients with ICD due to incontinence, there were 121 (59.31%) men, aged 27 to 90 years, with a height of 1.47 to 1.87 m and a weight of 44.82 to 77.15 kg. In addition, 67 (32.84%) patients suffered from fecal incontinence, 65 (31.86%) from urinary incontinence, and 72 (35.29%) from double incontinence. No statistically significant differences were found in sex, age, height, weight, PAT scores, or type of incontinence among the groups (P>.05), as shown in Table 1.
Comparison of ICD Due to Incontinence Incidence
As seen in Table 2, after different intervention measures, ICD due to incontinence incidence was 43.14% in the control group (n=22), 37.25% in research group 1 (n=19), 31.37% in research group 2 (n=16), and 21.57% in research group 3 (n=11). The intergroup differences were statistically significant (χ2=14.211, P<.001). Pairwise comparison showed statistically significant differences between the control group and research group 3 (χ2=12.829, P<.001), as well as between research group 1 and research group 3 (χ2=7.933, P=.005).
TABLE 2.
COMPARISON OF INCIDENCE OF ICD DUE TO INCONTINENCE IN DIFFERENT GROUPS
| Group | ICD Due to Incontinence, Number of Occurrences (n) | ICD Due to Incontinence, Occurrence Incidence (%) | χ2 | P |
|---|---|---|---|---|
| Control group (n=51) | 22 | 43.14 | 14.211 | <.001 |
| Research group 1 (n=51) | 19 | 37.25 | ||
| Research group 2 (n=51) | 16 | 31.37 | ||
| Research group 3 (n=51) | 11 | 21.57 | ||
| Control group vs. Research group 1 | 0.367 | .545 | ||
| Control group vs. Research group 2 | 1.510 | .219 | ||
| Control group vs. Research group 3 | 12.829 | <.001 | ||
| Research group 1 vs. Research group 2 | 0.391 | .532 | ||
| Research group 1 vs. Research group 3 | 7.933 | .005 | ||
| Research group 2 vs. Research group 3 | 3.435 | .064 |
Adjusted Inspection Level α′=0.008.
Abbreviation: ICD, irritant contact dermatitis.
Comparison of the Time of ICD Due to Incontinence Onset
As listed in Table 3, the time of ICD due to incontinence onset was 4.64±1.22 days in the control group, 5.22±1.17 days in research group 1, 5.35±1.08 days in research group 2, and 7.41±1.13 days in research group 3, and the intergroup differences were statistically significant (F=5.521, P=.013). According to pairwise comparison, the control group and research group 1 (t=2.450, P=.016), the control group and research group 2 (t=3.112, P=.002), the control group and research group 3 (t=11.896, P<.001), research group 1 and research group 3 (t=9.615, P<.001), and research group 2 and research group 3 (t=9.412, P<.001) had statistically significant differences.
TABLE 3.
COMPARISON OF ICD DUE TO INCONTINENCE OCCURRENCE TIME BETWEEN DIFFERENT GROUPS
| Group | Onset (d) | F/t | P |
|---|---|---|---|
| Control group (n=51) | 4.64±1.22 | 5.521 | .013 |
| Research group 1 (n=51) | 5.22±1.17 | ||
| Research group 2 (n=51) | 5.35±1.08 | ||
| Research group 3 (n=51) | 7.41±1.13 | ||
| Control group vs. Research group 1 | 2.450 | .016 | |
| Control group vs. Research group 2 | 3.112 | .002 | |
| Control group vs. Research group 3 | 11.896 | <.001 | |
| Research group 1 vs. Research group 2 | 0.583 | .561 | |
| Research group 1 vs. Research group 3 | 9.615 | <.001 | |
| Research group 2 vs. Research group 3 | 9.412 | <.001 |
Adjusted Inspection Level α′=0.008
Abbreviation: ICD, irritant contact dermatitis.
Comparison of ICD Due to Incontinence Severity
As displayed in Table 4, there were 10 patients with mild ICD, 6 with moderate ICD, and 6 with severe ICD in the control group; 10 patients with mild ICD, 5 with moderate ICD, and 4 with severe ICD in research group 1; 9 patients with mild ICD, 4 with moderate ICD, and 3 with severe ICD in research group 2; and 9 patients with mild ICD, 1 with moderate ICD, and 1 with severe ICD in research group 3, presenting statistically significant differences (P=.023). Pairwise comparison revealed statistically significant differences between the control group and research group 3 (P<.001), the research group 1 and research group 3 (P=.006), as well as between research group 2 and research group 3 (P=.013).
TABLE 4.
COMPARISON OF THE SEVERITY OF ICD DUE TO INCONTINENCE IN DIFFERENT GROUPS
| Severity of Developing ICD Due to Incontinence, n (%) | |||||||
|---|---|---|---|---|---|---|---|
| Group | Total Occurrence, n (%) | Mild | Moderate | Severe | No Occurrence, n (%) | χ2 | P |
| Control group (n=51) | 22 (43.14) | 10 (45.45) | 6 (27.27) | 6 (27.27) | 29 (56.86) | — | .023* |
| Research group 1 (n=51) | 19 (37.25) | 10 (52.63) | 5 (26.32) | 4 (21.05) | 32 (62.75) | ||
| Research group 2 (n=51) | 16 (31.37) | 9 (56.25) | 4 (25.00) | 3 (18.75) | 35 (68.63) | ||
| Research group 3 (n=51) | 11 (21.57) | 9 (81.82) | 1 (9.09) | 1 (9.09) | 40 (78.43) | ||
| Control group vs. Research group 1 | 0.760 | .859 | |||||
| Control group vs. Research group 2 | — | .284* | |||||
| Control group vs. Research group 3 | — | <.001* | |||||
| Research group 1 vs. Research group 2 | — | .750* | |||||
| Research group 1 vs. Research group 3 | — | .006* | |||||
| Research group 2 vs. Research group 3 | — | .013* | |||||
Adjusted Inspection Level α′=0.008.
Fisher exact test was used.
Abbreviation: ICD, irritant contact dermatitis.
Comparison of Daily Treatment Cost
As shown in Table 5, the daily treatment cost was $7.45±1.22 in the control group, $5.61±0.79 in research group 1, $5.17±0.74 in research group 2, and $4.96±0.68 in research group 3, and the intergroup differences were statistically significant (F=9.607, P<.001). After pairwise comparison, statistically significant differences were found between the control group and research group 1 (t=9.003, P<.001), the control group and research group 2 (t=11.397, P<.001), the control group and research group 3 (t=12.705, P<.001), research group 1 and research group 2 (t=2.899, P=.005), and research group 1 and research group 3 (t=4.428, P<.001).
TABLE 5.
COMPARISON OF TREATMENT COSTS BETWEEN DIFFERENT GROUPS
| Group | Cost of Treatment ($) | F/t | P |
|---|---|---|---|
| Control group (n=51) | 7.45±1.22 | 9.607 | <.001 |
| Research group 1 (n=51) | 5.61±0.79 | ||
| Research group 2 (n=51) | 5.17±0.74 | ||
| Research group 3 (n=51) | 4.96±0.68 | ||
| Control group vs. Research group 1 | 9.003 | <.001 | |
| Control group vs. Research group 2 | 11.397 | <.001 | |
| Control group vs. Research group 3 | 12.705 | <.001 | |
| Research group 1 vs. Research group 2 | 2.899 | .005 | |
| Research group 1 vs. Research group 3 | 4.428 | <.001 | |
| Research group 2 vs. Research group 3 | 1.467 | .146 |
Adjusted Inspection Level α′=0.008.
Comparison of ICD Due to Incontinence Nursing Efficiency
As presented in Table 6, after different intervention measures, there were 10 cured cases and 5 effective cases in the control group, 11 cured cases and 3 effective cases in research group 1, 11 cured cases and 2 effective cases in research group 2, and 9 cured cases and 1 effective case in research group 3, with effective rates of 68.18%, 73.68%, 81.25%, and 90.91%, respectively. The intergroup differences were statistically significant (P=.037). After pairwise comparison, statistically significant differences were found between the control group and research group 3 (P<.001), as well as between research group 1 and research group 3 (P<.001).
TABLE 6.
COMPARISON OF NURSING EFFECTIVE RATE AFTER ICD DUE TO INCONTINENCE IN DIFFERENT GROUPS
| Effectiveness, n (%) | |||||||
|---|---|---|---|---|---|---|---|
| Group | Total Occurrence, n (%) | Cure | Effective | Invalid | Effective Rate (%) | χ2 | P |
| Control group (n=51) | 22 (43.14) | 10 (45.45) | 5 (22.73) | 7 (31.82) | 68.18 | — | .037* |
| Research group 1 (n=51) | 19 (37.25) | 11 (57.89) | 3 (15.79) | 5 (26.32) | 73.68 | ||
| Research group 2 (n=51) | 16 (31.37) | 11 (68.75) | 2 (12.50) | 3 (18.75) | 81.25 | ||
| Research group 3 (n=51) | 11 (21.57) | 9 (81.82) | 1 (9.09) | 1 (9.09) | 90.91 | ||
| Control group vs. Research group 1 | — | .485* | |||||
| Control group vs. Research group 2 | — | .305* | |||||
| Control group vs. Research group 3 | — | <.001* | |||||
| Research group 1 vs. Research group 2 | — | .915* | |||||
| Research group 1 vs. Research group 3 | — | <.001* | |||||
| Research group 2 vs. Research group 3 | — | .625* | |||||
Adjusted Inspection Level α′=0.008.
Fisher exact test was used.
Abbreviation: ICD, irritant contact dermatitis.
Comparison of ICD Due to Incontinence Healing Time
As described in Table 7, the healing time was 7.22±1.13 days in the control group, 6.02±1.28 days in research group 1, 5.87±1.35 days in research group 2, and 4.15±0.82 days in research group 3, with statistically significant intergroup differences (F=3.907, P=.028). In pairwise comparison, statistically significant differences were observed between the control group and research group 1 (t=5.019, P<.001), the control group and research group 2 (t=5.476, P<.001), the control group and research group 3 (t=15.703, P<.001), research group 1 and research group 3 (t=8.785, P<.001), and research group 2 and research group 3 (t=7.776, P<.001).
TABLE 7.
COMPARISON OF HEALING TIME IN DIFFERENT GROUPS OF PATIENTS WITH ICD DUE TO INCONTINENCE
| Group | Number Cured, n (%) | Healing Time (Days) | F/t | P |
|---|---|---|---|---|
| Control group (n=51) | 20 (39.22) | 7.22±1.13 | 3.907 | .028 |
| Research group 1 (n=51) | 20 (39.22) | 6.02±1.28 | ||
| Research group 2 (n=51) | 20 (39.22) | 5.87±1.35 | ||
| Research group 3 (n=51) | 15 (29.41) | 4.15±0.82 | ||
| Control group vs. Research group 1 | 5.019 | <.001 | ||
| Control group vs. Research group 2 | 5.476 | <.001 | ||
| Control group vs. Research group 3 | 15.703 | <.001 | ||
| Research group 1 vs. Research group 2 | 0.576 | .566 | ||
| Research group 1 vs. Research group 3 | 8.785 | <.001 | ||
| Research group 2 vs. Research group 3 | 7.776 | <.001 |
Adjusted Inspection Level α′=0.008.
Abbreviation: ICD, irritant contact dermatitis.
DISCUSSION
ICD due to incontinence is an inflammatory condition characterized by local skin redness, edema, and clear exudate, typically occurring in the perineum, groin, buttocks, and medial thighs. Research has shown that the incidence of ICD due to incontinence is higher in ICUs and geriatric and neurology departments than in general departments, with patients experiencing double incontinence having a higher incidence of ICD due to incontinence than those with fecal or urinary incontinence alone.19 Without timely care, ICD due to incontinence can easily lead to the development of PIs. Therefore, it is crucial to take effective nursing measures to intervene and treat patients with ICD due to incontinence promptly.
The incidence of ICD due to incontinence in ICUs has been reported to be as high as 36% to 50%.20 The results of this study showed that the incidence of ICD due to incontinence was lowest in the double-pocket fecal catheter system combined with camellia oil application group (21.57%), followed by the double-pocket fecal catheter system combined with zinc oxide ointment application group (31.37%), the camellia oil application group (37.25%), and the zinc oxide ointment application group (43.14%), with statistically significant differences (χ2=14.211, P<.001). The incidence of ICD due to incontinence was the lowest in research group 3.
As for the time of ICD due to incontinence onset, research group 3 had the longest time of onset, followed by research group 2, research group 1, and the control group, with statistically significant differences (7.41±1.13 vs. 5.35±1.08 vs. 5.22±1.17 vs. 4.64±1.22, F=5.521, P=.013). The differences between research group 3 and research group 1 (t=9.615, P<.001) and research group 2 (t=9.412, P<.001) were statistically significant. In terms of ICD due to incontinence severity, research group 3 had the highest proportion of mild patients and the lowest proportion of moderate and severe patients, with statistically significant differences (P=.023). Zinc oxide’s white color can hinder clinicians’ ability to visualize the wound edges, potentially compromising clinical assessments. Clinical experience suggests that the greasy nature of zinc oxide formulations prevents the use of adhesive dressings and negative pressure wound therapy.21 Hoggarth et al22 evaluated the efficacy of 6 products in protecting against irritants, maintaining skin hydration and preserving the skin barrier against maceration in 18 healthy volunteers. Zinc oxide–based products provided protection against irritants but demonstrated poor skin hydration and barrier properties to prevent maceration. The study concluded that only the water-in-oil petrolatum-based product performed effectively across all the parameters tested.22 Camellia oil is more beneficial for the recovery of patients with ICD due to incontinence compared with zinc oxide ointment. Camellia oil is mainly composed of unsaturated fatty acids, such as oleic, linoleic, and linolenic acids.23 As an oil derived from Theaceae plants, camellia oil contains fatty oils that can clear heat and resolve dampness, as well as relieve pain and inflammation. In addition, it contains vitamin E and antioxidant components, which can protect the skin from damage and ageing and effectively block moisture evaporation from the skin. When applied externally, it forms a protective film, which can protect the skin and prevent irritation from urine and stool. A previous study found that an emollient containing camellia oil had a significant effect on the treatment of atopic dermatitis.24
In the present study, the daily treatment cost was $7.45±1.22 in the control group, and $5.61±0.79, $5.17±0.74, and $4.96±0.68 in research groups 1, 2, and 3, respectively, with statistically significant differences (F=9.607, P<.001). The daily treatment cost in research group 1 was higher than that in research groups 2 (t=2.899, P=.005) and 3 (t=4.428, P<.001), but no statistically significant difference was found between research groups 2 and 3 (t=1.467, P=.146). A financial study on ICD due to incontinence found that standardized preventive care had a product cost of $0.05 to $0.52 per product for ICD due to incontinence prevention and $0.20 to $0.35 per product for treatment. The daily cost of prevention and treatment for each patient is calculated to be between $0.23 and $20.17.25 The study by Glass et al25 on the cost of ICD due to incontinence prevention and treatment has shown that the cost of ICD due to incontinence care using skin cleansers and wipes is Singapore Dollar 51.00 ($38.48), whereas the cost of using only wipes is Singapore Dollar 15.00 ($11.32). Consequently, the price of prevention and treatment products will affect the choices made by physicians and patients, significantly impacting the efficacy of prevention and treatment.
After different nursing interventions for patients with ICD due to incontinence, the nursing efficiency of the control group, research group 1, research group 2, and research group 3 was 68.18%, 73.68%, 81.25%, and 90.91%, respectively, with statistically significant differences (P=.037). A statistically significant difference was found between research group 1 and research group 3 (P<.001). The healing time of ICD due to incontinence was 7.22±1.13 days in the control group and 6.02±1.28 days, 5.87±1.35 days, and 4.15±0.82 days in research groups 1, 2, and 3, respectively, with statistically significant differences (F=3.907, P=.028). The healing time in research group 3 was shorter than that in research groups 1 (t=8.785, P<.001) and 2 (t=7.776, P<.001), with statistically significant differences. Compared with zinc oxide ointment, camellia oil has the advantage of penetrating deeper into the skin to exert pharmacodynamic effects on skin trauma, directly acting on the infection source and maintaining and promoting the normal metabolism of healthy skin. In addition, camellia oil has significant functions of antioxidation, promoting blood circulation and accelerating tissue repair. It also has bactericidal, anti-osmotic, anti-inflammatory, antipruritic, and analgesic effects.26 It has been shown that camellia oil has good antibacterial effects against bacteria, fungi, and yeasts. Its antibacterial activity against Staphylococcus aureus and Escherichia coli is comparable to that of 100% μg/mL ampicillin. In addition, its antibacterial ability is almost unaffected by pH value and exhibits high thermostability.27 A clinical study has revealed that camellia oil was significantly effective in skin care,28 treating perianal erythema caused by friction, preventing perianal redness and swelling, and preventing infant diaper dermatitis and perianal skin damage in patients with fecal incontinence. All of these applications have achieved good therapeutic effects.
The present study indicates that the combined use of a double-pocket fecal catheter system during dressing treatment in patients with ICD due to incontinence can have a synergistic effect, improving therapeutic efficacy. Fecal incontinence is defined as the loss of anal sphincter control leading to the unwanted release of stool or gas. It is a type of abnormal bowel movement,29 which can cause uncontrolled discharge of contents from the anus. Patients have irregular bowel movements every day, up to dozens of times a day. The perianal region is contaminated with feces and moisture, leading to redness, itching, rupture, and even ulceration and necrosis of the perianal skin. The nursing workload for fecal incontinence is large, and measures are relatively few. Although some researchers have extensively explored options such as indwelling tracheal catheters and feces storage bags, the results have not been ideal. Based on these results, Chen et al30 conducted research on the anatomical and physiological characteristics of the human anus and rectum when defecating and combined it with clinical nursing practice. They developed a fecal catheter system based on a circular membrane material with double pockets, which drains and stores patients’ loose or formed stools in a collector. It can also maintain the normal physiological function of patients’ anuses and is characterized by its convenient and safe clinical application. The early-designed inner airbags lacked an elastic inner ring, which led to some airbags deforming and discharging during use. This issue was addressed by increasing the airbag pressure, but high pressure poses a risk to patients. After modification, an elastic inner ring was added to the inner airbag, allowing both the inner and outer airbags to secure the fecal catheter system to the anus. The maximum inflation diameter of the inner airbag was set to 5 cm, with a low inflation diameter of ~3 cm. The airbag pressure was set to 25 to 35 cm H2O, which was lower than the capillary perfusion pressure, causing no discomfort. By maintaining this pressure, the stability of the inner airbag was increased, effectively addressing issues of airbag deformation and discharge. In addition, this pressure level prevents compression damage to the local mucosa. The inner diameter of the fecal catheter system was set at 3 cm, facilitating smooth feces discharge.31
Limitations
This study has some limitations, such as a small sample size. Large-sample, multicenter research is needed to provide stronger evidence for the efficacy of camellia oil and the double-pocket fecal catheter system in patients with ICD due to incontinence.
CONCLUSIONS
On the basis of screening high-risk populations using the PAT, the combination of camellia oil and a double-pocket fecal catheter system demonstrates good efficacy in preventing and treating ICD due to incontinence among patients in ICUs. This approach can shorten hospital stays, reduce treatment costs, and improve patient and family satisfaction while being easy to operate. It effectively reduces nursing workload and enhances nursing service quality. This study provides a safe, convenient, and affordable plan to prevent and treat ICD due to incontinence among patients in ICUs, with good clinical application value.
Footnotes
This work was supported by the Jiangxi Provincial Administration of Traditional Chinese Medicine Research Fund (Project No. SZYYB20232640). Ganzhou Science and Technology Plan Project: Application of Double-Capsule Toilet Guide in Patients with Fecal Incontinence in the Intensive Care Unit No. 2022XM038904.
The authors have disclosed no other financial relationships related to this article.
Contributor Information
Qiulin Li, Email: liqlqunli2022@21cn.com.
Chunli Wang, Email: wangchunli0510@21cn.com.
Fen Wang, Email: wangf_fenwd0025@21cn.com.
Qinglin Xu, Email: xu_xxxuql1225@21cn.com.
Zhisheng Duan, Email: duan_dzszhis0606@21cn.com.
Chao Shi, Email: shichaogood4@21cn.com.
Liping Xing, Email: lipingxing74xx@163.com.
REFERENCES
- 1.Kohut I, Galnykina S, Kushynska M, Krynytska I, Marushchak M, Kamyshnyi A. The role of Candida spp. contamination and efficacy of camphorated oil in skin care of incontinent associated dermatitis patients. Pol Merkur Lekarski 2020;48:77-81. [PubMed] [Google Scholar]
- 2.Choudhary C, Kravvas G, Jones HT. What you need to know about common skin problems in older adults. Br J Hosp Med (Lond) 2024;85:1-8. [DOI] [PubMed] [Google Scholar]
- 3.Alderden J, Rondinelli J, Pepper G, Cummins M, Whitney J. Risk factors for pressure injuries among critical care patients: a systematic review. Int J Nurs Stud 2017;71:97-114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.González-Méndez MI, Lima-Serrano M, Martín-Castaño C, Alonso-Araujo I, Lima-Rodríguez JS. Incidence and risk factors associated with the development of pressure ulcers in an intensive care unit. J Clin Nurs 2018;27:1028-37. [DOI] [PubMed] [Google Scholar]
- 5.Tülü B, Üzen Cura Ş. Factors affecting the development of incontinence dermatitis among patients in intensive care unit. J Tissue Viability 2024;33:357-61. [DOI] [PubMed] [Google Scholar]
- 6.Zhou X, Wang Q, He Z, Xiao S, Ruan W. Application of fecal collection device in intensive care unit patients with fecal incontinence receiving extracorporeal membrane oxygenation: a comparison cohort study. Altern Ther Health Med 2024;30:244-9. [PubMed] [Google Scholar]
- 7.Yüceler Kaçmaz H, Kaplan Ö, Kaplan A, Şahin MG, Cetinkaya A, Avci A. Incontinence-associated dermatitis: prevalence in intensive care units and knowledge, attitudes, and practices of nurses. J Nurs Care Qual 2023;38:354-60. [DOI] [PubMed] [Google Scholar]
- 8.Zhang Y, Zhang P, Liu JE, Gao F. A qualitative study on the experience and training needs of ICU nurses for incontinence-associated dermatitis. Adv Skin Wound Care 2021;34:532-7. [DOI] [PubMed] [Google Scholar]
- 9.Del Cotillo-Fuente M, Valls-Matarín J, Sandalinas-Mulero I. Efficacy of a comprehensive strategy to reduce moisture-associated skin damage in an intensive care unit: a quasi-experimental study. Intensive Crit Care Nurs 2021;63:102964. [DOI] [PubMed] [Google Scholar]
- 10.Wang L, Zheng X, Ma R, Liu X. Interpretation of domestic and foreign expert consensuses of incontinence-associated dermatitis nursing. Chin Nurs Manage 2018;18:3-6. [Google Scholar]
- 11.Coyer F, Campbell J, Doubrovsky A. Efficacy of incontinence-associated dermatitis intervention for patients in intensive care: an open-label pilot randomized controlled trial. Adv Skin Wound Care 2020;33:375-82. [DOI] [PubMed] [Google Scholar]
- 12.Şahin F, Karadağ A, Avşar P. A survey of Turkish nurses’ knowledge of incontinence-associated dermatitis. J Wound Ostomy Continence Nurs 2019;46:434-40. [DOI] [PubMed] [Google Scholar]
- 13.Lin Z, Cheng B. Effects of topical application of camellia oil on the development of allergic contact dermatitis. Chin J Dermatol 2011;44:282-4. [Google Scholar]
- 14.Li X, Zhang H, Zhong Q. Efficacy observation of camellia oil in preventing radiodermatitis. Int J Nurs 2012;31:90-2. [Google Scholar]
- 15.Xu J, Gong H, Jia J. Survey on the knowledge of prevention and management of incontinence-associated dermatitis among clinical nurses. Chin Nurs Manage 2015;15:83-5. [Google Scholar]
- 16.Blake MR, Raker JM, Whelan K. Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 2016;44:693-703. [DOI] [PubMed] [Google Scholar]
- 17.Beeckman D, Campbell J, Campbell K, et al. Proceedings of the Global IAD Expert Panel Incontinence-associated Dermatitis: Moving Prevention Forward. Wounds International; 2015. [Google Scholar]
- 18.Qu Y, Qi B, Ma S, Wang C. Clinical efficacy observation of one-piece ostomy bag for perianal management in patients with fecal incontinence. Heilongjiang Med J 2016;40:93-4. [Google Scholar]
- 19.Jia J, Xu J, Qiu X. The prevalence and prevention of incontinence-associated dermatitis among hospitalized incontinence patients. Chin Nurs Manage 2014:1207-10. [Google Scholar]
- 20.Li X, Li D, Wei J. Application of one-piece ostomy bag combined with vacuum suction in ICU patients with fecal incontinence. Harbin Med J 2017;37:464-5. [Google Scholar]
- 21.Guest JF, Greener MJ, Vowden K, Vowden P. Clinical and economic evidence supporting a transparent barrier film dressing in incontinence-associated dermatitis and peri-wound skin protection. J Wound Care 2011;20:76; 78-84. [DOI] [PubMed] [Google Scholar]
- 22.Hoggarth A, Waring M, Alexander J, Greenwood A, Callaghan T. A controlled, three-part trial to investigate the barrier function and skin hydration properties of six skin protectants. Ostomy Wound Manage 2005;51:30-42. [PubMed] [Google Scholar]
- 23.Wang X. Clinical efficacy observation on prevention of incontinence-associated dermatitis by external application of aloe mastic combined with camellia oil. Jiangxi Med J 2015:946-8. [Google Scholar]
- 24.Huang SG, Yang XX, Mo LQ, Zhou XY. Optimization of emollient formulation for treating atopic dermatitis by skin physiological index testing. Nan Fang Yi Ke Da Xue Xue Bao 2017;37:967-74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Glass GF, Jr, Goh CCK, Cheong RQ, Ong ZL, Khong PCB, Chan EY. Effectiveness of skin cleanser and protectant regimen on incontinence-associated dermatitis outcomes in acute care patients: a cluster randomised trial. Int Wound J 2021;18:862-73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Zhong D, Jiang M, Wang T. Research progress on the chemical composition, pharmacological effects and clinical applications of camellia oil. Cent South Pharm 2012;10:299-303. [Google Scholar]
- 27.Jiang L, Wang L, Ou M. Study on the antimicrobial effect of the camellia oil. J Anhui Agric Sci 2008;36:5913-4. [Google Scholar]
- 28.Lv H, Xie D, Su R, Huang L, Wei J. Application of sanitary tampons and camellia oil in patients with fecal incontinence. Chin J New Clin Med 2010;3:788-9. [Google Scholar]
- 29.Beeckman D. A decade of research on Incontinence-Associated Dermatitis (IAD): evidence, knowledge gaps and next steps. J Tissue Viability 2017;26:47-56. [DOI] [PubMed] [Google Scholar]
- 30.Chen S, Xu Q, Liu X. Application of double-pocket fecal catheter system in patients with fecal incontinence in ICU. J Gannan Med Coll 2022;42:512-4. [Google Scholar]
- 31.Akinduro OG, Jacobs AP, Gunn AJ. Percutaneous cecostomy catheters. Semin Intervent Radiol 2025;42:66-70. [DOI] [PMC free article] [PubMed] [Google Scholar]