ADVERTISEMENT
Validity and Reliability of the Perineal Assessment Tool
Incontinence has a major impact on health and quality of life. In the general population, fecal incontinence affects approximately 2% of adults and urinary incontinence affects approximately 30% of adults.1,2 Dermatitis is a common problem for individuals experiencing incontinence. This skin condition affects all age groups, races, and genders. Up to 30% of hospitalized adult patients have been reported to have perineal dermatitis.3 Additionally, experts cite incontinence as a major risk factor in the development of pressure ulcers. The presence of pressure ulcers increases hospital stays up to five times longer than when none are present and can cost up to an additional $35,000 for treatment depending on the severity and stages of the wounds.4
Perineal skin injury resulting from incontinence has been found in as many as 33% of hospitalized adults.3 Products such as underpads and adult briefs commonly used with incontinent patients contribute to perineal skin injury by trapping moisture against the skin.5 To address the problem of perineal skin injury, the Perineal Assessment Tool (PAT) was developed through literature review. The PAT is a four-item instrument (see Table 1). The framework for the PAT is based on four factors that are determinants in perineal skin breakdown. These constructs include duration of irritant, intensity/type of irritant, perineal skin condition, and contributing factors that may cause diarrhea. Each subscale reflects degrees of risk factors. All subscales are rated from 1 (least risk) to 3 (most risk). Each rating has a descriptor and a description of each level of the scale. Total scores can range from 4 (least risk) to 12 (most risk).
Literature Review
Duration of irritant refers to the amount of time the skin is exposed to an irritant (ie, urine and/or stool). Skin wetness has been defined as fluid in contact with the skin for 2 or more hours.6 The Braden Scale for predicting pressure ulcers has a subscale for moisture. The Braden subscale definition for moisture is "degree to which skin is exposed to moisture." The Braden Scale further defines degree to which skin is exposed by frequency of garment/linen change: constantly moist (dampness is detected every time patient is moved or turned); often but not always moist (linen changes at least once a shift); occasionally moist (linen change once a day); and rarely moist (skin is usually dry).7
Intensity of irritant refers to the strength and ability of the irritant to cause epidermal barrier disruption in human skin. Factors that correlate with barrier disruption include moisture, increased pH, and invasion of microorganisms. Moist or wet skin has a higher pH than dry skin and is more permeable to irritants and bacteria.6,8 Stool from the large bowel is usually formed and has less moisture. In contrast, small bowel discharge is liquid and reported to be a strong irritant to the skin.9 Studies show that prolonged occlusive exposure to digestive enzymes in feces causes erythema and epidermal barrier disruption in humans. Digestive enzymes with higher pH have been associated with more severe skin alterations.10 The intestine is a natural reservoir of microorganisms that are exposed to the skin through feces.8
Perineal skin condition refers to the integrity of the skin. Erythema and denudement are classic signs of tissue destruction.9 Once tissue destruction is visible, barrier function is impaired. Visible changes should alert caregivers to a decrease in tissue tolerance and higher susceptibility to microbial attack.8 Damaged skin can be indicative of the loss of collagen, blood flow, or elastic fibrous connective tissues, conditions that affect skin nutrition, elasticity, and strength.11 An algorithm for perineal skin condition has been defined in three stages: clear and intact, erythema, and denudement.12
Contributing factors refer to variables that may lead to diarrhea; thus, increasing the frequency and consistency of the irritant. These factors, as previously discussed, can put the patient at a higher risk for skin breakdown. Low serum albumin, antibiotics, and tube feeding are associated with individuals with diarrhea.9 Additional etiologies for diarrhea such as bacterial pathogens, medical procedures, ischemic bowel, and other medical conditions13 put individuals at risk for developing perineal skin breakdown by increasing the intensity and frequency of the irritant.
Identifying individuals at risk for skin breakdown and the specific factors placing them at risk is the first step in developing a plan of care with intensive therapies aimed at reducing the risk factors that lead to skin breakdown. A valid and reliable risk assessment tool can assist nurses in identifying risk factors as well as the degree of risk leading to skin breakdown. This assessment enables caregivers to implement interventions that will minimize or eliminate these factors; thereby, preventing skin breakdown from occurring.4 The literature includes an assessment tool for grading the severity of perineal skin breakdown not commonly used in clinical practice.9,14 Through the design of a conceptual framework and a retrospective study that found a significant link between incontinence and skin breakdown, researchers have identified the need for valid and reliable risk assessment methods for perineal skin breakdown.8,15
Research Questions
In this study, the research objective was to answer two questions: 1. What is the level of agreement between PAT subscales and the opinion of expert (WOC) nurses? 2. What is the interrater reliability of the PAT between WOC nurses and staff RNs and LPNs?
Methods and Procedures
To assess validity, an exhibit floor intercept survey was conducted with 102 attendees of the 1999 Wound, Ostomy, Continence (WOC) Nurses Society Annual Meeting held in Minneapolis, Minn. (see Table 2), using a convenient sample. Survey participants represented hospitals, multiple settings (hospitals and other settings), home health, and long-term care. These nursing specialists also represented a wide geographical distribution from 31 states, the District of Columbia, and two Canadian provinces. They were experienced nursing providers, averaging more than 9 years as skin and wound care specialists. Due to the nature of the survey, participants were limited to those having at least 30% of their practice relate to continence issues (see Table 3). Level of agreement scores were calculated for all PAT subscales and comments and responses were tabulated. To examine the interrater reliability of the PAT, 20 patients from a long-term care setting were assessed twice (once by a WOC and once by a staff nurse). Pearson's product-moment correlation measures were used and confidence intervals (CI) calculated to ascertain the relationship between WOC and staff nurse scores obtained (N = 40).
Results/Findings
Interrater reliability of the PAT was acceptable with a calculated value of the Pearson product-moment correlation r = .970, 95%, confidence interval = .923 to .988, P = < .0001. A majority of the WOC nurses' opinions strongly agreed with the PAT (see Table 4).
All WOCN respondents agreed that the four subscales were valid risk factors for perineal skin injury. Specifically, consideration of the risk scoring scale revealed a designation in the 7 to 8 range that would best distinguish high risk from low risk (Mean = 7.64, SD = 1.74, Median = 8, Mode = 8). The level of agreement with PAT subscales was high. Averages ranged from 7.7 to 8.4 (see Table 4).
A clear majority of the WOC participants believed that a perineal risk assessment tool would be useful in the clinical setting (on a scale of 1 to 10, 1 = not valuable and 10 = very valuable, the mean rating was 7.4). Also, 87% of the participants stated that the PAT is needed and that multiple benefits would result from its use. Stated benefits included: prevention of skin breakdown, identification of risk, and earlier intervention. The positive reaction was substantiated by a favorable rating to the perceived value of the PAT in the participants' practices. More than half (56.2%) of the skin and wound care specialists would have general nursing staff complete this risk assessment. Opinions were mixed regarding how frequently the PAT should be completed. Of the respondents, 31.5% recommended daily completion, 21.9% said "on admission," 19.9% said "with change in condition," 15.8% said "weekly," 4.1% said "shift change," 2.7% said "monthly," 2.7% said quarterly," and 1.4% replied "other." Fifty-four of the participants indicated interest in trialing the PAT in the future and gave information for future communication. A limited number of changes were recommended. These included condensing the scale so it can be added to hospital admission forms; simplifying the wording so the form can be used by unlicensed personnel; using the tool in conjunction with the Braden scale; and making the tool part of the admission and weekly update material. The only consistent request was to recognize additional options for types of irritants, duration of exposure, and contributing factors.
Discussion
Although the results obtained are encouraging, the study sample and methods used had several limitations. First, predictive validity testing would have been useful for determining overprediction and underprediction (sensitivity and specificity), as would a more accurate score to cut off low- from high-risk perineal skin breakdown. The author omitted predictive validity as a research option because of its related ethical and practical dilemma. Once a PAT assessment was completed, the author expected that the caregivers would intervene. Because early intervention prevents perineal skin damage, the author could not know how many assessments actually predicted the development of perineal skin damage unless the interventions were withheld.
The interrater reliability testing was done with a small sample size at one long-term acute care setting. Data regarding age, race, and medical diagnosis were not collected in this study. These variables are potential study limitations and affect the ability to generalize the tool.
Aside from a short written conceptual statement of the tool, education on using the PAT was not offered. Despite the lack of education, the PAT yielded acceptable interrater reliability statistics in a small size in one long-term acute care clinical setting. Nursing assistants and other caregivers did not participate in the study. Therefore, the need for and type of education should be evaluated and will vary according to the clinical setting and intended user of the tool.
The level of agreement between the PAT subscales and the expert nurses in the sample was high and the overall reaction to the PAT was positive. No large-scale changes were suggested to the tool. The need for a tool for perineal risk assessment has been mentioned in the literature.8,15 Specific utility of the PAT and how it could be used was explored in this study. The author suggests that potential users such as staff nurses, nursing assistants, and/or other caregivers would provide the best answers to the question of utility.
Today's market for perineal skin products continues to proliferate. Indications for use of these products often refer to low risk and high risk for perineal skin breakdown. The PAT has the potential to assist caregivers in product selection. Although perineal skin care products are tested for safety, few studies in the literature support the effectiveness of these products. The PAT can be useful in studies that use perineal risk assessment as part of the study's selection criteria.16,17
Conclusion
The results of this study suggest that the PAT may be valid and reliable.. Recommendations for future research include: 1) further investigation aimed at determining content validity, revision needs, utility, frequency, and potential users of the PAT; 2) predictive validity testing that might be accomplished through a retrospective chart audit of persons with perineal skin breakdown; 3) additional reliability testing with a larger, more diverse sample size across multiple settings; 4) education on use of the tool before testing to determine if validity and reliability improve; 5) continued use of a perineal assessment tool for studies in which low risk/high risk for perineal skin injury should be used for inclusion/exclusion criteria.
Acknowledgment
The author wishes to thank Stephen E. Bohnenblust Ed.D, Professor, Department of Health, Minnesota State University, Mankato, Minn. for providing the statistical analysis.
1. Urinary Incontinence in Adults Guideline Panel. Clinical Practice Guideline Number 2: Urinary Incontinence in Adults. Rockville, Md.: U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research, 1996 AHCPR Publication.
2. McCormick KA. Research. From clinical trial to health policy - research on urinary incontinence in the adult, Part I. J Prof Nurs. 1991;7(3):147.
3. Lyder CH , Perineal dermatitis in the elderly. A critical review of the literature. J Gerontological Nursing. 1997:23(12):5-10.
4. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md.: U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research, 1992. AHCPR Publication 92-0047.
5. Garvin G. Skin care considerations in the neonate for the ET nurse. Journal of Enterostomal Therapy. 1990;17(6):225-230.
6. Faria DT, Shwayder T, Krull EA. Perineal skin injury: extrinsic environmental risk factors. Ostomy/Wound Management. 1992:42(7):28-37.
7. Bergstrom N, Braden B. A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing. 1987;12(1):8-12.
8. Storer-Brown D, Sears M. Perineal dermatitis: a conceptual framework. Ostomy/Wound Management. 1993;39(7):20-26.
9. Fiers S, Thayer D. Management of intractable incontinence. In: Dougherty DB. Urinary and Fecal Incontinence: Nursing Management, 2nd edition. St. Louis, Mo.: Mosby; 2000:183-207.
10. Anderson PH, Bucher AP, Saeed I, Lee JA, Davis LA, Maibach HI. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis. 1994;30:152-158.
11. Scardillo J, Aronovitch SA. Successfully managing incontinence-related irritant dermatitis across the lifespan. Ostomy/Wound Management. 1999;45(4):36-44.
12. Haugen V. Perineal skin care for patients with frequent diarrhea or fecal incontinence. Gastroenterology Nursing. 1997;20(3):87-90.
13. McFarland LV. Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients. Am J Infect Control. 1995;23(5):295-305.
14. Storer-Brown D. Perineal dermatitis: can we measure it? Ostomy/Wound Management. 1993;39(7):8-32.
15. Piloian B. Defining characteristics of the nursing diagnosis "High risk for impaired skin integrity." Decubitus. 1992;5(5):32-46.
16. Nix DP, Garvin C. Development and Pilot Study: Incontinent skin cleanser protectant lotion. Poster presented at: WOCN 32nd Annual Wound, Ostomy, Continence Conference in conjunction with CAET 19th Annual Conference, June 4-8, 2000, Toronto, Ontario, Canada.
17. Kula J, Nix P, Warshaw E. A multicentered product evaluation of a cleanser protectant lotion containing 2% dimethicone in the treatment of perineal skin breakdown in low-risk incontinent patients from long -term acute care and skilled long term care. Poster presented at: 15th Annual Clinical Symposium on Advances in Skin and Wound Care, October 5-8, 2000, Nashville, Tenn.
