Download Presentation on Skin integrity in the older

Welcome
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Contents
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Skin Facts
Section One: Skin changes in the older person
Section Two: Possible consequences of skin changes in the older person
Section Three: Skin tears
Section Four: Pressure damage
Section Five: Moisture Lesions
Section Six: Sun damage
Emollient workshop
Contents
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Skin Facts
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The largest organ of the body
Weighs approx. 2.5kg
Covers an area approx. 2 sq metres
Contains over 1 million nerve endings
Has ability to regenerate itself
Cell renewal takes approx. 28 days
Contains approx. 20% of total body water
Skin Facts
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Section One: Skin changes in the older person
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Section One: Skin changes in the older person
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Functions of the skin
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Temperature control
Vitamin D synthesis
Protection from harmful Ultra Violet Light
Acts as a sensory organ
Communication and display
Section One: Skin changes in the older person
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Structure of the skin
Epidermis: Outer layer
Stratum corneum - mainly composed
of keratinocytes made up of 4 layers
(basal/prickle/granular/horny)
Dermis: Inner layer
Thick layer beneath the epidermis consisting
of blood vessels, nerves, hair follicles and
supportive connective tissues
Subcutaneous layer
Made up largely of fatty and connective tissue.
Section One: Skin changes in the older person
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Quality of life
• We must not underestimate the importance of the skin as the organ through which we interact with
the outside world.
• Our psychological and social wellbeing are affected by what our skin looks like and how we feel
about it.
• Some grow old graciously while for others the ageing process is viewed negatively.
Section One: Skin changes in the older person
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✪ Key points
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Skin changes are inevitable
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Recognise problems
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Provide practical solutions
Section One: Skin changes in the older person
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Section Two: Possible consequences of skin changes in the older person
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Changes in the older skin and consequences
Epidermal turnover slows
= Thinner skin
Less effective barrier function
= More prone to infection/dryness
Less flexible and softer collagen
= More prone to wrinkles and shearing
Less evenly distributed melanin
= More prone to sun damage
Fewer sweat glands
= Less effective temperature control
Less sebum production
= Increased skin dryness
Section Two: Possible consequences of skin changes in the older person
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Skin assessment
• Assessing the skin is an ongoing process which requires great sensitivity
• Possible consequences of age related skin changes will be identified through good
skin assessment
•Checking the entire skin is important
•Consider the surrounding environment
Section Two: Possible consequences of skin changes in the older person
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Internal and External Factors Affecting Skin
Section Two: Possible consequences of skin changes in the older person
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Signs and symptoms of compromised skin
• Dryness
• Cracking
• Scaling
• Infection
• Pain – inflammation/swelling
• Itch – excoriation
Section Two: Possible consequences of skin changes in the older person
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Quality of life
• Quality of life for the individual experiencing itch should also be considered. Constant itching will
have a profound effect on the sleep pattern resulting in sleep deprivation and fatigue which can then
result in low mood
Section Two: Possible consequences of skin changes in the older person
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✪ Key points
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Internal and external factors contribute to skin changes
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Ongoing assessment and management will help optimise skin health
Section Two: Possible consequences of skin changes in the older person
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Section Three: Skin tears
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Skin tears
• A wound caused by shear, friction and/or blunt force resulting in separation of the skin layers
Section Three: Skin tears
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Age related skin changes and other factors associated with skin tears
• Immunological status
• Malnutrition
• Poor circulation
• Oxygen status
Section Three: Skin tears
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Prevention of skin tears
• Risk assessment on admission
• Have individuals at risk wear long sleeves, long trousers or knee high socks
• Provide shin guards/leg protectors for those individuals who experience repeat skin tears on shins
• Safe patient handling techniques and equipment/environment
• Involve individuals and families in prevention strategies
• Educate all staff and care givers
• Ensure adequate nutrition and hydration
• Keep skin well hydrated
• Protect individuals at high risk of trauma during routine care
Section Three: Skin tears
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Practical advice
• Ensure adequate lighting
• Upholster or pad sharp borders of furniture or bed
• Use appropriate aids when transferring patients
• Never use bed sheets to move patients as this can contribute to damage by causing
dragging effect on the skin. Always use lifting device or slide sheet
• Where possible reduce or eliminate pressure, shear and friction by using pressure relieving
devices and positioning techniques
• Include this practical advice in the patient care plan where relevant
Section Three: Skin tears
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Assessing a skin tear
• Classifying a skin tear aids planning appropriate treatment
• A validated tool such as the STAR Skin Tear Classification System should be used
Section Three: Skin tears
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Managing a skin tear 1
• Control bleeding
• Assess the wound
• Cleanse the skin tear
• Depending on healthcare setting a tetanus immunoglobulin may be administered
• Approximate the skin flap by gently easing the flap back into place using dampened cotton
bud or gloved finger
Section Three: Skin tears
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Managing a skin tear 2
• Moist wound healing should be encouraged by the application of appropriate dressings
• Avoid the use of adhesive strips
• If possible dressing should be left in place for several days to avoid disturbing the flap
• Complete a wound assessment form and document in care plan
• Complete accident/incident documentation and discuss with family or next of kin if relevant
Section Three: Skin tears
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Ongoing treatment
• Extra layers of absorbent dressing can be applied if exudate levels are high
• A wound assessment tool should be utilised
• The wound should be monitored for any changes including signs of infection
• For skin tears on legs, consider leg ulcer guidelines
Section Three: Skin tears
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When to refer
• When the skin tear is extensive
• When injury is full thickness
• When there is significant bleeding
• When there is haematoma
Section Three: Skin tears
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✪ Key points
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Skin tears are common wounds
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Be aware of and minimise risk factors wherever possible
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Use a recognised classification tool
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Treatment regimen structured on best available evidence
Section Three: Skin tears
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Section Four: Pressure damage
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Pressure ulcer
• A pressure ulcer is identified as damage to skin due to the effects of pressure together with, or
independently from a number of other factors such as shearing and moisture
Section Four: Pressure damage
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Prevention of pressure ulcers
Some important steps can be taken to reduce the risk to individuals who are vulnerable to skin
damage. These include:
• Inspecting the skin regularly
• Making sure all surfaces, such as the bed and chair, are appropriate to the individual
• Assisting the individual to reposition on a regular basis
• Using manual handling aids to minimise shear and friction injury
Section Four: Pressure damage
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Structured risk assessment
• Carried out within 6 hours of admission to hospital
• In other health care settings if this is not possible, risk assessment should be carried out as soon
as is reasonably possible
• Reassessment should be carried out regularly, but the frequency depends on individual need
• Reassessment should be carried out if there is a significant change in the individual’s condition
Section Four: Pressure damage
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Vulnerable areas
• Sacrum
• Heel
• Any area skin lies close to bone
• Under medical devices
Section Four: Pressure damage
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Preventing further damage
• Grade pressure ulcer
• Reduce further risk
Section Four: Pressure damage
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Dressings
Appropriate dressings should be used. The type of dressing will depend on several factors including:
• Position of the wound
• Size of the wound
• Tissue type in the wound bed
• Amount of exudates
• Condition of the surrounding skin
Section Four: Pressure damage
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✪ Key points
★ Pressure ulcers are wounds which can have serious consequences and are often seen at the
extremes of age
★ We should be aware of the risk factors associated with pressure ulcers and minimise risk
wherever possible by applying prevention strategies
Section Four: Pressure damage
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Section Five: Moisture Lesions
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Moisture lesions/incontinence dermatitis
• Damage caused by urinary and/or faecal
incontinence
• Often associated with increased age and
decreased mobility
• Factors such as overall health, cognitive
impairment and concurrent medication are
also involved
Section Five: Moisture Lesions
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How damage occurs
• Urine and faeces come into contact with the skin
• Fluid containing bacteria can penetrate the skin - potentially leading to infection
• Skin will have the appearance of a superficial burn
Section Five: Moisture Lesions
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Prevention and management of moisture lesions 1
• Skin inspection should include all the areas affected by urine and faeces, the perineal area, anal
cleft, between the thighs, skin folds and buttocks
• Use a pH balanced skin cleanser
• Cleanse skin after each episode of loose stool
Section Five: Moisture Lesions
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Prevention and management of moisture lesions 2
• Barrier creams
• Liquid barrier films
• Appropriate incontinence pads
Section Five: Moisture Lesions
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✪ Key points
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Moisture lesions occur as a result of incontinence
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They can be extremely painful
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Be aware of risk factors
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Minimise risk using prevention strategies
★ When a moisture lesion occurs follow management guidelines based on best available
evidence
Section Five: Moisture Lesions
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Section Six: Sun damage
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Lifetime sun exposure
• Early skin changes
• Photodamage
• Areas at increased risk
Section Six: Sun damage
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Actinic Keratoses
• Presents most commonly
on backs of hands, bald
scalp and temples
Section Six: Sun damage
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Basal Cell Carcinoma (BCC)
• Is the commonest type of skin cancer.
A slow growing, flesh coloured lump may
develop into a sore that will not heal.
It is often found on the forehead or the
side of the nose. On the trunk it may
take the form of a slowly enlarging red
dry patch
Section Six: Sun damage
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Bowens Disease
• Presents as multiple, red, slowly
growing, crusted, scaly patches
most often on the lower legs
Section Six: Sun damage
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Squamous Cell Carcinoma (SCC)
• May grow rapidly, forming a
tender crusting lump
• Found on exposed areas,
especially the ears, lips, hands
and lower legs
Section Six: Sun damage
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Malignant Melanoma (MM)
• Least common skin cancer but the
most dangerous. It usually takes the
form of a changing mole with an
unusual appearance
• A useful rule to follow when checking
for suspicious lesions is the ABCD
rule. It helps to distinguish between an
innocent mole and a possible MM
Section Six: Sun damage
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ABCD Rule
• ASYMMETRY: the two halves of the area may differ in their shape
• BORDER: the outside edges of the area may be irregular or blurred and sometimes show
notches or look ragged
• COLOUR: may be uneven and patchy. Different shades of black, brown and pink may be seen
• DIAMETER: most but not all melanomas are at least 6mm in diameter
Section Six: Sun damage
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Quality of life
• Many new treatments are available, most of them alter the appearance of the skin
• Surgical excision will result in significant trauma and scarring for the individual
• People with significant changes may experience a loss of body image and anxiety over their
diagnosis and prognosis
Section Six: Sun damage
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✪ Key points
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Skin becomes more vulnerable to sun damage as we age
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If any abnormal changes occur refer to the GP
Section Six: Sun damage
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Common conditions seen in the older person
• Different forms of eczema found almost exclusively in the older person.
Clockwise from top left: Asteatotic eczema, Contact dermatitis, Discoid
eczema, Lichen Simplex and Seborrhoeic dermatitis.
Section Six: Sun damage
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Emollient workshop
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Emollients
• Emollients are oils and lipids that spread easily on skin, providing partial occlusion that hydrates
and improves the appearance of the Stratum Corneum
• Basically emollient means a soothing, calming substance
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How emollients work
Occlusive emollients work by:
• Sealing in the moisture so that water loss is prevented from the stratum corneum
Humectant emollients work by:
• Drawing and retaining water from below into the stratum corneum increasing the amount of
moisture there
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Emollients
• Definition and function
• Classification
• When to apply
• How to apply
• Which emollient
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Definition and function
Medical term for moisturiser
• Safe
• Simple
• Effective
• Steroid sparing
• Intrinsic anti-inflammatory action
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Classification
Lotions/Gels
• Contain more water and less fat than creams
Creams
• Contain a mixture of water and fat
Ointments
• Do not contain water
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Classification continued
Bath oils
• Clean and hydrate - trap water in skin
Soap substitutes
• Not astringent - not alkaline - do not dry out the skin
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When to apply
As frequently and liberally as possible
• At least 3 times per day
• After bathing when the skin is still moist
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How to apply
• After bathing
• Generously but gently
• Do not rub vigorously - may cause itching or irritation
• Smooth emollient along arms, legs and body following the natural hair growth
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Which emollient
Important point to remember
• Use a cream base for moist/wet skin
• Use an ointment base for dry/cracked skin
Paramount importance
• Cosmetic acceptability essential
• Compromise between efficiency and cosmetic acceptability
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Quantities required
For an adult with dry or compromised skin
• Bath additives 300mls per month
• Creams or ointments 2000g per month
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Thank you
We will now have a practical workshop in emollient therapy
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