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Welcome 2 Contents • • • • • • • • 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 4 5 11 17 29 37 43 54 3 Skin Facts • • • • • • • 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 4 Section One: Skin changes in the older person 5 Section One: Skin changes in the older person 6 Functions of the skin • • • • • 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 7 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 8 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 9 ✪ Key points ★ Skin changes are inevitable ★ Recognise problems ★ Provide practical solutions Section One: Skin changes in the older person 10 Section Two: Possible consequences of skin changes in the older person 11 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 12 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 13 Internal and External Factors Affecting Skin Section Two: Possible consequences of skin changes in the older person 14 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 15 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 16 ✪ Key points ★ Internal and external factors contribute to skin changes ★ Ongoing assessment and management will help optimise skin health Section Two: Possible consequences of skin changes in the older person 17 Section Three: Skin tears 18 Skin tears • A wound caused by shear, friction and/or blunt force resulting in separation of the skin layers Section Three: Skin tears 19 Age related skin changes and other factors associated with skin tears • Immunological status • Malnutrition • Poor circulation • Oxygen status Section Three: Skin tears 20 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 21 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 22 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 23 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 24 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 25 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 26 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 27 ✪ Key points ★ Skin tears are common wounds ★ Be aware of and minimise risk factors wherever possible ★ Use a recognised classification tool ★ Treatment regimen structured on best available evidence Section Three: Skin tears 28 Section Four: Pressure damage 29 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 30 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 31 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 32 Vulnerable areas • Sacrum • Heel • Any area skin lies close to bone • Under medical devices Section Four: Pressure damage 33 Preventing further damage • Grade pressure ulcer • Reduce further risk Section Four: Pressure damage 34 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 35 ✪ 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 36 Section Five: Moisture Lesions 37 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 38 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 39 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 40 Prevention and management of moisture lesions 2 • Barrier creams • Liquid barrier films • Appropriate incontinence pads Section Five: Moisture Lesions 41 ✪ Key points ★ Moisture lesions occur as a result of incontinence ★ They can be extremely painful ★ Be aware of risk factors ★ Minimise risk using prevention strategies ★ When a moisture lesion occurs follow management guidelines based on best available evidence Section Five: Moisture Lesions 42 Section Six: Sun damage 43 Lifetime sun exposure • Early skin changes • Photodamage • Areas at increased risk Section Six: Sun damage 44 Actinic Keratoses • Presents most commonly on backs of hands, bald scalp and temples Section Six: Sun damage 45 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 46 Bowens Disease • Presents as multiple, red, slowly growing, crusted, scaly patches most often on the lower legs Section Six: Sun damage 47 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 48 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 49 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 50 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 51 ✪ Key points ★ Skin becomes more vulnerable to sun damage as we age ★ If any abnormal changes occur refer to the GP Section Six: Sun damage 52 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 53 Emollient workshop 54 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 Emollient workshop 55 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 Emollient workshop 56 Emollients • Definition and function • Classification • When to apply • How to apply • Which emollient Emollient workshop 57 Definition and function Medical term for moisturiser • Safe • Simple • Effective • Steroid sparing • Intrinsic anti-inflammatory action Emollient workshop 58 Classification Lotions/Gels • Contain more water and less fat than creams Creams • Contain a mixture of water and fat Ointments • Do not contain water Emollient workshop 59 Classification continued Bath oils • Clean and hydrate - trap water in skin Soap substitutes • Not astringent - not alkaline - do not dry out the skin Emollient workshop 60 When to apply As frequently and liberally as possible • At least 3 times per day • After bathing when the skin is still moist Emollient workshop 61 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 Emollient workshop 62 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 Emollient workshop 63 Quantities required For an adult with dry or compromised skin • Bath additives 300mls per month • Creams or ointments 2000g per month Emollient workshop 64 Thank you We will now have a practical workshop in emollient therapy Emollient workshop 65