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Aging skin and the importance of skin integrity assessment

Photo: Aging skin and skin integrity assessment
The integument (or skin) provides several important functions, namely protection from external environmental influences, thermoregulation, electrolyte balance and sensation – pain, touch, heat and cold. The skin comprises three major layers – the dermis, the epidermis and the subcutaneous fatty layer (containing the major nerves and blood vessels). As we age, the layers of the skin and the junction between the epidermis and dermis become thin and flatten and circulation is reduced. Evidence suggests that fibroblasts (responsible for the production and deposition of collagen in tissues) also become senescent and function diminishes resulting in loss of connective tissue.

Older skin is also subject to drying due to co-morbidities, drinking less and reduced mobility generally. This renders the skin vulnerable to infection or wounding resulting from trauma, such as a knock or bump, or from sustained unrelieved pressure over bony prominences, shear and friction. Acute illness and high temperatures consequent to fevers and moisture from diaphoresis and incontinence can add to the vulnerability of aging skin. Therefore it is vitally important to know the condition of your patient’s skin and to monitor for skin changes.

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Common skin conditions in an acute care setting

In the course of any day nurses come across a variety of skin conditions in their patients. These include irritant reactions to stoma appliances and other dressing adhesives; generalised rashes from latex allergies; blisters (or bullae) due to dressing adhesives or fixation tapes; eczema associated with dermatitis and venous stasis disease; hyperkeratosis (thick scaly skin) often seen in patients with lymphoedema or venous stasis disease; paper thin skin and purpura due to long term steroid therapy; dehydrated skin due to acute illness or nutritional compromise generally; and excoriated skin conditions from prolonged exposure to moisture, urine and faeces or acidic effluent from enterocutaneous fistulae. Such conditions place the individual at a high risk for compromised skin integrity and subsequent infection making assessment all the more important.

Skin integrity assessment
To identify patients at risk for skin failure, assessment should be conducted on admission to the ward to identify any issues with the skin’s integrity such as existing wounds (especially pressure injuries) or vulnerable pressure points, excoriation and rashes. Information gathered from the skin inspection and aspects of management should be clearly documented in the patient’s notes and care plan. Inspection should include assessment of the skin’s colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds. As a general guide, components of assessment of the patient’s skin are outlined in table 1.4



Assessment: Colour.
What to look for: What is normal for the patient? What colours can you see e.g. red, purple, unusual pigmentation of the lower limbs and gaiter regions (brownish) or blue/grey hues of distal limbs (lower limbs and feet)? Is there any bruising present? Or purpura?  More reading - the colour of wounds and its implication for healing.


Assessment: Temperature.
What to look for: Does the skin feel cool to touch (possibly due to poor peripheral perfusion) or hot due to fever or infection?

Assessment: Texture.
What to look for: Does the skin feel dry or moist, papery, thin or leathery?

Assessment: Moisture.
What to look for: Is moisture due to excessive sweating, urine or leakage from a wound or drain? Is the skin becoming macerated (white appearance)? Is oedema present?

Assessment: Integrity.
What to look for:
Are there any broken areas? Presence of skin tears, blisters, wounds, pressure injuries or epidermal stripping due to adhesive tapes or dressings?

Assessment: Location.
What to look for: If there is a failure in skin integrity identify and document the anatomical location i.e. sacrum, heels or toes, gaiter region of lower legs, dorsal/plantar surface of foot, groin or under skin folds and so on.

Adapted from: Holloway & Jones, 2005, p. 1175 4

Maintaining skin integrity
Skin integrity assessment is an essential part of nursing care and should be conducted on admission and at least daily depending on the individual’s circumstances. High risk patients require skin inspection at least once per shift in addition to admission to a ward. Just as nurses apply the six rights of medication administration each time they administer a medication to reduce the risk of errors, maintaining skin integrity should be given that same due process. By applying the following skin care basics patients are protected from further injury and the risk of hospital-acquired conditions, such as infection, skin tears and pressure injuries, is reduced. Skin basics include – assessment, movement, skin care, pressure relief, nutrition and hydration, education1 and communication (documentation, referral and clinical handover).

In addition to the skin integrity assessment discussed above, maintaining skin integrity requires a holistic approach. Mobility is important for circulation and in reducing prolonged exposure to external forces such a pressure, shear and friction implicated in pressure injury formation. It is important to ensure interventions are in place to limit the person’s exposure to such forces if they have reduced mobility or protective sensation (for example diabetic neuropathy), are at nutritional risk or malnourished, acutely unwell or have any condition which decreases their tissue tolerance to pressure.

Ask your patient to demonstrate they can independently move their arms and legs and reposition themselves in bed. If the patient is unable to do this easily they are at risk for skin failure and pressure injuries. Pressure relieving surfaces such as active pressure relieving mattresses and pressure redistributing seating cushions may be required. Other devices might include the Podus Boot to offload pressure to the heels and monkey bars and/or side bars to assist a person to reposition in bed. Always use proper transfer equipment to reduce shear and friction e.g. a slide sheet and lifter. If your patient is sitting out of bed educate them to reposition themselves regularly to relieve pressure to the buttocks.

Ensuring skin is cleansed, dried thoroughly and moisturised daily will reduce the risk of excoriation and help to keep the skin in peak condition. Using non-soap cleansers will help to protect the acid mantle and prevent the skin from drying out, while moisturisers provide hydration to the skin and help to keep it in good condition. The pH of skin is around 5.5, while soaps are generally alkaline having a pH of around 8 or 9.3 An alkaline pH creates an environment for opportunistic bacterial growth which may lead to infection, especially if the skin is compromised.3 If your patient is incontinent ensure their continence aid is checked and changed regularly and the exposed skin cleansed, dried and moisturised each change to reduce the risk of moisture lesions and painful excoriation. For patients with a high BMI be sure to pay particular attention to creases and skin folds. Be mindful of the pressure used to cleanse frail skin as this can cause skin tears and/or bruising if too much force is applied.

People come to hospital because they are unwell. In addition to the normal daily nutritional requirements, extra calories and protein are often necessary to assist their recovery and healing from surgery or their wounds. Monitor your patient’s oral intake and if in doubt place a referral to the dietician for a proper nutritional assessment and recommendation for oral nutritional supplementation (if required). Discuss your concerns with the patient’s doctor; extra fluids might be required. High wound exudate can lead to dehydration and loss of albumin and other electrolytes. Similarly high output stomas, and prolonged nausea, vomiting and diarrhoea, if excessive, will lead to dehydration, placing the person at risk for compromised skin integrity and reduce their tissue tolerance to pressure.

Most importantly it is essential to involve patients and their family or care givers in their care through education. Educating the patient on the basics of skin care will help them to look after their skin once discharged and arm family members and/or carers with the knowledge of what to look for, how best to manage skin failure and when to seek medical help.

Lastly, documentation is a key component to good communication. Document your findings and interventions in the patient’s health medical record and communicate these to your team members including nurses, doctors and allied health staff.  Referral to the dietician, physiotherapist and occupational therapist will provide interdisciplinary management for the patient to ensure the best possible outcome for the patient. Remember an acutely ill patient with a wound or a post-operative surgical patient with reduced mobility, or ongoing nausea and vomiting, or experiencing a delirium is at a high risk for skin failure. If appropriate interventions are not implemented and monitored on a regular basis, and outcomes clearly documented and communicated, patients are at risk of further injury, often leading to increased length of hospital stay or unplanned readmission post discharge.

By Bonnie Fraser BSc, BNUR, Clinical Nurse Educator.

References:
1. Biabchi J, Cameron J. Assessment of skin integrity in the elderly 1. Wound Care, 2008:S26-S32
2. Varani J, Dame MK, Rittie L, Fligiel SE, Kang S, Fisher GJ, Voorhees JJ.  Decreased collagen production in chronically aged skin: roles of age-dependent alteration in fibroblast function and defective mechanical function. Am J Pathol, 2006: 1861-8. British Journal of Nursing, 2005, 14 (22): 1172-6.
3. McLafferty E, Hendry C, Farley, A. The integumentary system: anatomy, physiology and function of skin. Nursing Standard, 2012: 27 (3): 35-42.
4. Holloway S, Jones V. The importance of skin care and assessment.

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Bonnie Fraser

A mother to three girls, previously Bonnie was an educator in the NSW secondary school system for 20 years before retraining to become a registered nurse. Bonnie has a Bachelor of Science with a Graduate Diploma in Education from the University of New England; and several certificates from TAFE NSW including Certificate IV in Workplace Training and Assessment and a Graduate Diploma in Management Communication. In 2009 Bonnie  attained a Bachelor of Nursing from Newcastle University, and is currently undertaking a Masters Degree in Wound Care though Monash University, this being her final year.  Currently Bonnie is employed as a registered nurse at the Port Macquarie Base Hospital located on the mid north coast of NSW. During her time as an RN she has worked in the areas of orthopaedic and general surgical nursing and fulfilled the roles of both clinical nurse educator for new and transitioning nurses and clinical nurse specialist wound management.