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Chapter 13

Skin Care

Skin

Functions of skin

Protect underlying structures

Regulate body temperature

Sensory input

Stores fat

Metabolism of salt and water

Gas exchange

Production of vitamin D

Review Table 13.1 for expected changes related to aging

You need to know what is normal to know what to consider abnormal and in

Need of intervention.

Often overlooked because focus is on acute problems or disease

Can affect health and compromise quality of life

Many age-related changes are visible

Due to aging, genetics, environment

Common Skin Problems

Xerosis

Extremely dry, cracked, and itchy skin

Most common skin problem associated with aging

Caused by decrease in epidermal filaggrin, which is a protein required for binding of keratin into macrofibrils

Seen primarily on the extremities, mostly legs, but may affect trunk and face

Best practices (Box 13-2)

How might the skin care be different for the older patient?

XEROSIS

Common Skin Problems

Pruritis

Itchy skin (not a disease, but a symptom)

Can cause skin injury secondary to scratching

Aggravated by perfumed detergents, fabric softeners, heat, sweating, restrictive clothing, fatigue, exercise, and medications

May result from systemic disease such as chronic renal failure, biliary, or hepatic disease

Failure to control itching increases risk for eczema, excoriations, cracks, infection

Itching can cause disruption in the skin and needs to be addressed to reduce risk of infection

Common Skin Problems

Scabies

Causes intense itching

Caused by tiny mite, Sarcoptes scabiei

Contagious, easily transmitted through close physical contact; intimate or casual

Scabies with thick crust contain large number of mites and eggs

May be transmitted on clothing, linen, furniture

Diagnosed visually or via skin scraping

Treated with prescribed lotions and creams; clothes and linens need to be washed in hot, soapy water and dried with high heat; rooms cleaned and vacuumed

Consider this a possibility if your patient has a lot of itchiness at night

Can spread easily, so you will want to identify it early and check others

Who have been in contact with the patient

All belongings must be treated also

Common Skin Problems

Purpura

Fragility of dermal capillaries secondary to dermal thinning causing blood vessels to rupture

Extravasation of blood into surrounding tissue is called purpura

Commonly seen on dorsal forearm and hands

Increases with age

Persons on blood thinners are more susceptible

How might you adjust care for this person because of increased bruising?

Common Skin Problems

Skin Tears

Occurs because skin is thin and fragile

Painful, acute, accidental in nature

Categorized according to the Payne-Martin classification system

Management: proper assessment, control of bleeding, cleanse with nontoxic solution, appropriate dressing, management of exudate, and prevention of infection

Common Skin Problems

Keratosis

Seborrheic Keratosis

Benign growth

Mainly see on trunk, face, scalp, and neck

Waxy, raised, stuck-on appearance

Flesh colored or pigmented, various sizes

Actinic Keratosis

Precancerous

Related to exposure to UV light

Risk: increased age, fair complexion

Rough scaly sandpaper patches

Pink to reddish brown with erythematous base

Actinic keratoses

Seborrheic keratosis

Seborrheic keratosis: Image of raised brown, scaly patch of skin

Actinic keratoses: Image of older man’s forehead with raised, crusty red patches, some with scabs

Common Skin Problems

Herpes zoster (Shingles)

Viral infection caused by reactivation of the varicella-zoster (chicken pox) virus

Preceded by itching, tingling, rash along the dermatome prior to outbreak of vesicular lesions

Lesions rupture, crust over, and heal

Infectious until it crusts over

Treatment: analgesics, calamine lotion, antiviral agents, Zoster vaccine if greater than 60 years

Complications: postherpetic neuralgia, eye involvement

NEVER goes around the entire body—is limited to one side, following the dermatome

Common Skin Problems

Candidiasis

Caused by fungus Candida albicans found on the skin

Risk factors for infection: obesity, malnourishment, antibiotic or steroid use, immunocompromised, chemotherapy, and diabetes

Found in warm, moist areas of skin, like skinfolds, axilla, groin

Commonly called “thrush” when inside the mouth

Tips for best practice (Box 13-6)

Skin Cancer

Cancer of the skin is the most common cancer

Major public health problem on the rise

One in five Americans will develop skin cancer in the course of a lifetime

Caucasian populations are at a higher risk

All skin types should minimize sun exposure

What is primary and secondary prevention for skin cancer? While much damage might have already been done

We can still teach them ways to reduce risk

Basal cell

Most common malignant skin cancer

Mainly in older persons

Slow growing and metastasis rare

Triggered by extensive sun exposure, burns, chronic irritation, or ulceration

Early detection and treatment minimizes damage

Squamous cell

Second most common

Aggressive and high incidence of metastasis

Major risk factors are sun exposure, fair skin, immunosuppression

Slightly different clinical presentations and may be overlooked

Treatment depends on size, histology, and patient preference

Skin Cancer

Basal cell

Squamous cell

Skin Cancer

Basal cell: Image of raised mole with irregular borders and visible vasculature on man’s nose

Squamous cell: Raised mole with irregular borders and dry, crusty ulceration

Skin Cancer

Melanoma

Neoplasm of the melanocytes

Accounts for less than 2% of all skin cancers

Highest incidence in Caucasians

Multicolored, raised, asymmetrical, irregular borders

More common in men than women

Risk factors: more than 50 moles, sun sensitivity, history excessive sun exposure, severe sunburns, tanning beds

Skin Cancer

Indoor tanning

Melanoma is most common cancer in people less than 30 years

Indoor tanning increases risk of melanoma by 75% when started before age 35

2.5 times more likely to develop squamous cell

1.5 times more likely to develop basal cell

Goal of Healthy People 2020 is to reduce the use of indoor tanning devices

Promoting Health Skin

Box 13-7 in text

Pressure Ulcers

70% of pressure ulcers (PU) occur in older adults

A PU is a “localized injury” to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear

Affects health and quality of life

Considered a geriatric syndrome

Major cause of morbidity and mortality worldwide

National Pressure Ulcer Advisory Panel has developed a PU registry to track the problem

Pressure Ulcers

Characteristics

Most frequently occur on the posterior aspects of the body, especially sacrum, heels, and greater trochanter

May also be seen on lateral knees and ankles, pinna of the ears, occiput, elbows, and scapulae

25%-35% of PU are on the heels

Persons with peripheral vascular disease at greatest risk for development of heel ulcers

Pressure Ulcers

Suspected deep tissue injury

First image: Cross-section of the layers of the skin

Second image: Stage 1 pressure ulcer on heel of African American client

Pressure Ulcers

Stage I

First image: Cross-section of skin showing stage 1 pressure ulcer

Second image: Red, purple discoloration of intact skin on client’s left hip

Pressure Ulcers

Stage II

First Image: Cross-section of skin showing stage II pressure ulcer

Second Image: Red discolored skin with open areas; client photo of stage II pressure ulcer

Pressure Ulcers

Stage III

First Image: Cross-section of skin, stage III pressure ulcer

Second Image: Large stage III pressure ulcer spreading across both buttocks; excoriated, red, sanguineous tissue

Pressure Ulcers

Stage IV

First Image: Cross-section of skin showing stage IV pressure ulcer

Second Image: Stage IV pressure ulcer showing muscle

Pressure Ulcers

Unstageable

First Image: Cross-section of skin showing unstageable pressure ulcer with black necrosis in center of image

Second Image: Unstageable pressure ulcer with black, necrotic center

Pressure Ulcers

Classification

EPUAP and NPUAP (Box 13-10)

Medical Device-Related Pressure Injury

Mucosal Membrane Pressure Injury

Pressure injuries are always classified by the highest stage “achieved”

Reverse staging is never used

Risk Factors

Changes in skin

Comorbid illnesses

Nutrition status

Frailty

Surgical procedure (orthopedic/cardiac)

Cognitive deficits

Incontinence

Reduced mobility

Risks (Box 13-11)

Consider intensity and duration of pressure and tissue tolerance

Redness or blanching may NOT be the first sign of PU in darker pigmented persons, but may look purplish in color or look like a bruise

Pressure Ulcers

Prevention of PU

Prevention is key

A comprehensive PU program with multiple interventions appears to improve outcomes

Significant interventions include addressing limited mobility, compromised skin integrity, and nutritional support

A team approach is best when addressing this complex problem

Pressure Ulcers

Key nursing sensitive quality indicator

Can significantly impair recovery and rehabilitation and impact quality of life

Increased risk of mortality

High prevalence of health care litigation

Centers for Medicare and Medicaid consider PU a preventable adverse event and do not reimburse treatment for PU acquired during admission

Promoting Healthy Aging Implications for Gerontological Nursing

Assessment of PU

Thorough assessment of skin

Braden Scale

Nutritional evaluation

Laboratory studies

Positioning

Incontinence care

Wound specialist nursing consult when indicated

Question 1

Which is the most common malignant skin cancer?

Melanoma

Squamous cell carcinoma

Basal cell carcinoma

Actinic keratosis

ANS: C

Question 2

What is the #1 treatment of PU?

Prevention

Early identification

Thorough patient history

Risk assessment

ANS: A