Welcome 2
Contents Skin Facts 4 Section One: Skin changes in the older person 5 Section Two: Possible consequences of skin changes in the older person 11 Section Three: Skin tears 17 Section Four: Pressure damage 29 Section Five: Moisture Lesions 37 Section Six: Sun damage 43 Emollient workshop 54 Contents 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