T

he most important function of the skin is to defend the body from the environment. With normal aging, patients are more prone to alterations in skin integrity. As healthcare providers, it is important to understand the skin's structure, skin changes related to aging, and use of "geriatric-friendly" skin care principles to protect and maintain skin integrity.

The Skin's Structure
       There are three tissue layers of the skin--the epidermis, dermis, and hypodermis. The epidermis is the tough, protective, outer layer. It is about as thick as a sheet of paper throughout most parts of the body and has four layers of cells that are constantly flaking off and being renewed with cells that ascend to the skin surface. Within these four layers are four distinct types of cells: 1) keratinocytes, which produce keratin, the basic component of skin, hair, and nail cells; 2) melanocytes, which produce melanin, the pigment that gives skin its color and provides a shield against ultraviolet radiation; 3) Langerhans cells, which help protect the body against infection; and 4) Merkel cells, which are important in tactile sensory perception.
       Underneath, the dermis nourishes and supports the epidermis. The dermis consists of the fibrous connective tissue--collagen and elastin--together with the ground substance. The haphazard arrangement of this connective tissue allows the skin to be mobile and to stretch and contract with body movements. Within the dermis are three special types of cells: 1) fibroblasts, which secrete the connective tissue matrix; 2) mast cells, which release histamine and play a role in hypersensitivity reactions in the skin; and 3) macrophages, which are able to destroy dead cells and germs and participate in immune responses. Also contained in the dermis are blood vessels that supply oxygen and nutrients to the epidermis and dermis, nerves, sweat and sebaceous glands, hair follicles, and lymph vessels. The outer portion of the dermis has tiny projections called papillae that fit the dermis to the epidermis.
       The third layer, the hypodermis or subcutaneous tissue, is made up of connective tissue, blood vessels, and cells that store fat. This layer helps protect the body from blows and other injuries and helps it hold in body heat. The subcutaneous tissue also contains the dermal appendages--nails, hair, sebaceous glands, and sweat glands. The sebaceous glands open onto the surface of the skin through a canal and secrete an oily substance--sebum. The main role of sebum is to waterproof the skin and hair and prevent drying.
       Sweat is a salty, watery solution produced by sweat glands, which have numerous microscopic channels that open onto the skin surface. As sebum and sweat combine on the skin surface, they form a protective layer referred to as the acid mantle. Acid mantle has a particular level of acidity characterized by a mean pH of 5.5. (Remember, pH--potential hydrogen--is described in a range of 0-14, with 7 being neutral. Any pH below 7 is considered acidic, and above 7 is alkaline.) The natural acidity of the skin maintains the natural flora and inhibits the growth of harmful bacteria and fungi.1

Skin Changes Related to Aging
       Age-related changes that place older patients at greater risk for alteration in skin integrity are described in Table 1.1

"Geriatric-Friendly" Principles
       Many of the protective functions of the skin are diminished with aging. Thus, aging skin is at higher risk for injury. Following are principles to prevent injury, improve patient comfort, and enhance clinical outcomes:
* Prior to enacting any sort of preventative skin care principles, the facility should be acquainted with regulatory standards outlined by the Centers for Medicare and Medicaid Services (http://www.cms.hhs.gov) and treatment guidelines, such as those issued by the Agency for Healthcare Research and Quality (http://www.ahrq.gov), the Wound, Ostomy, and Continence Society (http://www.wocn.org/), and by the American Medical Directors Association (http://www.amda.com). These agencies have designated what is accepted as reasonable (i.e., the standard of care). Therefore, is it vital for facilities to assure that their policies and procedures are revised according to these current, accepted standards of care.
* Since the majority of preventative skin care techniques and routine observations are delegated to nursing assistants, facilities need to invest in educating nursing assistants by ensuring they have the knowledge and skills to carry out basic preventative skin care. Nursing assistants should know basic skin changes that occur with aging, principles of "geriatric-friendly" skin care, safe transfer and repositioning techniques, correct use of "geriatric-friendly" supplies (e.g., extremity stockinette, long sleeves, etc.) and equipment (e.g., padded side rails, wheelchairs, etc.), how to report skin conditions to a professional, signs and symptoms of infection, and expected wound appearance during the healing process.
* Provide adequate staffing based on the needs of the residents. Inadequate staffing means that caregivers do not have enough time to do their jobs. As a result, caregivers are rushed, preventative care is not consistently provided, and the rate of negative outcomes increases.
* Maintenance of skin integrity is achieved by accurate and timely assessment of individuals at risk. Key elements of assessment to include are nutritional status, mobility, sensory perception, mental status, incontinence, medication review (especially for drugs causing somnolence, e.g., sedatives, hypnotics, etc.), or skin changes (e.g., steroids) and presence of predisposing conditions (e.g., edema, compromised immune status, underlying skin conditions, prone to falls/accidents, use of physical restraints, etc.). Once risk factors are identified, an individualized preventative skin care plan should be developed.2
* Gentle cleansing is essential to preventative skin care. Washing the skin with harsh soaps can dry and irritate skin and result in loss of the skin's protective acid mantle. Additionally, soap can leave residue that harbors germs and leads to infections. When choosing a skin-cleansing product, look for products with a pH range of 4 to 7. At this range, products are considered pH balanced and will not disrupt the skin's acid mantle.
* Exposure to urine and feces can alter skin integrity. Toileting programs can minimize skin contact to urine and feces. If an incontinent episode occurs, the perineal area should be thoroughly cleansed, and the skin should be protected with a barrier agent. Moisture should be sealed out with barrier agents, such as petrolatum or zinc oxide. Also, absorbent skin care briefs or pads that wick moisture away from the skin should be used.2
* Moisturizers, lubricants, and emollients help retain water in the skin. When choosing a moisturizer, check product labels containing any of the following ingredients: petrolatum, mineral oil, linoleum, ceramides, dimethicone, or glycerin. Avoid products containing alcohol, which is drying and irritating. For best results, apply moisturizers after bathing. This will help trap the water in the upper layers of the skin and decrease dryness and itching. Ointments will provide the most occlusive barrier; creams are the next best. Lotions are the least occlusive, but they offer the ease of application.3 Aggressive cleansing and massage, especially over bony prominences, has been shown to cause tissue damage, and must be avoided.2
* A repositioning schedule should be used. Due to changes in the elderly, repositioning every two hours may not be frequent enough for a frail elder. Consider repositioning every 60 to 90 minutes for some individuals.
* Since the elderly are prone to tear injuries, employing "geriatric-friendly" devices and techniques will reduce friction and shear. This includes simple interventions, such as using turn sheets, gloves, long sleeves, padded side rails and wheelchairs, transfer boards, trapeze bars, mechanical lifts, keeping head of bed lower than 30 degrees if possible, turning patients onto their side at a 30-degree angle (to keep direct pressure/friction off bony prominences), and suspending heels.2
* Capillary filling pressure is about 32mmHg--when pressure between support surface (i.e., bed or wheelchair) and bony prominence is higher, blood flow to the skin stops and cellular death occurs. When shopping for pressure reduction devices, determine the degree of pressure reduction achieved. The closer to 32mmHg, the more effective the device. Eggcrate mattresses provide inadequate pressure reduction and should be used for comfort only. Donut devices centralize tissue pressure and should not be used.2
* Nutrition and hydration are important for maintaining skin integrity. The elderly are more likely to be undernourished. A careful assessment of the patient's ability to feed self, chewing and swallowing abilities, mental and behavioral problems, nutrient-drug interactions, and medical causes (e.g., diarrhea, vomiting, infection, etc.) should be examined. A registered dietitian should be consulted to assure the patient has adequate fluid, calories, proteins, and Vitamins A, C, and E.2
* Ongoing evaluation of the condition and integrity of skin is essential. All patients should be assessed from head to toe with special attention to the heels at least weekly. When a patient leaves the facility for extended visits or hospitalization, the skin should be assessed upon leaving and re-entering the facility.
* The facility must have a robust documentation system that captures the preventative skin care services provided by the facility. This documentation includes risk assessments, care plans, flowsheets, etc.
* Finally, the facility needs an effectual continuous quality improvement program to assure ongoing compliance. Chart audits and observation of facility practices should be conducted to assess delivery and documentation of preventive services. Findings should then be compared with your facility's baseline measures and shared with staff.
       Keep in mind, "geriatric-friendly" skin care is a constant process that does improve patient care and comfort and provides legal protection and positive survey outcomes for the facility.