Skin as the largest organ of the body provides several important functions, namely protection from external environmental influences, thermoregulation, electrolyte balance and sensation – pain, touch, heat and cold and shock absorption.

External and internal environmental factors also impact skin resilience (for example, air pollutants, temperature, exposure, diet and life style choices) and how our skin ages.

As we age structural and functional skin changes occur leading to the loss of our skins ability to carry out these functions and act as a barrier, maintain homeostasis and thermoregulation. 

The layers of the skin and the junction between the epidermis and dermis become thin and flatten leading to loss of resilience to trauma 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.2

Older skin is 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, 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.

Common skin conditions

In the course of any day nurses come across a variety of skin conditions in their patients. These may include:

• Irritant reactions to stoma appliances and other dressing adhesives;
• Generalised rashes from latex allergies;
• Blisters (or bullae) due to dressing adhesives, fixation tapes or disease processes such as diabetes;
• Eczema associated with dermatitis and venous stasis disease;
• Hyperkeratosis (thick scaly skin) often seen in patients with lymphoedema, venous stasis disease or disease specific neuropathies and associated altered gait;
• Paper thin skin and purpura due to long term steroid or anticoagulation therapies;
• 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 e.g. incontinence, leaking SPCs, high output stomas, PEG tubes and other drains; and 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 and what to look for are outlined in table 1.

Table 1: Components of skin assessment and what to look for.




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 or transfer to another facility.

Following a consistent and evidence based skin care regime the risk of further injury and hospital-acquired conditions, such as infection, skin tears and pressure injuries, can be reduced.

Skin basics include – assessment, movement, skin care, pressure relief, nutrition and hydration, education and communication (documentation, referral and clinical handover).

In addition to the skin integrity assessment, maintaining skin integrity requires a holistic and interdisciplinary 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, loss of protective sensation (for example diabetic neuropathy), are at nutritional risk or malnourished, acutely unwell or have any condition which decreases their capacity to respond to pressure and/or reduces 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 and interventions are required to protect the individual from injury.

Pressure relieving surfaces such as active pressure relieving mattresses and pressure redistributing seating cushions may be required.

Other devices might include heel wedges and offloading shoes or boots to reduce pressure to heels and monkey bars and/or side bars to assist a person to reposition in bed.

Safe manual handling techniques and the use of appropriate manual handling equipment facilitates safe patient/resident transfer reducing the risk of injury.

Utilising slide sheets, pelican belts, additional assistance or a lifter aid in the safe transfer to patients. If your patient is sitting out of bed educate them to reposition themselves regularly to relieve pressure to the buttocks if able otherwise endeavour to reposition the individual on a regular basis.

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 with a pH close to 5.5 will help to protect the acid mantle and prevent the skin from drying out while moisturisers applied at least twice daily hydrate the skin helping to keep it in good condition.

Soaps are generally alkaline having a pH of around 8 or 9.3 creating 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, carefully dried and moisturised each change to reduce the risk of moisture lesions and painful excoriation.

The use of protective skin barriers may reduce incontinent associated dermatitis. 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. Be mindful of frail skin avoiding firm pressure when cleansing and drying or massaging areas that could be easily damaged. 4

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, prolonged nausea and 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. This will empower individuals to become involved in their care and help them to look after their skin once discharged.

Lastly, documentation is a key component to good communication. Document your findings and interventions in the patient’s clinical notes on eMR and communicate these to your team members including nurses, doctors and allied health staff. 

Referral to a dietician, physiotherapist and occupational therapist will provide interdisciplinary management ensuring the best possible outcome for the patient.

Remember the older adults, acutely ill individuals with a wound, or a post-operative surgical patients with reduced mobility, ongoing nausea and vomiting or experiencing a delirium are at a high risk for skin failure.

If appropriate interventions are not implemented proactively and monitored on a regular basis; and outcomes clearly documented and communicated, patients are at risk of further injury, potentially leading to increased length of hospital stay, unplanned readmission post discharge or in some cases death.

By Bonnie Fraser BSc, BNUR, Master of Wound Care, Clinical Nurse Consultant Chronic and Complex Wound Management.

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. Joanna Briggs institute, Recommended Practice. Skin Integrity: Basic Skin Care (older people). The Joanna Briggs Institute EBP Database, JBO@Ovid, 2019; JBI17402.