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SKIN INTEGRITY
REDUCING THE THREATS !
- Ruth Bryant RN, MS, CWOCN
- Director, webWOC Nursing Education Program
- Partner, Bryant Rolstad Consultants, LLC
- Minneapolis, MN
2Skin Integrity Reducing the Threats
Objectives
- 1. Correlate normal skin anatomy with maintaining
skin integrity. - 2. Describe how the skin protects the body from
threats to skin integrity. - 3. Describe the threats posed by aging, soap,
bathing, dry skin and skin tears. - 4. Identify nursing interventions that reduce the
threat to skin integrity.
3Why the Focus on Skin Integrity?
- Intact top layer of skin is a barrier from
environmental threats. - When skin integrity is altered, the risk of
problematic complications such as pressure
ulcers and skin infections is increased. - With aging, the skin is less efficient as a
barrier and less resilient to environmental
threats. - An increasing number of patients will be admitted
to our institutions who have a heightened risk
for altered skin integrity by virtue of their age.
4Anatomy of the Skin
5Skin Integrity Key Structures of the Skin
- Stratum Corneum
- Dermis
- Basement Membrane Zone (BMZ)
6Stratum Corneum
- Intact stratum corneum is the first line of
defense for the body. - The stratum corneum is constantly being replaced
and requires an orderly, regulated process of
keratinocyte proliferation and differentiation.
7Dermis
- The second layer of the skin.
- Contains sebaceous glands.
- Predominant proteins are elastin and collagen.
- Contains a ground substancecomposed of
proteoglycans (PGs) and glycosaminoglycans
(GAGs)
8Basement Membrane Zone (BMZ)
- Located where the epidermis and dermis meet.
- Epidermal surface consists of fingerlike
downward projections known as Rete pegs. - Dermal surface consists of upward projections
known as Dermal papillae. - Dermal papillae contains numerous capillary
loops.
9Functions of the Skin
- Sensation
- Metabolism
- Thermoregulation
- Communication
- Protection
10The Protective Function of the Skin
- An intact stratum corneum protects the skin from
Fluid and Electrolyte loss. - Capillary loops and dermal proteins assist in
retention of moisture in skin.
11The Protective Function of the Skin
- The collagen and elastin present in the dermis
protect the skin from Mechanical Injury .
12The Protective Function of the Skin
- Skin pigmentation and the presence of melanin
protects the skin from Ultraviolet Radiation.
13The Protective Function of the Skin
- Several characteristics of the skin provide
protection from Pathogens - Intact stratum corneum
- Presence of Sebum
- Acid pH (4.5-6.5)
- Normal skin flora (resident flora)
- Skin Immune System
14Threats to Skin Integrity
- Natural Threats
- Aging
- Dry Skin
- Man-induced Threats
- Skin Tears
- Soaps
- Conventional Bathing Techniques
15AGING Natural Threat to Skin Integrity
- Age alters the skins ability to retain moisture
- Decrease in dermal proteins.
- Decrease in number of capillary loops in
basement membrane zone. - Prolonged epidermal turnover.
16AGING Natural Threat to Skin Integrity
- Age changes that alter skins ability to resist
pathogens - Change in the composition of sebum
- Decreased number of Langerhans cells
- Decrease in number of mast cells
17AGING Natural Threat to Skin Integrity
- Age changes that alter skins ability to resist
mechanical stresses - Flattening of Rete ridge and Dermal papillae
- Decreased amount of dermal proteins (elastin and
collagen) - Decrease in subcutaneous fat
18DRY SKIN Natural Threat to Skin Integrity
- Affects 75 of people over 64 years of age.
- Results from prolonged epidermal turnover.
- The aging corneocytes in the stratum corneum
are less adherent so the barrier function of the
skin is compromised. - Less adherent corneocytes create a larger surface
area which allows more fluid loss through the
skin.
19SKIN TEARS Man-Induced Threat to Skin Integrity
- Risk factors for developing skin tears
- Advanced age
- Sensory loss
- Impaired nutrition
- Impaired cognition
- Dependency on staff for ADLs
- Need for mechanical devices
20SOAPS Man-Induced Threat to Skin Integrity
- Alkaline soaps decrease layers of stratum
corneum. - Soaps emulsify lipids.
- Soaps remove resident and transient flora.
- Alkaline soaps increase skin natural pH.
- Soaps may interfere with water holding capacity
of the skin.
21Conventional Bathing Techniques Man-Induced
Threat to Skin Integrity
- How is bathing a threat to skin integrity?
- Basins often remain damp between baths and are
therefore a a vehicle for bacterial proliferation
and transmission. - The negative effects of hand washing on the
integrity of the hands in nurses has been
extensively documented. - Basin bathing is analogous to hand washing.
22Conventional Bathing Techniques Man-Induced
Threat to Skin Integrity
- What are the negative effects of hand washing?
- Changes in resident skin flora.
- Heavy skin shedding so protective layer of
stratum corneum is compromised. - Broken skin increases the risk of transmission of
microorganisms.
23Conventional Bathing Techniques Man-Induced
Threat to Skin Integrity
Frequency
Function
Form
Basin Bathing
24Conventional Bathing Man-Induced Threat to Skin
Integrity
Alkaline Soaps
Force and Friction
Washcloths
Hot Water
25How is Alkaline Soap a Threat?
- Thins the stratum corneum.
- Emulsifies lipids.
- Removes resident flora.
- Alkalinizes skin pH.
- Reduces water holding capacity of skin.
26How is the Washcloth a Threat?
- Washcloth material becomes harsh and rough
because of frequent laundering in bleach. - Washcloth can transmit microorganisms to other
body parts during bathing process and
contaminate basin and surrounding environment.
27How is Hot Water a Threat?
- Hot water has a drying effect on the skin.
- The potable water source can be contaminated.
- Bath water can cross-contaminate personnel and
environment.
28How is Force or Friction a Threat?
- Considerable force and friction is typically used
to lather up the cloth and skin. - This amount of force or friction on the skin can
be abrasive to the stratum corneum. -
29Reducing the Threat to Skin Integrity
- How can we provide care to the patient, bathe
them and still do no harm to their skin?
30Reducing the Threat of Soap
- Recommendations
- Use soaps with neutral pH.
- Avoid detergent based antiseptics.
- Eliminate harsh skin care products.
- Minimize contact with soap and solvents.
- Consider using waterless cleansers.
- Use solutions that contain moisturizers.
- Use moisturizers during and after cleansing.
- Treat dry skin with moisturizers.
31Reducing the Threat of Washcloths
- Recommendations
- Use thick soft cloths.
- Additional Benefits
- Washcloths are a surprisingly costly item in
institutions because they must be replaced
frequently.
32Reducing the Threat of Hot Water
- Recommendations
- Avoid hot water use slightly warm water and
replenish as needed. - Use premoistened cloths that can be warmed.
- Explore utilization of new delivery mechanisms
for skin cleansing. - Additional Benefits
- Warm bath is very soothing and relaxing.
- Reduce down time for staff while waiting for tap
water to warm up. - A cool bath is uncomfortable and may have a
negative effect on thermoregulation.
33Reducing the Threat of Force Friction
- Recommendations
- Pat dry rather than rubbing and scrubbing.
- Avoid rough skin scrubbers.
- Minimize force/friction when bathing.
34Reducing the Threat to Skin Integrity
- Additional Recommendations
- Cleanse skin at time of soiling and at routine
intervals. - Individualize frequency of bathing according to
patient need and preference. - (AHRQ, 1992)
35Reducing the Threat to Skin Integrity Conclusion
- Dr. Elaine Larson in 1999 stated that
traditional hand washing practices warrant
re-examination. - With consideration of our ultimate responsibility
to the patient to optimize the protective barrier
function of the skin, it is reasonable to
propose Conventional bathing techniques
warrant re-examination.