AIMING FOR PREVENTION: TIPS TO MINIMIZE SKIN BREAKDOWN

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AIMING FOR PREVENTION TIPS TO MINIMIZE SKIN
BREAKDOWN

• OTN Presentation
• December 15, 2009
• Dr. Rosemary Kohr, RN, PhD, ACNP(cert)

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CONTRIBUTING FACTORS TO SKIN BREAKDOWN

• Pressure
• Moisture
• Immobility
• Nutritional/fluid deficits
• Chronic illness (e.g., diabetes)
• Aging process

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CONTRIBUTING FACTORS TO SKIN BREAKDOWN

• Chemicals and enzymes (urine, feces)
• Circulatory problems
• Bacteria
• Allergic reaction
• Radiation damage

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Back to Basics

• Risk Assessment
• Every patient has excellent skin care
• Full attention to nutrition and hydration
• Every mattress is at least pressure reduction

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Anatomy Physiology of the Skin

• Facts About The Skin
• Bodys largest organ
• Covers approximately 3000 square inches
• Expands seven times over a lifetime
• Weighs six pounds or 20 of body weight
• 3 to 100 cells thick
• Thinnest in the Tympanic Membrane thickest on
  the soles and palms
• Capable of self-regulations and self-regeneration

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Skin Function

• Protection from bacteria, chemicals, Ultraviolet,
  water
• Heat Regulation
• Insulation
• Communication through sensation.
• Vitamin D synthesis
• Holds everything together.

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Skin Layers
STRUCTURE OF THE SKIN

• Epidermis
• Dermis
• Subcutis

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Skin
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EPIDERMIS

• Outermost protective skin layer
• Formed by the continuous upward migration of
  keratinocytes
• Takes about I months to migrate to surface
• 3 to 100 cells thick
• Avascular layer (no blood supply)

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Epidermis
Stratum Corneumouter most layer

• Primarily responsible for protection
• Abraded daily by mechanical and chemical trauma
  (normal exfoliation)
• Skin tears are an example of mechanical trauma
• Composed of keratinocytes, melanocytes and lipids
  (fats and oils)

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Acid Mantle
IMPORTANCE OF THE STRATUM CORNEUM
Keratin and lipids maintain moisture
levels Acid Mantle retards bacterial growth
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Dermis

• Contains endocrine glands (sweat ducts), hair
  follicles, blood vessels, lymphatics and nerves
• Adipose tissue provides energy, insulation and
  pressure distribution
• Vascularity provides heat exchange, nutrition
  and inflammatory response

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ONE CUBIC CENTIMETER OF SKIN CONTAINS
Skin

• 10 hairs
• 15 sebaceous glands
• 3 yards of blood vessels
• 4 yards of nerves
• 100 sweat glands
• 3,000 sensory cells
• 300,000 epidermal cells

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What happens to the skin as an individual ages?

• Increased dryness
• Easy bruising
• Slower healing response
• Wrinkles
• Skin cancers precancers

Normal aging
Photoaging (ie. Sun damage)
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Aging Skin Whats the story?

• Functional Changes
• Altered skin permeability
• Decreased Inflammatory response
• Decreased immunologic responsiveness
• Decreased thermoregulation
• Impaired wound healing
• The Merck Manual of Geriatrics 1995

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Aging Skin What's the Story?

• Reduction in
• Decreased Vitamin D synthesis
• Impaired sensory perception
• Decreased sweating and sebum production
• Decreased elasticity
• Thickness and attachments
• The Merck Manual of Geriatrics 1995

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Aging Skin
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Incontinence And Aged Skin

• Excess of moisture and bacteria.
• Macerated skin requires less friction to cause
  damage
• Urea in urine is turned into ammonia
• This results in a high PH (alkaline)

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Incontinence And Aged Skin

• Acid mantle is now alkaline and cannot function
• If feces are present, digestive enzymes can be
  activated
• The barrier function of the skin can be
  overwhelmed

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Acid Mantle
IMPORTANCE OF THE STRATUM CORNEUM
Keratin and lipids maintain moisture
levels Acid Mantle retards bacterial growth
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Skin Care ProductsWhat to choose?

• Look for clinical evidence
• Goal should be to support normal skin functioning
• Look for
• Sensitizers such as lanolin AVOID THEM!
• PH of 4 -7
• Ingredients that support skin functioning

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So How do You Clean Skin?

• All Bar soap is alkaline
• Bar Soap therefore reduces the normal acid
  mantel, resulting in dry skin that is more prone
  to infections
• Washcloths are often rough and can result in
  friction injuries
• Think about a body wash and a method to wash the
  skin that reduces friction

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Factors Affecting Skin
Soaps

• Alkaline soaps reduce the thickness and number of
  cell layers in the stratum corneum
• Normal flora washed away
• Normal washing requires 45 minutes for skin to
  restore its acidic pH
• Repeating washing requires 19 to 24 hours to
  restore the skins normal pH

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No more rough washcloths
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Barriers

• Goal is to increase the barrier function
• Formulations Ointments, creams or films
• Petrolatum and Zinc are common
• Dimethicone more popular now
• Ointments or creams can reduce the effectiveness
  of incontinent products
• Liquid films (No Sting, Skin Prep)

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MoisturizersWhat's the Story?

• Occlusives, Emollients or Humectants
• Goal is to support well hydrated skin
• All work by either prevent moisture loss, adding
  moisture, or draw moisture from the environment
• Petroleum jelly is the most effective occlusive
  but is greasy
• Apply immediately after bathing

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MoisturizersEmollients

• Dimethicone is an emollient and an occlusive
• Emollients work by hydration, enhanced
  flexibility and smoothness
• Most tested ingredient
• Silicon based, non sensitizing
• Resists wash off by formulation
• Adding more dimethicone turns it into an
  occlusive

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Humectants

• Draws moisture from the ambient environment
• Urea and lactic acid are examples
• Can cause burning

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Moisture has to be just right!

• Skin that is too wet is 5 times more likely to
  ulcerate than dry skin
• Skin that is too dry is 2.5 more likely to
  ulcerate than normal skin

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Perineal Cleansers

• The goal should be to remove feces, maintaining a
  normal PH and deal with odour
• Consider a product with a surfactant that is PH
  balanced
• Odour Control
• Consider time with a no rinse formula

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Skin Assessment

• Accurate history
• Asses skin turgor
• Skin should feel warm and dry

• Remember to assess any area of skin that is
  hiding from the obvious
• Skin folds, creases, under breasts, abdominal
  pannis, behind the ears
• Lower legs, feet, between the toes
• Perineal and perianal areas
• Around joints and over bony prominences
• Around braces, casts, orthodics and prosthetic
  devices

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Fungal Infection

• Red flakey irritated skin
• Satellite lesions
• Skin folds

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Legs in need of skin care!
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Products to use?

• Skin cleansers
• Skin barriers
• Skin humectants
• Other conditions requiring topical treatments

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Happy Holidays!!!
See you in January!