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Care of aging_skin_fall 2013 abridged


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Care of aging_skin_fall 2013 abridged

  1. 1. 1Care of Aging SkinCare of Aging SkinNURS 4100 Care of the Older AdultFall 2013Joy A. Shepard, PhD(c), MSN, RN, CNE
  2. 2. 2ObjectivesObjectives Summarize the effects of aging on the skin Distinguish skin changes due to aging from thosethat result from diseases or injury List practices that promote good skin health inolder adults Describe signs of and nursing care for xerosis,pruritus, actinic keratosis, seborrheic keratosis,skin cancer, and pressure ulcers in older adults
  3. 3. 3Key TermsKey Terms Acrochordon – A small, soft penduous growth on the skin, especiallyaround the eyes or on the neck, armpits, or groin Actinic damage – Exposure & damage by the sun Actinic (solar) keratotic lesions - Red-tan scaly plaques occurring on sunexposed surfaces; increase in size, become raised with rough surface.Precancerous Friction - Occurs with the lateral movement of pulling sheet or clothingfrom under a persons bodyweight Keratosis - Raised, thickened, areas of pigmentation which look crusty,scaly and warty Lentigo – A brownish spot (of the pigment melanin) on the skin Melanocytes - Produce melanin, give the skin its color and shield thebody from the harmful effects of the sun
  4. 4. 4Key TermsKey Terms Premalignancy – Any abnormal tissue, which is not cancerous, butwhich could become cancerous (if left untreated) Pruritus – Intense itching sensation Seborrheic keratosis – Superficial benign skin growth on face, trunk, orextremities. Yellow, light tan, brown or black; round or oval. Is flat orslightly elevated with a scaly surface Sebum - Oily substance that keeps hair supple and lubricates the skin Senile purpura - Bruised and discolored areas caused by damage to thecapillaries Shearing Force - Occurs when tissue layers move on each other,causing blood vessels to stretch as they pass through subcutaneoustissue Xerosis – Abnormal dryness of the skin
  5. 5. 5Normal Skin Changes withNormal Skin Changes withAgingAging
  6. 6. 6Effects of Aging: IntegumentEffects of Aging: Integument Flattening of dermal-epidermal junction Reduced thickness of dermis– Degeneration of elastic fibers– Increased coarseness of collagen Atrophy of hair bulbs/ decline in hair growth Decrease in pain sensation Decreased sweat and sebum Loss of subcutaneous adipose tissue Increased fragility of skin
  7. 7. 7Normal Changes of Aging in theNormal Changes of Aging in theIntegumentary SystemIntegumentary System
  8. 8. 8Aging: EpidermisAging: Epidermis Less moisture in cells  dry,rough appearance > 50 years epidermal mitosisslows  longer time tohealing + potential forinfection Rete ridges flatten  easyskin tearing Melanocytes decrease pale complexion +increased UV damage +scattered pigmented areas(age spots, liver spots,and freckles)
  9. 9. 9Aging: DermisAging: Dermis Elastin quality decreases+ quantity increases wrinkling + sagging Collagen disorganized loss of turgor Decreased vascularity pale complexion Thinning capillaries easy damage  senilepurpura
  10. 10. 10Skin Turgor: LooseSkin Turgor: LooseForehead, collarbone, or sternumForehead, collarbone, or sternum(center of chest)(center of chest)Not on back of hand orNot on back of hand orforearm for an elder clientforearm for an elder client
  11. 11. 11Aging: SubcutaneousAging: Subcutaneous(Hypodermis)(Hypodermis) Loss of SubQ tissue &thinning of dermis Atrophy  thinningfeatures, hands andlower legs Hypertrophy increase inproportional body fat
  12. 12. 12Aging: GlandsAging: Glands Eccrine & apocrineglands– Decrease in size– Decrease in number– Decrease in function Sebaceous glands– Increased size +decreased sebum water evaporation cracked, dry skin
  13. 13. 13Aging: Skin and GlandsAging: Skin and Glands Decreasedsubcutaneous fat,elastic fibers, collagen(stiffening), skinthickness: wrinklesand sagging Decreased blood flow:delayed woundhealing
  14. 14. 14Changes in Wound Healing WithChanges in Wound Healing WithIncreased Age: DelayedIncreased Age: Delayed
  15. 15. 15Aging: Skin and GlandsAging: Skin and Glands Degeneration ofnerve endings Degeneration ofmelanocytes:Lentigo (“liverspots”)
  16. 16. 16Solar ElastosisSolar Elastosis: UV Radiation: UV Radiation Leathery skin/Roughness Inelastic Deep wrinkles Yellowish Depigmentation/hyperpigmentationPhotoagingPhotoaging superimposed on normal agingsuperimposed on normal aging
  17. 17. 17Aging: Skin and GlandsAging: Skin and Glands Decreased sebum:dry skin (xerosis) Decreased sweat:impairedthermoregulation Increasedtransparency andfragility Risk for Injury
  18. 18. 18Skin Changes in Older AdultSkin Changes in Older Adult Seborrheic keratosis– Dark raised lesions Actinic keratosis– Reddish raisedplaques on areas ofhigh sun exposure canbecome malignant Acrochordon– Skin tags
  19. 19. 19Seborrheic Keratosis (benign)Seborrheic Keratosis (benign) Description Increase in size and number with age Areas of the body affected Treatment Need to be evaluated to differentiate themfrom a precancerous lesion
  20. 20. 20Aging: HairAging: Hair Altered melanocytes nonpigmented (gray) hairfollicles Declining hormones graying, thinning, baldness– Pubic + axillary hair loss– Facial hair in women(hirsuitism)– Thicker hair in ears +nose– Balding in men by 50 yrs
  21. 21. 21Aging: NailsAging: Nails Decreased blood flow,rate of growththicker nails Longitudinal(striations) nail ridges Thick, brittle nails Dull, yellow, or graycoloration
  22. 22. 22Integumentary HealthIntegumentary HealthPromotionPromotion Avoid irritating agents Promote activity Adequate fluid intake Use emollients, topicalcreams, lotions, &moisturizers No bath oils Avoid excessive bathing Avoid exposure to UVrays
  23. 23. 23AssessmentAssessment
  24. 24. 24Nursing Assessment of SkinNursing Assessment of Skin Nurses: best opportunity/most direct contact Assessment Guide 28-1: SkinStatus Inspect scalp, head, neck,trunk, limbs Note: color, skin tears,lacerations, scars, lesions,ulcerations, edema, and tone Palpate: temperature,moisture, thickness, texture,turgor
  25. 25. 25Nursing DiagnosesNursing Diagnoses
  26. 26. 26Nursing Diagnoses (p. 388)Nursing Diagnoses (p. 388) Risk for Injury r/t thin skin& flattening of rete ridges Impaired Skin/ TissueIntegrity Risk for Infection Hypothermia r/t loss ofsubQ tissue IneffectiveThermoregulation Risk for Imbalanced BodyTemperature Ineffective PeripheralTissue Perfusion Impaired Oral MucousMembranes Disturbed Body Image Impaired SocialInteraction Anxiety
  27. 27. 27Dryness & ItchingDryness & Itching
  28. 28. 28Xerosis/ PruritusXerosis/ Pruritus Most common dermatologic problem– Very high incidence over age 70– Can be very severe in the elderly Thinner epidermis, less sebum, easilyirritated– Increase water loss/ decrease water content– Exacerbated by cold air/ dry air
  29. 29. 29Xerosis/ PruritusXerosis/ Pruritus Pruritus – find out cause– Rash or no rash?– Xerosis – most common cause Heat, temperature changes, perspiration, contact withclothing, emotional stress Persons in institutions at greater risk Risk for skin breakdown/ infection– Scratching: excoriation, lichenification Assess underlying cause– Dehydration, renal failure, liver dz, peripheral vascular dz
  30. 30. 30TreatmentTreatment Avoid perspiration Soft, absorbent clothing, such as cotton Tepid water to bathe or shower (90-105º)– At or just below body temperature Less soap– Mild soap only– Avoid soaps with fragrance Complete bath or shower every other day Daily partial sponge baths– Dirty areas: neck, underarms, groin, perineum
  31. 31. 31TreatmentTreatment Superfatted soap (Basis, Dove, Tone, Caress) Avoid: harsh soaps, rubbing alcohol, drying agents Use emollients, topical creams, lotions, &moisturizers (i.e., Vaseline petroleum jelly, Eucerin)– While skin is moist (immediately after bath)– At least 2-3 times daily Pat dry No bath oil (slippery!) Cool environment, cool mist humidifier
  32. 32. 32TreatmentTreatment Topical zinc oxide AVOID antihistamines (Benadryl, Atarax) AVOID topical or systemic corticosteroids Diversional activities
  33. 33. 33Skin CancersSkin Cancers
  34. 34. 34Skin CancerSkin Cancer Aging skin prone to skin cancer (but not a normalaging change) Most common cancers Two broad categories: nonmelanomanonmelanoma andmalignant melanomamalignant melanoma Nonmelanoma:– Actinic keratoses (premalignant)– Basal cell carcinoma– Squamous cell carcinoma Malignant melanoma
  35. 35. 35Actinic KeratosesActinic Keratoses
  36. 36. 36Actinic (Solar) KeratosesActinic (Solar) Keratoses Premalignant epidermal lesions Small, light-colored papule or plaque Reddened and swollen base Adherent yellow or brown scale Risk factors:– Chronic sun/ UV light exposure– Light-skin complexion Face, ears, scalp, lips, neck, hands May progress to squamous cell carcinoma
  37. 37. 37Actinic Keratoses: TxActinic Keratoses: TxMay disappear spontaneously orreappear after treatmentSkin biopsy and removalTopical 5-FU (a form of chemotherapy)CryotherapySurgical excision
  38. 38. 38Basal Cell CarcinomaBasal Cell Carcinoma
  39. 39. 39Basal Cell CarcinomaBasal Cell Carcinoma Most common skin cancer in Caucasions 80% of nonmelanoma cancers Arises in the basal cells (lower epidermis) Pearly papule with central crater; rolled, waxy borders Grows slowly and rarely metastasizes Advanced: oozing, crusty areas Sun-exposed areas (head, neck, nose, ears) Risk factors:– Chronic sun/ UV light exposure– Light-skin complexion
  40. 40. 40Basal Cell Carcinoma:Basal Cell Carcinoma:AdvancedAdvanced Invasion anderosion of adjoiningtissue withoutmetastasis Oozing, crustyareas Very disfiguring
  41. 41. 41Basal Cell Carcinoma: TxBasal Cell Carcinoma: Tx Biopsy (shave preferred): diagnosis Cryotherapy – area will be red with a blisterin the center Electrodessiccation and curettage Topical chemotherapy (5-FU) Photodynamic therapy Surgical excision– Mohs’ micrographic surgery Recurrence common
  42. 42. 42Squamous Cell CarcinomaSquamous Cell Carcinoma
  43. 43. 43Squamous Cell CarcinomaSquamous Cell Carcinoma Second most common skin cancer in Caucasions;most common in dark-skinned persons Squamous cells (top layer of epidermis) Sun-exposed areas (head, upper ear, lower lip,neck) Starts as dry scaly patch Firm, skin-colored or red nodule with scab or crust orcentral area of ulceration Advanced: ulcer with hard, raised edges Metastasis
  44. 44. 44Squamous Cell Carcinoma: RiskSquamous Cell Carcinoma: RiskFactorsFactorsChronic skin irritation or injurySun/ UV light exposureBurnsDamage by chemicalsX-ray exposure
  45. 45. 45Squamous Cell Carcinoma: TxSquamous Cell Carcinoma: Tx Biopsy (shave preferred): diagnosis– Cryotherapy– Electrodessiccation and curettage– Topical chemotherapy (5-FU)– Photodynamic therapy– Surgical excision– Mohs’ micrographic surgery– Chemotherapy: advanced stages
  46. 46. 46MelanomaMelanoma
  47. 47. 47MelanomaMelanomaLeast common, but most dangerousform of skin cancer–Spreads earlier than other skin cancers–Metastasize quickly–Invasive malignant disease–Potential for fatal outcome–Rising incidence
  48. 48. 48MelanomaMelanoma Melanocytes (pigment-producing cells) Moles, lentigo, freckles, birthmarks Irregularly-shaped, pigmented lesion Most begin on or near a mole Commonly found on trunk and lower legs Variation of colors: red, white, blue tones Most significant: change in color or size of amole (nevus)
  49. 49. 49Melanoma: Risk FactorsMelanoma: Risk FactorsLight-skin complexionExcessive sun/ UV light exposure–One blistering sunburn doubles riskMany moles, irregular or largemolesIncidence increases with age
  50. 50. 50ABCD’s of Melanoma: RecognizeABCD’s of Melanoma: RecognizeSuspicious MolesSuspicious Moles Asymmetry: halves don’tmatch Border: indistinct orirregular border Color: variation of colorwithin one lesion Diameter: greater than 5mm (pencil eraser)
  51. 51. 51
  52. 52. 52Melanoma: PathophysiologyMelanoma: Pathophysiology Two growth phases:radial and vertical Spreads outsuperficially, thendescends Prognosis mostdependent on depth oflesion 1.5mm or greater:possibility of metastasis
  53. 53. 53Early Identification: MonthlyEarly Identification: MonthlySkin Self-ExaminationSkin Self-Examination
  54. 54. 54Check for AsymmetryCheck for Asymmetry
  55. 55. 55Note this suspicious mole has severalNote this suspicious mole has severaldifferent shades of color presentdifferent shades of color present
  56. 56. 56Melanoma: PrognosisMelanoma: Prognosis Thickness of lesion Early diagnosis(before metastasis):– 100% curable Once melanomahas metastasized,prognosis is grim:– Six to nine months
  57. 57. 57Melanoma: TreatmentMelanoma: Treatment Excisional biopsy (removes lesion with at least 1cm border of healthy tissue; lymph nodes) Staging of the CA Prognosis: most dependent on the thickness ofthe lesion (≥ 1.5 mm) Check for metastasis: chest x-ray, liver profile,lymph nodes Metastasis: chemotherapy, immunotherapy,radiation
  58. 58. 58QuestionQuestion Which of the following types of skin cancersgrows slowly and rarely metastasizes andincludes small, dome-shaped elevationscovered by small blood vessels?– A. Basal cell carcinoma– B. Squamous cell carcinoma– C. Melanoma– D. Lymphoma
  59. 59. 59Skin Cancer PreventionSkin Cancer Prevention
  60. 60. 60Skin Cancer PreventionSkin Cancer Prevention Sunscreen (SPF of 30or greater) whenexposed to sun Avoid sun during peakhours (10AM-2PM) Long sleeve cottonshirts, long pants, sunhats, & sunglasseswhen outdoors No tanning beds
  61. 61. 61Pressure UlcersPressure Ulcers
  62. 62. 62Pressure Ulcers (PU)Pressure Ulcers (PU)Lesion: tissue ischemia, necrosis,ulcerationIncidence & prevalenceHigh costLonger healing periods (older adults)Medicare restrictions in reimbursementPrevention is key
  63. 63. 63PU: Staging (p. 392, Box 28-1)PU: Staging (p. 392, Box 28-1)
  64. 64. 64Pressure Ulcer Stage I:Pressure Ulcer Stage I:Nonblanchable erythema ofNonblanchable erythema oflocalized area of skinlocalized area of skin
  65. 65. 65Pressure Ulcer Stage II: PartialPressure Ulcer Stage II: PartialThickness Skin LossThickness Skin LossPartial-thickness loss of the epidermis and somePartial-thickness loss of the epidermis and someof the dermisof the dermis
  66. 66. 66Pressure Ulcer Stage III: FullPressure Ulcer Stage III: FullThickness Skin LossThickness Skin LossFull thickness loss of the skin and necrosisFull thickness loss of the skin and necrosis(death) of subcutaneous tissue(death) of subcutaneous tissue
  67. 67. 67Pressure Ulcer Stage IV: FullPressure Ulcer Stage IV: FullThickness Tissue LossThickness Tissue LossFull thickness loss of the skin/ underlying tissue includingFull thickness loss of the skin/ underlying tissue includingthe epidermis, dermis, and subcutaneous tissue (extendsthe epidermis, dermis, and subcutaneous tissue (extendsto muscle and/or bone)to muscle and/or bone)
  68. 68. 68Suspected Deep Tissue Injury:Suspected Deep Tissue Injury:Depth UnknownDepth UnknownLocalized area of discolored skin that isLocalized area of discolored skin that ispurple or maroon in colorpurple or maroon in color
  69. 69. 69Unstageable: Depth UnknownUnstageable: Depth UnknownFull thickness tissue loss covered by eitherFull thickness tissue loss covered by eitheran eschar or extensive necrotic tissuean eschar or extensive necrotic tissue
  70. 70. 70QuestionQuestionA client presents on admission withpressure ulcers extending into thebone. The nurse documents this ulcerat what stage?– A. I– B. II– C. III– D. IV
  71. 71. 71QuestionQuestionA serum-filled blister is an exampleof which stage pressure ulcer?–A. I–B. II–C. III–D. IV
  72. 72. 72PU: Common Sites (p. 393) –PU: Common Sites (p. 393) –Bony Prominences (Tailbone, hips, heels, etc.)Bony Prominences (Tailbone, hips, heels, etc.)
  73. 73. 73PU: Mechanism of BreakdownPU: Mechanism of BreakdownPressure– Tissue anoxia & ischemiaFriction– RubbingShearing force– Weight on tail or back boneMoisture– Perspiration, incontinence
  74. 74. 74Shearing ForceShearing Force
  75. 75. 75PU: Contributing & RiskPU: Contributing & RiskFactors for ElderlyFactors for Elderly Fragile skin Loss of subcutaneousfat and muscle tissue– Bony prominences Poor nutrition Reduced sensation Immobilization(primary risk factor)
  76. 76. 76PU: Priority InterventionsPU: Priority InterventionsPreventionFrequent assessment–Tools to assess pressure ulcer risk–InfectionReduce pressure, friction, andshearing forces
  77. 77. 77Pressure Ulcer RiskPressure Ulcer RiskAssessment: Braden ScaleAssessment: Braden Scale
  78. 78. Modifiable Risks Contributing to PUDevelopment in Nursing Homes
  79. 79. 79PU: Priority InterventionsPU: Priority Interventions Repositioning of immobilized patients: written schedule– Turn every 2 hr (right or left) 30° oblique position– Do not place on sides (90° lateral position)– Do not position on existing PU unless no alternative– HOB not elevated > 30° (except when eating)– Wrinkle-free pull sheet to move patients– Do NOT massage the skin near or on the ulcer. It can causemore skin damage.– Do NOT massage bony prominences.– Use pressure-relieving cushion in chairs, but do NOT use adonut-shaped or ring-shaped cushions. They interfere withblood flow to that area and cause complications.
  80. 80. 80PU: Priority InterventionsPU: Priority Interventions Correct transfer techniques– Use lift sheet– Do not drag across linens Moisture reduction– Clean incontinence promptly– Barrier creams Protective devices Nutritional Support– Protein, vitamin C, vitamin E, calcium or zinc Good skin care
  81. 81. 81QuestionQuestionWhich of the following assessmenttools is used to determine risk ofpressure ulcers?– A. Folstein Scale– B. Braden Scale– C. Geriatric Skin Scale– D. Pressure Sore Status Tool
  82. 82. 82Pressure Ulcer CarePressure Ulcer Care Cleanse the wound with a noncytotoxic cleanser (saline)during each dressing change If necrotic tissue or slough is present, consider the use ofhigh-pressure irrigation Debride necrotic tissue Do not debride dry, black eschar on heels Perform wound care using topical dressings determinedby wound and availability Choose dressings that provide a moist woundenvironment, keep the skin surrounding the ulcer dry,control exudates, and eliminate dead space
  83. 83. 83Pressure Ulcer Care (cont’d)Pressure Ulcer Care (cont’d) Reassess the wound with each dressing changeto determine whether treatment planmodifications are needed Identify and manage wound infections Clients with Stage III and IV ulcers that do notrespond to conservative therapy may requiresurgical intervention Note: Adapted from National Guidelines ClearingHouse Guideline for Prevention and Managementof Pressure Ulcers (
  84. 84. 84Nursing Diagnoses for PUsNursing Diagnoses for PUsRisk for Impaired Skin Integrity relatedto the effects of pressure, friction, orshearRisk for Impaired Tissue Integrityrelated to decreased circulationRisk for Infection related to pressureulcer