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Care of Aging SkinCare of Aging Skin

NURS 4100 Care of the Older Adult Spring 2014Joy A. Shepard, PhD(c), MSN, RN, CNE

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ObjectivesObjectives

Summarize the effects of aging on the skin Distinguish skin changes due to aging from those

that result from diseases or injury List practices that promote good skin health in

older adults Describe signs of and nursing care for xerosis,

pruritus, actinic keratosis, seborrheic keratosis, skin cancer, and pressure ulcers in older adults

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Key TermsKey Terms Acrochordon – A small, soft penduous growth on the skin, especially

around 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 sun

exposed surfaces; increase in size, become raised with rough surface. Precancerous

Friction - Occurs with the lateral movement of pulling sheet or clothing from under a person's 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 the

body from the harmful effects of the sun

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Key TermsKey Terms Premalignancy – Any abnormal tissue, which is not cancerous, but which

could become cancerous (if left untreated) Pruritus – Intense itching sensation Seborrheic keratosis – Superficial benign skin growth on face, trunk, or

extremities. Yellow, light tan, brown or black; round or oval. Is flat or slightly 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 the

capillaries Shearing Force - Occurs when tissue layers move on each other, causing

blood vessels to stretch as they pass through subcutaneous tissue Xerosis – Abnormal dryness of the skin

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Normal Skin Changes with Normal Skin Changes with AgingAging

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Effects of Aging: Effects of Aging: IntegumentIntegument 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

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Normal Changes of Aging in the Normal Changes of Aging in the Integumentary SystemIntegumentary System

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Aging: EpidermisAging: Epidermis

Less moisture in cells dry, rough appearance

> 50 years epidermal mitosis slows longer time to healing + potential for infection

Rete ridges flatten easy skin tearing

Melanocytes decrease pale complexion + increased UV damage + scattered pigmented areas (age spots, liver spots, and freckles)

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Aging: DermisAging: Dermis

Elastin quality decreases + quantity increases wrinkling + sagging

Collagen disorganized loss of turgor

Decreased vascularity pale complexion

Thinning capillaries easy damage senile purpura

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Skin Turgor: LooseSkin Turgor: Loose

Forehead, collarbone, or Forehead, collarbone, or sternum sternum (center of chest)(center of chest)

Not on back of hand or Not on back of hand or forearm for an elder clientforearm for an elder client

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Aging: Subcutaneous Aging: Subcutaneous (Hypodermis)(Hypodermis) Loss of SubQ tissue &

thinning of dermis Atrophy thinning

features, hands and lower legs

Hypertrophy increase in proportional body fat

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Aging: GlandsAging: Glands

Eccrine & apocrine glands– Decrease in size – Decrease in number – Decrease in function

Sebaceous glands– Increased size +

decreased sebum water evaporation cracked, dry skin

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Aging: Skin and GlandsAging: Skin and Glands

Decreased subcutaneous fat, elastic fibers, collagen (stiffening), skin thickness: wrinkles and sagging

Decreased blood flow: delayed wound healing

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Changes in Wound Healing Changes in Wound Healing With Increased Age: DelayedWith Increased Age: Delayed

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Aging: Skin and GlandsAging: Skin and Glands

Degeneration of nerve endings

Degeneration of melanocytes: Lentigo (“liver spots”)

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Solar ElastosisSolar Elastosis: UV Radiation: UV Radiation

Leathery skin/ Roughness

Inelastic Deep wrinkles Yellowish Depigmentation/

hyperpigmentationPhotoagingPhotoaging superimposed on normal superimposed on normal agingaging

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Aging: Skin and GlandsAging: Skin and Glands

Decreased sebum: dry skin (xerosis)

Decreased sweat: impaired thermoregulation

Increased transparency and fragility

Risk for Injury

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Skin Changes in Older Skin Changes in Older AdultAdult Seborrheic keratosis

– Dark raised lesions Actinic keratosis

– Reddish raised plaques on areas of high sun exposure can become malignant

Acrochordon– Skin tags

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Seborrheic Keratosis Seborrheic Keratosis (benign)(benign) Description Increase in size and number with age Areas of the body affected Treatment Need to be evaluated to differentiate them

from a precancerous lesion

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Aging: Hair Aging: Hair

Altered melanocytes nonpigmented (gray) hair follicles

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

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Aging: NailsAging: Nails

Decreased blood flow, rate of growth thicker nails

Longitudinal (striations) nail ridges

Thick, brittle nails Dull, yellow, or gray

coloration

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Integumentary Health Integumentary Health PromotionPromotion Avoid irritating agents Promote activity Adequate fluid intake Use emollients, topical

creams, lotions, & moisturizers

No bath oils Avoid excessive bathing Avoid exposure to UV

rays

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AssessmentAssessment

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Nursing Assessment of Nursing Assessment of SkinSkin Nurses: best opportunity/

most direct contact Assessment Guide 28-1: Skin

Status Inspect scalp, head, neck,

trunk, limbs Note: color, skin tears,

lacerations, scars, lesions, ulcerations, edema, and tone

Palpate: temperature, moisture, thickness, texture, turgor

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Nursing DiagnosesNursing Diagnoses

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Nursing Diagnoses (p. 388)Nursing Diagnoses (p. 388)

Risk for Injury r/t thin skin & flattening of rete ridges

Impaired Skin/ Tissue Integrity

Risk for Infection Hypothermia r/t loss of

subQ tissue Ineffective

Thermoregulation Risk for Imbalanced Body

Temperature

Ineffective Peripheral Tissue Perfusion

Impaired Oral Mucous Membranes

Disturbed Body Image Impaired Social

Interaction Anxiety

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Dryness & ItchingDryness & Itching

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Xerosis/ PruritusXerosis/ Pruritus

Most common dermatologic problem – Very high incidence over age 70 – Can be very severe in the elderly

Thinner epidermis, less sebum, easily irritated– Increase water loss/ decrease water content – Exacerbated by cold air/ dry air

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Xerosis/ PruritusXerosis/ Pruritus

Pruritus – find out cause– Rash or no rash?– Xerosis – most common cause

Heat, temperature changes, perspiration, contact with clothing, 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

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TreatmentTreatment

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

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TreatmentTreatment

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

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TreatmentTreatment

Topical zinc oxide AVOID antihistamines (Benadryl, Atarax) AVOID topical or systemic corticosteroids Diversional activities

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Skin CancersSkin Cancers

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Skin CancerSkin Cancer

Aging skin prone to skin cancer (but not a normal aging change)

Most common cancers Two broad categories: nonmelanomanonmelanoma and malignant malignant

melanomamelanoma Nonmelanoma:

– Actinic keratoses (premalignant) – Basal cell carcinoma – Squamous cell carcinoma

Malignant melanoma

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Actinic KeratosesActinic Keratoses

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Actinic (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

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Actinic Keratoses: TxActinic Keratoses: Tx

May disappear spontaneously or reappear after treatment

Skin biopsy and removalTopical 5-FU (a form of chemotherapy)CryotherapySurgical excision

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Basal Cell CarcinomaBasal Cell Carcinoma

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Basal 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

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Basal Cell Carcinoma: Basal Cell Carcinoma: AdvancedAdvanced Invasion and

erosion of adjoining tissue without metastasis

Oozing, crusty areas

Very disfiguring

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Basal Cell Carcinoma: TxBasal Cell Carcinoma: Tx

Biopsy (shave preferred): diagnosis Cryotherapy – area will be red with a blister in

the center Electrodessiccation and curettage Topical chemotherapy (5-FU) Photodynamic therapy Surgical excision

– Mohs’ micrographic surgery Recurrence common

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Squamous Cell CarcinomaSquamous Cell Carcinoma

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Squamous 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 or

central area of ulceration Advanced: ulcer with hard, raised edges Metastasis

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Squamous Cell Carcinoma: Squamous Cell Carcinoma: Risk FactorsRisk Factors

Chronic skin irritation or injurySun/ UV light exposureBurnsDamage by chemicalsX-ray exposure

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Squamous Cell Carcinoma: Squamous Cell Carcinoma: TxTx Biopsy (shave preferred): diagnosis

– Cryotherapy– Electrodessiccation and curettage– Topical chemotherapy (5-FU)– Photodynamic therapy– Surgical excision– Mohs’ micrographic surgery– Chemotherapy: advanced stages

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MelanomaMelanoma

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MelanomaMelanoma

Least common, but most dangerous form of skin cancer– Spreads earlier than other skin cancers– Metastasize quickly– Invasive malignant disease– Potential for fatal outcome– Rising incidence

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MelanomaMelanoma

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 a

mole (nevus)

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Melanoma: Risk FactorsMelanoma: Risk Factors

Light-skin complexionExcessive sun/ UV light exposure

–One blistering sunburn doubles riskMany moles, irregular or large

molesIncidence increases with age

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ABCD’s of Melanoma: ABCD’s of Melanoma: Recognize Suspicious MolesRecognize Suspicious Moles Asymmetry: halves don’t

match Border: indistinct or

irregular border Color: variation of color

within one lesion Diameter: greater than 5

mm (pencil eraser)

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Melanoma: Melanoma: PathophysiologyPathophysiology Two growth phases:

radial and vertical Spreads out

superficially, then descends

Prognosis most dependent on depth of lesion

1.5mm or greater: possibility of metastasis

http://matrix.ucdavis.edu/atlas/melanoma-ssmm-III-.72mm-aro.gif

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Early Identification: Early Identification: Monthly Skin Self-Monthly Skin Self-ExaminationExamination

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Check for AsymmetryCheck for Asymmetry

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Note this suspicious mole has Note this suspicious mole has several different shades of color several different shades of color presentpresent

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Melanoma: PrognosisMelanoma: Prognosis

Thickness of lesion Early diagnosis

(before metastasis): – 100% curable

Once melanoma has metastasized, prognosis is grim:– Six to nine months

http://www.columbia.edu/itc/hs/nursing/m8786/Skin-John.html

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Melanoma: TreatmentMelanoma: Treatment

Excisional biopsy (removes lesion with at least 1 cm border of healthy tissue; lymph nodes)

Staging of the CA Prognosis: most dependent on the thickness of

the lesion ( 1.5 mm) Check for metastasis: chest x-ray, liver profile,

lymph nodes Metastasis: chemotherapy, immunotherapy,

radiation

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QuestionQuestion

Which of the following types of skin cancers grows slowly and rarely metastasizes and includes small, dome-shaped elevations covered by small blood vessels?– A. Basal cell carcinoma– B. Squamous cell carcinoma– C. Melanoma– D. Lymphoma

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Skin Cancer PreventionSkin Cancer Prevention

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Skin Cancer PreventionSkin Cancer Prevention

Sunscreen (SPF of 30 or greater) when exposed to sun

Avoid sun during peak hours (10AM-2PM)

Long sleeve cotton shirts, long pants, sun hats, & sunglasses when outdoors

No tanning beds

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Pressure UlcersPressure Ulcers

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Pressure Ulcers (PU)Pressure Ulcers (PU)

Lesion: tissue ischemia, necrosis, ulceration

Incidence & prevalenceHigh costLonger healing periods (older adults) Medicare restrictions in reimbursementPrevention is key

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PU: Staging (p. 392, Box PU: Staging (p. 392, Box 28-1) 28-1)

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Pressure Ulcer Stage I: Nonblanchable Pressure Ulcer Stage I: Nonblanchable erythema of localized area of skin erythema of localized area of skin

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Pressure Ulcer Stage II: Partial Thickness Pressure Ulcer Stage II: Partial Thickness Skin LossSkin LossPartial-thickness loss of the epidermis and some of the dermis Partial-thickness loss of the epidermis and some of the dermis

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Pressure Ulcer Stage III: Full Thickness Skin LossPressure Ulcer Stage III: Full Thickness Skin LossFull thickness loss of the skin and necrosis (death) of subcutaneous Full thickness loss of the skin and necrosis (death) of subcutaneous tissue tissue

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Pressure Ulcer Stage IV: Full Thickness Tissue LossPressure Ulcer Stage IV: Full Thickness Tissue LossFull thickness loss of the skin/ underlying tissue including the epidermis, dermis, and Full thickness loss of the skin/ underlying tissue including the epidermis, dermis, and subcutaneous tissue (extends to muscle and/or bone) subcutaneous tissue (extends to muscle and/or bone)

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Suspected Deep Tissue Injury: Depth UnknownSuspected Deep Tissue Injury: Depth UnknownLocalized area of discolored skin that is purple or maroon in color Localized area of discolored skin that is purple or maroon in color

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Unstageable: Depth UnknownUnstageable: Depth UnknownFull thickness tissue loss covered by either an eschar or Full thickness tissue loss covered by either an eschar or extensive necrotic tissue extensive necrotic tissue

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QuestionQuestion

A client presents on admission with pressure ulcers extending into the bone. The nurse documents this ulcer at what stage?– A. I– B. II– C. III– D. IV

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QuestionQuestion

A serum-filled blister is an example of which stage pressure ulcer?–A. I–B. II–C. III–D. IV

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PU: Common Sites (p. 393) – PU: Common Sites (p. 393) – Bony Prominences (Tailbone, hips, heels, Bony Prominences (Tailbone, hips, heels, etc.)etc.)

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PU: Mechanism of PU: Mechanism of BreakdownBreakdownPressure

– Tissue anoxia & ischemiaFriction

– RubbingShearing force

– Weight on tail or back boneMoisture

– Perspiration, incontinence

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Shearing ForceShearing Force

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PU: Contributing & Risk PU: Contributing & Risk Factors for ElderlyFactors for Elderly Fragile skin Loss of subcutaneous

fat and muscle tissue – Bony prominences

Poor nutrition Reduced sensation Immobilization

(primary risk factor)

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PU: Priority InterventionsPU: Priority Interventions

PreventionFrequent assessment

–Tools to assess pressure ulcer risk– Infection

Reduce pressure, friction, and shearing forces

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Pressure Ulcer Risk Pressure Ulcer Risk Assessment: Braden ScaleAssessment: Braden Scale

Modifiable Risks Contributing to PU Development in Nursing Homes

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PU: 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 cause

more skin damage.– Do NOT massage bony prominences.– Use pressure-relieving cushion in chairs, but do NOT use a

donut-shaped or ring-shaped cushions. They interfere with blood flow to that area and cause complications.

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PU: 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

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QuestionQuestion

Which of the following assessment tools is used to determine risk of pressure ulcers?– A. Folstein Scale– B. Braden Scale– C. Geriatric Skin Scale– D. Pressure Sore Status Tool

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Pressure 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 of high-pressure irrigation

Debride necrotic tissue Do not debride dry, black eschar on heels Perform wound care using topical dressings determined by

wound and availability Choose dressings that provide a moist wound

environment, keep the skin surrounding the ulcer dry, control exudates, and eliminate dead space

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Pressure Ulcer Care Pressure Ulcer Care (cont’d)(cont’d) Reassess the wound with each dressing change to

determine whether treatment plan modifications are needed

Identify and manage wound infections Clients with Stage III and IV ulcers that do not

respond to conservative therapy may require surgical intervention

Note: Adapted from National Guidelines Clearing House Guideline for Prevention and Management of Pressure Ulcers (http://www.guideline.gov)

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Nursing Diagnoses for PUs Nursing Diagnoses for PUs

Risk for Impaired Skin Integrity related to the effects of pressure, friction, or shear

Risk for Impaired Tissue Integrity related to decreased circulation

Risk for Infection related to pressure ulcer