Care of aging_skin_fall 2013 abridged

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Care of Aging SkinCare of Aging Skin
NURS 4100 Care of the Older Adult
Fall 2013
Joy 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 withNormal Skin Changes with
AgingAging

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Effects 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

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Normal Changes of Aging in theNormal 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 sternumForehead, collarbone, or sternum
(center of chest)(center of chest)
Not on back of hand orNot on back of hand or
forearm for an elder clientforearm for an elder client

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Aging: SubcutaneousAging: 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 WithChanges in Wound Healing With
Increased Age: DelayedIncreased Age: Delayed

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 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/
hyperpigmentation
PhotoagingPhotoaging superimposed on normal agingsuperimposed on normal aging

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 Decreased sebum:
dry skin (xerosis)
 Decreased sweat:
impaired
thermoregulation
 Increased
transparency and
fragility
 Risk for Injury

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Skin Changes in Older AdultSkin Changes in Older Adult
 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 (benign)Seborrheic Keratosis (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: HairAging: 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 HealthIntegumentary 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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Nursing Assessment of SkinNursing Assessment of Skin
 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 CancerSkin Cancer
 Aging skin prone to skin cancer (but not a normal
aging change)
 Most common cancers
 Two broad categories: nonmelanomanonmelanoma and
malignant melanomamalignant melanoma
 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 removal
Topical 5-FU (a form of chemotherapy)
Cryotherapy
Surgical 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: RiskSquamous Cell Carcinoma: Risk
FactorsFactors
Chronic skin irritation or injury
Sun/ UV light exposure
Burns
Damage by chemicals
X-ray exposure

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Squamous 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

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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 complexion
Excessive sun/ UV light exposure
–One blistering sunburn doubles risk
Many moles, irregular or large
moles
Incidence increases with age

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ABCD’s of Melanoma: RecognizeABCD’s of Melanoma: Recognize
Suspicious MolesSuspicious 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: PathophysiologyMelanoma: Pathophysiology
 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: MonthlyEarly Identification: Monthly
Skin Self-ExaminationSkin Self-Examination

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Check for AsymmetryCheck for Asymmetry

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Note this suspicious mole has severalNote this suspicious mole has several
different shades of color presentdifferent shades of color present

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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 & prevalence
High cost
Longer healing periods (older adults)
Medicare restrictions in reimbursement
Prevention is key

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

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

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Pressure Ulcer Stage II: PartialPressure Ulcer Stage II: Partial
Thickness Skin LossThickness Skin Loss
Partial-thickness loss of the epidermis and somePartial-thickness loss of the epidermis and some
of the dermisof the dermis

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Pressure Ulcer Stage III: FullPressure Ulcer Stage III: Full
Thickness Skin LossThickness Skin Loss
Full thickness loss of the skin and necrosisFull thickness loss of the skin and necrosis
(death) of subcutaneous tissue(death) of subcutaneous tissue

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

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Suspected Deep Tissue Injury:Suspected Deep Tissue Injury:
Depth UnknownDepth Unknown
Localized area of discolored skin that isLocalized area of discolored skin that is
purple or maroon in colorpurple or maroon in color

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Unstageable: Depth UnknownUnstageable: Depth Unknown
Full thickness tissue loss covered by eitherFull thickness tissue loss covered by either
an eschar or extensive necrotic tissuean eschar or 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, etc.)Bony Prominences (Tailbone, hips, heels, etc.)

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PU: Mechanism of BreakdownPU: Mechanism of Breakdown
Pressure
– Tissue anoxia & ischemia
Friction
– Rubbing
Shearing force
– Weight on tail or back bone
Moisture
– Perspiration, incontinence

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Shearing ForceShearing Force

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PU: Contributing & RiskPU: 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
Prevention
Frequent assessment
–Tools to assess pressure ulcer risk
–Infection
Reduce pressure, friction, and
shearing forces

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

Modifiable Risks Contributing to PU
Development in Nursing Homes

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 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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 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 (cont’d)Pressure Ulcer Care (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)

84
Nursing Diagnoses for PUsNursing 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

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