Common Alterations in the Protective Systems of the Older Adult:

Skin and Mucous Membranes

Age-Related Changes
Skin is thinner and less elastic loss of subcutaneous tissue; elastin, collagen and fat
Wrinkling result of thinning skin layers and degeneration of elastin
Sweat glands production decreases, especially in advanced age
Production of sebum decreases, becoming apparent earlier in women than in men
Dryness (xerosis) and pruritus are common
Mottled or uneven skin pigmentation
Skin pales the number of cells that produce melanin decreases
Blood vessels, especially capillary loops decrease in number and size
Various proliferative skin lesions
o Lentigines
o Senile purpura
o Cherry or spider angiomas
o Seborrheic keratoses
o Acrochordons
o Xanthelasma
Hair growth gradually diminishes especially over lower legs
Hair thinning common on scalp, axilla and pubic areas
Scalp hair thins in women as well but usually less obvious
Increase in facial hair in both sexes
Men may have increased hair in the nares, eyebrows, or helix of the ear
Nails flatten; become dry, brittle, and discolored

Health History
Chief complaint and history of present illness
o Discomfort, pruritus, color changes, lesions, hair loss, or abnormal hair growth
o Onset of condition/precipitating or alleviating factors
Past medical history
o Previously diagnosed skin diseases or problems, current and recent medications, and allergies
o Diabetes mellitus, cancer, kidney failure, thyroid disease, liver disease, and anemia
Review of systems
o Change in skin color or pigmentation, change in a mole, sores slow to heal, itching, dryness or scaliness,
excessive bruising, rashes, lesions, hair loss, unusual hair growth, changes in nails
Functional assessment
o Past and present occupations, exposure to chemicals or other irritants, skin care habits, sun exposure
o Recent changes in the work or living environment
o Current stresses and sources of anxiety
Physical Assessment
Skin color and variations in pigmentation
Document dilated blood vessels and angiomas
Nevi (moles) inspected for irregularities in shape, pigmentation, and ulcerations or changes in surrounding skin
If a rash, location, distribution, and characteristics
If any drainage, the color, amount, and odor are noted
Palpate skin for temperature, moisture, texture, thickness, edema, mobility, and turgor
Hair color, distribution, oiliness, and texture. The scalp is inspected for scaliness, infestations, and lesions
Shape/contour of the fingernails and toenails
Color of the nail bed
Capillary refill checked by applying pressure to the nail to cause blanching and then releasing
Therapeutic Measures
Dressings
o Protect wounds; retain surface moisture
o Types: wet, dry, absorptive, and occlusive
Negative pressure wound therapy
o Reduce healing time of traumatic wounds, dehisced surgical wounds, pressure and chronic ulcers
Soaks and wet wraps
o Soothe, soften, and remove crusts, debris, and necrotic tissue
Phototherapy
o Ultraviolet light in combination with photosensitive drugs promotes shedding of the epidermis
Drug therapy
o Topical drugs: keratolytics, antipruritics, emollients, lubricants, sunscreens, tars, anti-infectives,
glucocorticoids, antimetabolites, antihistamines, antiseborrheic agents, and vitamin A derivatives
Burn Injury in Older Adults
Higher risk patient population
Reduced mobility
Coordination
Strength
Sensation changes
Vision changes
Difficulty with cooking and bathing
Predisposing factors and health history influence complexity of care
Whats the goal of care?
Severity of Burn Injury
Age
Burn depth
Extent of body surface area injured
Systemic effects
Comorbid conditions in older adults
Nursing Management of Burn Patient
Restore normal fluid balance
Prevent infection
Maintain adequate nutrition
Promote skin integrity
Relieve pain and discomfort
Promote physical mobility
Strengthen coping strategies
Support patient and family
Monitor and manage potential complication
Pressure Ulcers

Pressure Ulcer Etiology
Pressure exerted on bony prominences of the body that stops capillary flow to the tissues.
Deprives tissues of oxygen and nutrients causing cell death.
Pressure greater than 32mmHg exerted by bony prominences to disrupt blood flow.
Pressure Ulcer Staging
(depth & tissue type)
Stage I Persistent redness (culturally sensitive)
Stage II Partial thickness skin loss
Stage III Full thickness skin loss (subcutaneous)
Stage IV Full thickness skin loss (fascia)
Unstageable

*NPUAP does not endorse reverse staging
The Braden Scale for Predicting Pressure Ulcer
Pressure Ulcer Causes
Prolonged pressure
o duration and intensity of pressure
o location of pressure on body
o extended pressure that blocks flow to the tissue between the source of pressure & the bone
Shear
Friction
Most Common Sites
Sacrum (tail bone) - most common site
o Semi-fowlers position
o Slouching in bed or chair
o Higher risk in tube fed or incontinent patients
Heels - 2
nd
most common
o Semi-fowlers -Immobile or numb legs
o Leg traction
o Higher risk with PVD & diabetes neuropathy
Other Bony Prominences
Trochanter (hip bone)
o Side lying
o Highest risk contractured residents
o Ulcers on lateral foot rather than heel itself
Ischium (sitting erect bone)
o highest risk paraplegics
Pressure Ulcers from Other Sources of Pressure
Boots/boot straps
Heel protectors/protector straps
Oxygen tubing
Stockings
Casts, traction, restraints
Any device that can lead to pressure induced ischemia on the skin
59% report some degree of pain
Pressure Ulcer Risk Factors
Impaired bed or chair mobility
Urinary incontinence
Fecal incontinence
Poor nutritional status
History of pressure ulcer
PVD or Diabetes Mellitus
General Skin Care
Daily skin inspections for high-risk individuals
Skin cleansing with warm water & mild soap
Cleanse skin after soiling
Minimize excess moisture, drying & cracking
Use non-alcohol based moisturizers
Use skin protectants or barriers
Do not massage over reddened areas
Institute bowel or bladder training programs
Use briefs or absorbent underpads
Nursing Interventions
Relieve pressure may use devices
Positioning
Repositioning schedule (individualized)
o Minimum turn Q2 hours in beds
o Minimum shift Q1 hour in chair (15 mins)
o Heel relief
Improve mobility - rehabilitation
Improve nutritional status
Reduce friction and shear
Promote healing & prevent recurrence

Support Surface Selection
No one support surface ever has been shown to be the best for all users
Bed consider the number of body surfaces available for support
Wheelchair cushions are fundamentally different than horizontal support surfaces
Effectiveness is judged directly & indirectly
o Direct clinical outcomes
o Indirect interface pressure (IP), blood flow, etc. (never use 32 mmHg as the safe threshold for IP)
Pressure Reduction Helpful Hints
Static Devices
Air, gel, water, foam and combinations
o No statistical significant differences have been noted between static devices
Key to static devices
o Foam density of 1.3lbs/cubic foot
o 3 inches for solid foam, 4 inches for convoluted
o Ability to assume variety of positions without bearing weight
o Remember wear and tear factor (average life of foam overlay is 1 - 2 years).
Dynamic Surfaces
Alternating, low air loss pockets
Few studies demonstrate variances between dynamic surfaces
Must be operational (check instructions)
Oscillating or kinetic beds
Pressure, Friction and Shear Reduction
Reduce pressure over bony prominences
Individualized bed turning (min. q 2hrs)
Individualized chair repositioning (min. q1hr)
HOB < 30 degrees
Avoid positioning directly on great trochanter
Float heels off bed
Check devices for bottoming out
Avoid mechanical injury - use slide boards, turn sheet, trapeze
Increase mobility - consult PT/OT
Encourage Optimal Nutrition and Fluid intake
Conduct nutritional consultation
Consider resident preferences and special needs
Provide assistance and adequate time
Offer snacks and fluids between meals
Consider administration of vitamins and/or protein supplements
Assess lab values
Pressure Ulcer Prevention
Risk assessment upon admission
Admission interventions for each selected risk factor
Admission & daily skin exams documented for at-risk population
Description of Ulcers for Documentations
Stage ulcer
Location
Size
Wound bed
Granulation tissue
Necrotic tissue
Wound edges
Drainage
Infection
Pain
Identification
Consider risk factors that are present
o Shortness of breath, weight loss, inability to eat, orthopedic surgery (hip, knee) diabetes
Consider if patient cannot move voluntarily
o Bedridden, chair ridden, coma, restrained, desaturation with movement, traction, pain
Consider the pattern of ulcer development
o High risk? Or acquired, trapped in one place for extended time?
Consider location of the ulcer
Bony prominence, in location of medical devices
Descriptions (photographs)
Crater like ulcers common
Do not use staging terms as evidence that a wound is a pressure ulcer
Management of Ulcers
Wound Care
debridement
wound cleansing
dressings
adjuvant therapies
Pressure reduction
Physician and nursing documentation should correlate
Address risk factors
Continence care
Nutritional improvement
Mobility
Consider operative repair
Monitor skin changes
Healing the Heels Hints
Heel pressure ulcers easier to acquire, challenging to heal
Pressure relief with pillows
Semipermeable membrane dressing for pre-Stage I
Hydrocolloid for Stage I
Heel protector boots (check warranty, check wear and tears, usual heel protector last 1 year!)
Heel lift suspension (usually last 1-2 yrs)
Good fitting sneakers with cushion pads
Heels can be vulnerable independent of support surfaces on bed/wheelchair
Wound Cleansing
Completed with each dressing change
Clean with saline or water
Literature also supports use of tap water if quality
Do not use skin cleansers or antiseptic agents
Use appropriate irrigation pressure between 4-15 psi
>15 psi may drive wound fluid & debris into wound
Consider availability, ease of use and cost syringe
Debridement Techniques
Removal of devitalized necrotic tissue
Do NOT debride eschar on heels
Natural
Mechanical includes dressing change
Chemical
Surgical sometimes with skin graft
Wound Dressings
Keep wound bed moist
Keep surrounding tissue clean & dry
Eliminate dead space
Do not use antiseptic agents
Types of dressings Gauze, Transparent films, Hydrocolloid, Hydrogel, Alginates, Foam, Composite
Keys to Selecting Dressings
Must use clinical judgment
Keeps ulcer bed continuously moist
Keeps surrounding periulcer skin dry
Controls exudate without dessicating (drying out) ulcer bed
Caregiver time
Bacterial Infection
Clinically Infected
redness of the skin around
purulent drainage
foul odor
edema
All wounds colonize!
Helpful Hints to Prevent Infection
Sterile vs. Clean Technique
o Wounds are not sterile
o Assure wound care products/dressing supplies do not become contaminated during storage and use
To Swab or not to Swab?
o Has little value in determining whether wound is infected, not currently recommended
Nutritional Interventions
Supplements
Feeding assistance programs
Feeding assistance devices
Vitamins & minerals
Track percent meals consumed
Monitor changes in weight
Monitor protein intake
Pressure Ulcer Treatment
Assessment upon admission
Admission treatment order based on current standards or product guidelines
Weekly ulcer assessments
Herpes Simplex
Etiology and risk factors
o Viral infection begins with tingling and burning
o Progresses to vesicles that rupture and form crusts; up to 24 hours
o Nose, lips, cheeks, ears, genitalia most often affected
o Oral lesions called cold sores or fever blisters
o Infections on the face and upper body usually caused by HSV-1; genital infections by HSV-2
Medical diagnosis laboratory studies of lesion exudate and blood studies for antibodies
Assessment
o Describe the development of the herpetic lesions
o Sexual contacts documented so that they can be advised of the need for medical evaluation
o Inspect the lesions
Interventions
o Acute pain
o Ineffective coping
o Ineffective therapeutic regimen management
Herpes Zoster
Etiology and risk factors
o Commonly called shingles
o Varicella-zoster virus; also causes chickenpox
o Symptoms: pain, itching, and heightened sensitivity along a nerve pathway, followed by the formation of
vesicles in the area
o When the skin is affected, crusts form
o Older adults especially susceptible to complications
o Immunosuppressed at greater risk for herpes zoster infections; may have serious systemic complications
Medical diagnosis
o Health history and physical examination findings
o Tzanck smear or viral culture of material from a lesion
Medical treatment
o Antiviral agents: acyclovir, famciclovir, valacyclovir
o Wet dressings soaked in Burows solution
o Pain may be treated with analgesics and sedatives
Assessment
o Conditions or treatments that might cause the patient to have a reduced immune response
o Distribution and appearance of the lesions
Interventions
o Impaired skin integrity
o Acute pain
o Ineffective coping
o Avoid complications
Malignant Skin Tumors
Basal cell carcinoma
Painless, nodular lesions; transluscent, pearly appearance
Telangiectatic vessels may be present
Related to sun exposure
Grow slowly and rarely metastasize
Treated with surgical excision, Mohs micrographic excision, electrodesiccation and curettage, cryotherapy, radiation,
or drugs that are applied topically or injected into the lesion
Squamous cell carcinoma - epidermoid
Scaly ulcers or raised lesions
Develop on sun-exposed areas including the lips, and in the mouth
Caused by overuse of tobacco and alcohol
Grow rapidly and metastasize
Treatment may include surgical excision, cryotherapy, and radiation therapy
Melanoma
Arises from pigment-producing cells in the skin
Most serious form of skin cancer; fatal if it metastasizes
Found anywhere on the body
Irregular borders and uneven coloration; many are dark, but some are light. Begin as tan macule that enlarges
Removed surgically; a wide area around a melanoma is usually excised
Chemotherapy and immunotherapy also may be employed