Through thick and thin
Elderly and frail adults’ skin requires extra protection, since it can be especially susceptible to tears and infections.
EDITOR'S NOTE: This article has been slightly modified from its original form.
As senior clinical director for First Quality Healthcare, Michele Mongillo spends about 80% of her time educating clients on skin care and incontinence and a mere 20% pitching products.
Mongillo, RN, BSN, MSN, RAC-CT, knows all too well how a simple skin impairment can lead to major problems, specifically moisture-associated skin damage and incontinence-associated dermatitis.
Keeping skin healthy and intact has numerous benefits. But the body's protective barrier needs some protecting of its own, particularly in the frail and elderly.
Thin, crepey skin is susceptible to minor tears and infection, and broken skin can easily become a dangerous and care-intensive pressure ulcer. Nowhere is that truer than in the perineal area, especially prone to moisture, heat and friction.
“Our sweat glands and our sebaceous glands together create a layer that helps protect our skin,” explains Nicole Maynard, BSN, RN, WCC, wound and product specialist for Gentell. “We need to protect it. Age has to do with risk, but so do health conditions — if they're diabetic or a long-time smoker or someone on chemo or with circulation problems. All of those make it harder to heal.”
How can your facility safeguard residents and help them heal faster when wounds happen?
Julia Melendez, RN, BSN, JD, CWOCN, is national clinical director for Joerns Healthcare. She says incontinence-associated dermatitis prevention should focus on identifying the at-risk population and incontinence type, as well as identifying interventions that can modify or eliminate the cause and providing individualized care plans.
Stocking the right preventive products and involving all caregivers in skin care solutions are also important. Constant education on skin care and addressing patient-specific needs with everyone from CNAs to housekeeping to dietitians helps.
“That's where the rubber meets the road,” says Dan Beecher, RN, BSN, WCC, clinical educator with DermaRite Industries. “Make the education very concrete and very personal for your staff.”
Hands can be especially susceptible to skin tears and injuries.
Joel Rich, director of long-term care and alternate care for PDI, says go-to skin care tools should be endorsed by clinical protocols — an imperative step for improving and promoting healthy skin.
For instance, hand hygiene products should be formulated for healthcare standards, such as a 70% ethyl alcohol formulation called for by the World Health Organization and the Centers for Disease Control and Prevention.
Maynard agrees, adding that what residents are washing with can be as important as when and how well they wash.
“The pH balance of our skin is usually 4 to 4.5, but a lot of soaps that we use are 9 to 12,” Maynard said “That's really alkaline, and that dries out skin.”
The drier the skin, the more likely it is to develop the kind of microscopic cracks that can grow bigger or allow infection into the body.
Beecher acknowledges that can be a hard sell in more independent settings where residents might still select their own products.
“Mrs. Smith wants to use her Ivory soap that she's been using her entire life. So we talk to her about being immuno-compromised, how any tear in the skin can be dangerous. It's the same as having a conversation about positioning with someone who prefers lying in bed with their head at 30 degrees all the time. We have to follow through and explain the rationale.”
Toileting accidents open patients up to a new category of risk in wound development.
Cleaning and drying the patients' perineal area thoroughly after any incident is critical to preventing wounds and helping existing wounds heal completely.
Even if skin looks dry, it's not enough to just change a brief.
“All of that ammonia is still there,” notes Mongillo. “Never skip the moisture wipe, and a wipe is better than soap and water because soap is drying and a washcloth can be rough.”
Any body fluid — sweat, urine or fecal matter — is likely to have a pH level at or above 7.45, which is slightly alkaline, says Elaine McGowan, BSN, RN, CWCN, DermaRite's Vice President of Clinical Affairs. That alkaline nature alters the skin's top layer during exposure, which can then make skin more vulnerable to damage from friction or shearing forces.
Treat 'em all
Beecher suggests skilled nursing facilities use a peri wash and barrier protection on all residents, even if just to protect skin from sweat that collects there. Vital, he says, is using clear products so that clinicians can still see the skin and any emerging problems.
“The variety of ingredients that can be in a barrier can be confusing,” acknowledges McGowan. She recommends customers look for emollients such as petroleum or dimethicone, whose oils boost skin's flexibility; an occlusive agent for a waterproof film; a potency suited to a facility's specific population; and for macerated skin, zinc oxide or calamine as an astringent to dry oozing.
DermaRite suggests all facilities have on hand one basic barrier cream for prevention and one for treatment, to be applied by a nurse in case of broken skin.
Having an array of undergarments also can help. Using the least restrictive option will encourage residents to be more active, Mongillo says. All bladder control pads and briefs should also be designed to wick moisture. First Quality's 360-degree breathable zones have an absorbent core, odor guard and “skin smart” additives such as aloe to create a “favorable microclimate.”
For patients who do develop wounds, perineal or otherwise, experts suggest a formulary that addresses multiple needs.
For patients with a pressure injury in the sacral and/or ischial areas and IAD, Melendez recommends a therapeutic support surface with microclimate management to help maintain normal skin temperature, inhibit sweating and reduce excessive moisture.
“Care must be taken to choose the support surface that strikes the balance between maintaining normal skin hydration and temperature and overly drying the skin, as some surfaces which provide high levels of air loss may cause skin dehydration,” she notes.
And Maynard encourages her clients to stock a variety of dressings with various active ingredients, including collagen (with or without silver), honey for debriding and its antimicrobial benefits, and alginate for high-drainage cases.
The ingredients in a patient's diet can serve as a weapon against skin degradation.
“It's important for the dietitian to get on board for at-risk patients,” Maynard says. “They need increased calories and increased protein.”
Whatever a doctor and dietitian deem appropriate has to be consumed to work.
Protein speeds cell regeneration for better wound healing, says Martie Moore, RN, MAOM, CPHQ, chief nursing officer at Medline Industries.
Given as part of meals or snacks, they often go uneaten. Miscommunication among care providers concerning protein and other nutritional intake also contributes to a lack of tracking.
For better compliance, she suggests giving and tracking dense nutritional supplements through medication administration, noting that a 30cc cup can hold as much protein as a chicken breast.
Once the gold standard, serum protein levels no longer can be the sole basis for understanding a patient's nutritional needs, she says. Observing changes in eating habits can be just as revealing.
“We've got to think about this differently,” says Moore, a corporate advisory council member for the National Pressure Ulcer Advisory Panel. “In the elderly, many are not taking in as much protein because of the chewing, the lack of taste and trouble swallowing. That chicken breast might be a great source of protein, but are they really eating it?”
Protein may not be the only nutrient to bulk up on. Maynard noted that vitamins A, C and E and the amino acid L-arginine can be helpful for wound healing, but some supplements may interact with blood pressure medications or are not recommended for individuals with kidney disease.
Vitamins can be grouped with ferrous sulfate, insulin and thyroid hormones as drugs that may facilitate wound healing, according to research conducted by Janice Beitz, Ph.D., RN, director of nursing at Rutgers School of Nursing-Camden.
Her review of more than 500 articles on the impact of pharmacologic treatments on wounds was published in Ostomy Wound Management in March. Beitz found the medications “most likely to impair wound healing and damage skin integrity” include antibiotics, anticonvulsants, steroids, and angiogenesis inhibitors used to treat some cancers and macular degeneration.
She suggested clinicians work to “deprescribe” contraindicated medications when possible.
“Selected clinical practices, including obtaining a detailed medication history that encompasses herbal supplement use; assessing nutrition status … and scrutinizing patient history and physical characteristics for risk factors can help diminish or eliminate adverse integumentary outcomes,” she wrote.
Maynard said assessments become even more important when patients use medication for extended periods, such as radiation for prostate cancer that weakens skin in the perineal area.