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Best care for older people everywhere - The toolkit Nutrition
Skin integrit Skin integrity

Five facts everyone should know about skin integrity

 
1.
Older skin is thinner, sometimes very frail. It will sustain injury easily and take longer to heal.
 
2.
Skin integrity in hospital is not just about pressure ulcers. Refer point 5.
 
3.
Skin must be clean and dry. Three proactive steps should be taken to protect skin: avoid using 'drying' soaps, apply protective moisturisers and use skin protection devices to avoid both skin tears and pressure injuries.
 
4.
To choose an appropriate wound dressing, assess the whole person and then decide what can be achieved for each wound. For more information refer to Skin integrity booklet: Its maintenance and support.
NutritionMobility, vigour and self-careDementiaDepressionDeliriumContinence
5.
Maintenance of other functional areas, such as nutrition, mobility, cognition, falls prevention, pain management and continence, is integral to the management of skin integrity. Do not allow older patients to experience functional decline. Refer to other sections of The toolkit for guidance and refer older patients early to all appropriate members of the interdisciplinary health care team.

Why is it important to consider skin integrity when working with older people in hospital?

Further reading or reference
Maintaining skin integrity is important because hospital-acquired pressure areas, skin tears and infections are associated with pain, reduced mobility, increased risk of in-hospital complications and increased health care costs due to a prolonged length of stay [1].
Further reading or reference
Wound prevalence increases with age [113].
Intact, healthy skin protects all our other body organs and their functions.

Ageing changes the ability of the skin to perform its important functions.

Older people's skin is more vulnerable to damage and stress, and slower to heal.

Any breakdown in skin integrity makes the body susceptible to infection.

What is skin integrity?

Skin is the largest body organ.

Having integrity means being whole, intact and undamaged.

When skin has integrity, it performs these very important functions:
  • It shields the body's vital metabolic functions from harmful temperatures, chemicals, radiation and pathogens.
  • It assists in the maintenance of fluid and electrolyte balance and optimal inner body temperature.
  • It conveys pleasant and unpleasant sensations.
  • It communicates our individuality by its texture, colour and characteristics.
The integrity of our skin is vital to our physical and psychological health.

Skin integrity is something we usually take for granted, until it is damaged.

Further reading or reference
As skin ages it:
  • Becomes thinner
  • Loses elasticity and moisture
  • Develops folds and wrinkles
  • Loses its cushioning layer of subcutaneous fat
  • Is more easily injured - prone to tearing and bruising
  • Is slower to heal [114] [115].
Health care workers, aware of these changes, can be proactive in protecting the skin and preventing hospital-acquired damage. Health care workers can also educate patients and their families or carers to assist in the maintenance of skin integrity.

How can I help older people maintain skin integrity while in hospital?

On admission to hospital

Screen for the risk of skin damage.

To assess pressure injury risk, use a validated tool:

Resource or tool
Braden Scale for Predicting Pressure Sore Risk [116]
Resource or tool
The Norton Scale [117]
Resource or tool
Waterlow Scale [118].
NutritionMedication
Do not just consider pressure injury. Look for other risk factors affecting skin function and integrity (for example, potential for skin tear risk, under-nutrition, use of medications that affect skin integrity, past history of chronic wounds, compromised circulation or neuropathy).

While in hospital and during transfers between wards, departments or hospitals

Actively prevent injury

Take these important actions everyday:

Assess skin integrity. This is easily done while assisting patients with personal hygiene. Documenting observations will help identify any changes.
NutritionMobility, vigour and self-care
Refer patients at risk or with existing skin, nutrition, swallowing, balance or mobility problems to appropriate interdisciplinary expertise, for example, podiatry, nutrition, nursing, speech, medical, physiotherapy.
Orient patients to their environment and keep the environment free of clutter, well signed and easy to navigate.

Carefully avoid any collision with environmental hazards such as bed rails, lifting machine parts and wheelchair footplates.

Further reading or reference
Any falls risk is also a skin integrity risk [119].
Employ protective mattresses, seat cushions, heel wedges and limb protection as appropriate [120, 121].
Further reading or reference
For guidelines, refer to Clinical practice guidelines for the prediction and prevention of pressure ulcers.
Do not use drying soaps on skin. They alter the pH balance and make skin drier and more susceptible to breaks and infections.

Never use aggressive tapes or adhesives.

Further reading or reference
Keep frail skin on limbs moisturised and covered for protection [122].
Educate patients and carers about their risks in hospital and the importance of preventative actions.
Information for families or carers
For information for patients, families, or carers, refer to Move Move Move.
Nutrition
Ensure meals are not interrupted by unnecessary, non-urgent activities.
Nutrition
Nutrition is vital to skin integrity. Ensure patients' hydration is constantly optimal and they eat their meals.
Nutrition
Sit patients out of bed for meals so they can see their meals properly and be in a good position to swallow and digest their food. Assist with meals as needed. Fill out menus, open packets, encourage consumption of any prescribed nutritional supplements, as well as meals, providing feeding assistance when required.
Document interventions in order to communicate and progress them as necessary.

Further information

Further reading or reference
For more information, refer to Skin Integrity Booklet: Its maintenance and support (pp. 3-4).

How can I recognise a potential problem with skin integrity?

If patients have one or more of the following risk factors, they are at a high risk of developing problems with skin integrity. Patients' skin should be assessed during every shift if they are at significant risk of problems.

Note: Removal and replacement of anti-embolic stockings to visualise the heels and toes properly is required.

Document your observations of skin condition to assist other clinicians in identifying any changes.

Skin integrity is at significant risk for patients with any of the following characteristics:

Losing protective layers of skin due to ageing.

Underweight or overweight.

Having difficulties washing or drying any part of their skin (for example, contractures, folds beneath abdominal aprons or hard to reach areas between toes).

Presenting with, or at risk of, developing problems with:

Sensation.

Blood circulation (for example, diabetes).

Quality of circulating blood (for example, anaemia).

Having radiation therapy.

Fasting for theatre.
Nutrition
Under-nourished.
Nutrition
Dehydrated.
Mobility, vigour and self-care
Immobile.
Continence
Incontinent.
Mobility, vigour and self-care
At high risk of falls.
Medication
Taking medications such as warfarin, prednisolone or chemotherapy.
Cognition
Confused or disoriented.

What can I do if I recognise that someone has a potential problem with skin integrity?

Person-centred practice
Discuss the problem with the patient, their family or carer and with the interdisciplinary health care team as appropriate.
Develop a person-centred care plan to manage the problems using the actions as outlined in What do I need to do to help older people maintain skin integrity while in hospital?

Document and report what has been done to effectively communicate the patient's care plan to others.

Further reading or reference
For specific prevention strategies for skin tears (page 10), and important actions to take to prevent pressure ulcers (page 7), refer to Skin Integrity Booklet: Its maintenance and support.

What are the care or management principles I should follow if an older person has a wound, skin tear, pressure ulcer or other skin problem?

Person-centred practice
The important thing to remember is to assess the whole person, not just the wound. Plan the dressing and management regime to suit the person's needs. Consider what the goal is for the wound (for instance, will it heal or is that not possible? Does discharge need to be contained and odours managed to improve the person's comfort level?) and consider who will change the dressings and how often.
Further reading or reference
Refer to the Australian Wound Management Association at www.awma.com.au
Further reading or reference
For more information and references, refer to Skin Integrity Booklet: Its maintenance and support (pp. 3-4).
Use clinical practice guidelines to plan specific care.
Further reading or reference
For simple strategies supporting clinical best practice, refer to Long Stay Older Patients: Skin integrity domain.
In different settings of care consider
  • The goals for the wound.
  • Who will be there.
  • What resources and supplies do they have?
  • Then plan.

At night

For nearly all wounds it should be possible to choose a dressing regime that does not require overnight changes and supports sleep and comfort throughout the night.

If the patient is at risk of pressure ulcers, recommend pressure-reducing mattresses and overnight repositioning.

Continence
If the patient is incontinent and cannot get up to the toilet at night, develop a plan to keep the skin dry overnight.

What can patients, families or carers do to maintain skin integrity in hospital and at home?

Person-centred practice
Educate patients and carers about how they can:
Use only moisturising, pH balanced lotions or skin cleansing bars instead of drying soaps.

Perform a daily skin inspection to pick up any problems and address them immediately.

Use moisturisers regularly to protect dry skin.

Use skin tear protection strategies and equipment, and provide advice about obtaining these.

Avoid pressure and teach about the positioning and availability of pressure offloading equipment (refer to occupational therapy, podiatry, physiotherapy or specialist local suppliers as appropriate).

Ask questions of their general practitioner or practice nurses.

Educate patients about pressure risk in hospitals.
Nutrition
Maintain optimal hydration.
Nutrition
Maintain optimal nutrition, refer to a dietitian for advice and follow up and ensure patients are supported to optimise food intake.
Mobility, vigour and self-care
Maintain good balance and mobility, encourage regular exercise and refer to a physiotherapist or podiatrist if appropriate.
Mobility, vigour and self-care
Avoid falls.
Further reading or reference
For information for patients, families, or carers, refer to Move Move Move..

What should I consider when planning discharge to help an older person maintain skin integrity at home?

If a patient is ready to go home with a continued need for wound dressings, involve the patient and family or carers early in discussions and decisions about the type of dressing regime that will work for them.

Involve support services such as home nursing services as appropriate, and communicate the person-centred care plan to ongoing care providers. Refer as soon as possible.

Discuss the need for any further referrals with patients and carers.
Nutrition
Refer to a dietitian if under-nutrition is suspected, to ensure optimal nutrient intake to maximise wound healing.

Further information

Refer to a podiatrist if foot care or footwear advice is needed.
Further reading or reference
For more information, refer to Skin Integrity Booklet: Its maintenance and support.

Case study

Mr Jackson, 70, is a retired engineer living in his own home with his wife. He has diagnosed dementia. He does not initiate daily tasks but is able to walk, shower, dress and toilet himself once prompted. Mrs Jackson understands that unless she prompts her husband regularly to drink and eat the food she prepares he will become dehydrated and under-nourished, placing him at risk of decline in other areas, such as his ability to walk safely and independently and complete tasks of daily living.

Scenario 1

Mr Jackson was admitted to an acute surgical ward for pre-operative bowel preparation three days prior to a colonoscopy, scheduled to diagnose the cause of chronic constipation with recent bleeding and anaemia. A previous colonoscopy was unsuccessful due to inadequate bowel preparation at home.

In hospital, Mr Jackson was quiet and uncomplaining. The nurses wheeled him into the toilet on a commode chair and helped him shower and dress. The colonoscopy failed again due to inadequate preparation, and the surgeon directed a repeat preparation in hospital.

The day after the second colonoscopy, Mr Jackson collapsed due to hypotension. Investigations revealed anaemia, dehydration and hypokalaemia. Treatment involved intravenous fluids and electrolytes and bed rest. Mrs Jackson reported that her husband had complained of sore heels.

Dressings were applied to Stage 2 pressure ulcers on both heels. The next day Mr Jackson's blood pressure was normal and he was feeling better. The doctors said he could go home.

However, Mr Jackson was unable to walk due to pain, weakness and the heel dressings. He had lost strength in his legs after not walking and not eating much for the last six days, and his wife said she would be unable to care for him at home until he could walk and toilet by himself.

He waited another two days in acute care for a rehabilitation bed.

On admission to rehabilitation he was noted to have lost five kilograms since his acute admission and developed Stage 3 pressure ulcers. He was provided with specially-made boots to enable walking while the pressure sores were healing, however due to his dementia, he had trouble adjusting to the new boots. He only regained his confidence in walking once the ulcers had healed and he was able to wear his own shoes.

Mr Jackson was admitted for a minor procedure yet ended up spending seven days in acute care and 28 days in sub-acute care to get back to regain his premorbid level of function. What went wrong?

Scenario 2

The following strategies from The toolkit were utilised:
Dementia
Information about 'me' for planning care in hospital.
Person-centred practice
Engage family and carers of people with dementia.
Nutrition
Ensure patient is sitting out of bed for all meals.
Adapt hospital environment to suit needs.

Braden skin integrity risk screening tool.

Nutrition risk screening tool MNA-SF.

Interdisciplinary assessment of mobility and nutrition issues.

Maintain patients own continence routine.

When Mr Jackson was admitted for the pre-operative preparation, the nurses consulted with Mrs Jackson about his care. Risk screens were performed and discussed with Mr and Mrs Jackson. Together, the staff, patient and carer made a care plan that would enable Mr Jackson to retain his functional independence in hospital. The nurses knew they needed to prompt Mr Jackson regularly to drink enough fluid to keep him well hydrated. Referrals were made to physiotherapy and dietetics for further professional assessment and to ensure his mobility and optimal nutrition were maintained.

Mrs Jackson was encouraged to spend time with her husband in hospital outside visiting hours, and was able to continue looking after him and maintain his daily routine as much as possible throughout his stay. Mr Jackson's admission was uncomplicated.

Person-centred practice
The difference was the person-centred care plan.

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