Skin, the Preservation of Integrity

In our last post we discussed how protection is one of the most important functions of our skin. Unfortunately, as we age, our skin health starts to deteriorate, making it less effective in its protective role. This diminishing protection is generally referred to as the loss of skin integrity. Losing skin integrity makes patients more vulnerable to skin damage. The consequences of such damage can range from minimally bothersome to life threatening depending on the circumstances.

The process of aging can result in a number of skin changes. You may notice that elderly skin is not as smooth, dries out more quickly and is not as firm or thick. The structure and function of an older person’s skin reflects the cumulative effects of “natural” aging and “environmental” aging. Natural aging is the true biological process, whereas environmental aging refers to the damage caused by exposure to the environment. As we age, the  process of cell renewal within the skin is slowed down considerably, making it less healthy than younger skin.

Altered skin integrity can have significant consequences like infection or impaired mobility, and may even result in the loss of limb or life. In addition to natural and environmental effects, skin is also affected by both intrinsic and extrinsic human factors. Intrinsic factors can include altered nutritional status, vascular disease, and diabetes. Extrinsic factors include falls, accidents, pressure, immobility, and surgical procedures. These factors can impact the integrity of the skin, resulting in physical changes and possibly wounds and cancer. 

The following examples demonstrate the consequences of skin change:

Epidermal turnover slows --------> Thinner skin more prone to damage

Less effective barrier function ---> More prone to dryness & infection

Less flexible (weaker collagen) --> More prone to wrinkling & shear forces

Less melanin content --------------> More prone to sun damage

Less sebum production ------------> Increased dryness

Fewer sweat glands -----------------> Less effective temperature control

These changes can render the skin vulnerable to infection or wounding resulting from trauma, such as a knock or bump, or from sustained unrelieved shear, friction, or pressure over bony prominences. Illnesses involving high temperatures (fevers) and consequent moisture (diaphoresis) can also add to the vulnerability of aging skin, as can incontinence. Therefore, it is vitally important to know the condition of a patient’s skin and to monitor for changes regularly. Ongoing assessment and management of intrinsic and extrinsic factors will optimize skin health. 

Skin Changes That Can Occur with Compromise of Skin Integrity

Skin tears are an increasing problem for the elderly. If appropriate treatment is not provided, these injuries may become chronic wounds, causing unnecessary pain and suffering. 

For the elderly one of the biggest complications arising from loss of skin health is the greater risk of pressure injuries. Most of which are preventable with appropriate clinical care. 

Moisture lesions are often associated with increased age, decreased mobility, and the presence of incontinence. Once urine and faeces encounter the skin, its bacterial content can penetrate the skin, potentiating infection. 

The elderly have generally had a lifetime of exposure to sun resulting in photo-damage. Such damage makes them more at risk of developing benign or malignant skin cancer. 

Moisturizing the skin is the cornerstone of maintaining skin integrity in the elderly. This is best achieved using complete emollient therapy. The objective of this approach is to restore the skin barrier function and reduce the likelihood of further damage. Basic skin care strategies including low-irritating cleansers and humectant-containing barrier products are helpful for treating dry skin and improving the skin barrier in the elderly.  

Skin integrity assessment is an essential part of nursing care and should be conducted on admission and at least daily depending on the individual’s circumstances. The American Diabetes Association states that all individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions that may lead to amputation or foot ulcerations. In addition to gathering a thorough medical and foot history, the diabetic foot examination should include an assessment of skin integrity, vascular status, protective sensation, foot structure, and biomechanics. Assessment of skin integrity is not a simple look and see, as it involves the assessment of many intrinsic and extrinsic factors to fully understand the compromise to integrity in any one individual. Maintaining skin integrity requires a holistic and interdisciplinary approach, and this can include seeing into or under the skin itself.