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Group 05
NURSING CARE OF ELDERLY PATIENTS WITH SKIN DISEASES
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Group 05

NURSING CARE OF ELDERLY PATIENTS WITH SKIN DISEASES

14. References

15. Team members

13. Common skin management

12. Skin growths

10. Pressure sores

9. Chronic venous insufficiency

11. Purpura

8. Skin infections

7. Eczema dermatitis

6. Pruritus

5. Xerosis

4. Common causes of skin diseases

2. Changes of the skin with aging

3. Introduction on adult skin diseases

1. Anatomy of the skin

CONTENTS

Hypodermis(subcutaneous fascia)

This is the bottom layer of the skin. this layer is made up of connective and fatty tissue. It produces the fat cells that provide the padding for protection, insulation and temperature regulation. The hypodermis attaches to the muscles of the body

Dermis

The dermis is the layer of skin directly below the epidermis layer. This layer is much thicker than the epidermis and consists of connective tissue. It contains blood vessels, nerve endings, sebaceous glands, hair follicles, elastic fibers, lymph vessels and sweat glands.

This is the top layer of the skin. This layer is formed by stratified squamous epithelium cells. The epidermis layer does not have any blood vessels and nerve endings. the stratum corneum is the outer layer of the epidermis. It consists of dead skin cells which sloughs off with daily activities. Therefore, this continuous turnover of cells allows for the skin to repair itself when injured.

Epidermis

The skin mainly consists of 3 layers.1. Epidermis2. Dermis3. Hypodermis

ANATOMY OF THE SKIN

CHANGES OF THE SKIN WITH AGING

  • Skin changes are related to environmental factors, genetic make up, nutrition and other factors.
  • With aging, the outer skin layer (epidermis) thins.
  • Skin in aged people look thinner, paler and more clear (translucent)
  • Pigmented spots including age spots or "liver spots" may appear in sun-exposed areas.
  • Changes in the connective tissue reduces the skin's strength and elasticity. It is more noticeable in sun exposed areas. It provides the leathery , weather beaten appearance to skin.
  • The blood vessels of the dermis becomes more fragile. this leads to bruising, bleeding under the skin(often called senile purpura) and similiar conditions.

CONT...

  • The subcutaneous fat layer thins so it has less insulation and padding. This increases your risk of skin injury and reduces your ability to maintain body temperature. Because you have less natural insulation, you can get hypothermia in cold weather.
  • The sweat glands produce less sweat. This makes it harder to keep cool. Your risk for overheating or developing heat stroke increases.
  • Growths such as skin tags, warts, brown rough patches (seborrheic keratoses), and other blemishes are more common in older people. Also common are pinkish rough patches (actinic keratosis) which have a small chance of becoming a skin cancer.
  • Sebaceous glands produce less oil as we age. Men experience a minimal decrease, most often after the age of 80. Women gradually produce less oil beginning after menopause.This can make it harder to keep the skin moist, resulting in dryness and itchiness.

Skin disorders vary greatly in symptoms and severity. They can be temporary or permanent and may be painless or painful. Some have situational causes, while others may be genetic. Some skin conditions are minor, and others can be life-threatening. While most skin disorders are minor, others can indicate a more serious issue. Caregivers and medical personnel can help decrease or prevent many skin diseases in the elderly by addressing several factors.Included in factors to consider are;

  • The patient's nutritional state
  • Medical history
  • Current medications
  • Allergies
  • Physical limitations
  • Mental state
  • And personal hygiene

INTRODUCTION TO ADULT SKIN DISEASES

As we age, our skin changes in ways that can make it more prone to diseases. That’s because older skin is less oily, less elastic, and thinner. It bruises easily and take a long time to heal when cut.

What causes skin diseases? Certain lifestyle factors can lead to the development of skin disease. Underlying health conditions may affect your skin, too. Common causes of skin diseases include:

  • Bacteria trapped in your pores or hair follicles.
  • Conditions that affect your thyroid, kidneys or immune system.
  • Contact with environmental triggers, such as allergens or another person’s skin.
  • Genetics
  • Fungus or parasites living on your skin.
  • Medications, such as the ones that treat inflammatory bowel disease (IBD).
  • Viruses.
  • Diabetes.
  • Sun.

Lets take a look at common skin disorders found in elderly individuals. These include;

  • Xerosis
  • Pruritus
  • Eczematic dermititis
  • Purpura
  • Chronic venous insufficiency
  • and many more

COMMON CAUSES FOR ADULT SKIN DISEASES

Xerosis is characterized by pruritic, dry, cracked and fissured skin with scaling.Xerosis occurs most often on the legs of elderly patients but may present on hands and trunk. It is the most common underlying dermatological condition.The skin's inability to retain moisture and provide an effective barrier impacts xerosis in ageing skin. Defects in both skin hydration and lipid content play a key role in xerosis.Symptoms:

  • White and flaky skin
  • Fissuring
  • Dryness itchiness
  • Dermatitis inflammations
  • Red or pink, irritated skin
Causes:
  • Over-cleansing or over scrubbing the skin or using strong cleansers
  • Taking baths using boiling water
  • Bathing too frequently and vigorous towel drying
  • Living in areas with high humidity with cold, dry winters
  • Exposure to high temperatures and dehydration.
  • Pre-existing disease conditions, therapies and medications
e.g.: radiation, thyroid issues, HIV, endstage renal diseases, anti-androgen medications, malignants ... etc

XEROSIS

Nursing Interventions

  • As nurses it is important to carefully evaluate the patient’s dry skin
  • Topical steroid creams should be applied to the elderly patient with careful instructions and gently.
  • It is critical to advise the old patient or a bed-bound patient not to take extended hot showers but rather to take brief, slightly warm showers.
  • Wash gently
  • Prevent itch

Nursing management for elderly with xerosis

Treatment :

  • Treatment focuses on removing the cause of itch using corticosteroid creams and oinments, oral medications and phototherapy.
  • Once the temparary pruritic relief is obtained efforts should focus on finding and treating underlying etiology

Causes :

  • Skin conditions such as eczema, xerosis and parasites, burns, scars or insect bites or allergies to chemicals, drugs or medicines
  • Pruritus is often associated with other underlying diseases like renal failure, HIV, thyroid and parathyroid diseases, hypervitaminosis A, iron deficiency anaemia, neuropathy, hepatic disease, malignancy.

Pruritus is severe itching of the skin, with an irritating sensation that makes you want to scratch. Pruritic skin diseases are the most common dermatological problem in the elderly.Sometimes this could last long and can be intense. As you rub or scratch the area, it gets itchier. Breaking this itch-scratch cycle can be difficult.Symptoms:

  • redness
  • scratch marks
  • bumps, spots or blisters
  • dry, cracked skin
  • leathery or scaly patches

pruritus

1. Topical treatments are widely used to break the scratch-itch cycle. Some of them are:

  • A wide variety of emollients and lubricants are available as moisturizers, soap substitutes and bath additives.
  • Cooling agents usually containing menthol and phenol are intended to mask the itchy and irritating sensation.
  • Topical anaesthetic agents such as lidocaine are widely used in neuropathic pruritus.
  • Topical antihistamines
  • Oral corticosteroids such as prednisolone should be used as a last resort to the elderly, and, if prescribed, they should be taken for a limited duration.
  • UV light therapy has been effective for patients with certain types of pruritus. Other complementary therapies include acupuncture, nutritional therapy and hydrotherapy.
2. Physical examination
  • A general examination should begin the physical assessment of a patient with pruritus to determine its cause.
  • It is necessary to examine vital signs. Fever (i.e., a temperature of more than 100.8°F) may suggest that pruritus is the result of an infectious process.
  • Skin inspection is, without a doubt, an essential element of the physical examination.
  • The doctor must check the colour of the skin. The presence or absence of erythema in the itchy regions might aid in the diagnosis, particularly in the case of infection. A secondary cause of pruritus, such as neoplastic illness, may be indicated by haemorrhage. Itching caused by liver illness might cause jaundice. In addition, it is essential to search for lesions on the skin.
3. The basic role for a nurse for the management of a patient diagnosed with Pruritus covers a challenging and broad area.

Nursing management for elderly with Pruritus

Eczema is a common skin problem in older people. The terms eczema and dermatitis are interchangeable.Eczema is poorly demarcated skin inflammation with scaling and thickening that includes several types of eczema which affect older people.Dermatitis is used to describe an inflammatory skin response that results from contact with an external agent or an allergic reactionAsteatotic eczema, nummular eczema, seborrheic dermatitis, gravitational eczema, auto schematization eczema falls under this category, and several of these disorders are commonly seen in elderlyCauses:

  • Reduction of barrier lipids in the outer layers of the skin and changes in the skin structure with age.
  • Environmental factors such as cold weather, low humidity, soap and detergents.
  • Allergies- an overreaction of the immune system
  • genetics
  • Psychological factors, such as depression, anxiety, Parkinson's
  • Nutrient deficiencies and medications, drugs
Symptoms:
  • Nummular eczema- pruritic coin-shaped lesions that may develop into scales on lower legs, dorsum of hands and trunk.
  • Seborrheic dermatitis - xerotic, scaly, flaky skin in the scalp, face, trunk or anogenital region
  • Strategic eczema - abnormally dry, itchy, cracked and peeling skin.
  • Stasis dermatitis- varicose veins, brownish colour results from hemosiderin deposition, ulceration

eczema dermatities

Nursing management for elderly with Eczema

1. Skin assessment

  • Determine if it is generalized or localized
  • Being able to describe and elaborate the infection of eczema
  • During skin examination patient should be questioned on previous or current external therapies- History of body surface therapies
  • Other important questions to be asked by the patient include; how long eczema has been present and when it initially occurred?
2. Medical history 3. Eczema exists as acute or in chronic stages, and both of these stages require constant therapy and treatment.
  • Emollients, medical soaps, topical corticosteroids, and avoid triggers factors are the mainstays of eczema therapy for the elderly. Topical corticosteroids should be used first-line for eczema flare-ups since they effectively decrease inflammation symptoms through anti-inflammatory, immunosuppressive, anti-proliferative, and vasoconstrictive effects. Avoiding trigger factors includes avoiding instances such as over washing, soaps, detergents, salt water, washing hair separately, sitting by radiators, in contact with animal skins and fur and finally ensuring room temperature is not too high.
  • If control of symptoms is difficult and less progress is depicted, then antibacterial will be required. Furthermore, topical calcineurin inhibitors, bandages, therapeutic clothing, UV light and oral therapies are also options to promote comfort and protection to the skin.
  • Other additional therapies for moderate to severe eczema needs to be prescribed by a dermatology specialist.
  • Devise an Eczema Treatment Plan.

Causes :

  • Bacteria trapped in skin pores
  • Fungus, viruses or microorganisms living on the skin
  • Genetic factors
  • Weak immune system

Symptoms:

  • Red or white raised bumps
  • Painful or itchy rashes
  • Rough skin
  • Open sores which might be painful

More common skin infections are eczema and pruritus among aults.Skin infections become more fatal if correct diagnosis are not carried out.

Skin Infections

Sympotms:

  • Pain
  • Itchiness
  • Swelling or heaviness , specially in the lower leg and ankle
  • Skin that looks like leather

Causes :-Women are more likely than men to get CVI-Chances might be high if you are,

  • obese
  • over age 50
  • have a family history of CVI
  • history of blood clots
  • a smoker

  • Chronic venous insufficiency is a condition that occurs when the venous wall and valves in the leg veins are not working effectlively
  • CVI causes to collect blood in veins and this pooling is called statis.
  • CVI is not a fatal health threat but it can be painful and disabling.

CHRONIC VENOUS INSUFFICIENCY

Nursing management for elderly with Chronic Venous Insufficiency

CVI, like any disease is best treated in its early stages for elderly patients. For elderly patients with CVI, vascular medicines and treatments are usually prescribed. The goal of treatments is to decrease blood collection and avoid leg ulcers 1. Conduct a physical examination 2. Advice the elderly patient to avoid long periods of standing and sitting. 3. Advice the patient to engage in exercises frequently and that it is mandatory to lose weight if patient is overweight. 4. Compression therapy- Compression treatment (bandages or hosiery) decreases oedema, heals ulcers, and reverses venous hypertension by:

  • Increasing the efficiency of the calf muscle pump
  • Keeping venous dilation at bay when walking or standing
  • Increasing the velocity of venous blood flow reduces inflammation by preventing leukocytes from being trapped.
  • Preventing venous backflow by reducing valvular insufficiency
  • Reduced capillary filtration reduces lymphatic burden
  • Improves blood flow efficiency, resulting in better nutrition delivery to the skin
  • and faster ulcer healing.
5. Practice good skin hygiene because it is critical to maintain proper skin health and care.

Risk factors:

  • Immobility
  • Poor nutrition intake and hydration
  • Lack of sensory perception

Causes :

  • Prolonged pressure on the skin
  • Friction occurs when the skin rubs against clothing.
  • When 2 surfaces move in the opposite direction (shear)

Symptoms:

  • Red edges
  • Pus like drawning
  • Odour
  • Heat (the area of the skin feels cooler or warmer)

  • Also known as pressure uclers or bed sores
  • Pressure sores are injuries to the skin and underlying tissue
  • Can be extremely painful
  • Can happen to anyone but usually affect people restricted to bed or who sit in a chair or wheelchair for longer period of time.
  • There are 4 grades of pressure sores

PRESSURE SORES

Nursing management for elderly with pressure sores

Skin care:

  • Keep the skin clean and dry
  • Investigate and manage incontinence (Consider alternatives if incontinence is excessive for age)
  • Do not vigorously rub or massage the patients’ skin
  • Use a pH appropriate skin cleanser and dry thoroughly to protect the skin from excess moisture
  • Use water based skin emollients to maintain skin hydration where possible
  • Apply barrier cream
Redistributing pressure:
  • Employ appropriate manual handling techniques in line with Occupational Health and Safety guidelines when transferring and repositioning patients. Please adhere to Smart Move/Smart Lift guidelines.
  • Provide transfer assistance devices. Example: Hoist to reduce friction and shear forces.
  • Provide the right positioning aids and use of appropriate support surfaces to help reduce friction and shear.
Positioning and repositioning the patient:
  • Patients at risk of pressure injury should be suitably positioned to redistribute pressure, repositioned regularly by minimising shear and friction forces on the skin.
Nutrition:
  • Offer frequent fluids and diet to at risk patients to maintain adequate nutrition and hydration and the diet for pressure injuries include protein, arginine, vitamin C, vitamin A, and zinc.
Moisture:
  • Moisture on the skin increases the risk of pressure injury development. Should pay attention on keeping the patient’s skin out of moisture but not too dry. A bowel training program must be instituted for elderly spinal cord injury patients.

Causes :

  • Aging skin
  • Chronic sun exposure
  • Vascular diseases
  • Certain drugs
  • Minor trauma
  • Thrombocytopenia
  • Non-thrombocytopenia

Symptoms:

  • Purplish spots
  • Thin skin
  • Loose skin
  • Fatigue
  • Sometimes yellowish stains appear

  • Affects older adults
  • Equally common in both genders
  • Sometimes called actinic purpura

SENILE PURPURA

Nursing management for elderly with Purpura

3. Nursing care planning and goals The major nursing care planning are:

  • Take measures to prevent bleeding
  • Maintain a stabilized blood pressure and normal vital signs
  • Patient remains free of injuries
  • Patient remains free of infections
  • Early recognition of infection to allow for prompt treatment

2. Nursing diagnoses

  • Risk for bleeding due to decreased platelet count
  • Risk for injury related to abnormal blood profile
  • Risk for infective protection
  • Risk for infections related to suppression of the immune system by steroids

1. Nursing assessment

  • History
  • Physical examination

cancerous skin growth

non-cancerous skin growth

Additionally most common skin growths:

  1. Moles
  2. Skin tags
  3. Dermatiofibromas
  4. Keratoacanthoma
  5. Cysts

Cancerous skin growths

  1. Basal cell carcinoma
  2. Squamous cell carcinoma
  3. Solar keratosis

Non- cancerous skin growths

  1. Seborrheic keratosis
  2. Cherry angiomas
  3. Sebaceous hyperplasia

Skin growths

skin growth

  • Affect to elderly skin
  • Lump of tissue
  • There are 2 kinds of skin growths
  1. Non-cancerous skin growths
  2. Cancerous skin growths

Causes for skin growths:

  • viruses
  • systemic diseases
  • genetics
  • environmental factors

Symptoms:

  • a waxy bump
  • flesh colored lesion
  • a bleeding sore
  • a firm
  • may itch
  • ranges in size

For cancerous skin growths: 1. Basal cell carcinoma:

  • Radiotherapy maybe used for those that are high risk
  • Surgical excision is known to cure both high risk and low risk basal carcinoma
  • Photodynamic Therapy (PDT)
2. Squamous cell carcinoma
  • Patients should be trained to inspect pigmented lesions at least once a year, recognize melanoma symptoms, understand who is at risk, and know what to do if a suspicious lesion is discovered.
For non-cancerous skin growths: 1. Seborrheic keratosis:
  • Cryotherapy
  • Shave excision
  • Electrodessication
  • Or a combination of these
2. Cherry angiomas
  • A cherry hemangioma may be removed for a variety of reasons, the most common of which are aesthetic or the avoidance of bleeding after trauma
  • Treatment for smaller lesions includes local anesthesia with 1% lidocaine, followed by electrocauterization.
  • Larger lesions are often treated with shave excision
  • Superficial lesions may also be treated with CO2 laser therapy
  • Pulsed dye laser or intense pulsed light

Nursing management for elderly with Skin growths

Applying sunscreen

skin care routine

COMMON SKIN MANAGEMENT

Step 1

01

Cleansing

Step 2

02

Moisturizing

Step 3

03

  1. Cleansing
  2. Apply toner
  3. Apply serum
  4. Apply eye cream
  5. Use spot treatment
  6. Moisturize
  7. Apply retinol
  8. Apply face oil
  9. Apply sunscreen

Follow these 9 steps;

  1. Day time skin care routine
  2. Night time skin care routine

perfect skin care routine

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ISURI SATHARASINGHE

GAYATHRINI FERNANDO

SAKINDU GUNAWARDHANA

RANITHI SILVA

METHSUWEE WIJESINGHE

GROUP 05 MEMBERS

  1. Cowdell, F. (n.d.). Role of nurses in promoting the skin health of older people in the community. Fiona Cowdell. https://journals.rcni.com/nursing-standard/evidence-and-practice/role-of nurses-in-promoting-the-skin-health-of-older-people-in-the-community-ns.2019.e11394/abs.
  2. Contributor, N. T. (2019, August 3). Maintaining skin health in older people. Nursing Times. https://www.nursingtimes.net/clinical-archive/maintaining-skin-health-in-older-people-29-11- 2012/.
  3. Healthline. (2014). Skin Disorders: Pictures, Causes, Symptoms, Treatments, and Prevention. [online] Available at: https://www.healthline.com/health/skin-disorders.(Healthline, 2014)
  4. Onselen, J. V. (2012, June 4). Managing eczema in older patients. Independent Nurse. https://www.independentnurse.co.uk/clinical-article/managing-eczema-in-older patients/63600/.
  5. WebMD. (n.d.). Error 500. [online] Available at: https://www.webmd.com/skin-problems-and-treatments/eczema/atopic-dermatitis-eczema#1.(WebMD, n.d.)
  6. WebMD. (n.d.). Chronic Venous Insufficiency: What to Know. [online] Available at: https://www.webmd.com/dvt/dvt-venous-insufficiency.(WebMD, n.d.)

REFERENCES

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