REDUCING THE THREATS !
Created by:
Ruth Bryant RN, MS, CWOCN
Director, webWOC Nursing Education Program
Partner, Bryant Rolstad Consultants, LLC
Minneapolis, MN
Skin Integrity: Reducing the Threats
Objectives:
1. Correlate normal skin anatomy with maintaining
skin integrity.
2. Describe how the skin protects the body from threats
to skin integrity.
3. Describe the threats posed by aging, soap, bathing,
dry skin and skin tears.
4. Identify nursing interventions that reduce the threat to
skin integrity.
Why the Focus on Skin Integrity?
• Intact top layer of skin is a barrier from
environmental threats.
• When skin integrity is altered, the risk of
problematic complications such as pressure
ulcers and skin infections is increased.
• With aging, the skin is less efficient as a barrier
and less resilient to environmental threats.
• An increasing number of patients will be admitted
to our institutions who have a heightened risk for
altered skin integrity by virtue of their age.
Anatomy of the Skin
Skin Integrity:
Key Structures of the Skin
• Stratum Corneum
• Dermis
• Basement Membrane Zone (BMZ)
Stratum Corneum
• Intact stratum corneum is the first line of
defense for the body.
• The stratum corneum is constantly being
replaced and requires an orderly, regulated
process of keratinocyte proliferation and
differentiation.
Dermis
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The second layer of the skin.
Contains sebaceous glands.
Predominant proteins are elastin and collagen.
Contains a “ground substance”
composed of proteoglycans (PG’s) and
glycosaminoglycans (GAG’s)
Basement Membrane Zone (BMZ)
• Located where the epidermis and dermis meet.
• Epidermal surface consists of fingerlike
downward projections known as Rete pegs.
• Dermal surface consists of upward projections
known as Dermal papillae.
• Dermal papillae contains numerous
capillary loops.
Functions of the Skin
• Sensation
• Metabolism
• Thermoregulation
• Communication
• Protection
The Protective Function of the Skin
• An intact stratum corneum protects the
skin from Fluid and Electrolyte loss.
• Capillary loops and dermal proteins
assist in retention of moisture in skin.
The Protective Function of the Skin
• The collagen and elastin present in
the dermis protect the skin from
Mechanical Injury .
The Protective Function of the Skin
• Skin pigmentation and the presence of
melanin protects the skin from
Ultraviolet Radiation.
The Protective Function of the Skin
• Several characteristics of the skin
provide protection from Pathogens:
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Intact stratum corneum
Presence of Sebum
Acid pH (4.5-6.5)
Normal skin flora (resident flora)
Skin Immune System
Threats to Skin Integrity
“Natural” Threats
» Aging
» Dry Skin
“Man-induced” Threats
» Skin Tears
» Soaps
» Conventional Bathing Techniques
AGING:
Natural Threat to Skin Integrity
• Age alters the skin’s ability to retain moisture:
– Decrease in dermal proteins.
– Decrease in number of capillary loops in
basement membrane zone.
– Prolonged epidermal turnover.
AGING:
Natural Threat to Skin Integrity
• Age changes that alter skin’s ability
to resist pathogens:
– Change in the composition of sebum
– Decreased number of Langerhan’s cells
– Decrease in number of mast cells
AGING:
Natural Threat to Skin Integrity
• Age changes that alter skin’s ability to resist
mechanical stresses:
– Flattening of Rete ridge and Dermal papillae
– Decreased amount of dermal proteins (elastin
and collagen)
– Decrease in subcutaneous fat
DRY SKIN:
Natural Threat to Skin Integrity
• Affects 75% of people over 64 years of age.
• Results from prolonged epidermal turnover.
• The “aging” corneocytes in the stratum
corneum are less adherent so the barrier
function of the skin is compromised.
• Less adherent corneocytes create a larger
surface area which allows more fluid loss
through the skin.
SKIN TEARS:
Man-Induced Threat to Skin Integrity
Risk factors for developing skin tears:
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Advanced age
Sensory loss
Impaired nutrition
Impaired cognition
Dependency on staff for ADL’s
Need for mechanical devices
SOAPS:
Man-Induced Threat to Skin Integrity
• Alkaline soaps decrease layers of
stratum corneum.
• Soaps emulsify lipids.
• Soaps remove resident and transient flora.
• Alkaline soaps increase skin natural pH.
• Soaps may interfere with water holding
capacity of the skin.
Conventional Bathing Techniques:
Man-Induced Threat to Skin Integrity
How is bathing a threat to skin integrity?
• Basins often remain damp between baths and
are therefore a a vehicle for bacterial
proliferation and transmission.
• The negative effects of hand washing on the
integrity of the hands in nurses has been
extensively documented.
• Basin bathing is analogous to hand washing.
Conventional Bathing Techniques:
Man-Induced Threat to Skin Integrity
What are the negative effects of hand washing?
• Changes in resident skin flora.
• Heavy skin shedding so protective layer of
stratum corneum is compromised.
• Broken skin increases the risk of transmission
of microorganisms.
Conventional Bathing Techniques:
Man-Induced Threat to Skin Integrity
Frequency
Function
Form
Conventional Bathing:
Man-Induced Threat to Skin Integrity
Alkaline Soaps
Force
and
Friction
Basin Bathing
Hot Water
Washcloths
How is Alkaline Soap a Threat?
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Thins the stratum corneum.
Emulsifies lipids.
Removes resident flora.
Alkalinizes skin pH.
Reduces water holding capacity of skin.
How is the Washcloth a Threat?
Washcloth material becomes harsh
and rough because of frequent laundering
in bleach.
Washcloth can transmit microorganisms
to other body parts during bathing
process and contaminate basin and
surrounding environment.
How is Hot Water a Threat?
• Hot water has a drying effect
on the skin.
• The potable water source
can be contaminated.
• Bath water can cross-contaminate
personnel and environment.
How is Force or Friction a Threat?
Considerable force and friction is typically
used to lather up the cloth and skin.
This amount of force or friction on the skin
can be abrasive to the stratum corneum.
Reducing the Threat to Skin Integrity
How can we provide care to the patient, bathe
them and still “do no harm” to their skin?
Reducing the Threat of Soap
Recommendations:
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Use soaps with neutral pH.
Avoid detergent based antiseptics.
Eliminate harsh skin care products.
Minimize contact with soap and solvents.
Consider using waterless cleansers.
Use solutions that contain moisturizers.
Use moisturizers during and after cleansing.
Treat dry skin with moisturizers.
Reducing the Threat of Washcloths
Recommendations:
– Use thick soft cloths.
Additional Benefits:
– Washcloths are a surprisingly costly item in
institutions because they must be replaced
frequently.
Reducing the Threat of Hot Water
Recommendations:
– Avoid hot water; use slightly warm water and replenish as
needed.
– Use premoistened cloths that can be warmed.
– Explore utilization of new delivery mechanisms for skin
cleansing.
Additional Benefits:
– Warm bath is very soothing and relaxing.
– Reduce down time for staff while waiting for tap water to
warm up.
– A cool bath is uncomfortable and may have a negative
effect on thermoregulation.
Reducing the Threat of Force & Friction
Recommendations:
– Pat dry rather than “rubbing and
scrubbing”.
– Avoid rough skin scrubbers.
– Minimize force/friction when bathing.
Reducing the Threat to Skin Integrity
Additional Recommendations:
1. Cleanse skin at time of soiling and at
routine intervals.
2. Individualize frequency of bathing
according to patient need and preference.
(AHRQ, 1992)
Reducing the Threat to Skin Integrity:
Conclusion
Dr. Elaine Larson in 1999 stated that “… traditional
hand washing practices warrant re-examination.”
With consideration of our ultimate responsibility to the
patient to optimize the protective barrier function of
the skin, it is reasonable to propose: “Conventional
bathing techniques warrant re-examination.”