The skin is the first line of defense against invasion by pathogenic bacteria living in the environment. When an area of the skin is destroyed by disease or trauma, its protective functions are immediately impaired. This impairment makes the body susceptible to infection. If very large areas of skin are destroyed, as in an extensive burn, fluid and electrolyte balance is disturbed. Protein and body heat are lost from burned areas. Skin diseases are common; they are often difficult to diagnose and cure and tend to recur. The physical effects of skin diseases are not often serious. However, when the disorder renders the patient unattractive, there is a psychological impact that threatens self-image and damages self-esteem. The skin also reflects systemic diseases.

Disorders of the Integumentary System

Causes

More than 3000 disorders of the skin have been officially named, and many more are not included in any official nomenclature. The majority of the recognized and named skin disorders arise from some pathology in the skin itself. The remainders are manifestations of some systemic disease. Skin disorders may occur from immunologic and inflammatory disorders, proliferative and neoplastic disorders, metabolic and endocrine disorders, and nutritional problems. Physical, chemical, and microbiologic factors also can damage the skin.

Many patients with dermatologic disease are not hospitalized and are seen only in physicians’ offices and outpatient clinics. Others do not seek medical attention but treat their skin disorder themselves with home remedies and over-the-counter drugs. In some cases self-care measures are successful, but they also have the potential for aggravating the condition or only temporarily relieving more severe symptoms. This can lead to delay in treatment and allows the disease to progress to a chronic and sometimes untreatable state.

Prevention

Hygiene

The ritual of the daily bath is almost an obsession with the average American. Traditionally, plenty of soap, hot water, and friction were considered a necessity for cleanliness; however, many facilities have adopted disposable cleaning cloths to replace the individual bathing basin. In a recent study, Johnson and colleagues (2009) cultured bath basins and cleaning sponges and found bacteria growing in 98% of the samples, including Staphylococcus aureus (23%), vancomycin-resistant enterococci (13%), and methicillin-resistant S. aureus (8%). Soap and water continues to have a place in hygiene, but beyond infection control, the astute nurse will assess for and consider skin type. Blondes and redheads with a fair complexion usually have very delicate skin that requires special care to prevent drying and irritation. If the skin appears dry and scaly, frequent bathing with soap and hot water only aggravates the condition. Oils and creams are available that cleanse the skin quite effectively and help replace the natural oils at the same time. On the other hand, people with dark hair usually have skin that is oilier and less susceptible to excessive drying and irritation. The person with oily skin will need to clean the skin frequently with a liberal amount of soap and water and there will be less need to apply additional oils to the skin.

Think Critically

You assist an elderly patient with a bath and notice that he has very dry skin. What interventions would you use?

Clinical Cues

Remember to dry areas where two skin surfaces touch, such as the axilla and under the breasts.

Diet

Even borderline deficiencies of vitamins and minerals will cause the skin to take on a sallow and dull appearance. Severe nutritional deficiencies lead to skin breakdown and the development of sores and ulcers. Dehydration causes loss of skin turgor and predisposes to pressure ulcers. People can be so concerned about their physical appearance that they refuse to eat properly for fear of gaining weight; however a well balanced diet will enhance appearance.

Age

Young people are not the only ones who should be concerned with the care of their skin. As we grow older, our skin undergoes certain changes that easily lead to irritation and breakdown if proper care is not given. The oil and sweat glands become less active, and the skin has a tendency to become dry and scaly. It also loses some of its tone, becoming less elastic and more fragile. Frequent cleansing of the skin becomes unnecessary as the skin ages, and alcohol and other drying agents must be used sparingly, if at all. Assist older patients to establish a regular routine of massaging oil, cream, or oily lotion into the skin.

Elder Care Points

The elderly patient who has dry skin does not need a full bath every day; cleansing of the axillae and genital-rectal area between bathing days should be sufficient. Elderly patients should use a mild lotion-based soap or body wash for bathing. After showering or bathing, a lotion or cream that helps seal in moisture should be applied while the skin is still damp. Moisturizing lotion or cream should be reapplied at bedtime.

Environment

Several environmental factors can have a direct effect on the health of the skin. These include prolonged exposure to chemicals, excessive drying from repeated immersions in water, very cold temperatures, and prolonged exposure to sunlight. Some of these are occupational hazards. A change of jobs may be necessary to eliminate contact with a factor that is causing a skin disorder. One of the Healthy People 2020 objectives is to reduce occupational skin diseases or disorders among full-time workers.

Overexposure to the ultraviolet rays of the sun can seriously and permanently damage the superficial and deeper layers of the skin. The damage results in severe wrinkling and furrowing, as well as loss of elasticity, and the skin assumes a tissue-paper transparency. In addition to the potential for premature aging and degenerative changes, solar damage also can result in malignant changes. Ultraviolet rays from the sun have long been known to be carcinogenic. This is especially true for fair-skinned people who have subjected their skin to prolonged exposure to sunshine. Although sunburns are particularly harmful, it is the normal daily exposure of unprotected fair skin to sun that causes long-term damage.

Health Promotion

Sun Exposure Precautions

Health teaching to inform the public about the dangers of solar ultraviolet radiation should include the following information:

• Although fair-skinned people who freckle easily are more likely to suffer sun-damaged skin, people of all complexions and races can and do burn if exposed to sufficient sunlight.

• Although a good tan might be considered by many to be desirable, dermatologists say that there is no such thing as a “healthy tan.” Tanning causes damage to the skin. If one insists on lying out in the sun, the initial exposure should be slow and gradual, and an adequate sunscreen with a sun protection factor (SPF) of at least 30, as well as ultraviolet A (UVA) and ultraviolet B (UVB) protection, should always be used. Too much sun too soon only leads to blistering and peeling.

• Select a sunscreen preparation on the basis of skin type and ability to tan, as well as its active ingredients and the amount of time to be spent in the sun. Remember that the sunscreen can be washed off by water or perspiration or rubbed off on sand and towels and must be periodically reapplied. Apply sunscreen liberally 15 to 30 minutes before sun exposure (American Academy of Dermatology, 2010). Reapply every 2 hours.

• Avoid exposure to the sun during the time its rays are most hazardous; that is, between 10 A.M. and 2 P.M. standard time or 11 A.M. and 3 P.M. during daylight saving time. Local radio and television stations often give information about current weather conditions and the chances for being burned by the sun at particular times during each day.

• You can be sunburned on a cloudy or overcast day.

• Light, loosely woven clothing will not give adequate protection from the sun’s rays.

• Remember that snow, water, and sand can reflect the sun’s rays and increase the intensity of exposure.

• Do not try to gauge how much you are being burned while in the sun. It may be 6 to 8 hours before a painful burn becomes obvious.

• Wear sunglasses and a hat when you go out in the sun, and, when possible, wear protective clothing.

• Never use a tanning booth; there is an eightfold increased risk to develop melanoma for persons under age 36 (Strayer & Schub, 2009).

Complementary and Alternative Therapies

Ultraviolet Radiation Protection

An oral form of fern plant extract may help protect the skin from ultraviolet (UV) radiation. The fern extract is from Polypodium leucotornos and is a natural antioxidant with tumor inhibition properties. Initial studies showed that volunteer subjects could tolerate threefold to sevenfold longer sun exposure time. A 2004 study showed a microscopic decrease in sunburned cells and less infiltration of mast cells, which typically respond in allergic disorders (Fox, 2009).

Clinical Cues

It is estimated that 90% of persons between 50 and 71 are not getting adequate vitamin D. During spring, summer, and autumn, 5 to 15 minutes of sun exposure without sunscreen twice per week to the face, arms, hands, and back is sufficient for adequate vitamin D production (Kalro, 2009).

Think Critically

You are talking to a young man who works as a ski instructor. He is fair-skinned and says that “on really sunny days, my hat is in my pocket and I never use sunscreen.” Discuss some issues related to this man’s integumentary health.

Integrity of Skin

Good nursing care includes protection of the skin and prevention of skin tears. A skin tear is a potentially preventable, traumatic wound that occurs primarily on the extremities of older adults because of age and debility. The wound occurs as a result of careless handling, friction alone or shearing and friction forces that separate the epidermis from the dermis or separate both structures from the underlying tissue. More than 1.5 million skin tear injuries occur each year among institutionalized adults in health care facilities; 80% occur on upper extremities, 50% have no apparent cause, 25% are wheelchair injuries, and 25% are caused by simply bumping into objects (Miner et al., 2009). The epidermis thins and becomes less elastic with age, making it susceptible to tearing with little trauma. Those individuals who require total care are at the highest risk. Risk factors for skin tears, other than age over 65, are presented in Box 42-1.

Box 42-1

Risk Factors for Skin Tears in the Elderly

Assess the patient for the following factors:

• Dry skin with dehydration

• Areas of ecchymoses

• Presence of friction, shearing, or pressure from bed or chair

• Impaired sensory perception

• Impaired mobility

• Taking multiple medications

• Prolonged use of corticosteroids

• Presence of renal disease, congestive heart failure, or stroke impairment

• Incorrect removal of adhesive dressings

• Rough handling when being bathed, dressed, transferred, or repositioned

The Payne-Martin classification system (Ayello & Sibbald, 2008) classifies skin tears as:

• Category I: A skin tear without tissue loss

• Category II: A skin tear with partial tissue loss

• Category III: A skin tear with complete tissue loss in which the epidermal flap is missing

Nursing Management

Rigorous nursing care (Box 42-2) to prevent skin tears is obviously preferable to treating skin tears that could have been avoided. However when a skin tear is discovered, steps for its management are: