Sabrina Friedman, MSN, PhD, EdD, FNP, CNS On completion of this chapter, the reader will be able to: 1. Discuss the primary functions of the integumentary system. 2. Identify normal age-related skin changes. 3. Discuss four common skin problems and conditions experienced by older adults and their associated nursing implications. 4. Describe three types of skin cancer that affect older adults. 5. Differentiate between the three types of lower leg ulcers. 6. Describe the risk factors for pressure ulcer development. 7. Identify five pressure ulcer preventive strategies endorsed by the Agency for Healthcare Research and Quality (AHRQ) clinical guidelines. 8. State three principles necessary for successful wound healing. 9. Conduct an assessment for a client with impaired skin integrity. 10. Determine when to appropriately use antiseptics. 11. Discuss six types of dressings, including indications, contraindications, advantages, and drawbacks. A careful and thorough assessment of the integumentary system is essential when a physical assessment is performed on a patient. Skin assessment can help determine hydration status, potential for or actual infection, and other information about the individual (e.g., sun exposure, attention to personal appearance, and scars). Palpation of the skin can identify tender areas, nodules, and masses (see Assessments in Chapter 4). The integumentary system reflects the normal aging process, which includes graying hair, increased number and depth of wrinkles, loss of elasticity, and discoloration and thickening of the nails. Box 30–1 describes basic age-related skin changes. With aging, fewer eccrine glands (sweat glands of the palms, feet, and forehead) and apocrine sweat glands (sweat glands of the axilla, scalp, face, and genital areas) exist, resulting in decreased body odor and reduced evaporative heat loss because of decreased sweating. There is less need for antiperspirants and deodorants. However, older adults are at greater risk of heat stroke as a result of a compromised cooling mechanism. Older adults should avoid heat exposure over long periods and in areas of high humidity. Hats with wide brims and cool, light, breezy clothing should be worn when outdoors. It is important that older adults drink extra fluid (minimum of 2000 mL/day, unless contraindicated by a medical condition, such as renal failure or congestive heart failure) to maintain adequate hydration (Ebersole, Touhy, Hess, et al, 2008). Hair thins, and its growth declines. A progressive loss of melanin occurs, resulting in graying of the hair. Heredity influences when this graying process begins. Older women may have increased lip and chin hair while experiencing a thinning of hair on the head, axilla, and perineal area. Men lose scalp and beard hair yet experience increased growth over eyebrows and in ears and nostrils. The increased hair in ears predisposes men to cerumen impaction, which leads to impaired hearing (see Chapter 31). Changes in patterns of hair growth and distribution as a person ages are thought to be hormone related. Nails grow more slowly with age and become thicker, brittle, and dull and also develop longitudinal striation with ridges (Ebersole et al, 2008). These changes can affect a person’s body image and self-concept (see Cultural Awareness Box). Psoriasis is an autoimmune condition that affects 2% to 5% of the world’s population and approximately 2.6% of the United States population (Aldredge, 2009). The condition may affect persons of any age, although it often begins during early adulthood. Psoriasis is sometimes associated with other diseases such as arthritis, myopathy, enteropathy, spondylitic heart disease, and acquired immunodeficiency syndrome (AIDS). Approximately one third of patients with psoriasis have a first-degree relative affected by the disease; those developing the disease before age 40 have a stronger genetic component (Aldredge, 2009). Once psoriasis begins, there are periods of remission and relapse with varying degrees of intensity. There is no known cure. Pruritus is another term for itching that is so intense it causes the client to scratch. The most common cause of itching is dry skin, or xerosis. The mechanism of itching is not fully understood, but histamine is a known mediator of pruritus. Itching can be precipitated by heat, sudden temperature changes, sweating, clothing, cleaning products such as soap, fatigue, and emotional stress, and it can be more severe in the winter (Ebersole et al, 2008). Pruritus can be related either to a skin disorder or systemic disease; therefore the complaint should not be dismissed and warrants a complete assessment (Box 30–2). Pruritus can occur with other dermatologic conditions, and systemic disorders such as liver, renal, hematologic, and thyroid conditions. Herpes zoster, also known as shingles, is caused by the reactivation of latent varicella zoster (chickenpox) virus. The virus remains in the dorsal nerve endings after an episode of chickenpox, which is usually experienced in childhood. The main reason for recurrence is an immune system deficiency. Conditions that may impair the immune system are advanced age, stress or emotional upset, fatigue, or radiotherapy. An immunocompromised state caused by disease (e.g., human immunodeficiency virus, lymphoma, leukemia, and other malignancies) or drugs (e.g., chemotherapy and steroids) can also activate the latent virus. Chickenpox is highly contagious because it is an airborne virus. Herpes zoster is not as infectious because it is related to reactivation of latent varicella zoster. Therefore it is not necessary to isolate a client with herpes zoster. Cases of contracting shingles after personal exposure have been reported, but these have been in individuals who have not had chickenpox. Consequently, clients with herpes zoster should be cared for only by health care personnel who have had chickenpox or have positive serum varicella titers (Habif, 2004). As always, universal precautions should be exercised. Herpes zoster often has prodromal symptoms of tingling, hyperesthesia, tenderness, and burning or itching pain along the affected dermatome. The prodromal symptoms are followed by vesicles with an erythematous base occurring within 3 to 5 days. A unilateral, bandlike, erythematous, maculopapular rash first occurs along the involved dermatome and rarely crosses the midline of the body. The rash develops into clustered vesicles (usually on an erythematous base) that become purulent, rupture, and crust. These vesicles are vulnerable to secondary bacterial infections. Some lesions become necrotic or hemorrhagic. This occurs more often in older adults. It may take up to 1 month for the crusting lesions to heal; mild cases resolve in 7 to 10 days. The average duration for herpes zoster is 3 weeks. Scarring and permanent or temporary pigment discoloration may occur, especially in severe cases. Lymphadenopathy and an occasional temperature elevation are not uncommon. Postinfection paresthesias and meningoencephalitis may occur for 2 to 4 weeks when motor neurons and the central nervous system (CNS) are involved (Habif, 2004). The incidence of herpes zoster increases with age, most likely as a consequence of diminishing immune function. The older adult is also at a greater risk of developing postherpetic segmental pain. Dissemination is often seen in older adults or immunosuppressed clients. Disseminated herpes zoster, which is rare and occurs in only 2% to 5% of clients, is more serious because of its systemic nature. In disseminated herpes zoster, satellite lesions appear outside the affected dermatome within 4 to 6 days after the initial eruption. Dissemination may be associated with fever, lymphadenopathy, headache, neck rigidity, and an increased risk of serious complications such as encephalitis, hepatitis, and pneumonitis. Disseminated herpes zoster may occur in as many as 15% to 50% of clients with active Hodgkin’s disease, and 10% to 25% of these clients die (Habif, 2004). One of the major complications from this acute viral infection is postherpetic neuralgia, which is pain that persists along the affected dermatome after resolution of vesicular lesions. Postherpetic neuralgia can last less than 1 year, but it may last a lifetime with little pain relief. It affects approximately 33% of clients age 40 or older, and by age 70 the risk increases to 74%. Postherpetic neuralgia is more common in persons with trigeminal nerve involvement (Habif, 2004). Nursing diagnoses for a client with herpes zoster include • Impaired skin integrity related to immunologic deficit • Risk for infection related to impaired skin integrity • Sleep pattern disturbance related to impaired skin integrity or pain • Pain related to inadequate pain relief from analgesia • Knowledge deficit: disease process and treatment related to lack of previous exposure 1. Skin lesions will remain free from necrotic tissue and infection. 2. The client will experience adequate periods of restful sleep, as evidenced by • No requests for pain medication during the night • Reports of uninterrupted sleep during the night and feeling well rested on arising 3. The client will obtain adequate pain relief, as evidenced by • Verbalizing comfort and pain relief after taking an analgesic • Augmenting analgesic pain relief with the use of relaxation exercises, music diversion tapes, or guided imagery 4. The client will demonstrate increased knowledge of his or her condition, as evidenced by The nurse should teach the older adult client, family members, and staff the cause of shingles so that anxiety and misconceptions can be alleviated, and he or she should explain the treatment measures to increase compliance and involvement in care. Herpes zoster can be very painful, so prompt administration of pain medications is crucial for client comfort. For optimum pain control, clients should be instructed to inform the nurse when they experience the initial onset of pain, before the pain becomes well entrenched. Effective pain management is one area in which nurses can have a positive effect on a client’s quality of life (see Chapter 15). If postherpetic neuralgia occurs, antidepressants are used as adjuncts to analgesics for control of pain. Evaluation of interventions focuses on pain control, with documented results of analgesics and adjunct therapies, and on prevention of secondary infection by frequent monitoring of the site. Many barriers to effective pain management in older adults exist, leading to frequent underrecognition and undertreatment of pain (see Chapter 15). If pain is not relieved, the physician or APN should be consulted to obtain an alternative analgesic agent or adjunct drug therapy. The inflammatory response in an older adult may be diminished, even in the presence of severe infection, so the nurse should be alert to even slight symptoms of a secondary bacterial infection. If evidence of cellulitis is noted, the physician or APN should be informed to implement topical or oral antibiotic therapy. Documentation of assessment, the response to treatment measures, client comprehension of teaching, and other nursing interventions demonstrates nursing accountability (see the Nursing Care Plan: Herpes Zoster). Actinic keratosis is a premalignant lesion of the epidermis that is caused by long-term exposure to UV rays. This precancerous lesion is more common in individuals with light complexions and occurs most commonly on the dorsum of the hands, scalp, outer ears, face, and lower arms. Actinic keratosis may evolve into squamous cell carcinoma (SCC) if not treated, so it should receive prompt attention (Habif, 2004). Actinic keratosis begins in vascular areas as a reddish macule or papule that has a rough, yellowish brown scale that may itch or cause discomfort. During assessment the nurse should be attuned to the rough surface of the lesion and its location and be particularly alert if a suspicious lesion is on a sun-exposed area. Accumulation of keratin can also lead to the formation of a cutaneous horn that tends to develop on the outer ear. Because of an abundant vascular supply, removal of the crust may cause bleeding. Induration, inflammation, or oozing may be indicative of malignancy and merit prompt referral (Habif, 2004). The nurse should teach older adult clients and family members strategies necessary to prevent recurrence and stress the need to wear hats with wide brims and long-sleeved shirts to protect the skin from sun exposure. If an individual is going to be in the sun, a sunscreen with a sun protection factor of at least 15 should be applied (Habif, 2004). Basal cell carcinoma (BCC) is the most common skin cancer and is more prevalent in fair-skinned, blond, or red-headed individuals with extensive previous sun exposure. BCC rarely occurs in black persons because the darker skin pigmentation plays a protective role against UVB radiation, the spectrum thought to be causative in the development of skin cancer (Johnson, Moy, & White, 1998). It occurs more often in men than women; however, this gender difference has decreased in recent years. BCC is most commonly found on the face and scalp, less often on the trunk, and rarely on the hands. It may also arise from scars or burns, particularly in older adults who have experienced chronic sun damage. BCC usually does not metastasize, but if left untreated, it may metastasize to the bone, lungs, and brain (Habif, 2004). Nursing diagnoses for a client with BCC include • Impaired skin integrity related to removal of a cancerous lesion • High risk for infection related to a break in skin integrity and a surgical wound • Body image disturbance related to disfigurement and scarring resulting from removal of a cancerous lesion • Fear of cancer, pain, or death related to having a cancerous skin lesion
Integumentary Function
Age-Related Changes in Skin Structure and Function
Appendages
Common Problems and Conditions
Benign Skin Growths
Cherry Angiomas
Psoriasis
Nursing Management
Assessment
Pruritus
Nursing Management
Assessment
Herpes Zoster (Shingles)
Nursing Management
Assessment
Diagnosis
Planning and Expected Outcomes
Intervention
Evaluation
Premalignant Skin Growths: Actinic Keratosis
Nursing Management
Assessment
Intervention
Malignant Skin Growths
Basal Cell Carcinoma
Nursing Management
Assessment
Diagnosis
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