Theris A. Touhy
12
T H E L I V E D E X P E R I E N C E
I can’t thank you enough for helping me with my feet. I have been to the podiatrist, but no one has made them, and me, feel so good. I feel like I can walk forever now—you are an angel.
Tom, age 86
G L O S S A R Y
Debride To remove dead or infected tissue, usually of a wound.
Emollient An agent that softens and smoothes the skin.
Eschar Black, dry, dead tissue.
Hyperemia Redness in a part of the body caused by increased blood flow, such as in area of an infection.
Maceration Tissue that is overhydrated and subject to breakdown.
Slough Dead tissue that has become wet, appearing as yellow to white and fibrous.
Tissue tolerance The amount of pressure a tissue (skin) can endure before it breaks down, as in a pressure ulcer.
Xerosis Very dry skin.
L E A R N I N G O B J E C T I V E S
Upon completion of this chapter, the reader will be able to:
• Identify age-related changes of the integument and feet.
• Identify skin and foot problems commonly found in late life.
• Identify preventive, maintenance, and restorative measures for skin and foot health.
• Identify risk factors for pressure ulcers and design interventions for prevention and evidence-based treatment.
G
erontological nurses have an instrumental role in promoting the health of the skin and the feet of the persons who seek their care. These areas of function may often be overlooked when the focus is on management of disease or acute problems. However, pres- ervation of the integrity of the skin and the functioning of the feet is essential to well-being. In order to promote healthy aging, the nurse needs information about com- mon problems encountered by the older adult and skill in developing effective interventions for both acute and chronic conditions.Skin
The skin is the largest organ of the body. Exposure to heat, cold, water, trauma, friction, and pressure notwithstanding, the skin’s function is to maintain a homeostatic environ- ment. Healthy skin is durable, pliable, and strong enough to protect the body by absorbing, reflecting, cushioning, and restricting various substances and forces that might enter and alter its function; yet it is sensitive enough to relay subtle messages to the brain. When the integument malfunctions or is overwhelmed, discomfort, disfigurement, evolve.elsevier.com/Ebersole/gerontological
or death may ensue. However, the nurse can both promptly recognize and help to prevent many of the sources of danger to a person’s skin in the promotion of the best possible health.
Many skin problems are seen with aging, both in health and when compromised by illness or mobility limitations. The skin problems seen in older adults are influenced by the environment and age-related changes.
The most common skin problems of aging are xerosis (dry skin), pruritus, seborrheic keratosis, herpes zoster, and cancer. Those who are immobilized or medically fragile are at risk for fungal infections and pressure ulcers, both major threats to wellness.
Common Skin Problems Xerosis
Xerosis is extremely dry, cracked, and itchy skin. Xerosis is the most common skin problem experienced by older people. Xerosis occurs primarily in the extremities, espe- cially the legs, but can affect the face and the trunk as well.
The thinner epidermis of older skin makes it less efficient, allowing more moisture to escape. Inadequate fluid intake worsens xerosis as the body will pull moisture from the skin in an attempt to combat systemic dehydration.
Exposure to environmental elements such as artificial heat, decreased humidity, use of harsh soaps, and frequent hot baths or hot tubs contributes to skin dryness. Nutri- tional deficiencies and smoking lead to dehydration of the outer layer of the epidermis. Dry skin may be just dry skin, but it may also be a symptom of more serious systemic disease (e.g., diabetes mellitus, hypothyroidism, renal disease) or dehydration.
To prevent excessive loss of moisture and natural oil during bathing, only tepid water temperatures and super- fatted soaps or skin cleansers without hexachlorophene or alcohol should be used. Products such as Cetaphil, Basis, Dove, Tone, and Caress soaps or Jergens, Neutro- gena, and Oil of Olay bath washes are effective in helping to prevent the loss of the protective lipid film from the skin surface. Most lubricants such as creams, lotions, and emollients work by trapping moisture and are most effective when applied to towel-patted, damp skin im- mediately after a bath. Bath oils and other hydrophobic preparations may also be used to hold in moisture. Light mineral oil is as effective and more economical than com- mercial brands of lotions and oils. However, oils poured directly into a tub or shower increase the risk for falls. It is safer and more effective to apply the oil directly to the moist skin. Water-laden emulsions without perfumes or alcohol are best.
Pruritus
One of the consequences of xerosis is pruritus, that is, itchy skin. It is a symptom, not a diagnosis or disease, and is a threat to skin integrity because of the attempts to relieve it by scratching. It is aggravated by perfumed detergents, fabric softeners, heat, sudden temperature changes, pres- sure, sweating, restrictive clothing, fatigue, exercise, and anxiety. If rehydration of the stratum corneum is not suf- ficient to control itching, cool compresses, or oatmeal or Epsom salt baths may be helpful. Failure to control the itching increases the risk for eczema, excoriations, cracks in the skin, inflammation, and infection. Pruritus also may accompany systemic disorders such as chronic renal failure, biliary or hepatic disease, and iron deficiency anemia. The nurse should be alert to signs of infection.
Scabies
Scabies is a skin condition that causes intense itching, particularly at night. Scabies is caused by a tiny burrowing mite called Sarcoptes scabiei. Scabies is contagious and can spread quickly through close physical contact in a family, child care group, school class, or other close communal living facilities such as nursing homes. To diagnose scabies, a close skin examination is conducted to look for signs of mites, including their characteristic burrows. A scraping may be taken from an area of skin for microscopic exami- nation to determine the presence of mites or their eggs.
Scabies treatment involves eliminating the infestation with prescribed lotions and creams (Elimite, Lindane).
Treatment is usually provided to family members, caregiv- ers, and other close contacts even if they show no signs of scabies infestation. Medication kills the mites but itching may not stop for several weeks. The oral medication ivermectin (Stromectol) may be prescribed for individuals with altered immune systems, for those with crusted scabies, or for those who do not respond to prescription lotions and creams. All clothes and linen used at least three times before treatment should be washed in hot, soapy water and dried with high heat.
Purpura
Thinning of the dermis leads to increased fragility of the dermal capillaries and to blood vessels rupturing easily with minimal trauma. Extravasation of the blood into the surrounding tissue, commonly seen on the dorsal forearm and hands, is called purpura. These are not related to a bleeding disorder, and individuals who are prone to pur- pura should be advised to protect the skin against trauma and friction. Health care personnel must be advised to be gentle when handling the skin of older patients because even minor trauma can cause purpura. Long-sleeved shirts
reduce shear and friction, and protect the skin against trauma. If a skin tear occurs, use nonadherent dressings secured with tubular retention bandages.
Keratoses
There are two types of keratosis: seborrheic and actinic.
Actinic keratosis is a precancerous lesion and is discussed later in the chapter. Seborrheic keratosis is a benign growth that appears mainly on the trunk, the face, the neck, and the scalp as single or multiple lesions. One or more lesions are present on nearly all adults older than 65 years of age and are more common in men. An individual may have dozens of these benign lesions. Seborrheic keratosis is a waxy, raised, verrucous lesion, flesh-colored or pigmented in various sizes. The lesions have a “stuck on” appearance, as if they could be scraped off. Seborrheic keratoses may be removed by a dermatologist for cosmetic reasons. A variant seen in darkly pigmented persons occurs mostly on the face and appears as numerous small, dark, possibly taglike lesions (see www.dermatlas.com).
Herpes Zoster
Herpes zoster (HZ), or shingles, is a viral infection frequently seen in older adults. HZ is caused by reactiva- tion of latent varicella-zoster virus (VZV) within the sensory neurons of the dorsal root ganglion decades after initial VZV infection is established. HZ occurs most commonly in adults over 50 years of age, those who have medical conditions that compromise the immune system, or people who receive immunosuppressive drugs. HZ always occurs along a nerve pathway, or dermatome. The more dermatomes involved, the more serious the infec- tion, especially if it involves the head. When the eye is affected it is always a medical emergency. Most HZ occurs in the thoracic region but it can also occur in the trigeminal area and cervical, lumbar, and sacral areas. HZ vesicles never cross the midline.
The onset may be preceded by itching, tingling, or pain in the affected dermatome several days before the outbreak of the rash. It is important to differentiate HZ from herpes simplex. Herpes simplex does not occur in a dermatome pattern and is recurrent. During the healing process, clusters of papulovesicles develop along a nerve pathway. The lesions themselves eventually rupture, crust over, and resolve. Scarring may result, especially if scratching or poor hygiene leads to a secondary bacterial infection. HZ is infectious until it becomes crusty. HZ may be very painful and pruritic.
Prompt treatment with the oral antiviral agents acyclovir, valacyclovir, and famciclovir decreases the severity and dura- tion of acute pain from zoster. Zoster vaccine (Zostavax) is
recommended for all persons 60 years of age and over who have no contraindications, including persons who report a previous episode of zoster or who have chronic medical conditions. Before administration of the vaccine, patients do not need to be asked about their history of varicella or have serologic testing to determine varicella immunity.
A common complication of HZ is postherpetic neu- ralgia (PHN), a chronic, often debilitating pain condition that can last months or even years. The risk of PHN in patients with HV is 10% to 18%. Another complication of HZ is eye involvement, which occurs in 10% to 25% of zoster episodes and can result in prolonged or permanent pain, facial scarring, and loss of vision. The pain of PHN is difficult to control and can significantly affect one’s quality of life. The American Academy of Neurology (2012) treatment guidelines for PHN include the use of tricyclic antidepressants, anticonvulsants, steroids, lidocaine skin patches, and opioids, as well as nonphar- macological treatments such as stress reduction tech- niques and behavioral cognitive therapy. Assessment and management of pain are discussed in Chapter 15.
Photo Damage of the Skin
Although exposure to sunlight is necessary for the produc- tion of vitamin D, the sun is also the most common cause of skin damage and skin cancer. “Photo-damage, not the aging process, has been estimated to account for 90% of age-associated cosmetic problems” (Ham et al., 2007, p. 616). The damage (photo or solar damage) comes from prolonged exposure to ultraviolet (UV) light from the environment or in tanning booths. Although the amount of sun-induced damage varies with skin type and genetics, much of the associated damage is preventable. Ideally, preventive measures begin in childhood, but clinical evi- dence has shown that some improvement can be achieved at any time by limiting sun exposure and using sunscreens regularly.
Skin Cancers
Cancer of the skin (including melanoma and nonmela- noma skin cancer) is the most common of all cancers.
The exact number of basal and squamous cell cancers is not known for certain because they are not reported to cancer registries, but it is estimated that there are more than two million basal and squamous cell skin cancers found each year. Most of these are basal cell cancers.
Squamous cell cancer is less common. Most of these are curable but melanoma, which accounts for less than 5% of skin cancer cases, has the greatest potential to cause death.