- End of Chapter 1-
Common skin disorders in older adults
Moisture-Associated Skin Damage (MASD) and Skin Tear
Moisture-Associated Skin Damage (MASD) and skin tear are two skin conditions commonly found in frail older adults, which required proper skin care for prevention of skin injury.
Moisture-Associated Skin Damage (MASD)
MASD is classified as an irritant-contact dermatitis. The skin has developed inflammation and erosion caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus or saliva. The excessive exposure of the skin to bodily fluids can compromise its integrity and barrier function, making it more permeable and susceptible to damage. It has negative impact on wellbeing and quality of life.
Management of MASD
What is skin tear?
o occur at any age and any part of our body
In Chapter 1, you have learnt about how our skin aged and changed the composition. Aged skin has increased the risk for skin tear especially among the vulnerable old age group. You may see some frail older adults' skins become vulnerable and easily injured. The ageing skin turns out to be thin, fragile, or easily bruises. If not care properly, it could be a series problem like pressure injury. Skin tear can become a chronic wound that is painful and distressing.
Risk factors for development of skin tear
Assessments of skin tear
image source from: www.skintears.org
Management for skin tear
Warning signs that require attention:
• the skin tear is widespread or associated with a full thickness skin injury
Consult medical advice if any of the above. It may require surgical review and intervention to repair the injury.
Skin Tear Prevention Program
Skin Tear Prevention Program helps to lower the risk of skin tear in nursing homes or other care settings.
• Assess all older adults on admission for skin tear risk factors
Fletcher J, Beeckman D, Boyles A et al., (2020). International Best Practice Recommendations: Prevention and management of moisture-associated skin damage (MASD). Wounds International. Retrieved from www.woundsinternational.com
LeBlanc, K., Langemo, D., Woo, K., Campos, H., Santos, V., & Holloway, S. (2019). Skin tears: Prevention and management. British Journal of Community Nursing, 24(Sup9), S12-S18.
- End of Chapter 2-
Case scenario 1
Mr M is a 70-year-old man who is suffering from hypertension and stroke with lower limbs weakness for 6 months. He is reluctant to move and always loves to sit on his wheelchair and watch TV. Recently, his skin is remarkably red in colour over his buttock and legs area especially sever over the sacrum area. He also complains of pain over his buttock and legs.
What's wrong with him?
Is there anything you could do?
You will find the answers in this Chapter. Let’s start!
3.1 What are pressure injuries?
According to the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP) & Pan Pacific Pressure Injury Alliance (PPPIA) (2019), a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbid conditions, and condition of the soft tissue.
Pressure injury (PI) updates:
(Edsberg, et al., 2016)
Pressure injury can happen to anyone at any age. It’s not uncommon to see older adults with pressure injuries or at risks of developing pressure injuries.
Common sites of pressure injuries
How do we differentiate Stage 1 pressure injuries?
Differentiation of tissue injuries
Staging of pressure injuries
According to the level of damaging, pressure injury is differentiated into several staging including Stage 1 to 4, Unstageable and Deep Tissue Pressure Injury.
Do not reverse stage a pressure injury. Once a Stage 4 always a Stage 4. For examples:
Alert for any warning signs of pressure injuries over bony prominence:
Complications of pressure injuries can be life threatening!
3.2 What causes pressure injuries?
In the early stage of pressure injuries, it shows up as persistent redness in light-colored skin. In dark-colored skin, the area may appear red, blue or purplish color.
Multiple factors may cause pressure injuries
All factors interact with each other that influences the level of risk for pressure injury.
Factors associated with increased risk of pressure injury
Who are at risk of pressure injury?
Why are older adults more prone to develop pressure injuries?
Older adults are the high-risk group of pressure injury. As we age, age-related changes make us more prone to develop pressure injuries:
These changes affect skin integrity and tissue healing, and raise the risk of pressure-related skin injury.
3.3 Identifying older adults at risk of pressure injury
Assessment should be performed on admission for care planning and monitoring. Reassessment for any changes of health condition.
Comprehensive assessments of pressure injuries
Alert to the risk factors
Pressure injury risk assessment scale
Risk assessment is essential for prevention of pressure injury and plan for the care. In addition, clinical judgment is also the key in managing pressure injury.
The Norton scale and the Braden Scale for Predicting Pressure Injury Risk were widely used to foster early identification of patients at risk for developing pressure injuries.
Items included in the Norton scale and Braden Scale
After studying the previous chapters, what will you do for the below case?
Case scenario 2
Amy is a 78-year-old woman who is living in a residential care home. She is suffering from Parkinson’s disease and diabetic mellitus. She has double incontinence. Her body mass index is below 18 kg/m2 which is lower than normal. She always rests on her bed and seldom go to the activity room or dining room.
Let's return to case scenario 1 Mr. M's situation:
3.4 Prevention and Management of Pressure Injuries
Prevention is always the golden rule. It is the most cost-effective treatment for pressure injuries.
Prevention of pressure injuries
3.4.1 Skin care
3.4.3 Nutritional support
3.4.1 Skin care
Skin care is playing an important role in prevention of pressure injuries.
3.4.2 Pressure Redistribution
Reduce friction and shearing forces
Proper sitting position
For chair-bound cases:
Can you recommend a suitable chair to the case Mr. M and educate him on the proper sitting position now?
Also, let’s teach him on the following pressure relief exercise!
Pressure relief exercises for wheelchair/chairbound clients
Regular pressure relief techniques are effective for prevention of pressure injury.
Performing each movement for 10 seconds for every 15 minutes of wheelchair use.
Use of pressure relieving devices
3.4.3 Nutrition and Pressure Injuries
Role of nutrition in pressure injuries
Challenges in nutrition Management
Nutritional Risk Factors
Delayed healing due to nutrition issues
1. Screening – suggest reviewing regularly (monthly)
2. Risk identification
Risk identification - delayed healing of pressure injury site
Actions if the older adult is identified as…
Monitoring by Dietitian
Common nutrition strategies used
• Small frequent meals
• Food fortification
• Minimize food restriction
Case Study – Mary Q1
Case Study – Mary Q2
Summary of nutritional support
3.5 Treatment in pressure injuries
Multidisciplinary team care approach
Bergstrom N, Braden BJ, Laguzza A, Holman V. (1987). The Braden Scale for Predicting Pressure Sore Risk. Nursing Research, 36, 205-210.
Cowan, L., Broderick, V., & Alderden, J. (2020). Pressure Injury Prevention Considerations for Older Adults. Critical Care Nursing Clinics of North America, 32(4), 601-609.
Edsberg, L., Black, J. , Goldberg, M. , McNichol, L. , Moore, L. , & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. Journal of Wound, Ostomy and Continence Nursing, 43 (6), 585-597. doi: 10.1097/WON.0000000000000281.
European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Emily Haesler (Ed.).
Gefen, A. (2008). How much time does it take to get a pressure ulcer? Integrated evidence from human, animal, and in vitro studies. Ostomy Wound Manage, 54(10), 26-8, 30-5
Hajhosseini, B., Longaker, M., & Gurtner, G. (2020). Pressure Injury. Annals of Surgery, 271(4), 671-679.
Li, Z., Lin, F., Thalib, L., & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalized adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, 105, 103546.
Morley, J., Tolson, D., Ouslander, J. G., Vellas, B. (2013). Nursing home care. McGraw Hill Professional.
Munoz, N., Posthauer, M. E., Cereda, E., Schols, J. M., & Haesler, E. (2020). The role of nutrition for PRESSURE injury prevention And Healing: The 2019 international clinical PRACTICE Guideline Recommendations. Advances in Skin & Wound Care, 33(3), 123–136.
Norton, D., McLaren, R. and Exton-Smith, A.N. (1962) An Investigation of Geriatric Nursing Problems in Hospital. Churchill Livingstone, London, 193-224.
Thomas, M., & Compton, M. (2014). Pressure Ulcers in the Aging Population: A Guide for Clinicians.
Trans Tasman Dietetic Wound Care Group (2011). Evidence based practice guidelines for the dietetic management of adults with pressure injuries.
- End of Chapter 3-
Quiz, feedback and certificate
The videos in this course provide information for educational purposes only. The videos do not provide medical recommendations or diagnoses and are not substitutes for medical advice. It is crucial that you talk with your healthcare providers to discuss any questions you may have and seek them for medical advice, before you make any medical decisions. As the videos are only for educational purposes, we will not be responsible for any decisions you will make or consequences you will have based on the information they provide. In no event shall the Funder have any liability of any kind to any person or entity arising from or related to any actions taken or not taken as a result of any of the contents herein.
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