Apr 122012
 

You are helping your parent out of their wheelchair to the bed when you notice blood running down their arm. Your eyes automatically travel upwards to the source and you see a wound that looks as if someone peeled back the top layer of skin. A skin tear, probably the most common of skin injuries among the elderly due to changes that occur as we age. The skin becomes more fragile, less elastic, and thinning of the fat layer just below the surface, increase the risk for injury.

Skin Tears

Skin tears are a painful injury where the top layer of skin (the dermis), is torn from the layer just below the skin (epidermis), often leaving a skin flap. While they usually aren’t serious, they are painful and disfiguring. Dressing changes may be painful and if not done right, may cause further damage and pain. And as with any break in skin integrity, there is the risk of infection.

According to a study done by the Patient Safety Authority, 88% of all skin tears reported by healthcare facilities occurred in patients 65 years of age or older. “The Authority chose to highlight the skin tear issue because of the high number of patients who experience these painful wounds, especially among older and more fragile populations,” said Alan B.K. Rabinowitz, administrator of the Patient Safety Authority.

Risk factors include:

  • Advanced age
  • Poor nutritional status
  • Immobility
  • Dry skin
  • Mental impairment
  • Loss of vision, sensation, searing
  • Long-term use of steroids
  • Multiple medications and/or disease processes
  • gitation and restlessness

Prevention:

Most skin tears occur on the arms and legs so particular effort should be made to protect these areas.

  • Wear long-sleeve shirts and pants
  • Apply moisturizer twice a day
  • Drink plenty of fluids
  • Adequate nutrition
  • Wearing glasses and/or hearing aids as indicated

Caregivers Should:

  • Check equipment such as bed rails and wheelchairs for rough edges that could cause injury
  • Be especially careful when handling a person such as for personal care or transfers
  • Keep pathways clear of objects
  • Avoid wearing rings, watches or bracelets when providing care
  • Keep fingernails trimmed and smooth

Treatment:

  • Gently clean the area with normal saline or water (Never use peroxide on an open wound unless dirt is visible and doesn’t come off with water or saline).
  • Gently replace the skin flap. The flap may not cover the entire wound, but should be positioned to increase the chance for it to “take” in the wound bed.
  • If bleeding cover with gauze and apply light pressure
  • Apply a dressing

Choosing the type of dressing to apply involves several factors including skin fragility, amount of drainage, size and location of injury.

If you parent’s skin is relatively healthy, my favorite dressing is a clear, semi-permeable dressing that allows you to see the wound, air to get to the wound, and contains drainage. Tegaderm and Opsite are the two I have worked with the most.

They are a little tricky to handle at first because the plastic will stick to itself and you will never get it unstuck. Be very careful when peeling off the backing. Place it over the wound pressing it in place and then remove the top paper or the one around the edges, depending on the product you use. These can stay on 3-7 days unless drainage is leaking from them. Decreasing the number of dressing changes reduces the risk of reinjuring the wound and infection.

These types of dressings will not stick if there is lotion or oil on the surrounding skin, so you made need to gently wash around the wound with soap and water. Rinse well to avoid leaving soap on the wound. To protect the surrounding skin, I like to use a skin barrier such as Skin Prep. This is an impressive and underutilized tool in my opinion. It forms a protective barrier between the skin and the adhesive, so that when you remove the dressing the Skin Prep comes off instead of more skin. And yet, it actually helps the dressing to stick better.

I had a patient who was allergic to Tegaderm, but as long as we put Skin Prep on first, he could wear it up to a week with no problem. I use it under tape all the time. Skin Prep should be in the medicine cabinet of every caregiver’s home! (No, I am not a representative of the product).

Another dressing I use, especially if the drainage is heavy, is to place Vaseline gauze over the wound, cover with dry gauze, and wrap it with rolled gauze. There is also netting that you can slip over the extremity to hold the dressing in place but if the person is restless or moves a lot, it probably will not work.

Whatever type dressing you apply, remove it slowly and carefully. Peel it off in the direction the skin flap is growing to avoid peeling the skin flap back and causing further damage.

Always monitor skin tears for signs of infection, which can lead to cellulitis, a serious infection of the skin. That is a topic for another day.

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Apr 112012
 

Our skin is our first line of defense against infection making caring for it important. For our elderly parents, it is even more of a priority. As we age skin becomes thinner, looses elasticity, is more easily injured and slower to heal. In addition to abrasions and cuts, the elderly are prone to skin tears and skin breakdown also known as pressure sores or decubitus ulcers. If you are taking low doses of steroids, blood thinners such as daily aspirin or Coumadin, your skin is at even greater risk for injury.

The older we get, the more our skin loses its ability to moisturize itself. Dry, thin skin is more susceptible to injury allowing bacteria to get into the body.

A common complaint people have is dry, itchy skin. Here are some tips to reduce dryness:

  • Take warm, not hot showers or baths. Hot water exacerbates dryness. Keep the temperature of the water at 120 degrees Fahrenheit or less. Check your home’s water temperature with a thermometer since older adults may have impairment with sensation and be unable to tell if the water is too hot.
  • Unless you are very active and sweating, you only need to bathe 2 or 3 times a week. You can bathe under your arms, skin folds and genitalia daily to prevent body odor. We sweat less as we get older so it’s easier to prevent unwanted body odor.
  • Use soaps or body wash formulated for dry skin. Rinse well to remove all soap residues.
  • Lotion as soon as you get out of the shower or tub, after drying but while the skin is still moist. This helps to lock in moisture.
  • Apply lotion in the morning and at bedtime. If your feet and hands are especially dry, apply lotion at bed time and cover with white cotton socks and gloves to retain moisture.
  • Drink more fluids. (See You Need A Drink – for ideas on increasing fluid intake.)
  • Avoid alcohol and caffeine as these are drying to the skin.
  • Use a humidifier is the winter and if you live in a dry climate.
  • Rinse off immediately after exiting a pool or hot tub as the chemicals used to treat the water are harsh on the skin.
  • Avoid saunas. The dry hot air is bad for your skin, can dehydrate you and can play havoc with your blood pressure.
  • Keep your nails short and avoid scratching.
  • Caregivers should check the skin of seniors routinely for signs of injury, redness that doesn’t go away and moles.
  • A caregiver may need to also check the bottom of the feet daily especially if there is decreased sensation or the person is diabetic. (More about diabetic foot care in another post.)

If the person you are caring for has incontinence, decreased mobility, paralysis or bedridden, good skin care is vital to their health.

  • Check them at least every two hours to make sure they are clean and dry. If they are soiled, clean thoroughly especially the groin and buttocks folds. Urine is like an acid eating at the skin and “diaper rash” in the elderly is hard to clear up. Also, dry completely after washing to prevent fungal infections.
  • Inspect skin for red areas. If red areas are found, turn and reposition them to relieve pressure and allow unimpeded blood flow. If the redness is still present after 20-30 minutes, this is the start of a pressure sore, consult a health care professional promptly!
  • Keep your own nails short and smooth.
  • Avoid jewelry on your hands and wrists that might injure the skin when providing care.
  • Talk with a health care professional about products that can reduce pressure such as gel cushions and air mattresses.
  • Skin barrier creams and lotions help protect skin against excess moisture and irritants such as urine and feces.

Next up….Injuries to the skin

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Apr 092012
 

Summer has arrived! The days are longer, we are outside more and tee-shirts, shorts and flip-flops are our favorite attire. Swimming, fishing, boating, gardening, and cookouts, we love the summer! We have no problem getting our daily dose of vitamin D. Our skin, however, needs a little extra care.

Sunburns are a risk that becomes increasingly more serious as we get older. Sunburns are painful and increase the risk of skin cancer, can lead to dehydration and in severe cases hospitalization. Sunburn in the elderly can be dangerous not to mention it hurts!

  • Sun screens are rated with a Sun Protection Factor or SPF, which rates how well it protects against UVB rays only. The higher the number the more protection it offers. Use a sunscreen that offers both UVA and UVB protection.
  • Always use a sunscreen with an SPF of 15 or higher if you are going to be outside for more than 20 minutes. If you live in the southern part of the United States or are fair skinned, use at least a 30 SPF.
  • Even if it is overcast, wear sunscreen.
  • There is no rating to tell how well a sunscreen protects against UVA rays and while they don’t cause burns, they do penetrate deeper and increase cancer risk as well as more wrinkles.
  • Sunscreens absorb the sun’s rays, while sun blocks literally block the rays.
  • Apply sunscreen 15-20 minutes before going outside and reapply at least every two hours; more often if swimming, sweating or near water.
  • Apply sunscreen to all exposed skin including the tops of the ears, thinning or bald areas, face, back of the neck, hands, arms and feet.
  • Use lip balm with sunscreen added to protect the lips.
  • Apply sunscreen even if you will be in a vehicle. Every summer my left arm is darker than my right arm because the sun coming in the driver’s side window tans it. I have even gotten a mild burn while driving.
  • Make your life easier and use a lotion with sunscreen already in it. The smell reminds me of the beach so I refer to use it as my daily aroma therapy.

If despite all your precautions you do get sunburned, treatment includes:

  • Aspirin, acetaminophen (Tylenol), ibuprofen (Motrin) or naproxen sodium (Naprosyn) for pain.
  • Cool compresses, cool (not cold) baths.
  • Lotions or sprays that help numb sunburn pain are alright for short-term use only.
  • Products with aloe, such as aloe gel.
  • Burow’s solution (a solution of Aluminium Acetate) is an old remedy that you can get in a modified form called Domeboro at most drug stores. Dissolve the tablets in or powder in boiling water and allow to cool, before using. You can soak in it or use it on a clean cloth or gauze as a compress. It’s good for all kinds of skin issues like insect stings and poison ivy!
  • Stay out of the sun until healed.
  • Drink plenty of fluids.

There is nothing you can do about peeling, it is going to happen and is part of the healing process.

Seek prompt medical attention if there is severe pain, severe or multiple blisters, headache unrelieved by medication, nausea and vomiting, fainting, confusion, trouble thinking, remembering or focusing, or if you suspect dehydration.

Now put on your sunscreen, grab your water bottle and get outside!

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