Gero skin integrity

Can the skin have organ failure?

Yes, the skin is the largest organ and it can fail

Protective function of the skin

Protects against mechanical damage heat, cold, and infection

Keratosis

Small light colored benign lesions common on older adults

Mongolian spots

Darkened areas of pigmentation that sometimes resemble bruises

Pressure injury

damage of the skin and the subcutaneous tissue caused by prolonged pressure

pruritus

itching

What causes pruritus?

Dry skin, excessive bathing

Effects of aging on the skin

Flattening of the dermal - epidermal junction. Reduced thickness and vascularity of the dermis. decreased rate of epidermal turnover. Degeneration of elastic fibers. increase crisis of collagen. Reduction in melanocytes. Increased fragility of the skin. Culture of aging in the United States.

Promotion of skin health

Educate on avoiding irritating agents; increase nutrition and hydration. Promote activity, avoid excessive, bathing, early treatment of itching, avoid exposure to ultraviolet rays.

Vascular age related changes

Vein walls, weaken. Reduced ability of veins to respond to increased venous pressure and hereditary factors compound the problem, varicose veins, and lower extremity edema may be present.

What are pressure injuries caused by?

Tissue anoxia and ischemia result in necrosis, sloughing and tissue ulceration

Predisposing factors to pressure injuries

Fragile skin that damages easily. Poor nutritional state. Reduced sensation. Affected by immobile and edematous conditions.

Nursing interventions for prevention of pressure ulcers.

Turn the patient every two hours. Make sure that the patient is dry. Promote good nutrition.

What Braden's scale score indicates a high risk for pressure injuries

12 or less

Unstageable, pressure injuries

Full thickness, loss of tissue, base covered by slough or eschar. Stage cannot be determined until slough is removed to expose the base and actual depth of the wound.

Deep tissue pressure injury

Localized area of non-blanchable, deep red or purple discoloration with dark wound bed or blood filled blister due to intense or prolonged pressure or shearing force skin may be intact or non-intact

Pressure injury stage one

non-blanchable erythema of intact skin

Stage two pressure injury

Partial thickness, loss of skin layers involving the epidermis. Presents as intact or open/ruptured blister, or a shallow open crater.

Stage three pressure injury

Full thickness skin loss through the epidermis, exposing subcutaneous tissues. Presents as a deep crater with or without tunneling and undermining adjacent tissue.

Stage four pressure in injury

Full thickness with tissue loss. Skin and subcutaneous tissue are lost exposing muscle or bone or both deep crater may include necrotic, tissue slough or eschar. Tunneling and undermining are often present.

How to document pressure injury

Document the stage and the level of healing if any.

Undermining wound

- dead space under the edges of the wound

tunneling wound

A passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound. Open wound.